Mishap Investigation
Handbook
VERSION 11
APRIL 2022
This training material may not be reproduced without consent of the author.
This handbook, dated April 1, 2022 supersedes any previous handbook and must
be used in conjunction with DoDI 6055.07, OPNAV M-5102.1_/MCO P5102.1_
and OPNAVINST 3750 series for mishap investigations conducted
throughout the Navy and Marine Corps.
This handbook is intended for use by uniformed safety officers/managers and
civilian safety and occupational health specialists assigned to operational units,
installations or supporting organizations as a guide to conduct investigations of
minor mishaps as well as formal safety investigation boards.
This handbook is not all encompassing yet defines the core investigation
processes common among all communities. Regulations, processes or standard
operating procedures (SOP) unique to a specific communities or major commands
are not delineated in this handbook.
This handbook derives from multiple sources and does not introduce or impose
requirements beyond those addressed in the 29 CFR 1904, DoDI 6055.07,
OPNAV M-5102.1/MCO P5102.1 series, OPNAVINST 1500.75 series, MCO
5100.34 series, MCO 5100.29 series, NAVMC Directive. 5100.8, or NAVMC
1553.2, and is intended to:
 Provide more detailed information and guidance addressed in the previous
stated references;
 Serve as a reference tool for conducting a mishap investigation within the
DON;
 Support Naval Enterprise training in mishap investigation and prevention
strategies.
This training material may not be reproduced without consent of the author.
Table of Contents
PART I
Department of the Navy (DON)
Mishap Investigation Program Requirements
Unit 1 – Introduction to Mishap Investigation …...………….……………………….……...
1
Unit 2 – Mishap and Hazard Reporting Requirements ….…..……………………..………
8
Unit 3 – Protecting Safety Information ……………………….….……….….………….…..
34
Unit 4 – Mishap Preparation (Mishap Action Plan and Kit) ………………………………
39
PART II
Mishap Investigation Process
Unit 5 – Mishap Investigation Process (Overview) ………………………………………
42
Unit 6 – Mishap Site Management ………….……………………………………………..
45
Unit 7 – Evidence Collection ………………..…………….………………………………….
47
Unit 8 – Causal Factor Analysis ……………………….…………………………………....
62
Unit 9 – Developing Factor Statements, Findings and Recommendations …….......….
97
PART III
Safety Investigation Reports and Corrective Action Process
Unit 10 – Preparation of Safety Reports …...……………….…………………………….
111
Unit 11 – Safety Officer’s Role to a Safety Investigation Board ….……..……………..
125
Appendices
Appendix A – USMC Mishap Investigation Process …………………..…………………
127
Appendix B – USN Mishap Investigation Process ……………………………………….
128
Appendix C – High Potential Mishaps (HIPOM) ………………………………………….
129
Appendix D – MARADMINs (Changes to USMC 8-Day Brief Requirements) ………… 131
Appendix E – DoD HFACS integration into METT-T (mission hazard identification) .... 133
Appendix F - References and Resources ………………………………………………… 134
Commandant of the Marine Corps (Safety Division) Mishap Investigation Course
i
Course Objectives
PURPOSE: This course prepares DON Safety and Occupational Health personnel (GS-0018, GS-0019,
and unit level uniformed safety personnel) to investigate all near mishaps and mishaps. Upon completion,
personnel will have the fundamental knowledge and skills to analyze and synthesize mishap causes and
develop effective recommendations to enhance future hazard reduction strategies. Additionally, course
attendees will understand the OSHA, DoD, and DON mishap reporting and recordkeeping requirements.
APPROVAL: This course is approved by the Director of Marine Corps Safety Division (CMC
SD) and COMNAVSAFECOM with the course identification number A-493-0078.
LEARNING OBJECTIVES: Upon course completion, students will be able to:
 Determine the purpose of mishap investigation and its relationship to risk management and planning;
 Determine which mishaps or hazards require investigation and reporting to OSHA and the DON;
 Determine which mishaps require a formal Safety Investigation Board (SIB);
 Classify Department of Defense and Naval mishaps;
 Differentiate the difference between privileged and factual (non-privileged) information;
 Determine the procedures for sharing or obtaining safety information;
 Conduct an audit of a mishap action plan;
 Determine the aspects of mishap scene management;
 Conduct evidence collection to include use of cognitive interviewing techniques;
 Deduce causal factors through causal factor analysis using multiple analytical tools;
 Conduct error pathway analysis utilizing the Department of Defense Human Factors Analysis and
Classification System (DoD HFACs);
 Develop effective recommendations to enhance hazard reduction strategies and reduce mishaps;
 Explain the roles and responsibilities of unit safety officers to a formal Safety Investigation Board;
 Formulate and submit a Safety Investigation Report (SIREP) in Risk Management Information (RMI)
Safety Module.
Author and Course Developer: C.R. Acord (HMC ret.) BSHS, CSHS
Safety & Occupational Health Manager / Training Chief, CMC Safety Division
ACKNOWLEDGEMENTS
Although the essence of this course, the material, and instructional methodology is the vision and years of
effort, recognition is warranted to those who helped bring this course to fruition and setting the stage for
receiving the Navy League of the United States, SECNAV Gordon R. England Safety Award for 2016.
LtCol Walter “Otter” Audsley (USMC/ret.), LtCol Mike Miller (USMC/ret) and Col Jeff “Flattop” Gardner
(USMC/ret.) for coercing me into the Marine Corps safety community and empowering my innovative
approaches to force preservation efforts. Mr. Jon Natividad (Naval Mishap Investigations Branch Head) for
identifying the critical need to incorporate the application of the DoD HFACS taxonomy into ground mishap
investigation training. To Dr. Ray Baker for providing the educational foundation of the DoD HFACS
taxonomy’s application to the investigation process. Mrs. Vicki Arneson-Baker for the “sanity checks” during
the process of instructional design and development. To the mishap investigation team (Ryan Carlson
(Capt/USMC), Andrew Gay (Capt/USMC) and Trevor Jones (Capt/USMC)) for their dedication and
contributions to refining the process of causal factors analysis mapping, advocating a vision to incorporate
the DoD HFACS taxonomy into the mission planning process and leadership continuums.
Most importantly, to the active duty and civilian safety personnel who inspired me to create this course and
to all who provided feedback necessary to enhance this product and ensure future leaders obtain the
problem solving skills essential to prevent unnecessary loss. Your “boots on the ground” action and
leadership is what turns this reactive aspect of “safety” into proactive risk reduction efforts to effectively
increase combat readiness through education, assertiveness, and leadership. C.R. Acord
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
ii
Unit 1:
Introduction to Mishap Investigation
1-1. HAZARD vs MISHAP vs NEAR-MISHAP.
a. Hazard OPNAVINST 3500.39C and MCO 5100.29C define Hazard as: “Any real or potential condition
that can cause injury, illness, or death to personnel; damage to or loss of equipment or property; degradation
of mission capability or impact to mission accomplishment; or damage to the environment. (A hazard is
synonymous with the term “threat.”)”
 Environmental Hazards: (Exposure to environmental conditions that create unsafe situations such
as heat, cold, air quality, water, altitude, insects, rain, illumination, sewage, etc.)
 Physical Hazards: (Exposure to hazards in the operating environment that may create unsafe
situations such as objects, terrain, equipment conditions or equipment design)
 Human Hazards: (Conditions of team members and/or conditions of non-members of the team
that may create unsafe situations)

Condition: a distinct state that facilitates the occurrence of an event.

A condition
leading to an event may be equipment status, meteorological conditions and/or conditions of
the human(s) involved or anything that affects an event.
a. Mishap DoD and DON define mishaps as: “An unplanned event or series of events that results in
damage to DoD property; occupational illness to DoD personnel; injury to on-or off-duty DoD military
personnel; injury to on-duty DoD civilian personnel; or damage to public or private property, or injury or
illness to non-DoD personnel, caused by DoD activities.”
Remember - All mishaps, regardless of cause, have the same result – they degrade combat power or
mission effectiveness. The near-miss may be your one & ONLY warning to tragedy if not corrected.
b. Near-miss / Near-mishap DoD defines a Near Miss as: “An undesired event that, under slightly
different circumstances, would have resulted in personal harm, property damage, or an undesired loss of
resources.” In other words – “An unplanned, unintended, unwanted, and unexpected, but controllable event
which disrupts the work process and has the potential to cause material loss or damage, death, injury or
occupational illness but was avoided merely by chance.
Regardless of technology and enhancements to industrial processes, the "near miss", in each case
had the potential to become a mishap with more serious consequences. Each of these “near miss” events
indicate a failure of barriers or controls. Often, it is only by inches or seconds or the quick reaction of a team
member, that a near miss was not become a tragic event. The "near misses" at the base of the mishap
triangle offers the GSO, GSM, HRTSO, or civilian Safety & Occupational Health Specialist (GS-0018)
numerous opportunities to investigate the hazards and implement controls to prevent the more serious event.
If more scrutiny is taken at the level of unsafe acts, the near miss and minor mishaps, leaders can
significantly reduce the chances of more serious events that damages operational readiness.
NOTE: If the hazards are left uncorrected, they will become a mishap with an unknown injury severity.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
1-2. WHY MISHAPS OCCUR.
a. Overview. Mishaps are rarely simple and likely never result from a single cause, or caused by a single
individual. Instead, mishaps are caused by a series of events deriving from multiple latent failures and/or
hazardous conditions that provide the opportunities for an active failure to occur resulting in either a near
miss or a mishap. This remains true as many of the on-duty mishaps (Class E up to A) that occur during
military or industrial type activities are usually caused by multiple, interrelated causal factors and should be
investigated by a multi-disciplinary team.
These interrelated latent failures/conditions include such things as unrecognized hazards, ineffectively
assessed hazards, errors, oversights, omissions, unanticipated process changes, program deficiencies,
failure to enforce standards, ineffective procedural documents, or possibly ineffective material design.
These deeper rooted latent failures often influence other failures. Mishap investigations often reveal other
causes such as a lack of communication, lack of situational awareness, knowledge, assertiveness, teamwork
and resources in addition to ineffective planning & deliberate risk management. The same latent failures
influence other common causes such as an abundance of fatigue, pressure to meet mission, distractions,
ineffective supervision and/or unsafe culture and/or climate which perpetuate unnecessary high risk taking.
This is because the human factor is the greatest influence to contributing and causal factors. Various
studies prove that human error is the leading cause of mishaps. According to studies conducted within the
DoD and DON, greater than 85% of all mishaps are caused by human error. While mishaps involving
mechanical factors have been greatly reduced over the years, those attributable to human error continue to
plague the DoD. Think about this - every hand that operates or fixes military equipment, or is involved in the
writing and execution of policies, SOPs, LOIs, risk assessments, or Operational Plans each have an
opportunity to introduce human error which can easily result in a cascading effect of errors, omissions, or
deviations from standards that influence the occurrence of a near miss or mishap.
More often than not the mishap is a predictable and preventable event. It is critical that military and
supporting civilian personnel first understand that in the on-duty environment, active failures of individuals
and latent conditions are interrelated.
Once this is understood, then mishap investigators can more effectively identify the obscured causes to
proceed towards more effective solutions to reduce hazards.
b. The Human Factor. Drawing from James Reason’s model (1990) along with Dr. Shappell’s & Dr.
Wiegmann’s (2003) concept of active and latent failures, human factors are broken down into four major
tiers. Reason proposed what is referred to as the “Swiss Cheese Model” of system failure. Every step in a
process has the potential for failure to varying degrees. The ideal system is analogous to a stack of slices of
Swiss cheese. (See figure 1-1)
Consider the holes as opportunities for a process to fail and each of the slices as “defensive layers” in the
process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are
in different places, and the problem should be controlled, preventing it from passing through. For a mishap to
occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting
in an unsafe act. If the layers are set up with all the holes lined up, this is an inherently flawed system that
will allow a problem to progress all the way through to cause a near miss or mishap. Each slice of cheese is
an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the
smaller the holes, the more likely you are to catch/stop risky conditions. DoD Risk Management (RM) and
planning is the proactive approach to preventing hazardous conditions from becoming detrimental to a
commander’s operational readiness.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
The Human Factor
TIP: Effective hazard identification
and risk management prevents
holes in the cheese.
Dr. James Reason’s Swiss Cheese Model
H.W. Heinrich
Mishap Pyramid
Figure 1-1
1-3. COST OF MISHAPS TO THE DoD.
a. Overview. No matter how minor the mishap, a military organization always loses some of its capability
to accomplish its mission. According to OSHA, workplace injuries, illnesses and deaths cost our nation $170
billion every year (OSHA.gov, 2012). The DON is not immune to similar fiscal and human losses and each
unavoidable loss becomes more significant as the DoD budget continues to decrease. Fortunately, our
leaders are gaining a better understanding of the importance of funding safety initiatives. One study
estimated that a good safety management system (SMS) can save $4 to $6 for every $1 invested. To clearly
understand the negative impact any mishap has on an organization, one must consider not only the
immediate effect, but the second, third, and fourth order of effect. How do all mishaps effect the operating
budget of the Navy or Marine Corps?
b. Direct Costs. Includes known financial costs that are “above the water line” that is obvious to the
organization. It is intuitive to all that damaged or destroyed equipment has a financial impact and that any
loss of personnel from the team degrades productivity.
c. Indirect Costs are the additional costs associated with a mishap that are normally not considered
because they are “below the waterline”. And as an iceberg is much larger below the waterline and more
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
dangerous, indirect costs are usually much greater than direct costs. (From two to ten times as expensive.)
Unlike direct costs, indirect costs have a more severe effect on the Navy or Marine Corps budget and future
needs. Indirect costs may include: Safety investigation board costs (TAD funds, supplies used, etc.);
production time lost by the injured employee, fellow workers, and supervisors; degraded production or
mission readiness, environmental cleanup costs; recovery, transportation, and repair costs of military
vehicles and equipment; replacement costs for military equipment; replacement costs to train new
employees or military members; medical treatment cost (immediate and long term); civilian worker’s
compensation costs; casualty assistance costs; legal costs (fines, lawsuits, etc.)
d. Calculating Mishap Costs. In accordance with OPNAV M-5102.1_/MCO P5102.1_, the following
must be included when calculating costs of a Navy and Marine Corps mishaps:
1) DoD Property Damage Costs. The cost of acquisition, repair or replacement of all DoD property
involved in the mishap by determining the actual cost of materials or by estimates provided by the
repair activity.
If necessary, use estimates based on the actual cost of materials and $18 for each hour of
organizational- or intermediate-level labor or $60 for each hour of depot-level labor.
When damage occurs to Navy and Marine Corps property as a result of non-government (i.e.,
contractor or private citizen) activities, any damage to non-government property is not considered in
determining costs.
2) Other Property Damage Costs. Is the actual cost of repair or replacement of the damaged item, if
available.
3) Injury Costs. The cost based on the extent of injury reported and current costs estimates. These
cost are calculated by COMNAVSAFECOM from data received on mishap reports.
1-4. PURPOSE OF MISHAP INVESTIGATIONS.
a. Overview. The primary objective of the Navy and Marine Corps safety program is to enhance
readiness by preserving human and material resources. A proactive mishap prevention process identifies
unsafe acts and conditions and applies corrective measures before mishaps occur. Prevention is
accomplished through aggressive DELIBERATE RISK MANAGEMENT (DRM) during pre-mission or event
planning in which the planning team should capitalize on engineering, systems safety, education and
training, personal protective equipment, and measures to enforce standards. Effective causal factor analysis
during the DRM / mission planning process will identify not just the known hazards, but the previously
unknown hazardous conditions that were either ignored or ineffectively assessed.
b. Goal. The goal of a mishap investigation is to discover the multiple hazardous conditions and failures
that collectively allow mishaps to occur. Then commanders and their staff must incorporate more proactive
actions into the risk assessment during the planning processes to better manage risks and accomplish the
mission. (See figure 1-2) There are three key reasons to investigate all near-mishaps and mishaps:
1) Identify Causes: Before a commander can implement any effective corrective action to prevent
another mishap, safety must first identify the causes. Getting to the roots of an issue identifies how
the roots effect the symptoms (risky behaviors & conditions) which cause the near-miss or mishap.
Events and/or conditions in the mishap sequence that are necessary and sufficient to produce or
contribute to an unwanted result is called a mishap cause. Events within a mishap may have
multiple causes assigned. Causes are the genesis of the mishap, not the reason that damage or
injury occurred. To better understand their relationship to each other and which have greater
precedence in determining how to prevent further mishaps, causal factors determined during
mishap investigations are commonly placed into one of three mishap cause types.
2) Maintain Accurate Recordkeeping: Monitor and analyze trends to measure prevention program
effectiveness. Comply with Federal (OSHA), DoD and DON reporting requirements.
3) Prevent Future Near-mishaps and mishaps: Expose deficiencies in processes, programs and/or
equipment, eliminate or mitigate hazards to reduce injury and compensation costs. The systematic
approach of the RM process assists military and civilian personnel to identify hazards (human and
human interaction with the operating environment) so the organizational leadership may apply more
effective controls in order to prevent the holes of “swiss cheese” from aligning.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
Figure 1-2
The following illustration demonstrates the relationship between the processes of deliberate planning,
threat assessments, troop leading steps (BAMCIS), DoD human factors analysis (DoD HFACS) and
the DoD risk management (RM) process. The DoD HFACS is an excellent tool to enhance Causal
factor analysis post mishap and effective to enhance hazard identification during the METT-TC
process, specifically to the areas of assessing “Terrain and Weather”, “Troops and Equipment”, and
“Time”. (See figure 1-3)
Marine Corps Planning
Process (MCPP)
and
Navy Planning Process
(NPP)
Figure 1-3
END STATE:
Enhance risk assessment & management during deliberate planning and execution of the plan.
“Manage the risks – accomplish the Mission”
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
“When a Marine is injured or killed while training, more than the immediate
environment of the occurrence must be examined. The quality of the leadership at
every echelon of the organization, its overall level of training, the degree of
supervision over those directly involved, and organizational SOP’s are among the
matters which must be closely and carefully investigated.”
General Al Gray, 29th Commandant of the Marine Corps, 4 Jan 1989
1-5. TYPES OF MISHAP INVESTIGATIONS.
a. Unit / Command / Installation Mishap Investigations. The unit/command or installation level safety
investigation is required for all mishap classes A through D and “other” mishaps that do not require a formal
mishap investigation board. Ground Safety Officers (GSO), Aviation Safety Officers (ASO), High Risk
Training Safety Officers (HRTSO) and civilian SOH Specialists (GS-0018) are required to conduct the vast
majority of mishap investigations that do not require a SIB which include;
1) All Off-duty, Off-base mishaps. (Class A, B, C, D, other reportable)
2) All On-duty mishaps that do-not require a SIB. (Class B, C, D and other reportable)
3) All On-duty Fed-Civilian mishaps that do-not require a SIB. (Class B, C, D, and other reportable)
4) All On-duty contractor mishaps under DIRECT supervision of DON Personnel that do not require
SIB. (Class B,C,D, and other reportable)
b. Formal Safety Investigation Boards: A formal safety investigation board is formally appointed body
to investigate a few select mishaps. There are four types of formal investigation boards applicable to the
Department of the Navy which include:
1) Directed Mishap Investigations: CNO or CMC directed in special cases.
2) Standing Boards: Common in Naval aviation.
3) Joint Mishap Investigation Boards: Occurs when a mishap involves members or equipment from
two or more services.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 1:
Introduction to Mishap Investigation
1-6. SAFETY OFFICER’S ROLE AND RESPONSIBILITIES.
a. Overview. The OPNAVINST 5100.23H, OPNAVINST 5100.1D/MCO P5102.1C, OPNAVINST
3750.6_, OPNAVINST 1500.75D, MCO 5100.29 series, and NAVMC Dir. 5100.8, each outline the roles and
responsibilities for “Safety officers, safety directors, safety managers, safety specialists and civilian
supervisors” to investigate and report mishaps.
Only about 2% of mishaps that occur around the fleet require a formal SIB. This means that the majority of
mishaps in the Navy and Marine Corps require investigation and reporting by trained unit safety officers
(GSO/ASO/ADSO/HRTSO) or civilian SOH specialists (GS-0018).
As indicated by the “mishap pyramid” in section 1-2, this means for every SIB, there were abundant
opportunities to identify the hazardous conditions and prevent needless loss. Proactive safety officers who
place more emphasis and investigative vigor into causal factor analysis of high potential near mishaps and
lower classification of mishaps of becoming more serious, they can help their Commanders to enhance
mission readiness and combat effectiveness.
b. Key Responsibilities.
 Guide organizational planners and leaders in the development of a Mishap Action Plans for
incorporation into duty binders, operational plans, lets of instruction, etc.
 Ensure all mishaps and al near mishaps are investigated and reported in the CNO and CMC
approved mishap reporting tool.
 Submit Hazard Reports (HAZREPS) as required for near mishaps and/or hazardous conditions
(See OPNAV M-5102.1_/MCO P5102.1_ and Appendix XX of this handbook)
 Protect privileged safety information. (See unit 3 of this handbook)
 Develop a mishap investigation kit if needed.
 Provide training to key unit/command personnel in hazard identification and reporting, near-miss
reporting, mishap reporting,
 Coordinate with safety officers from embarked units and detachments on the investigation, reporting,
and correction of the causes of mishaps.
 Conduct trend analysis of mishaps for lessons’ learned and your Commander’s readiness programs
or mishap prevention programs.
 Ensure command wide dissemination of lessons learned.
 Assist the Commander, Commanding Officer, or Officer-in-Charge in conducting mishap
investigations for all on-duty Class A mishaps until the SIB arrives.
NOTE: Per DoDI 6055.07 and OPNAV M-5102.1_/MCO P5102.1_, personnel assigned to duties as a
safety officer shall neither assist or be assigned to conduct any legal (i.e. JAGMAN) investigation.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
Mishap and Hazard Reporting Requirements
2-1. KEY DEFINITIONS (For Safety Reporting Purposes ONLY). All definitions are found
in the DoDI 6055.07, OPNAV M-5102.1_/MCO P5102.1_ and OPNAVINST 1500.75D.
a. Contractor-Caused Mishaps. Injuries, work-related illnesses of DoD personnel, or damage caused by
contractor operations. The parent command of affected DoD personnel shall report these mishaps. Mishaps
involving civilian contractor personnel caused by contractor operations shall be referred to COMNAVSAFECOM
or CMC (SD) for guidance.
b. Contractor Mishaps. There are two categories for contractor mishaps:
1) Non-Reportable Contractor Mishap. Any contractor mishap involving his or her employee is not
reportable if that employee is not under direct DON supervision and DoN has no direct means to correct,
control, eliminate or prevent recurrence of similar incidents. The command is required to submit an
OPREP-3 or UNIT SITREP report and the contractor is responsible for OSHA notification.
2) Reportable Contractor Mishap. Contractor employee mishaps are reportable when DoN provides direct
day-to-day supervision and has a means to change the work environment, correct, control, eliminate or
prevent workplace hazards or mishaps.
c. DoD Personnel. Defined as: On-duty, DoD civil service employees (including National Guard and Reserve
technicians, unless in military duty status); non-appropriated fund employees (excluding part-time military); Corps
of Engineers civil works employees; Youth or Student Assistance Program employees; foreign nationals employed
by DoD components; and Army-Air Force Exchange Service (AAFES) employees.
All U.S. military personnel on active duty; U.S. Military Reserve or National Guard personnel on active duty or in
a drill status; Service Academy cadets or midshipmen; Reserve Officer Training Corps (ROTC) cadets or
midshipmen when engaged in directed training activities; Officer Candidate School (OCS) students when engaged
in directed training activities; and foreign national military personnel assigned to DoD components.
d. Personnel. For investigation, reporting and record keeping, personnel are either Navy and Marine Corps
personnel or non-Navy and Marine Corps personnel.
1) Navy and Marine Corps Personnel. The term "Navy and Marine Corps personnel" refers to all of the
following:
 Military Personnel. All military personnel on active duty; Reserve personnel on active duty or in a drill
status; Naval Reserve Officer Training Corps (NROTC), Naval Junior Reserve Officer Training Corps
(NJROTC), Marine Corps Junior Reserve Officer Training Corps (MCJROTC, Sea Cadets, Devil
Pups, and personnel in the delayed entry program involved in an official military function; officer
candidate students; recruits; and other DoD and foreign national military personnel assigned to the
DON.
 Civilian Personnel. The following are Navy and Marine Corps civilian personnel:
 Federal Civilian Personnel. All career, careerconditional and temporary (full-time, part-time,
intermittent) personnel, who are subject to civil service regulations, paid from appropriated federal
funds, and covered by the Federal Employees' Compensation Act. This excludes civilians paid on a
contract or fee basis.
 Non-Appropriated Fund Civilian Personnel. All civilian personnel whose employment by the Navy and
Marine Corps is paid by non-appropriated funds and are covered by the Longshore and Harbor
Workers Compensation Act. This excludes civilians paid on a contract or fee basis.
 Foreign National Civilian Personnel. Includes nationals employed by the Navy and Marine Corps in
direct (appropriated or non-appropriated funds) or indirect hire (contract or fee basis) status when the
Navy and Marine Corps has supervisory control. It excludes those paid by contract or fee basis when
the host government has supervisory control.
2) Non-Navy and Marine Corps Personnel. Includes the following: Off-duty Navy and Marine Corps civilian
personnel. Personnel employed by other federal or DoD agencies not assigned to the Navy and Marine
Corps.(3) All other civilians and foreign nationals not employed by the Navy and Marine Corps.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
Mishap and Hazard Reporting Requirements
e. Duty Status. A Sailor or Marine is either on duty, on liberty, on leave, or an unauthorized absentee. Sailors
and Marines on liberty, on leave, and in an unauthorized absentee status are off duty. The following definitions are
for safety purposes only and bear no relationship to compensation or line of- duty determination.
1) On Duty. (FOR SAFETY REPORTING PURPOSES ONLY) Navy and Marine Corps personnel are on
duty when they are:
 Physically present at any location to perform there officially assigned work. This includes activities
normally associated with work, such as walking to and from parking lots, lunch periods, rest breaks,
and all activities aboard military vessels. All active duty personnel on board a military vessel are
considered on duty.
 Being transported anytime by a government motor vehicle (GMV) or commercial vehicle for the
purpose of performing officially assigned work. This includes travel in private motor vehicle (PMV), or
commercial conveyance while performing official duty, but not routine travel to and from home and
work or duty station. Sailors and Marines in a government leased or chartered water taxi are on duty.
 Participation physical training activities while on station, on board ship, or anyplace while under
orders.
 Participating in command-directed events.
 Reservists are on duty when they are at their designated drill sites performing inactive duty training
(IDT) or are performing Annual Training (AT), Active Duty Training (ADT) or Active Duty Special Work
(ADSW).
 Civilians are considered on duty when they reach federal property. This includes on the way to or
from work site or in the performance of their official duties.
 Navy and Marine Corps personnel on Temporary Additional Duty (TAD) and temporary duty (TDY),
away from their regular place of employment are covered during performance of duties and during
travel for any injury that results from activities essential or incidental to the temporary assignment.
However, when personnel deviate from the normal incidents of the trip and become involved in
personal activities not reasonable or incidental to the assignment, the person ceases to be considered
on duty for investigation and reporting purposes of occupational injuries or illnesses.
2) Off Duty: (FOR SAFETY REPORTING PURPOSES ONLY)
 Whether on or off a Navy and Marine Corps installation, Navy and Marine Corps personnel are off
duty when they are on leave, liberty, on permissive TAD, or are an unauthorized absentee.
 Reservists considered off duty from the time they depart home/office until they reach their appointed
site of duty for drill, and, from the time they depart the drill site until they reach domicile or government
provided billeting at the conclusion of the scheduled drill or drill periods.
 Participating during non-working hours in base or installation team sports and events sponsored by
the command in which participation is voluntary.
3) DoD Civilian Employees: For safety reporting purposes ONLY - Navy and Marine Corps civilian
personnel are off duty during the workday (even though on federal property) when they are engaged in
personal activities unrelated to employment such as eating, physical training, resting, shopping, running
errands, etc.
f. High Risk Training. (See OPNAVINST 1500.75D) “All basic or advanced, individual or collective training in
a traditional or non-traditional environment which exposes the crew, staff, students, and assets to the potential
risks of death, permanent disability, or loss during training. For the purpose of this instruction, an assignment of
any initial risk assessment code (RAC) of 1 or 2, as well as an assignment of RAC 3 in severity level I (death or
loss of asset) or severity level II (severe injury or damage), although the "probability" of an injury or loss is "unlikely
(E)" or "seldom (D)," must be considered high-risk training.”
g. Injury Type and Subcategories of Injury Dispositions.
1) Injury. A traumatic wound or other condition of the body caused by external force including stress or
strain. The injury is identifiable as to time and place of occurrence and the part or function of the body
affected, and is caused by a specific event or series of events within a single day or work shift. Injuries
include cases such as, but not limited to, a cut, fracture, sprain, or amputation.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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2) First Aid Case.
 Military members: any initial one-time treatment and any follow-up visit for observation of minor
scratches, cuts, burns, and splinters that does not ordinarily require medical care. Such one-time
treatment and follow-up visit for observation is considered first aid, even though provided by a
physician or medical professional.
 DoD civilians: any case that requires one or more visits to a medical facility for examination or
treatment during working hours, as long as no leave or continuation of pay (COP) is charged to the
employee and no medical expense is incurred. Also, a case that requires two or more visits to a
medical facility for examination or treatment during non-duty hours beyond the date of injury as long
as no leave or COP is charged and no medical expense is incurred.
3) First Aid Treatment. (See OPNAV M-5102.1E/MCO P5102.1C, Page A-23, paragrap124c.)
4) Permanent Partial Disability (PPD). An injury or occupational illness that does not result in death or
permanent total disability, but, in the opinion of competent medical authority, results in permanent
impairment through loss of the use of any part of the body with the following exceptions: teeth,
fingernails, toe nails, tips of fingers or tips of toes without bone involvement, inguinal hernia,
disfigurement, or sprains or strains that do not cause permanent loss of motion.
5) Permanent Total Disability (PTD). Any nonfatal injury or occupational illness that in the opinion of
competent medical authority permanently or totally incapacitates a person to the extent that he or she
cannot follow any gainful occupation and results in a medical discharge or civilian equivalent. (The loss,
or the loss of use of both hands, both feet, both eyes, or a combination of any of those body parts as a
result of a single mishap shall be considered as a permanent total disability.)
6) Hospitalization. The admission of Navy and Marine Corps personnel to a hospital or shipboard medical
facility on an inpatient basis related to the immediate injury or occupational illness if pay (COP) is
charged to the employee and no medical expense is incurred.
7) Light Duty. A duty status recommended after treatment of an injury that stipulate exactly limitations on a
service member during the recommended period, equivalent to placing a civilian in a restricted work
status. When an injury or occupational illness results in light-duty days, assigned light duty days are not
counted as lost workdays. On light duty, the military member normally remains at their original duty
station but is gainfully employed even though not performing their normal duties.
8) Limited Duty. A military duty status formally assigned as a result of a medical board. Time spent on
limited duty is not chargeable as lost time regardless of the cause for assignment to limited duty. Under
limited duty, the military member is frequently reassigned from their permanent duty station to a
temporary duty station until the medical issue is resolved.
9) Lost Workdays or Days Away from Work. A non-fatal traumatic injury that causes any loss of time from
work after the day or shift on which it occurred; or non-fatal non-traumatic illness and/or disease that
causes any loss of time from work. The total number of full calendar days, weekends included, that a
person was unable to work as a result of an injury or occupational illness, excluding the day of the
mishap and the day returned to duty or work.
 For active duty military personnel, these include days hospitalized, sick-in-quarters, or on
convalescent leave as a result of injury or work-related illness.
 For reserve personnel, in a not physically qualified (NPQ) status sustained as a result of an injury at
any time en route to, during, or returning from drill, or during annual training, is considered lost time.
 For DoD civilian employee personnel, this includes continuation of pay (COP) leave, annual leave,
sick leave, days hospitalized, and leave without pay granted, or a full work shift missed because of a
work-related illness or injury.
10) Restricted Work or Job Transfer. Restricted work activity or temporary transfer from that work occurs
when, as a result of a work-related injury or illness, a supervisor or health care professional keeps, or
recommends keeping, a civilian employee from doing the routine functions of his or her job, or from
working the full work day that the employee would have been scheduled to work before the injury or
illness occurred. The employee has not lost work time, but is restricted from routine functions. The
military equivalent of restricted work is Light or Limited Duty.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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h. Weapons Mishap Category and Subcategories.
1) Explosive Event / Chemical Agent Event. Any event involving conventional ordnance, ammunition,
explosives, explosive systems and devices resulting in an unintentional detonation, firing, deflagration,
burning, launching of ordnance material (including all ordnance impacting off-range), leaking or spilled
propellant fuels and oxidizers (less OTTO fuel II), or chemical agent release. (E.g. round explodes in the
breech, marine location markers, flares, fire suppression systems, CS gas, etc.).
2) Explosives Mishaps. A Class A, B, C, or D mishap resulting in damage or injury from: An explosion or
functioning of explosive materials or devices (except as a result of enemy action); Inadvertent actuation,
jettisoning, and releasing or launching explosive devices; or Impacts of ordnance off-range.
3) Chemical Agent Mishaps. A mishap involving any unintentional or uncontrolled release of a chemical
agent where: Reportable damage occurs to property from contamination or costs are incurred for
decontamination; Individuals exhibit physiological symptoms of agent exposure; or The agent quantity
released to the atmosphere is such that a serious potential for exposure is created by exceeding the
applicable maximum allowable concentration-time levels for exposure of unprotected workers or the
general population or property.
4) Small Arms / Live Fire Mishaps. A mishap resulting from the use of small arms. (I.e. ricochets, negligent
discharge, direct impact, etc.)
5) Directed Energy. A mishap involving directed energy: Applying directed energy primarily as a weapon to
damage, disrupt, disable, or destroy enemy resources. Directed energy weapons include, but are not
limited to: high-power lasers and microwave systems, and sonic and ultrasonic beam weapon systems.
Applying electromagnetic radiation primarily for purposes other than as a weapon.
i. Motor Vehicle Mishap Category and Subcategories.
1) Government Motor Vehicle (GMV). A mishap involving a motor vehicle that is: Owned, leased, or rented
by a DoD Component (not individuals); Primarily designed for over-the-road operations; For the general
purpose of the transportation of cargo or personnel. (E.g. passenger cars, station wagons, vans,
ambulances, buses, motorcycles, trucks, and tractor-trailer trucks). Vehicles on receipt to, and operated
by, non-DoD persons or agencies and activities such as the U.S. Postal Service or the American Red
Cross are not GMVs.
2) Government Vehicle, Other (GVO). A mishap involving a vehicle that is owned, leased, or rented by a
DoD Component (not individuals) designed primarily for off-the-highway operation such as: Construction
tracked vehicles; Powered industrial trucks (e.g., fork lifts); Road graders; Agricultural-type wheeled
tractors; Aircraft tugs; Military combat and tactical vehicles (e.g., tanks, self-propelled weapons, armored
personnel carriers, amphibious vehicles, and high-mobility multipurpose wheeled vehicles)
3) Private Motor Vehicle (PMV). A privately owned motor vehicle (2-wheel, 4-wheel, etc.) primarily designed
for the transportation of people or cargo over public streets or highways.
NOTE: These definitions are critical to all DON reportable and OSHA “recordable” mishaps as
illustrated in figure 2-1 and 2-2 as well as Tables 2-1 through 2-13.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
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Figure 2-1
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
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2-2. DEPARTMENT OF THE NAVY REPORTABLE MISHAPS (For Safety Reporting
Purposes ONLY)
a. All On-duty civilian and On-off-duty military Injury or occupational illness that results
in:
 medical treatment beyond first aid. (see definition of 1st aid & 1st aid treatment)
 loss of consciousness (on-duty, work related)
* First Aid Case
Appendix A-26 para
146
 days away from work, (beyond the day of the mishap)
 Light duty or Limited duty (for all On-duty or Off-duty military personnel only)
 Job transfer or restricted work. (for all On-duty federal civilian employees)
b. All on-duty fatality or Permanent Total Disability w/in 1 hour of command-sponsored
Physical Training: (PFT, PRT, CFT, conditioning hike, O-Course, Unit Run, etc.)
c. Any DoD operation, activity, or evolution that results in the injury or death of a guest
or military dependent.
d. All on-duty training related fatalities.
HRT/MRT –
see
OPNAVINST
1500.75D or
MCO 1553.5
e. Any high risk training (HRT) or medium risk training (MRT) mishaps that result in loss
of one training day, roll-back or disenrollment.
f. All explosive related mishaps (i.e. ordnance impacting off range and live fire mishaps)
g. All on - duty diving mishaps: (CNS involvement, O2 toxicity, hyperbaric treatment,
pulmonary over inflation syndrome (POIS))
h. Ship grounding, collision, or flooding and fires afloat.
i. All GMV & GVO mishaps of $______________ or more. (Includes cost to DOD or non-
Explosive
Event: Appendix A
para 70;
Explosive
Mishap: Appendix A
A-11 para, 73
GMV vs GVO:
Appendix A, A-15 para,
86 & 87
DoD property and personnel when operator of the GMV/GVO is the cause.)
j. All Helicopter Rope Suspension Technique (HRST), air-cargo drop and/or parachuting
(regardless of damage or injury).
k. All on-duty contractor mishaps where the contractor is under ______________
supervision of Dept. of the Navy personnel (i.e. military or federal civilian).
l. All contractor caused mishaps that result in injury to DoD personnel or damage to
DoD property.
m. Medically diagnosed occupational-related illness or injury. (E.g. respiratory, blood, or skin
disease, ergonomics related cumulative trauma or musculoskeletal disease, etc.)
n. Work related Significant Threshold Shift (STS) or Permanent Threshold Shift (PTS).
(see MCO 6260.3A, OPNAVINST 5100.19E, OPNAVINST 5100.23G, & NMCPHC-TM 6260.51.99-2)
o. Work related needle stick or cut from sharp object that is contaminated w/ blood or
potentially infectious material.
p. Occupational related Tuberculosis (Tb) infection. (Verified by a positive TST).
q. Any on-duty heat stress or cold injury requiring medical treatment.
r. Any employee (military / civilian) medically removed under requirements of an OSH
Contractor
Caused
Mishaps Appendix A,
A-8, para 44
STS: Appendix A,
A-38, para 217
Needle Stick:
29 CFR 1904.8
Heat Stress,
Appendix A, A-17, para
97
** Alcohol:
See appendix A-2
health standard. (e.g. chemical exposure)
s. All alcohol related mishaps (Includes alcohol overdose.) **
t. Combat Zone mishaps: Any reportable mishap that is NOT the result of DIRECT enemy
action.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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The following mishaps are required to be investigated and reported by safety to the DON
and/or OSHA (Refs: 29 CFR 1904, DoDI 6055.07, and OPNAV M-5102.1_/MCO P5102.1_)
Active Duty Personnel
On- or Off-duty mishap where injuries result in a fatality (immediate or months following
the mishap) Permanent Total Disability (PTD).
DON
reportable
OSHA
reportable
YES
Call
NAVSAFECOM
w/in 8hrs.
n/a
On- or Off-duty mishap where injuries result in a Permanent Partial Disability (PPD)
YES
n/a
On- or Off-duty mishap where injuries cause one or more days away from work beyond
the day of the injury. (includes: SIQ, hospitalization, and convalescent leave)
YES
n/a
On- or Off-duty mishap where injuries result in Light Duty or Limited Duty.
(I.e. Injuries incurred during PT, work, field training, recreational activities, etc.)
YES
n/a
On- or Off-duty mishap where injuries result in medical treatment beyond first aid.
(The injury may not have resulted in light-duty, limited-duty, SIQ, etc.)
YES
n/a
On- duty mishap resulting in a loss of consciousness.
(I.e. a training event, physical screening event, confined space activity, etc.)
YES
n/a
On- or Off-duty mishaps where alcohol was a contributing factor
(I.e. motor vehicle crash, alcohol overdose, recreational mishaps, etc.)
YES
n/a
On-duty heat stress or cold injury requiring medical treatment above first-aid.
(includes hyperthermia causing heat exhaustion or heat stroke; hypothermia or frost bite)
YES
n/a
On-duty diving mishaps (hyperbaric treatment for any reason, CNS involvement, O2
toxicity, pulmonary over inflation syndrome, etc.)
YES
n/a
On-duty formal school training related mishaps. (Includes loss of one training day or
rollback in training or disenrollment during High or Medium Risk Training, etc.)
YES
n/a
On-duty injury resulting from a violent act while performing official duties.
(E.g. assaulted while standing duty, conducting an inspection, shore patrol, security, etc.)
YES
n/a
All live fire training mishaps with any degree of injury caused by impact from ammunition.
(I.e. ricochets, negligent discharge, direct impact, etc.)
All injuries from explosive related mishaps resulting from military operations, activity or
evolution. (i.e. “cook-off”, ordnance impacting outside SDZ, unexploded ordnance, etc.)
All ordnance impacting off range (outside SDZ) during training (with or with injury).
YES
(Requires
SIB)
YES
(Requires
SIB)
YES
(Requires
SIB)
n/a
n/a
n/a
All Helicopter Rope Suspension Technique (HRST), air-cargo drop and/or
parachuting (regardless of injury).
YES
n/a
Medically diagnosed occupational-related illness or injury. (E.g. respiratory, blood, or
skin disease, ergonomics related cumulative trauma or musculoskeletal disease, etc.)
YES
n/a
YES
n/a
Work related needle stick or cut from sharp object that is contaminated w/ blood or
potentially infectious material.
YES
n/a
Occupationally related Tuberculosis (Tb) infection. (Verified by a positive TST)
YES
n/a
Any member medically removed under medical surveillance requirements of an OSH
health standard. (e.g. chemical exposure) (See DoD 6055.05-M)
YES
n/a
All combat zone mishaps (not the result if direct enemy action.)
YES
n/a
Work related Significant Threshold Shift (STS) or Permanent Threshold Shift (PTS).
(See MCO 6260.3A, OPNAVINST 5100.19E, OPNAVINST 5100.23G & NMCPHC-TM 6260.51.99-2)
NOTE: Active duty reportable mishaps include any on or off-duty mishap where alcohol may have been a
contributing factor. (I.e. MV mishaps, etc.)
Table 2-1
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
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The following mishaps are required to be investigated and reported by safety to the DON and/or
OSHA (Refs: 29 CFR 1904, DoDI 6055.07, and OPNAV M-5102.1_/MCO P5102.1_)
Civilian Employees
DON
(Includes FedCiv & NAF employees. Also includes all Foreign National Civilian
Reportable
personnel, volunteers & temporary workers under supervisory control of DON personnel.)
YES
On-duty, occupational related mishap where injuries result in a fatality or permanent total
(Requires
disability (PTD).
SIB)
OSHA Reportable
YES
(W/in 8 hrs.)
Call
NAVSAFECOM
YES
(W/in 24 hrs.) Call
NAVSAFECOM
YES
(W/in 24 hrs.) Call
NAVSAFECOM
YES
(W/in 24 hrs.) Call
NAVSAFECOM
On-duty, occupational related mishap resulting in in-patient hospitalization of one or
more personnel.
YES
On-duty, occupational related mishap resulting in an amputation of a body part. (With or
without bone loss. With or without re-attachment. (E.g. Earlobe, fingertip, nose, arm, etc.)
YES
On-duty, occupational related mishap resulting in a loss of an eye.
YES
On-duty, occupational related mishap resulting in days away from work beyond the day
of the injury.
(I.e. any leave associated with the mishap such as sick leave, convalescent leave, etc.)
YES
Only if the injury
meets one of the
above four criteria
On-duty, occupational related mishap resulting in restricted work or transfer to another
job.
YES
Only if the injury
meets one of the
above four criteria
On-duty, occupational related mishap resulting in Medical Treatment beyond first aid.
(E.g. heat-stress, cuts, sprains, strains, blunt force trauma, etc.)
YES
On- duty mishap resulting in a loss of consciousness.
(I.e. a training event, physical screening event, confined space activity, etc.)
YES
On-duty heat stress or cold injury requiring medical treatment above first-aid.
(includes heat exhaustion, heat stroke, hypothermia or frost bite)
YES
On-duty diving mishaps (CNS involvement, O2 toxicity, hyperbaric treatment, pulmonary
over inflation syndrome, etc.)
YES
On-duty Any injury or fatality from a violent act while performing official duties.
(E.g. assaulted as a member of Law enforcement, EMS, Firefighter, etc.)
YES
All live fire training mishaps with any degree of injury caused by impact from
ammunition.
(I.e. ricochets, negligent discharge, direct impact, etc.)
All injuries from explosive related mishaps resulting from military operations, activity or
evolution. (i.e. “cook-off”, ordnance impacting outside SDZ, unexploded ordnance, etc.)
Medically diagnosed occupational-related illness or injury. (E.g. respiratory, blood, or
skin disease, ergonomics related cumulative trauma or musculoskeletal disease, etc.)
YES
(Requires
SIB)
YES
(Requires
SIB)
YES
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
Work related Significant Threshold Shift (STS) or Permanent Threshold Shift (PTS).
YES
n/a
Occupational related needle stick or cut from sharp object that is contaminated with
blood or potentially infectious material.
YES
n/a
Occupational related Tuberculosis (Tb) infection. (Verified by a positive TST).
YES
Any member medically removed under medical surveillance requirements of an OSH
health standard. (e.g. chemical exposure) (See OSHA 3162-01R & DoD 6055.05-M)
YES
(See MCO 6260.3A, OPNAVINST 5100.19E, OPNAVINST 5100.23G & NMCPHC-TM
6260.51.99-2)
Only if the injury
meets one of the
above four criteria
Only if the injury
meets one of the
above four criteria
NOTE: Reporting all OSHA required occupational related “recordable” mishaps to NAVSAFECOM via the
current authoritative mishap data collection system (i.e. RMI), satisfies the OSHA “recording” requirement.
Table 2-2
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
Mishap and Hazard Reporting Requirements
The following mishaps are required to be investigated and reported by safety to the DON and/or
OSHA (Refs: 29 CFR 1904, DoDI 6055.07, and OPNAV M-5102.1_/MCO P5102.1_)
Family members, guests, off-duty federal civilian employees, other civilians
Any death of a civilian (i.e. guest, military family member, off-duty federal civilian
employee, etc.) as the result of a DoD operation, activity or evolution.
(Includes any activity where the host commander has responsibility or means to assess,
eliminate or mitigate hazards associated with the activity. E.g. family fun day, “in their
boots day”, retirement ceremony, tent sale, military ball, static display, demonstration of
operational capability, Tiger Cruise, MWR / MCCS event, etc.)
Any injury of a civilian (i.e. guest, military family member, off-duty federal civilian
employee, etc.) as the result of a DoD operation, activity or evolution.
(Includes same activities as above)
Any injury or death of a civilian (i.e. guest, military family member, off-duty federal
civilian employee, etc.) that did NOT result from a DoD operation, activity or evolution.
Property Damage
Any damage to DoD property and/or Non-DoD property as the result of a military
operation, activity or evolution suspected of costing $2,000,000.00 or greater.
(I.e. GMV/GVO crash, explosives, maritime or amphibious operations, fire, etc.)
DON Reportable
OSHA
Reportable
YES
Call
NAVSAFECOM
w/in 8 hrs.
n/a
(Requires SIB)
YES
n/a
n/a
n/a
DON Reportable
OSHA
Reportable
YES
Call
NAVSAFECOM
w/in 8 hrs.
n/a
(Requires SIB)
Any damage to DoD property and/or Non-DoD property as the result of a military
operation, activity or evolution suspected of costing $20,000 up to $1,999,999.00.
YES
n/a
All GMV & GVO mishaps (i.e. collision, rollover, etc.) causing $5,000 or more in
damage. (Includes cost to DOD and/or non-DoD property when the operator of the
GMV/GVO is a cause.)
YES
n/a
Ship grounding, collision, or flooding and fires afloat (except small trash can fires)
YES
n/a
YES
(Requires SIB)
n/a
YES
n/a
All ordnance impacting off range (outside the SDZ), with or without damage, during a
training event.
All Helicopter Rope Suspension Technique (HRST), air-cargo drop and/or
parachuting mishap. (Regardless of damage).
Table 2-3
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
Mishap and Hazard Reporting Requirements
The following mishaps are required to be investigated and reported by safety to the DON and/or
OSHA (Refs: 29 CFR 1904, DoDI 6055.07, and OPNAV M-5102.1_/MCO P5102.1_)
Contractors / Contracted Employees
DON Reportable
On-duty contractor fatality or permanent total disability (PTD) where the contractor is
under direct supervision of Department of the Navy (DON) personnel (military or
federal civilian employee).
YES
(Requires SIB)
On-duty, occupational related mishap resulting in in-patient hospitalization of one or
more contracted personnel under direct supervision of Department of the Navy (DON)
personnel.
YES
On-duty, occupational related mishap resulting in an amputation of a body part while
under direct supervision of Department of the Navy (DON) personnel. (With or without
bone loss. With or without re-attachment. (E.g. Earlobe, fingertip, nose, arm, etc.)
YES
On-duty, occupational related mishap resulting in a loss of an eye while under direct
supervision of Department of the Navy (DON) personnel.
YES
Other on-duty contractor work-related injuries where the contractor is under direct
supervision of Department of the Navy (DON) personnel.
OSHA
Reportable
YES
(W/in 8 hrs.)
Call
NAVSAFECOM
YES
(W/in 24 hrs.)
Call
NAVSAFECOM
YES
(W/in 24 hrs.)
Call
NAVSAFECOM
YES
(W/in 24 hrs.)
Call
NAVSAFECOM
YES
Call
NAVSAFECOM
Fatality or PTD to any on-duty DoD civilian personnel caused by contractor operations,
or activities.
YES
(Requires SIB)
YES
Call
NAVSAFECOM
Fatality or PTD to on or off-duty military personnel (on-base) caused by contractor
operations, or activities.
YES
(Requires SIB)
Call
NAVSAFECOM
YES
n/a
YES
Call
NAVSAFECOM
Damage to DoD property caused by contractor operations, or activities.
Any injury or death of a contractor caused by or as the result of a DoD operation,
activity or evolution.
On-duty contractor fatality or permanent total disability (PTD) resulting solely from
contractor operations where DoN commanders have no direct means to correct,
control, eliminate or prevent hazards or the recurrence of similar incidents. (Note,
although this is not a reportable event for the DON, your Installation Commander / Unit
Commander needs to be briefed about the event.)
Off-Duty contractor injury or death not related to military operations, activities, or
evolutions.
NO
(Call CO)
NO
Only for the
contractor
(Call CO and
NAVSAFECOM)
n/a
Table 2-4
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 2:
Mishap and Hazard Reporting Requirements
2-3. HAZARD RERPORTS (HAZREPS). The following hazards are required to be reported as a
“HAZREP” to the Naval Safety Commad and CMC (Safety Division) IAW OPNAV M-5102.1/MCO
P5102.1_.
HAZARD: A hazard is an unsafe act or condition, such as a flaw in established work procedures; training
deficiency, or the design, manufacture, or use of a piece of equipment with the potential to cause injury or
damage. (see Chapter 4) A hazard report (HAZREP) is intended to be submitted when the elimination and control
of a given hazard has community-wide implication in reducing mishaps. Providing information on problems with
widespread relevance will help reduce mishaps. Commanders, commanding officers, and officers-in-charge should
ensure investigation and submission of a HAZREP on hazardous conditions or near-mishaps that may affect other
commands but do not warrant submission of a SIREP. (See Tables 2-6 through 2-13)
NOTE: The HAZREP does not replace a SIREP for reportable mishaps.
 A hazard or near-mishap and the recommended remedial or corrective action taken to eliminate the hazard.
 A previously unrecognized hazard so that another agency may determine appropriate corrective action to
eliminate the hazard.
 A significant, unexpected, or unusual occupational overexposure, as the result of industrial hygiene
assessments of industrial processes or operations, to bring that potential exposure to the attention of medical
and safety authorities and others.
 Electrical shock incidents where the mishap did not result in any medical treatment or injury/fatality and where it
was determined that the shock was caused by equipment design.
 Afloat man overboard mishaps while underway where the mishap did not result in a recordable/reportable
injury/fatality.
 Any other unusual hazard discovered during maintenance, repair, inspections, or evolutions where notifying
other activities may prevent future mishaps.
 If a Safety Investigation Board (SIB) discovers a hazard unrelated to the mishap that warrants immediate
widespread dissemination, the unit will prepare and submit the HAZREP.
 If a Safety Investigation Board (SIB) discovers a hazard that warrants immediate widespread dissemination, the
senior member will prepare and submit a HAZREP.
USMC units shall notify CMC(SD) and MARCORSYSCOM for all tactical equipment, and weapons
systems related hazards. (See Tables 2-6 through 2-13)
MCO 5100.34A, 19 Jun 2017- All Commanders, Commanding Officers, and Officers-In-Charge shall:
- Report all potential hazards associated with the operation of Marine Corps ground equipment and weapons
systems. Individuals may report potential hazards to MARCORSYSCOM Safety at MCSC_Safety@usmc.mil
and/or to Commandant of the Marine Corps Safety Division (CMC SD) at hqmc_safety_divison@usmc.mil.
MARCORSYSCOM and affiliated PEOs shall issue DSOUM, SOUM, and/or MAM to: suspend operations,
provide instructions for limited use, or communicate safety related information.
- Take necessary actions in accordance with DSOUM, SOUM, and/or MAM. During combat operations, General
Officer level commanders and forward deployed Marine Expeditionary Unit (MEU) commanders may continue
operation of suspended equipment after a documented Risk Management assessment, per reference (d),
determines that continued use is a necessary and accepted risk.
- Adhere to the directions and action(s) contained in DSOUM, SOUM, and/or MAM.
- Identify and report situations that negatively affect safety of operation via the Automated Message Handling
System to: COMMARCORSYSCOM OOT QUANTICO VA; PEO LS QUANTICO VA SAFETY; CMC SD
WASHINGTON DC; CMC WASHINGTON DC PPO; CMC WASHINGTON DC I&L; and COMNAVSAFECOM
NORFOLK VA.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
18
Unit 2:
Mishap and Hazard Reporting Requirements
2-4. DoD & DON MISHAP CLASSIFICATIONS (Table 2-5)
Class
Property
Damage
Severity of Injury or Illness
Fatality (immediately or months after the mishap)
or
Injury or occupational related illness causing Permanent Total Disability (PTD)
A
$2,500,000+
and/or
aircraft
destroyed
PTD: Any nonfatal injury or occupational illness that in the opinion of competent medical authority
permanently or totally incapacitates a person to the extent that he or she cannot follow any gainful
occupation and results in a medical discharge or civilian equivalent. Also, the loss of the following
body parts or the use thereof during a single mishap is a permanent total disability:
 Both hands
 Both feet
 Both eyes
 A combination of any two of these body parts.
Hospitalization of 3 or more personnel in same mishap
or
An injury or occupational related illness resulting in a Permanent Partial Disability (PPD)
B
$600,000
to
$2,499,999
PPD: An injury or occupational illness that results in permanent impairment or loss of any part of the
body such as, but limited to:
 loss of the great toe or thumb,
 non-repairable inguinal hernia,
 traumatic acute hearing loss of 10 dB or greater documented by medical authority.
Exceptions include the following:
 loss of teeth.
 loss of tips of fingers/toes without bone loss.
 repairable hernia.
 disfigurement.
 sprains or strains that do not cause permanent limitation of motion.
C
$60,000
to
$599,999
Military: An on-or off-duty injury causing a minimum of one (1) lost workday beyond the day of
the injury (weekends included).
DoD civilians & military: An occupational related illness or injury causing one or more days away
from work beyond the day or shift on which the injury occurred or the illness was diagnosed.
Lost workdays *** include;
 SIQ for 24 hours or more
 Hospitalization as an inpatient, beyond the day of mishap.
 Mishap related convalescent leave.
Military: An injury or illness resulting in light duty or limited duty
DoD Civilians: An injury or illness resulting in restricted work, transfer to another job
D
$25,000
to
$59,999
Class E/Other
reportable
Also includes:
 medical treatment greater than first aid,
 needle stick injuries and cuts from sharps that are contaminated from another person’s blood or
other potentially infectious material,
 medical removal under medical surveillance requirements of an OSHA standard,
 occupational hearing loss resulting in a Significant Threshold Shift (STS),
 A work–related tuberculosis case.
- Less than $25,000 in property damage (Includes collateral damage costs to other property)
- Any On- duty mishap resulting in a loss of consciousness.
- Any Near Miss related to a hazard with equipment hazard or a process requires a HAZREP
Military Injuries: Include injuries as a result of either on- or off-duty mishaps.
DoD Civilian Injuries: Includes on-duty mishaps. If off-duty, the injury must be the result of a military operation or
activity.
Illness: Whether one is DoD civilian or military, the illness must be occupational related in order to meet the mishap
classification criteria. (E.g. illness due to an exposure to a workplace health hazard.)
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
19
Unit 2:
Mishap and Hazard Reporting Requirements
Figure 2-2
Classify the following
While conducting maintenance, the halon fire suppression system inadvertently activates into a space
onboard USS Gator Freighter. The inspection revealed a potential material design flaw. No one was
injured. No damage occurred.
MISHAP CLASS? ______
WHY? _______________________________________________________
A service member driving a tactical government vehicle (GVO) loses control and crashes into a civilian
vehicle resulting in one civilian fatality. No military injuries.
MISHAP CLASS? ______
WHY? _______________________________________________________
Two off-duty DoD civilian employees and five civilian guests are hospitalized after a large canopy collapsed
during a military retirement ceremony held at an on-base facility.
MISHAP CLASS? ______
WHY? _______________________________________________________
Fire destroys a large backup generator for a military facility as well as other property on board a military
installation, the estimated cost of damage (ECOD) is around $600,000. No one was injured.
MISHAP CLASS? ______
WHY? _______________________________________________________
AAV BN was conducting amphibious training when the AAV sunk in 30 feet of salt water. The combined
cost of recovery, environmental clean-up, transportation and repair was over $516,000. There were no
injuries.
MISHAP CLASS? ______
WHY? ______________________________________________________
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
20
Unit 2:
Mishap and Hazard Reporting Requirements
2-5. MISHAPS THAT REQUIRE A FORMAL SAFETY INVESTIGATION BOARD (SIB). The
following mishaps require a formal SIB in accordance with OPNAV M-5102.1/MCO P5102.1
 All _________ duty Class A mishaps. (On or Off installation).
 All _________ duty Class A Mishaps that occur ________ base, involving military personnel.
 Military death that occurs during or within 1 hour after completion of organized, command sponsored
physical training (PT) activities regardless of pre-existing medical condition. (E.g. PFT, CFT, MCMAP,
Conditioning Hikes, Swim qualification, etc.)
 When DoD property damage is expected to exceed 2.5 million ($2,500,000.00) and/or aircraft destroyed.
 An on-duty injury where death or permanent total disability (PTD) is likely to occur.
 Hospitalization, beyond observation, of 3 or more personnel involved in a single mishap where
at least one is an on-duty DoD _______________________.
 All explosive mishaps. (Class A, B, C, or D in accordance with DoDI 6055.07)
 All live fire mishaps resulting in an injury. (Includes 1st Aid. The injury must result from firing of weapons)
 All ordnance impacting off range. (outside the surface danger zone)
 Any mishap that a Controlling Command or higher determines the need for a more thorough investigation
and report, beyond that provided by the command’s safety investigator.
What type of safety investigation is required? (Unit or SIB or None & why)
A GVO (tactical motor vehicle) rollover on an interstate that resulted in 2 active duty fatalities.
Unit or SIB or None WHY?
A live fire mishap on a small arms rifle range were a ricochet injury resulted in 1st aid treatment with a Band-Aid.
Unit or SIB or None WHY?
A negligent discharge occurs during a pistol qualification range were the round impacted the ground just inches in front of
another service member.
Unit or SIB or None WHY?
A guest and two military family members are hospitalized with injuries after a stage collapsed at the annual Birthday Ball.
Unit or SIB or None WHY?
While on a holiday weekend liberty, a Sailor, her civilian spouse and brother die in a PMV crash on a mountain road (offbase).
Unit or SIB or None WHY?
While riding to work, a Marine wrecks his motorcycle on base resulting in two amputated fingers and a femur fracture.
Unit or SIB or None WHY?
While hunting deer on base, an off-duty federal civilian employee dies from a broken neck after falling from his tree stand.
Unit or SIB or None WHY?
A military family member is injured by the detonation of unexploded ordnance (UXO) while digging a fire pit at an on base
camp ground.
Unit or SIB or None WHY?
Seven Marines and a civilian bus driver (contractor) are transported to a local hospital following a bus crash. The civilian is in
critical condition and permanent total disability is expected. The Marines are all treated and released within six hours and all
placed on two days light duty. The bus was contracted to transport the Marines to a training site.
Unit or SIB or None WHY?
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
21
Unit 2:
Mishap and Hazard Reporting Requirements
2-6. TYPES OF SAFETY RELATED REPORTS (Table 2-6)
Report
Immediate
Notification
(To NSC &
CMC-SD)
Hazard
Report
(HAZREP)
Safety
Investigation
Report
(SIREP)
OSHA 300
log
Purpose
– Class-A (on-duty DoD Civilian)
– Class-A (on & off duty Military)
– Class-A (Explosive mishaps)
– Hospitalization of 3 or more
personnel in same mishap caused by
a DoD activity, operation, or event.
(Note: This is a Class B)
– All other non-combat military fatalities.
– All other civilian fatalities caused by
military activity.
To notify the appropriate systems
command of hazards or near-mishaps
that have the potential to affect other
commands or a community who has or
may have the same type of equipment
or process.
Required for all near misses and
specific hazards that do not warrant
submission of a Safety Investigation
Report (SIREP) in RMI.
Action Office
NonMishaps:
Unit Duty
Officer
Mishaps:
Unit Duty
Officer or
Safety
Report due
To CMC(SD) &
NAVSAFECOM
NLT 8 hrs. of unit
learning of mishap
Method
– Phone 757444-2929
(preferred)
29 CFR 1904
(civilian fatality)
OPNAV M-
– PCR and/or
5102.1_/MCO
OPREP-3
P5102.1_,
SIR message
– RMI
USN: Immediately to
Safety
Reference
NAVSAFECEN and
SYSCOM
RMI
OPNAV M5102.1_/MCO
P5102.1_
USMC: Immediately to
Safety
Marine Corps Systems
Command (MCSC)
and CMC (Safety
Division) for hazards
related to tactical
equipment and
weapons systems
Email to MCSC
and CMC (SD)
followed by
RMI entry.
OPNAV M5102.1_/MCO
P5102.1_
MCO 5100.34A
OPNAV M5102.1_/MCO
P5102.1_
Report all causal factors and corrective
actions for all DON reportable mishaps
per OPNAV M- 5102.1/MCO P5102.1
Safety
w/in 30 days of the
mishap
RMI
Capture all OSHA “recordable” and
“reportable” mishaps for on-duty DoD
Civilian personnel.
Safety
w/in 30 days of
mishap and IAW
OSHA 1904
RMI
Safety
Annually. Posted NLT Generated from 5102.1_/MCO
P5102.1_
01 Feb.
RMI
29 CFR 1904
OPNAV M-
OSHA 300A
log
Summary of all DoD civilian
occupational related mishaps
(Military reports are optional.)
7-Day Brief
(USN)
USN: All on/off-duty fatalities
(Especially MV mishaps)
NLT seven days to 1st In person or
Unit
Commander Flag Officer
VTC
8-Day Brief
(USMC)
USMC: Commander’s report to inform
CoC of “what is known”. (Not a
substitute the SIREP or other reports).
Safety (mishaps)
– All class A & B mishaps.
Non-Safety (non-mishaps)
– Non-hostile/combat & non-morbidity
fatalities resulting from mishaps,
suicides, & homicides.
– Suicide attempts verified by a MO
- NLT seven days to
PPT via Email
1st G.O.
See
- NLT eight days to MARADMIN
Unit
the local LtGen
672/16 for
Commander
specific e-mail
- Monthly (from local addresses.
LtGen to ACMC)
Informs local General Officer of detailed
Unit
Death
facts and lessons learned about a non- Commander
Brief
combat fatality resulting from both
and all
(USMC Only)
mishaps and non-mishaps.
sections
Command
Dependent
OPNAV M5102.1_/MCO
P5102.1_
MCO 5100.29_
NAVMC Dir
5100.8
MARADMIN
490/18
PPT, in person MCO 5100.29_
Table 2-6
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
22
Unit 2:
Mishap and Hazard Reporting Requirements
2-7. DON MISHAP REPORTING MATRIX. Use the matrix below to determine various mishap
reporting requirements for each mishap classification. These following report requirements are standard
across the DON. Other reporting requirements are in addition to these reports and specific to a regional
command, local command or supporting establishment. (See Tables 2-7 through 2-13)
REFERENCES:
A. MCO 5100.29B, Marine Corps Safety Program, 19 OCT 2020
B. OPNAV M-5102.1/MCO P5102.1C, Navy & Marine Corps Mishap and Safety Investigation, Reporting and
Record Keeping, 2022
C. MCO 5100.34A, Deadline Safety of Use Message Instructions to Suspend Operations of Marine Corps
Ground Equipment and Weapons Systems, Safety of Use Message and Maintenance Advisory Messages,
19 June 2017
D. MARADMIN 490/18, Change to 8-Day briefs routing and distribution.
NOTES:
1. A Safety Investigation Board (SIB) is required if the mishap results in a hospitalization, beyond
observation, of 3 or more personnel, (at least 1 of who is a DoD civilian), involved in a single mishap. Also
for all on-duty Class-A mishaps involving either military personnel, or on-duty DoD civilian employees, or
fatality of guests caused by DoD/DON/USMC activity or operations. (see chapters 3 and 6 reference B)
2. A Safety Investigation Board (SIB) is required if the mishap is an explosives related mishap, or ordnance
impacting off range, or live fire mishap resulting in an injury. (see chapter 6 of reference B)
3. A HAZREP must be submitted when the elimination and control of a given hazard has community-wide
implication in reducing mishaps. Note: Providing information on problems with widespread relevance will
help reduce the likelihood of mission degrading mishaps.(see chapter 4 of reference B)
4. If the hazard, injury, illness, or property damage resulted from military activity or operation, then see note
5 for immediate notification requirements. Then see notes 1, or 2 to determine SIB requirements. Then
see reference A to determine USMC 8-day & death brief requirements.
5. Regardless of cause (mishap, suicide, or homicide, notify COMNAVSAFECOM and CMC(SD) within 8
hours by telephone (Comm: (757) 444-2929. DSN: 564) if the mishap or non-combat incident meets one
of the following criteria:




Hospitalization of three or more personnel caused by DoD activity, operation, or event or,
On-duty DoD civilian fatality or PTD or,
On- or off-duty fatality or PTD of military personnel or,
Explosive mishap causing fatality, PTD, or potential for greater than $2 million in damage. (see
chapter 3 of reference B)
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
23
Unit 2:
Mishap and Hazard Reporting Requirements
DoD Mishap Class - A
Minimum of or expected to reach $2.5 million in property damage, and/or aircraft destroyed, or Fatality,
or Injury or Occupational related illness causing Permanent Total Disability (PTD) or expected
Category
Immediate
Notification
USN
7-Day
Brief
USMC
8-Day
Brief
USMC
Death
Brief to 1st
GO
HAZREP in
RMI &/or
MCSC
(Immediate)
YES
note 5
YES
note 5
YES
note 5
YES
note 5
YES
ref B
YES
ref B
YES
ref B
YES
ref B
YES
refs A & D
YES
refs A & D
YES
refs A & D
YES
refs A & D
YES
ref A
YES
ref A
YES
ref A
YES
ref A
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
YES
refs A & D
YES
refs A & D
If meets
criteria of
notes 4
YES
ref A
YES
ref A
If meets
criteria of
notes 4
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
n/a
If meets
criteria of
notes 4
n/a
n/a
n/a
n/a
n/a
YES
refs A & D
YES
refs A & D
YES
ref A
YES
ref A
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
n/a
YES
Unit Safety
Investigation
& Report
(30 days)
SIB &
Report
(30 days)
n/a
YES
n/a
YES
n/a
YES
YES
n/a
n/a
YES
Active Duty
On - duty / On - base
On - duty / Off - base
Off - duty / On - base
Off - duty / Off - base
n/a
Federal Civilian Employees
On - duty / On - base
On - duty / Off - base
Off - duty / On - base
Off - duty / Off - base
YES
note 5
YES
note 5
If meets
criteria of
note 4
n/a
n/a
n/a
n/a
n/a
Contractors
On-base - under Direct supervision of
DoD personnel
Off-base - under Direct supervision of
DoD personnel
Under supervision of Contractor
personnel
Caused by military activity or hazard
YES
note 5
YES
note 5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
YES
note 5
n/a
YES
refs A & D
YES
ref A
Note 3 &
Ref C
n/a
YES
YES
refs A & D
YES
refs A & D
YES
ref A
YES
ref A
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
n/a
YES
Family members, guests, other
civilians
On-base - caused by Military activity or
hazard
Off-base - caused by Military activity or
hazard
On-base - not caused by military activity
or hazards
Off-base - not caused by military activity
or hazards
YES
note 5
YES
note 5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
YES
n/a
YES
n/a
YES
n/a
YES
n/a
n/a
Property Damage (Minimum of or
expected to reach cost of $2 million)
DoD property caused by military activity
DoD property caused by civilian or
contractor activity
Non-DoD property caused by military
activity
Combined cost of DoD & Non-DoD
property caused by military activity
Non-DoD property caused by non-DoD
civilian or contractor
YES
note 5
YES
note 5
YES
note 5
YES
note 5
n/a
n/a
n/a
n/a
n/a
YES
refs A & D
YES
refs A & D
YES
refs A & D
YES
refs A & D
n/a
n/a
n/a
Note 3 & Ref
C
Note 3 & Ref
C
Note 3 & Ref
C
Note 3 & Ref
C
n/a
n/a
n/a
n/a
n/a
Table 2-7
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
24
Unit 2:
Mishap and Hazard Reporting Requirements
DoD Mishap Class - B
$600,000 to $2,499,999 in property damage, or Hospitalization of 3 or more personnel in the same
mishap, or Injury or Occupational related illness causing Permanent Partial Disability (PPD)
(This includes an on-duty, occupationally related, acute, traumatic hearing loss)
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
HAZREP in
RMI &/or
MCSC
(Immediate)
Unit Safety
Investigation
& Report
(30 days)
Immediate
Notification
USN
7-Day
Brief
On - duty / On - base
See note 5
n/a
On - duty / Off - base
See note 5
n/a
Off - duty / On - base
See note 5
n/a
Off - duty / Off - base
See note 5
n/a
On - duty / On - base
See note 5
n/a
On - duty / Off - base
See note 5
n/a
Off - duty / On - base
If meets
criteria of
notes 4
n/a
Off - duty / Off - base
n/a
n/a
See note 5
n/a
See note 5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
See note 5
n/a
YES
refs A & D
n/a
Note 3 &
Ref C
YES
If meets criteria
of note 4
See note 5
n/a
See note 5
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Category
SIB & Report
(30 days)
Active Duty
YES
refs A & D
YES
refs A & D
YES
refs A & D
YES
refs A & D
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
YES
YES
YES
If meets criteria
of notes 1 or 2
If meets criteria
of notes 1 or 2
If meets criteria
of notes 1 or 2
n/a
Federal Civilian Employees
YES
refs A & D
YES
refs A & D
If meets
criteria of
notes 4
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
YES
YES
n/a
Note 3 &
Ref C
If meets
criteria of
notes 4
n/a
n/a
n/a
If meets criteria
of notes 1 or 2
If meets criteria
of notes 1 or 2
If meets criteria
of note 4
n/a
Contractors
On-base - under Direct supervision of
DoD personnel
Off-base - under Direct supervision of
DoD personnel
Under supervision of Contractor
personnel
Caused by military activity or hazard
YES
refs A & D
YES
refs A & D
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
YES
YES
If meets criteria
of notes 1 or 2
If meets criteria
of notes 1 or 2
Family members, guests, other
civilian
On-base - caused by Military activity or
hazard
Off-base - caused by Military activity or
hazard
On-base - not caused by military
activity or hazards
Off-base - not caused by military
activity or hazards
YES
refs A & D
YES
refs A & D
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
YES
YES
If meets criteria
of note 4
If meets criteria
of note 4
Property Damage (Minimum of or
expected to reach cost of $500,000
DoD property caused by military activity
DoD property caused by civilian or
contractor activity
Non-DoD property caused by military
activity
Combined cost of DoD & Non-DoD
property caused by military activity
Non-DoD property caused by non-DoD
civilian or contractor
YES
refs A & D
YES
refs A & D
YES
refs A & D
YES
refs A & D
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
YES
YES
YES
n/a
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
n/a
Table 2-8
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
25
Unit 2:
Mishap and Hazard Reporting Requirements
DoD Mishap Class - C
$60,000 to $599,999 in property damage, or occupational related illness or injury causing a minimum of (1) lost
workday beyond day of injury, including weekends, or an individual off-duty military injury causing a minimum of (1)
lost workday beyond day of injury, including weekends. (Lost workdays include; SIQ for 24 hours or more,
Hospitalization beyond the day of mishap, Mishap related con-leave)
Immediate
Notification
USN
7-Day
Brief
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
On - duty / On - base
n/a
n/a
n/a
n/a
On - duty / Off - base
n/a
n/a
n/a
n/a
Off - duty / On - base
n/a
n/a
n/a
n/a
Off - duty / Off - base
n/a
n/a
n/a
n/a
On - duty / On - base
n/a
n/a
n/a
n/a
On - duty / Off - base
n/a
n/a
n/a
n/a
Off - duty / On - base
n/a
n/a
n/a
n/a
Off - duty / Off - base
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Category
HAZREP in
RMI &/or
MCSC
(Immediate)
Unit Safety
Investigation
& Report
(30 days)
SIB & Report
(30 days)
Active Duty
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
YES
YES
If meets criteria
of note 2
If meets criteria
of note 2
If meets criteria
of note 2
YES
n/a
Federal Civilian Employees
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
YES
YES
Note 5
If meets criteria
of note 2
If meets criteria
of note 2
If meets criteria
of note 4
n/a
n/a
Contractors
On-base - under Direct supervision of DoD
personnel
Off-base - under Direct supervision of DoD
personnel
Under supervision of Contractor personnel
Caused by military activity or hazard
Note 3 &
Ref C
Note 3 &
Ref C
YES
YES
If meets criteria
of note 2
If meets criteria
of note 2
n/a
n/a
YES
If meets criteria
of note 4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
DoD property caused by military activity
n/a
n/a
n/a
n/a
DoD property caused by civilian or
contractor activity
n/a
n/a
n/a
n/a
Non-DoD property caused by military activity
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
n/a
n/a
n/a
n/a
n/a
Family members, guests, other
civilian
On-base - caused by Military activity or
hazard
Off-base - caused by Military activity or
hazard
On-base - not caused by military activity or
hazards
Off-base - not caused by military activity or
hazards
YES
YES
If meets criteria
of note 4
If meets criteria
of note 4
Property Damage (Minimum of or expected
to reach cost of $50,000)
Combined cost of DoD & Non-DoD property
caused by military activity
Non-DoD property caused by non-DoD
civilian or contractor
YES
YES
YES
YES
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
n/a
n/a
Table 2-9
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
26
Unit 2:
Mishap and Hazard Reporting Requirements
DoD Mishap Class - D
$25,000 to $59,999 in property damage, or injury or occupational illness resulting in medical treatment beyond 1st Aid. This
includes: LIGHT DUTY, LIMITED DUTY, restricted days away from work for federal civilians, any medical removal under
medical surveillance requirements of an OSHA standard, needle stick injuries or cuts from sharps that are contaminated from
another person’s blood or other potentially infectious material, a prolonged occupational related hearing loss, or occupationally
related tuberculosis exposure.
Immediate
Notification
USN
7-Day
Brief
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
On - duty / On - base
n/a
n/a
n/a
n/a
On - duty / Off - base
n/a
n/a
n/a
n/a
Off - duty / On - base
n/a
n/a
n/a
Off - duty / Off - base
n/a
n/a
On - duty / On - base
n/a
On - duty / Off - base
HAZREP in
RMI &/or
MCSC
(Immediate)
Unit Safety
Investigation
& Report
(30 days)
YES
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
YES
If meets criteria
of note 2
If meets criteria
of note 2
If meets criteria
of note 2
n/a
n/a
n/a
YES
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Off - duty / On - base
n/a
n/a
n/a
Off - duty / Off - base
n/a
n/a
n/a
Category
SIB & Report
(30 days)
Active Duty
YES
Federal Civilian Employees
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
Note 5
If meets criteria
of note 2
If meets criteria
of note 2
If meets criteria
of note 4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
YES
YES
Contractors
On-base - under Direct supervision of DoD
personnel
Off-base - under Direct supervision of DoD
personnel
Under supervision of Contractor personnel
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
DoD property caused by military activity
Caused by military activity or hazard
Note 3 &
Ref C
Note 3 &
Ref C
YES
YES
If meets criteria
of note 2
If meets criteria
of note 2
n/a
n/a
YES
If meets criteria
of note 4
Family members, guests, other
civilian
On-base - caused by Military activity or
hazard
Off-base - caused by Military activity or
hazard
On-base - not caused by military activity or
hazards
Off-base - not caused by military activity or
hazards
YES
n/a
Note 3 &
Ref C
Note 3 &
Ref C
YES
If meets criteria
of note 4
If meets criteria
of note 4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
YES
DoD property caused by civilian or
contractor activity
n/a
n/a
n/a
n/a
Non-DoD property caused by military activity
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
Note 3 &
Ref C
YES
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
If meets criteria
of note 4
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Property Damage (Minimum of or expected
to reach cost of $20,000)
Combined cost of DoD & Non-DoD property
caused by military activity
Non-DoD property caused by non-DoD
civilian or contractor
YES
YES
Table 2-10
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
27
Unit 2:
Mishap and Hazard Reporting Requirements
DoD, DON & USMC specific “Other” Safety Reportable Events
(Active Duty, On-Duty Federal Civilian Employee, or on-duty contractor under direct supervision of DON personnel)
Category
Immediate
Notification
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
HAZREP in
RMI
(Immediate)
HAZREP
to Marine
Corps
Systems
Command
A loss of consciousness related to work or
training with no light duty or lost time. (e.g.
water survival training, confined space, PT,
inhaling fumes, etc.)
n/a
n/a
n/a
If meets
criteria of
note 3
See
Ref C
All Property Damage less than $25,000
n/a
n/a
n/a
YES
See
Ref C
See ref B
All on-duty diving cases involving the
Central Nervous System (CNS), oxygen
toxicity, Pulmonary Over Inflation Syndrome
(POIS), or hyperbaric treatment.
Any high or moderate risk training mishaps
that result in the loss of one training day,
rolling back or disenrollment of the student
from a course. (regardless if it meets
severity)
Any on-duty military heat stress or cold
injury requiring medical treatment above
first aid.
Individual Injury or occupational related
illness with NO lost work time.
Any parachuting, HRST, or cargo airdrop
mishap (regardless of severity of injury or
damage)
See ref B
YES
If meets If meets
criteria criteria
of ref A of ref A
If meets
criteria of
note 3
See
Ref C
See ref B
If meets
criteria of
Note 5
If meets If meets
criteria criteria
of ref A of ref A
If meets
criteria of
note 3
See
Ref C
See ref B
If meets
criteria of
Note 5
If meets If meets
criteria criteria
of ref A of ref A
If meets
criteria of
note 3
If meets
criteria of
note 3
See
Ref C
See ref B
See
Ref C
If class D
(see ref B)
If meets
criteria of
note 3
See
Ref C
See ref B
YES
YES
See ref B
See ref C
n/a
If meets
criteria of
Note 5
n/a
n/a
If meets If meets
criteria criteria
of ref A of ref A
n/a
n/a
n/a
Any cracks or unusual wear, tear, or
damage to ordnance received from the
ASP.
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Any failure of a bilge pump on any
amphibious vehicle (e.g. AAV, LAV, etc.)
that does not result in damage or injury.
YES
If meets
criteria of
Note 5
Any malfunction of any Navy-Marine Corps
weapons system or ordinance that does not
cause injury or damage.
Any Parachute related malfunction that does
not cause injury or damage.
Unit Safety
Investigation
& Report
(30 days)
Any inadvertent actuation of tactical vehicle
functions (seats, turrets, braking,
accelerator, hatches) where the location of
a leaver or switch is easily bumped by the
operator or personnel.
n/a
n/a
n/a
Any braking system or electrical failure on
any GMV/GVO not resulting in a reportable
injury or property damage.
n/a
n/a
n/a
YES
YES
See ref B
See ref C
YES
YES
See ref B
See ref C
YES
YES
See ref B
See ref C
YES
YES
See ref B
See ref C
YES
YES
See ref B
See ref C
YES
YES
YES
YES
Highly
encouraged
yet not
required
Highly
encouraged
yet not
required
Highly
encouraged
yet not
required
Highly
encouraged
yet not
required
SIB & Report
(30 days)
If meets
criteria of
notes 1 or 2
If meets
criteria of
notes 1 or 2
If meets
criteria of
note 1
If meets
criteria of
notes 1 or 2
If meets
criteria of
notes 1 or 2
If meets
criteria of
note 2
If meets
criteria of
notes 1 or 2
n/a
n/a
n/a
n/a
Highly
encouraged
yet not
required
n/a
Highly
encouraged
yet not
required
n/a
Table 2-11
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
28
Unit 2:
Mishap and Hazard Reporting Requirements
DoD, DON & USMC specific “Other” Safety Reportable Events
(Active Duty, On-Duty Federal Civilian Employee, or on-duty contractor under direct supervision of DON personnel)
Immediate
Notification
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
Any inadvertent release of HALON in
any tactical owned vehicle system
without injury or damage.
n/a
n/a
n/a
Any inadvertent release of HALON in any
government owned workspace without
injury or damage.
n/a
n/a
n/a
Category
Any inadvertent explosion, fire, or chemical
release of any government owned battery
that did not cause injury, Illness, or
property damage (e.g. batteries).
Any unintentional explosion or explosive
release of energy from a pressurized
system on Marine Corps equipment,
vehicle systems, shipboard systems or in
facilities, without reportable injury or
damage.
n/a
n/a
n/a
n/a
n/a
n/a
HAZREP
in RMI
HAZREP
to Marine
Corps
Systems
Command
YES
YES
See ref B
See ref C
YES
See ref B
Unit Safety
Investigation
& Report
(30 days)
SIB &
Report
(30 days)
Highly
encouraged
yet not
required
n/a
Highly
encouraged
yet not
required
n/a
Highly
encouraged
yet not
required
n/a
Highly
encouraged
yet not
required
n/a
n/a
YES
YES
See ref B
See ref C
YES
YES
See ref B
See ref C
Table 2-11 (continued)
Events or fatalities that are not mishaps per the DoD or DON and not reportable by Safety.
However, these non-safety events / incidents require the Commander to use some of the same
reports as used for safety to report mishaps.
Category
Homicide
(committed against a service member or
on-duty federal civilian)
Immediate
Notification
YES
See note 5
Suicide
YES
(Military only)
See note 5
USMC
8-Day
Brief
n/a
YES
refs A & D
YES
n/a
YES
refs A & D
YES
Suicide Attempt
Verified by competent medical authority.
n/a
n/a
(USMC military only)
Verified unintentional death due to use of
an illegal drug
(Military or on-duty federal employee)
Injury or fatality in the act of escaping or
evading law enforcement.
(Military or on-duty federal employee)
YES
See note 5
YES
See note 5
USMC
Death
Brief to
1st GO
USN
7-Day
Brief
YES
ref D
ref A
ref A
n/a
n/a
YES
refs A & D
YES
n/a
YES
refs A & D
YES
ref A
ref A
HAZREP in
RMI &/or
MCSC
(Immediate)
Unit Safety
Investigation
& Report
(30 days)
SIB &
Report
(30
days)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Table 2-12
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
29
Unit 2:
Mishap and Hazard Reporting Requirements
Recommended Safety Reportable Events as a HAZREP
HAZREPS: In addition to current requirements for HAZREPS, the following specific events are considered a “nearmiss” and are highly recommended to be reported via RMI for the purpose of capturing hazardous conditions or
processes that require review or intervention by major supporting commands (e.g. Systems Command, Training
Command, Facilities Command, etc.)
Immediate
Notification
USMC
8-Day
Brief
USMC
Death
Brief to
1st GO
HAZREP in
RMI
(Immediate)
HAZREP to
Marine
Corps
Systems
Command
(Immediate)
Unit Safety
Investigation
& SIREP
(30 days)
SIB
(30
days)
More than one on-duty, occupationally related heat
stress injuries, in the same event, without medical
treatment (e.g. heat exhaustion or heat cramps or
heat syncope) & NOT resulting in light duty, SIQ,
or hospitalization.
n/a
n/a
n/a
YES
See note 3
n/a
Highly
encouraged
yet not
required
Note 3
Any failure of DoD/DON owned recreational
equipment or machinery that causes injury or
illness to any human (regardless of severity of
injury) that occurs on an installation, whether it is
stationary for public use or temporarily issued or
rented.
n/a
n/a
n/a
YES
See note 3
n/a
Only if
Only if meets
meets
criteria of
criteria of
Ref B
Ref B
Any slip, trip, or fall of any individual (military,
Federal employee, or visitor) that occurs in any
government owned facility as a result of a
controllable hazard, yet does not result in medical
treatment.
n/a
n/a
n/a
If meets
criteria of
note 3
n/a
Only if meets
criteria of
Ref B
n/a
If meets
criteria of
Ref C
Highly
encouraged
yet not
required
n/a
Category
Any unintentional occupationally related chemical
exposure without hospitalization.
n/a
n/a
n/a
If meets
criteria of
note 3
Any GMV or GVO mishap (crash, rollover, etc.)
without injury & less than $5,000 in damage. This
includes where the driver/operator stated his/her
vision was restricted during operation.
n/a
n/a
n/a
YES
See note 3
If meets
criteria of
Ref C
Highly
encouraged
yet not
required
n/a
Any electrical shock to any on- or off duty DoD
personnel, family member, or guest that occurs at
a Navy or Marine Corps owned facility yet did not
result in the medical treatment.
n/a
n/a
n/a
YES
See note 3
If meets
criteria of
Ref C
Highly
encouraged
yet not
required
n/a
Any electrical shock to any on- or off duty DoD
personnel, family member, or guest resulting from
Navy or Marine Corps owned equipment, yet did
not result in the medical treatment
n/a
n/a
n/a
YES
See note 3
If meets
criteria of
Ref C
Highly
encouraged
yet not
required
n/a
Any unexpected malfunction of any DoD/DON
owned equipment or components used in the
movement or transportation of materials or
personnel that does not cause injury or damage.
n/a
n/a
n/a
YES
See note 3
If meets
criteria of
Ref C
Highly
encouraged
yet not
required
n/a
Table 2-13
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
30
Unit 2:
Mishap and Hazard Reporting Requirements
2-8. DON NON-REPORTABLE INCIDENTS (NON-MISHAPS) The following mishaps need not
be investigated, recorded, or reported per OPNAV M-5102.1/MCO P5102.1C, Chapter 3. However, for
DON civilians, if these mishaps are considered to have occurred in the performance of duty under
provisions of Federal Employee Compensation Act (FECA), they are considered reportable to the
Department of Labor (DOL)/OSHA.
a. Mishaps associated with naval nuclear propulsion plants.
b. Mishaps involving nuclear weapons.
c. Damage or injury by direct action of an enemy or hostile force. This does not include suspected cases
of friendly fire.(Fratricide)
d. Intentional, controlled jettison or release, during flight, of canopies, cargo, doors, drag chutes, hatches,
life rafts, auxiliary fuel tanks, missiles, target drones, rockets, conventional munitions, and externally carried
equipment not essential to flight, when there is no injury, no reportable damage to the aircraft or other
property, and, in the case of missiles, drones, or munitions, when the reason for jettison is not a malfunction
of the launch or release system.
e. Replacement of component parts due to normal wear and tear, and when any associated damage is
confined to the component part. This exemption only applies to items that are normally used until they fail or
until predetermined wear limits are reached. Replacement need may not be evident until malfunction or
failure of the part.
f. Injuries associated with non-occupational diseases, when the disease, not the injury, is the proximate
cause of the lost time, such as diabetes and its resultant complications, such as loss of vision. Complications
of the injury (such as the infection of a cut aggravated by a work-related activity) that result in lost time are
reportable.
G. Attempted or consummated suicide, homicide, or intentionally self-inflicted injuries; e.g., Russian
roulette, hanging, overdose (except alcohol), etc. However, notification of these types of death to
COMNAVSAFECEN is required.
h. Injuries resulting from altercations, attack, or assault, unless incurred in the performance of official
duties.
i. Injuries sustained before entry into military service or employment by the United States government,
unless specifically aggravated by current tenure of service
j. Hospitalization for treatment where the patient is retained beyond the day of admission solely for
administrative reasons.
k. Hospitalization for observation or administrative reasons not related to the immediate injury or
occupational illness.
l. Injuries that result from Pre-existing musculoskeletal disorders unless aggravated or accelerated by
federal employment, as determined by a medical authority.
m. Injuries that result from Minimum stress and strain (simple, natural, and nonviolent body positions or
actions, as in dressing, sleeping, coughing, or sneezing), those injuries unrelated to mishap producing
agents or environments normally associated with active participation in daily work or recreation.
n. Injuries or fatalities to persons in the act of escaping from or eluding military or civilian custody or
arrest.
o. Death due to natural causes that are unrelated to the work environment.
p. Intentional or expected damage to DoD equipment or property incurred during authorized testing or
combat training, including missile and ordnance firing.
q. Property damage, death, or injury as a result of vandalism, riots, civil disorders, sabotage, terrorist
activities, or criminal acts, such as arson. The exception is for occupationally related death or injury to
emergency responders in the performance of their duties.
r. Adverse bodily reactions resulting directly from the use of drugs under the direction of competent
medical authority.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
31
Unit 2:
Mishap and Hazard Reporting Requirements
s. Death or injury resulting solely from illegal use of drugs or other substances. This shall not preclude
reporting motor vehicle mishaps in which the use of alcohol was a contributing factor.
t. Normal residual damage as a result of a missile launch.
u. Contractor mishaps, for contractor’s not under direct DON supervision or caused solely by contractor
operations, as defined in Glossary G-1 “Contractor Mishap.”
v. First aid treatment for a work-related injury, as defined in Glossary G-1 “First Aid”.
2-9. OSHA NON-REPORTABLE or RECORDABLE EVENTS FOR CIVILIAN
WORKERS: Under the 29 CFR 1904, any injury or illness occurring in the work environment that falls
under one of the following exceptions is not work-related, and is not recordable. (See Table 2-14)
1904.5
Organizations are not required to record civilian injuries and illnesses if . . .
(i)
At the time of the injury or illness, the employee was present in the work environment as a member
of the general public rather than as an employee.
(ii)
The injury or illness involves signs or symptoms that surface at work but result solely from a nonwork-related event or exposure that occurs outside the work environment.
(iii)
The injury or illness results solely from voluntary participation in a wellness program or in a medical,
fitness, or recreational activity such as blood donation, physical examination, flu shot, exercise
class, racquetball, or baseball.
(iv)
The injury or illness is solely the result of an employee eating, drinking, or preparing food or drink
for personal consumption (whether bought on the employer's premises or brought in). For example,
if the employee is injured by choking on a sandwich while in the employer's establishment, the case
would not be considered work-related. Note: If the employee is made ill by ingesting food
contaminated by workplace contaminants (such as lead), or gets food poisoning from food supplied
by the employer, the case would be considered work-related.
(v)
The injury or illness is solely the result of an employee doing personal tasks (unrelated to their
employment) at the establishment outside of the employee's assigned working hours.
(vi)
The injury or illness is solely the result of personal grooming, self-medication for a non-work related
condition, or is intentionally self-inflicted.
(vii)
The injury or illness is caused by a motor vehicle mishap and occurs on a company parking lot or
company access road while the employee is commuting to or from work.
(viii)
The illness is the common cold or flu (Note: contagious diseases such as tuberculosis, brucellosis,
hepatitis A, or plague are considered work-related if the employee is infected at work).
(ix)
The illness is a mental illness. Mental illness will not be considered work-related unless the
employee voluntarily provides the employer with an opinion from a physician or other licensed
health care professional with appropriate training and experience (psychiatrist, psychologist,
psychiatric nurse practitioner, etc.) stating that the employee has a mental illness that is workrelated.
Table 2-14
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
32
Unit 2:
Mishap and Hazard Reporting Requirements
Is a MCSC 7 or 8-day
What type of
Is a
Is an
HAZREP
brief
safety
HAZREP
Immediate
required
required?
investigation?
required
in
Notification
per MCO
USN or
RMI?
A, B, C, D, required?
5100.34A?
USMC,
Other, or
Unit, SIB,
Yes, No,
Yes, No,
Both or
None
Yes or No
or None
or Maybe
or Maybe
None
Mishap
Class
Mishap Scenario Exercise
1
PFC Flatt is loading vehicles into the well-deck of the USS
Gator when he is pinned between two GVO’s resulting in
internal injuries and now paralyzed from the waist down.
2
While at a friend’s house during a 96 hour liberty, a service
member inadvertently shoots himself in the leg while
checking out his buddy’s new personal pistol. The mishap
service member is hospitalized for 3 days, then placed on
30 days convalescent leave. Alcohol was a contributing
factor. Both are under 21.
3
MSgt and Chief are installing a motor into MSgt’s
76‘Firebird Trans Am. While tuning the engine, MSgt
inadvertently gets his hand too close to the alternator belt
and amputates the first knuckle on an index finger.
4
During a swim training event, a service member goes
unconscious as a result of “shallow water blackout”. The
instructors and “Doc” pull the member out, revive him and
he is sent to be observed and continue recovery. No light
duty, No lost time.
5
While conducting live fire training, Cpl Whoops receives a
minor cut to the face from shrapnel when a round “cooked
off”. The platoon Doc cleaned the cut and applied a BandAid. Training continued after ensuring everyone and the
weapons were “ok” and a new RM brief.
6
Six service members suffer mild “heat exhaustion” during a
training event. The WBGT is 99ºF. Each are taken to the
Aid Station for treatment with IV fluids and each are placed
on two days light duty.
7
8
9
An off-duty, active duty member is assaulted in the BEQ by
another active duty member. The service member died
from the injuries in the emergency room.
A service member dies in a motorcycle crash during a unit
approved, mentorship club ride. The ride began at the unit
HQs during working hours and the crash occurred on a
public highway (off-base).
An active duty member and a DoD civilian are welding
parts on a piece of military equipment at a base
maintenance facility. They both become ill from the fumes
Both are treated and released from the Emergency Room.
The service member is placed on light-duty and the DoD
civilian is placed on restricted work status. You discover
there is poor ventilation in the designated welding area.
10
SN J.S. Ragman backed a GMV (F250) into the Admiral’s
GMV (Tahoe) causing $5,628.00 in damage to both
vehicles. He was not using a ground guide.
11
A contracted civilian dies from electrocution while working
on a 440v panel during construction on the new base
fitness center. Her team is supervised solely by the
contracted organization.
12
While working in the galley on the USS Gator. LCpl Grace
is shocked by the food service equipment (220v) due to a
short. The OIC sent the LCpl to medical. The LCpl had no
injuries and was sent back to full duty.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 3:
Protection of Safety Information
3-1. INTRODUCTION AND OVERVIEW. Safety privilege is based on a national defense need for
rapid and accurate assessment of the causes of mishaps to prevent a recurrence and maintain mission
readiness. This privilege creates restrictions on handling and releasing information in mishap investigation
reports. (See DoDI 6055.07 and OPNAV M-5102.1_/MCO P5102.1_, Chapter 7)
a. Release Authority. Commander, Naval Safety Center (COMNAVSAFECOM) is the Department of
Navy'sthe
(DoN) sole release authority for privileged safety information. This ensures commanders and safety
officials can obtain accurate mishap information to promote safety and readiness.
b. Critical Need to Sustain Safety Credibility. Obtaining safety information is dependent upon
protecting privileged information against use for other than safety purposes. To continue the revelation,
development, and submission of privileged information in mishap investigation reports and endorsements, all
personnel in naval safety must keep faith with the promises we make while gathering evidence. Violations of
this trust will destroy the credibility of the safety programs that have based their success on the ability to
protect privileged information. (See OPNAV M-5102.1_/MCO P5102.1_,)
“Obtaining safety information is dependent upon protecting privileged
information against use for other than safety purposes.
Violations of this trust will destroy the credibility of the safety programs that have
based their success on the ability to protect privileged information.”
3-2. LEGAL INVESTIGATIONS vs SAFETY INVESTIGATIONS
a. Overview. Generally, there may be up to three types of investigations into a mishap (JAGMAN,
Safety, and NCIS). Each is conducted apart and independently from the other and all three investigative
bodies provide the unit commander with information. Only the unit commander is privy to the information
developed by each of the investigative bodies. (Refs: OPNAV M-5102.1_/MCO P5102.1_, Chapter 1, para
8.g, pg. 1-12; Chapter 6, para 6003.2; figure 6-1 on pg. 6-20; Appendix A, para 1.g on pg. A-3.)
NOTE: DoD and Naval policies mandate legal investigations for all “on-duty” Class-A mishaps. Also,
NCIS is required to investigate all “on-base” fatalities to determine if foul play was a result.
b. The Difference. Legal investigations of a mishap are used in litigation, claims against the government,
and other administrative and disciplinary actions against individuals, whereas the mishap investigation is
conducted solely to identify systemic failures for mishap prevention purposes. Personnel designated as unit
safety or participating in the mishap investigation will not participate in the conduct or formal review of a legal
investigation of a mishap. (See Figure 3-1)
NOTE: DoDI 6055.07 requires legal investigations for all on-duty Class-A mishaps.
Fig 3-1
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Unit 3:
Protection of Safety Information
c. Relationships. In addition to a mishap investigation, a mishap may also require an investigation
pursuant to the Judge Advocate General Manual (JAGMAN). Mishap investigations must be separate and
distinct from all other investigations. To ensure this independence, DoDI 6055.07 and OPNAV M-5102.1_/
MCO P5102.1_ mandate the following:
1) JAG and Safety/Mishap investigators are NEVER the same person(s).Personnel assigned to
conduct safety investigations shall not conduct legal investigations of the same mishap.
Commanders shall ensure personnel assigned to conduct unit or command mishap investigations,
or assigned as a member of a SIB, or assigned to assist the SIB are excluded from assignment to a
Judge Advocate General Manual (JAGMAN) investigation of the same incident conducted in
accordance with JAGINST 5800.7 series. Personnel currently assigned to full-time safety positions
shall not be appointed as members of a legal investigation board.
2) JAGMAN shall be conducted independently and separately from the safety investigation.
3) JAGMAN investigators have access to ONLY factual information.
4) The Office of the Judge Advocate General (OJAG) and Staff Judge Advocates (SJA) shall not have
access to any safety investigation reports (SIREP). However, safety investigators may have access
to legal investigation reports.
5) A SIREP and privileged information shall not be made available to or included in any JAGMAN
investigation. However, the safety investigator may review information gathered during the
JAGMAN investigation.
6) A SIREP shall not include witness statements from the JAGMAN or Naval Criminal Investigative
Service (NCIS) investigation. The mishap investigator can summarize the witness statements for
inclusion with the SIREP.
7) The OJAG and SJA shall not be addressee on any SIREP messages or endorsements nor shall
copies be provided to them.
8) Do not include endorsements of SIREPs in JAG investigations.
3-3. CONCEPT OF PRIVILEGE. (Ref: DoDI 6055.07, Enclosure 5 and OPNAV M-5102.1_/ MCO
5102.1_, Chapter 8)
a. Overview. Military and federal courts grant protection under executive privilege to the analysis,
conclusions and recommendations of:
1) Command safety investigators,
2) Members of Safety Investigation Board (SIB),
3) Mishap/Safety Investigation reports and endorsement of reports and
4) Endorsers of mishap/safety investigation reports.
b. Purpose. The concept of privilege:
1) Encourages mishap investigators and the endorsers of MIREPs to provide complete, open, and
forthright information, opinions, causes, and recommendations about a mishap.
2) Overcomes any reluctance of an individual to reveal complete and candid information to an
investigator about the events surrounding a mishap. They may believe the information could be
embarrassing or detrimental to themselves, fellow service members, their command, employer, or
others. They may also elect to withhold information by exercising their constitutional right to avoid
self-incrimination. Individual members of the armed forces must be assured they may confide with
the investigator for the mutual benefit of fellow service members without incurring personal jeopardy
in the process.
NOTE: Rationale for designating mishap investigation information as privileged is more important than the
rationale for encouraging witnesses. Every investigation involves command safety investigators, SIB
members, or endorsers. Not every mishap has witnesses who would require an assurance of privilege as
encouragement to make a statement.
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Unit 3:
Protection of Safety Information
3-4. PRIVILEGED INFORMATION.
a. Overview. IAW DoDI 6055.07 and OPNAV M-5102.1_/MCO P 5102.1_, DoD components protect
privileged safety information to ensure commanders quickly obtain accurate mishap information. For a
mishap investigation, privileged safety information include:
1) Safety personnel or assistants conducting mishap investigations. This includes both unit/command
mishap investigations and SIBs. Mishap Investigators shall not, or be asked to, divulge their opinion
or any information gathered during the investigation.
2) Products of the deliberative processes of mishap investigators:
 Draft and final findings, evaluations, opinions, preliminary discussions, conclusions, mishap
causes, recommendations, analyses, and other material that would reveal the deliberations of
safety investigators
 Draft and final diagrams and exhibits if they contain information that depicts the analysis of
safety investigators. (i.e. causal factor maps/diagrams)
 Animations that incorporate privileged safety information.
 Photographs, films, and videotapes that are staged, reconstructed, or simulated reenactments of
possible or probable scenarios developed by or for the analysis of the safety investigator.
 Life sciences material (i.e. Human Factors analysis) that contains analysis by a safety
investigator.
 Notes taken by safety investigators in the course of their investigation, whether or not they are
incorporated, either directly or by reference, in the final safety investigation report. Investigators
summaries of witness statements should be “the only written record should be notes taken by
the investigator.”
3) Witness statements under the “Promise of Confidentiality”
NOTE: The “Promise of Confidentiality” and “Advice to witness” are not authorized for unit / command /
installation level mishap investigations. They may only be used during a formally appointed SIB”
4) The narrative, conclusions and recommendations in the SIREP resulting from any safety
investigation (unit, installation, or SIB).
5) All endorsements of SIREPs are privileged against disclosure. (SIB and non-SIB)
3-5. FACTUAL INFORMATION.
a. Overview. Factual information is information that clearly originated from non-privileged sources as
defined by DoDI 6055.07 and may be segregated from privileged data so as to be meaningful to a reader.
This information has not been altered or edited by the mishap investigator and does not have indicators of
the investigator’s deliberations, analysis, or opinions. Some factual information may be shared with nonsafety personnel investigating the same mishap while other factual information may only be approved for
sharing or release by the COMNAVSAFECEN SJA under the Freedom of Information Act (FOIA).
b. Sharable Factual Information. The following information may be shared with a JAGMAN and NCIS
investigator during an active mishap investigation:
1) Physical evidence (pieces, parts, etc.)
2) Unedited photographs with or without scale devices.
3) Original or unedited copies of Log books, Police Reports, casualty reports, flash reports, OPREP-3
reports, Personnel Casualty Reports PCR), etc.
4) A plain list of witness names.
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Unit 3:
Protection of Safety Information
c. Factual Information that requires NAVSAFECOM JAG Approval. The following information may
ONLY be released to non-safety personnel upon the approval from the NAVSAFECOM JAG:
1) Outlines & sketches drawn by witnesses (without investigator marking s or comments).
2) Witness’ written statements or sketches without investigator markings or comments.
3) “Advice to witness” forms without investigator markings or comments.
NOTE: “Advice to Witness” is not authorized for unit / command / installation level mishap
investigations. They are only authorized for use by a formally appointed SIB.
4) The “what happened” section (Part A) of a SIREP.
5) Hazard Reports (HAZREPS).
3-6. DISSEMINATION OF INFORMATION.
a. Overview. Safety information cannot be used for other than safety purposes.
NOTE: “Unauthorized disclosure of Safety information by military personnel is a criminal
offence punishable under article 92 of the UCMJ.”
“Unauthorized disclosure by civilian personnel will subject them to disciplinary action
under DON Civilian Human Resources Manual, Subchapter 752.”
OPNAVINST 5102.1_/MCO P5102.1_
b. Unauthorized Use of Privileged Information. Unauthorized uses of privileged information. Privileged
information shall not be used:
 In making any determination affecting the interest of an individual making a statement under
assurances of confidentiality or involved in a mishap.
 As evidence or to obtain evidence in determining the misconduct or line-of-duty status.
 As evidence to determine the responsibility of personnel for disciplinary or administrative action.
 As evidence to assert affirmative claims on behalf of the government.
 As evidence to determine the liability of the government for property damage caused by the mishap.
 As evidence before administrative bodies, such as officer or enlisted separation boards, judge
advocate general manual investigations or inquiries, naval aviator or naval flight officer evaluation
boards (USN) and field performance boards (USMC).
 In any other punitive or administrative action taken by the Department of Navy.
 In any other investigation or report of the mishap.
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Unit 3:
Protection of Safety Information
c. Freedom of Information Act (FOIA): A FOIA request is a written request for records from the
military. Any American citizen can submit a FIOA request. (Including persons employed by the government,
but acting in their personal capacity). Freedom of Information Act (FOIA) requests cannot be made by any
part of a business, organization or the United States government, including the federal courts. Any person
has a right, enforceable in court, to obtain access to federal agency records, except to the extent that such
records (or portions of them) are protected from public disclosure by one of nine exemptions or by one of
three special law enforcement record exclusions. One of these exemptions is “Privileged Information” from a
safety investigation.
d. Release of Safety Information. Organizations must request safety information from
COMNAVSAFECOM in accordance with Federal Regulations as defined in the DoDI 6055.07 and OPNAV
M-5102.1_/MCO P5102.1_. Individuals must request safety information under the FOIA. The DoDI 6055.07
and OPNAV M-5102.1_/MCO P5102.1_ defines the process and limitations for the request of safety
information. In general, ALL requests for safety information must be referred to the COMNAVSAFECEN SJA.
This includes requests from individuals, private businesses,
 COMNAVSAFECOM JAG may release reports under FOIA to ONLY individuals – not a business or
organization.
 One government agency may NOT request info from another government agency under FOIA.
 Members of Congress must request from the _________________________________
 Non-DoD Federal agency must request from the ______________________________
 Subpoenas referred to SJA must be forwarded to the ___________________________
Note: Requests for access to Mishap reports from other staff, commands and DoD organizations may
be releasable if sole purpose is for mishap prevention. If not solely for mishap prevention, the release
excludes:
Findings, recommendations and analysis, Contents of witness statements given under promises of
confidentiality, and Medical records.
3-7. CRITERIA TO SUSPEND MISHAP INVESTIGATIONS.
a. Overview. During your mishap investigation, you may determine the event might be or is the result of
intent to commit a criminal act rather than human error. This may occur during a witness interview or during
the analysis where you feel the DoD HFACS nano-code of AV 003 is applicable, If this occurs, you may need
to suspend the investigation and confer with the COMNAVSAFECOM SJA and your commander.
b. Evidence of Criminal Acts: In accordance with DoDI 6055.07, if criminal conduct is found to be
causal to the mishap is discovered in the course of conducting a safety investigation, suspend the
investigation, preserve the evidence, and immediately notify the safety investigation convening authority,
legal investigative authority, and the responsible Military Criminal Investigative Organization (MCIO) in
accordance with DoD Instruction 5505.03, or Federal or local law enforcement, depending on jurisdiction at
the location of the mishap. The safety investigation convening authority shall determine, under the
circumstances, whether the safety investigation will proceed.
If during the course of the investigation, any investigator discovers a criminal act, the Safety Officer or the Sr.
member of the SIB will:
1) Suspend the investigation.
2) The unit/command safety officer will seek guidance from his/her appointing authority (Commanding
Officer).
3) The SIB Sr. Member will seek guidance from the SIB’s appointing authority and Controlling
Command.
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Unit 4: Mishap Preparation (Mishap Action Plan and Response Kit)
4-1. MISHAP ACTION PLANS (MAP).
a. Overview. All command/units need a plan and checklist to follow when a mishap occurs and ensure
key personnel are familiar with the plan. The 29 Code of Federal Regulations and OPNAV
M-5102.1_/MCO P5102.1_ define the requirements for all units/commands to have a Mishap Action Plan for
various types of activities to include garrison functions, training and in the deployed setting.
The MAP is no different than any other “Emergency Action Plan” such as Anti-Terrorist Force
Protection Plans, Disaster Preparedness Plans, Emergency Evacuation Plans, or Active Shooter Plans.
Each are mandated by OSHA, the DoD and the DON.
The development of these plans are taught during several Navy and/or Marine Corps Safety Officer
courses and templates are posted to both the Naval Safety Center website and the CMC (Safety Division)
website. For assistance, call the Naval Safety Center’s Mishap Investigations team.
b. Purpose. Each MAP defines duties, responsibilities, immediate actions, and training requirements of
the Command response to mishaps as well as interactions with other commands and civilian agencies. The
MAP should be incorporated into the unit duty binder, LOIs, and annexes of OPLANs. A copy of the
command/unit's mishap plan must be available to all investigators (Unit or SIB). If your unit experiences a
mishap which requires a SIB, the MAP is useful to ensure that all board members understand the
investigation concept and plan. The investigation plan is a systematic process that ensures continuity of
effort from the preliminary examination of the mishap site to the submission of the final report. Each plan
should complement all Naval and local policies and the mishap investigation process defined in this
handbook.
c. Elements of a M.A.P.
1) Phone Contact list.
 Command, Trained Safety Officer/investigator, PAO, Higher Command Safety Office
 Emergency Services and Fire Department, Law Enforcement, Base Environmental Office,
 EOD, G4 (vehicle recovery), Utility Companies/Dept. of Public Works (DPW),
 Mortuary Affairs / County Coroner / Medical Examiner
 Naval Safety Center (Crash Line) (Comm: (757) 444-2929, DSN 564-444-2929)
2) Procedures for mishap site preservation, security and scene priorities. To ensure the unit/command
safety officer, or civilian SOH specialist, or members of a SIB can effectively conduct the mishap
investigation, commanders should incorporate the requirement from the OPNAV M-5102.1_/MCO
P5102.1_ into all Mishap Action Plans. (See figure 4-1 below)
3) Define tasks / responsibilities and equipment requirements.
4) Define coordination w/ internal & external agencies.
5) Define reporting procedures.
6) Protection of safety information requirements (Privileged vs Non-Privileged Information)
7) Training and Rehearsal Plan.
8) Administrative support procedures for incoming SIB.
9) Procedure to review for deployment or training events.
10) Protection of safety information requirements (Privileged vs Non-Privileged Information)
11) Training and Rehearsal Plan.
12) Administrative support procedures for incoming SIB.
13) Procedure to review for deployment or training events.
CMC (Safety Division) Mishap Investigation Course
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Unit 4: Mishap Preparation (Mishap Action Plan and Response Kit)
Command duty officers, staff duty officers, officer of the day or the senior person at the
scene of a mishap shall:
a. Ensure care and first aid is provided to the injured personnel. Emergency Medical Services
(EMS) personnel may need to disturb or remove items of evidence to preserve life.
b. Eliminate or control hazards created by the mishap. Operational requirements or damage
control measures may require disturbing the scene of the mishap.
c. Inform proper authorities; e.g., unit commander (and responsible commander if other than unit
commander), unit or installation safety officer or manager, Provost Marshal's Office (PMO), fire
and rescue, and public affairs.
d. Secure the mishap site to protect the public, safeguard Navy and Marine Corps property, and
prevent disturbance of the site. For on-duty Class A and B mishaps and all explosive mishaps,
assign personnel to:
1) Make an accurate plot of the scene before moving or removing any wreckage or equipment.
2) Take photographs or videotape recordings of the wreckage, its distribution, and the
surrounding area. Photograph the mishap site from a minimum of eight points surrounding
the site and all items of evidence prior to removal, when possible.
3) Make a diagram of any damage. A sketch should accompany the items to depict "as found"
location and condition.
4) Collect all log books, maps, charts, overlays and other documents to prevent the loss of vital
information.
e. Make a list of witnesses and encourage them to develop personal notes concerning the mishap
for them to refer to during witness interviews. Witnesses should write down their own
observations and should not discuss the mishap with other witnesses.
Ref: Chapter 1, Para 1005.9.d (pg. 1-14) and Appendix A, para 2.d (pg. A-5)
4-2. MISHAP INVESTIGATION KITS.
a. Overview. Each unit’s mishap investigation kit is determined by the scope of your unit’s involvement
in an investigation. Kit size varies based in the unit’s mission
b. Recommended Items:
1) Marking Equipment: Colored flags or numbered cones, “Caution” or “Do not enter” barrier tape,
chemlights, etc.
2) Electronics: Camera, GPS, range finder, flashlights, electrical outlet tester, voice recorder, etc.
3) Admin Supplies: Permanent markers, clipboard, duct tape, ID badge, graph paper, etc.
4) Tools: Multi use tool, etc.
5) Measuring Equipment: Retractable tape measures (25 ft. and 100ft), bar level or string level, metal
ruler, deck of playing cards, etc.
6) PPE: Tyvek suits, respiratory protection (consider placement on the RPP), hearing protection,
sunscreen, insect repellent, poncho, first aid kit, etc.
7) Bagging Equipment, Waterproof labels, re-sealable plastic bags, paper bags.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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PART II
Mishap Investigation Process
Unit 5 – Mishap Investigation Process Overview
Unit 6 – Mishap Site Management
Unit 7 – Evidence Collection
Unit 8 – Causal Factor Analysis
Unit 9 – Developing Conclusions and Recommendations
CMC (Safety Division) Mishap Investigation Course
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Unit 5: Mishap Investigation Process Overview
5-1. INVESTIGATION PROCESS – THE THREE “W” APPROACH.
a. Overview (The 3 W Approach). The mishap investigation process utilizes the “3W” approach of
“What Happened?”, “Why the mishap occurred?”, and “What to do about it.” (See figure 5-1 below). The
circumstances surrounding mishaps are diverse. It is not possible to describe every circumstance under
which specific kinds of evidence are collected during a mishap investigation. Great reliance is placed on the
single investigator or the members of the SIB. The “3W” approach reveals adverse interactions of humans,
machine and the operating environment which both caused and contributed to the mishap.
NOTE: USN/USMC mishaps have 30 days from time of mishap to complete investigation and submit the
mishap investigation report in the DON mandated mishap reporting database.
Figure 5-1
1) What happened (facts regarding human actions, machine / equipment status, and environmental
conditions). The first step is to determine the facts or "what happened." Collecting evidence to
identify all relevant facts to define what actually happened enables the investigator to satisfy this
requirement.
2) Why it happened (Causal Factors(s)/system inadequacies). From the standpoint of prevention, the
most significant element is the WHY did the individual or team commit an unsafe act? Or WHY did
the machine malfunction? This is the element that lends itself to solutions to prevent further
mishaps. (See figure 5-2)
Was it and error or violation on behalf of the individual? If so, did supervision, training, standard
operating procedures and/or policies play a role in the individual’s decision making or lack thereof?
Was there a mechanical issue with the equipment involved? If so, how did its function or
malfunction or design play a role in the mishap?
Your investigation should lead to identify the system inadequacies (aka: contributing and causal
factors). The following factor types are adopted from COMNAVSAFCOM ALSAFE 20-107.
 Factors: Any deviation, out of the ordinary, or deficient action or condition discovered in the
course of a mishap investigation that in the opinion of the SIB or Investigating Officer contributed
to the eventual outcome
o
Causal Factors: Factors which caused the mishap. If the factor was corrected, eliminated, or
avoided, the mishap/hazard or incident would not have happened
o
Contributing Factors: Factors which were present but not necessarily causal (formerly
referred to as other damage or injury in RMI)
CMC (Safety Division) Mishap Investigation Course
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Unit 5: Mishap Investigation Process Overview
o
Non-Factors Worthy of Discussion (NFWOD): Other areas uncovered during the
investigation that did not lead or contribute to the mishap but need to be addressed
Figure 5-2
NOTE: Finding human fault is a function more appropriate for legal inquiries and can often be a
distraction during the conduct of a mishap investigation. Identifying who is at fault does little or
nothing in pointing out how to prevent a similar mishap in the future. Focus on all the reasons why,
not who.
3) What to do about it (recommendations). A proactive mishap prevention process identifies unsafe
acts and conditions and applies corrective measures before mishaps occur. Prevention is
accomplished through engineering, systems safety, education and training, personal protective
equipment, and enforcement of standards. Safety’s mishap investigations will reveal previously
unknown, ignored, and improperly corrected conditions or actions, and identify risks.
This is the phase to identify the recommended actions and identify the proponent activity or lowest
level of command that is most responsible for taking action targeted at eliminating/correcting the
system inadequacies/ causes (both at the unit and, if applicable, Navy and/or Marine Corps levels).
It is important to provide the local commander with recommendations to address his/her local
situation, but it is equally important to provide the Department of the Navy with recommendations to
address common hazards across the Navy and/or Marine Corps. Recommendations are based on
the circumstances as they existed at the time of the mishap.
Often units make immediate changes based on the early understandings of a mishap. While that is
a unit commander’s prerogative and certainly appropriate it does not affect the resulting findings
and recommendations. If the circumstances existed in this organization they most likely exist in
other organizations and it is the responsibility of the CNO’s and CMC’s safety team to ensure the
widest dissemination of mishap prevention information possible.
Additionally, the appropriate activity responsible for correcting each identified system inadequacy is
notified by either CMC(SD), COMNAVSAFECOM or the appropriate adjudicator as defined in the
OPNAV M-5102.1_/MCO P5102.1_. This process is continually followed up to ensure
recommendations have been adopted by the fleet and that appropriate measures are in place to
ensure mishap prevention.
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 5: Mishap Investigation Process Overview
USS Forrestal Mishap Case Study
Instructions: Watch the USS Forrestal disaster video. Identify and write down the causal factors. Be
prepared for class discussion.
Causes
Human or
Material
Causal or
Contributing
“When cutting corners becomes routine, and routine violations become the norm, then they
may not be seen as violations at all to a newcomer who perceives, That is the way it’s always been
done around here. The practice becomes the rule, rather than the exception to the rule. Over time,
the correct rule is lost.
With so much on-the-job training (OJT) conducted in the fleet to train new personnel, routinely
cutting corners is a setup for future calamity”. Dr. Robert Figlock (President, Advanced Survey Design,
LLC)
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
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Unit 6:
Mishap Investigation Process (Mishap Site Management)
6-1. SECURING AND PRESERVING THE MISHAP SCENE.
a. Overview. Many immediate post-mishap activities are concurrent with emergency actions taken to
save lives, limit loss and hazards. Emergency action considerations, particularly lifesaving and life-protecting
activities always take first priority, even if property or evidence is destroyed, distorted, or broken in the
process. The adverse effects of tradeoffs that must be made during emergency response can be minimized
through advance preparation and planning to ensure proper coordination of emergency actions with initial
investigative activities.
b. Goal. The effectiveness of a mishap investigation depends on immediate preservation of the mishap
scene and the physical, human, and documentary evidence related to the mishap. To ensure the
unit/command safety officer, or civilian SOH specialist, or members of a board can effectively conduct the
mishap investigation, first line supervisors on the scene should take all actions outlined in the commands
“mishap action plan” (see Unit 3) to gain control and secure of the mishap scene until safety investigators
can arrive. Three key reasons to secure the scene are:
1) Protect personnel from scene hazards that could result in a secondary mishap or an adverse health
exposure.
2) Protect evidence from well-intentioned, but uninformed interested personnel feeling the need to
inspect the scene personally and may inadvertently destroy evidence in the process.
3) Preserve evidence with photos and diagrams to capture perishable evidence. Also, sometimes
impending inclement weather is an obvious scenario. Therefore, it is critical to investigation that
senior personnel on the scene preserve all evidence as possible until mishap investigation trained
safety personnel arrive.
6-2. COMMON HAZARDS OF A MISHAP SITE. The senior person on the scene and the safety
officer should take every precaution to protect responders from exposure to hazards of the mishap scene.
Common hazards of an on-duty mishap scene are likely to include:
a. Ammunition and/or unexploded ordnance (UXO),
b. Energized equipment,
TIP: Securing a frequently used or public area may require additional efforts. Security personnel can
be posted around the area to help secure the mishap scene long enough for the safety officer to
complete a thorough walk-through and document the scene, if long-term access controls are not
feasible. If the mishap occurs in an area that makes securing the mishap scene difficult, the walkthrough may be the sole opportunity to collect and preserve important evidence.
c. Fire and/or toxic smoke,
d. Terrain hazards (slip and trip hazards)
e. Sharp objects
f. Equipment / machinery movement during recovery,
g. Blood-borne pathogens,
h. Low or high oxygen levels,
i. HAZMAT (i.e. POLs; Toxic Chemicals; Radioactive material such as Depleted Uranium or Thorium
coated optical elements Lithium Batteries; Friable or burning Advanced Composite Materials, etc.)
1) Advanced Composite Materials (ACM) are composite materials applicable to aerospace
construction / environments that are comprised of high-strength and high-modulus reinforcement(s).
ACM can be found in essentially all airframes, tactical ground vehicles, and body armor. As safety
professionals we must deal with advanced composite material components released from burning
and burnt military equipment, the hazards must be assessed as completely and accurately as
possible. Potential hazards of ACM include inhalation of fibers (similar to asbestos fibers) and toxic
compounds from smoke or from fibers.
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Unit 6:
Mishap Investigation Process (Mishap Site Management)
2) Based upon the known and unknown hazards there are still unknown risks. Administrative controls
in conjunction with adequate PPE need to be immediately implemented. Such practices include:
 Minimize exposure – keep unnecessary personnel out of the area.
 PPE: PPE includes uniform with sleeves worn down; Non-disposable/disposable HEPA
respirator; Safety glasses with side shields; Nitrile gloves (internal), and Hard-soled work boots.
If any debris is to be manipulated, the previously discussed glove ensemble is also required.
Likewise, if special conditions exist that would increase the hazard, increased protection is highly
recommended. As a general rule, it is easier to protect than correct a health problem.
 For Burning/Smoldering Composites, personnel should use Self-Contained Breathing Apparatus
(SCBA); Aluminized proximity suits; Aluminized/puncture resistant gloves, and No rubber gloves.
 For Broken or Splintered Composite Material; personnel should use full or half face respirator
with dual cartridge filters; Hooded Tyvek suit with optional booties; Leather work gloves
(internal); Nitrile gloves (internal); Hard-soled, leather work boots. Obtain a fixant or hold-down
solution, such as Polyacrylic acid (PAA) or acrylic floor wax and water. Light oil is not
recommended because it may become an aerosol and collect on equipment, hamper material
investigations, and present a health hazard. Generic acrylic floor wax, available at a wide variety
of stores, should be mixed in a 10:1 water-to-wax ratio. (Refer to Crash, Fire, & Rescue units for
assistance)
6-3. PERSONNEL AT HIGHEST RISK OF EXPOSURE TO SCENE HAZARDS. Personnel
at greatest risks of exposure to scene hazards include – first responders, emergency response personnel
(Fire Fighters, Medical Rescue Personnel, Law Enforcement), Explosive Ordnance Disposal (EOD),
Recovery personnel, HAZMAT Team, Investigators (Safety, NCIS, JAG, other) and Coroner / Mortuary
Affairs personnel.
6-4. JURISDICTION OF THE MISHAP SITE.
a. Concurrent Investigations. Sometimes several other investigations can be underway at same time
such as JAGMAN, NCIS, Police and Fire Department. Safety can leverage all other investigations to their
benefit.
b. Memorandum of Agreement (MOA) Between NAVSAFECOM AND NCIS. Defines Lanes, Site
Preservation, and Sharing of Evidence. NCIS keeps evidence if criminal activity is suspected and mishap
investigators may have access if required.
NOTE: Witness statement summaries cannot be shared.
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7-1. INTRODUCTION AND OVERVIEW. Crucial to any investigation is the gathering of
information/evidence. In the combat zone, the tactical situation dictates the level of detail evidence can be
collected. The information/evidence collected during a mishap investigation becomes the very basis of the
mishap investigator’s (unit or SIB) analysis and conclusions. Therefore, a thorough effort to collect all
relevant data and evidence must be made.
7-2. TYPES OF EVIDENCE. Evidence collected during a mishap investigation should include:
a. Physical Evidence. Matter related to the mishap such as equipment, parts of equipment, machine
guards, tools, debris, skid marks, cell phones, strike marks, gouges, PPE, clothing, chemicals, hardware,
voice recorders, etc.
b. Documentary Evidence. Any evidence that paper or electronic form, excluding medical records.
Includes photos, video, technical manuals, emergency action plan/mishap action plan, operational plan
(OPLAN), policies and regulations, SOPs, letter of instruction (LOI), training records, maintenance records,
safety data sheets, job hazard analysis sheets or risk assessment worksheets, safety committee minutes,
weather reports, duty logs, past mishap reports, diagrams, charts, maps, mishap site diagrams, investigator
notes, etc. NOTE: Environmental evidence (lighting, noise, vapors, etc.,) is captured through documentation
evidence.
c. Medical Evidence. Medical information about the operator and/or other team members that may
provide insight to preconditions that contributed to the actions of the operator, team members and/or
immediate supervisor. This includes medical records, lab results, pathological / autopsy reports and the 72
hour profile.
d. Witness Interviews. The importance of a witness varies with the mishap. In some cases, witnesses
are absolutely vital when there is no recoverable wreckage, survivors or recorded information. In other
cases, there is plenty of factual evidence available where witness statements are merely corroborative. In
these cases, it is interesting to note the differences between what witnesses say and what the facts support.
Case Study Exercise 1
What evidence would you begin to collect and why?)
What physical evidence (if any) are you interested in? Why?
What documentary evidence (if any) are you interested in? Why?
What medical evidence (if any) are you interested in? Why?
What witnesses (in priority) are you interested in? Why?
Case Study
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7-3. EVIDENCE COLLECTION PRIORITIES.
a. Step – 1 Photograph / Video record the scene and evidence. Photography is one of
the best methodologies for securing and preserving transitory evidence. Photographs are
perhaps the most valuable piece of evidence as it can assist witness with recall and help the
investigator(s) corroborate other evidence and reconstruct the scene if needed. You must
plan your shots to make the best use of limited time and not miss critical information. Video
recording is also valuable method of recording a mishap scene, but it is not a substitute for still photography.
A video may show responders in action and shows movement and color; but it cannot be studied as well as a
photo.
If an installation photographer is provided, the mishap investigator (unit safety officer or a SIB member)
supervise him/her. Remember: It is always better to have too many photos than not enough. A
recommended photographic checklist is as follows:
1) Plan out the shoot.
2) Do not change or trample evidence.
3) Take pictures with flash and without flash.
4) Keep photo log: (Scene/subject, date, time, direction, orientation. Why a photo was taken).
5) Use scale devices when required. (E.g. Ruler, Playing card, etc.)
6) Use exemplars if needed: Photograph the result and what the equipment should look like (Before
and After)
7) Prioritize photos / Video:
 First - Photograph perishable evidence. (i.e. fluids, positions of deceased, items that may switch
positions during mishap’s aftermath or a rescue in progress, tire of foot tracks, gauge readings,
radio setting, and positions of switches on equipment.)
 Second - Overall Views. General overview of the scene/wreckage (beginning at the front of the
aircraft or vehicle or machinery, circling site every 45 degrees. (Ground view from four directions
(N,E,S,W), yet eight points are preferred (N,NE, E, SE, S, SW, W, NW). If needed, an aerial view
from same directions.
 Third - Approach views. (i.e. direction of travel or the view as the mishap operator would have
seen the area.)
 Fourth - Detailed Views. Photograph of any scars/marks on the ground, other vehicle systems,
bulkheads, trees, buildings, Photograph major components (E.g. control panels, parts,
instrument panels, consoles, cockpit/cabin/cab areas, seats, restraining systems, canopy,
turrets, roll cage, suspension, ladders, weapon system, etc.).Take detailed photographs of
suspected failed parts, disassembly of parts/equipment (if done).
 Last - Other photographs deemed necessary.
b. Step 2 – Identify Witnesses: Be sure to obtain a list of witnesses. Priorities of witnesses includes:
1) Participants,
2) Eyewitnesses (saw or heard),
3) First responders,
4) Background witnesses (someone who knows details about those involved or the equipment
involved or the processes involved).
NOTE: Initial contact information should be provided to the unit investigator or the mishap investigation
board president from the on-site designated representatives.
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TIP for at-scene interviews. (If possible)
• Identify yourself as the safety officer and explain the purpose of
the interview.
• Obtain the name, address, phone number, and the background.
• Allow the witness to recount the event in their own words.
• If possible, have witness make a drawing & Establish witness
location in relation to the mishap.
• If recording - Obtain permission to record the interview.
c. Step 3 – Diagram the Scene: A sketch should accompany the items to depict "as found" location and
condition.
1) Advantages: The advantage that a diagram has over a photograph is that it is less cluttered and
helps capture information not captured in photos (e.g. temperatures, airflow, noise levels, lighting
sources, etc.). Sketches may be the only evidence you have from a mishap scene if photographs
were not available before evidence was moved. A diagram can show movement, distances, angles,
position of personnel in relation to key areas, positions of components or parts, and key distances.
Drawn closely to scale, it can emphasize certain aspects of a photograph to clarify a point.
Depending upon the location and type of mishap, investigators may need to use different versions
of diagrams. (See Figures 7-1 through 7-4). A good diagram also assists in reconstruction,
inventory of components and corroborating witness testimony and/or other evidence. Whichever
diagram is most appropriate for the mishap, a best practice is to use grid or graph paper to help
draw to scale. You may also use Navy/Marine Corps terminology using forward and aft, port and
starboard. Use key landmarks or features to orient your drawing.
2) Key items to diagram and record include:
 Magnetic North. (Mark sketches or diagrams using magnetic north or place north in the upper left
corner.)
 Environmental factors (Terrain features, sun position, humidity, air temperature, water
temperature, pressure, wind direction, wind speed, lunar illumination, glare, lighting, noise,
vapors, oxygen levels, dust, fog, wet surfaces, road surfaces, IR crossover times for FLIR,
electromagnetic effects, etc.)
TIP: To obtain astronomical data (sun & moon) on any given day, use the Naval Observatory
website: http://aa.usno.navy.mil/index.php
 Machines and equipment affected.
 Defects or irregularities.
 Light source, direction of light, shadows, etc.
 Sources of possible distractions.
 Locations and height of signs (road, work areas, etc.)
 Geographical elevations that may have effected visual fields.
 Objects damaged (includes under water).
 Gouges, scratches, dents, or paint smears.
 Areas of debris resulting from the mishap.
 Direction of weapons fire.
 Stains or fluids from POLs, body fluids, chemicals, etc.
 Path of travel to impact points.
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 Skid distance of vehicles.
 Distance between vehicle tip/trip to impact points and final resting position.
 Length of yaw marks.
 Road or lane width, curve median, and chord of curve,
 Working space distances between dangerous equipment and other hazards.
 Proximity and positions of witness and injured or deceased personnel to hazardous energy
sources such as pressure valves, hydraulics, pneumatics, springs, electricity, explosives.
 Tracks or similar indications of movement.
 Movement of personnel, before, during, or after a mishap
 Movement of machines/equipment or vehicles before, during and after a mishap.
 Size of operator’s compartment and proximity to hazards, switches, buttons, etc.
 Storage areas (to identify appropriate or inappropriate maneuverability of humans and/or
machines).
 Shoot house (potential hazardous components, target distances, etc.)
 Height of workstations (regarding maneuverability, visual field, etc.)
 Location of safety devices, safety barriers, and safety equipment (PPE)
NOTE: Vehicle Speed Calculation. It may be necessary to calculate speeds and distances for analysis. If it is
vital to the sequence of events and the analysis to determine the speed in which an object (i.e. MV) was
traveling at the time of the mishap, investigators should contact law enforcement (Military Police, State
Troopers, County Sherriff, etc.) for assistance in calculating speeds in vehicle mishaps.
Keep in mind that trained experts will not be available in the operational environment or the tactical training
environment. Therefore, it is highly recommend that unit and installation safety personnel (ASO, GSO, GSM,
and GS-0018) attend training from law enforcement in crash dynamics in order to collect required information
and calculate minimum speed for tactical MV mishaps. If not trained, investigators should collect
measurements, vehicle specifications, road surface type and the MV braking efficiency before you request
assistance from local enforcement (Military, City, County or State Police) to determine speed.
Example from
NAVEDTRA 12971, Jun 1993
Figure 7-1
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TIP: In the event of a mishap on a public
roadway and the scene has been cleared
away; investigators should maximize local
resources such as state, local, or military
police reports and site diagrams.
Figure 7-2
Linear Diagram
Figure 7-4 (Example diagram from Law Enforcement of a MV collision at a school zone.)
Figure 7-3
(Good for long debris fields of tactical vehicle & aviation crash sites)
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CASE STUDY (Mishap Sketch)
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d. Step 4 – Collect Physical Evidence: If it is important to collect physical evidence to further examine
later, carefully wrap them in protective material or place them in paper, glass, or plastic containers.
Accurately label each item with the following types of information:
1) Who gathered the item (You may want to question the person later about the position or location in
which it was found).
2) The description / identification of the item.
3) The time and date it was gathered.
4) The original location of the item when removed.
NOTE 1: It is critical to preserve digital source data from aircraft or vehicle recording devices (See
Appendix J).
NOTE 2: Physical evidence is NEVER wrong. Only human interpretation or manipulation makes it wrong.
TIP 1: When labeling evidence, make sure you do not put any information on the label that might be
privileged such as the source leading to your findings on the item or any deliberative comments.
Remember, physical evidence may need to be shared with non-safety agencies.
TIP 2: If the mishap requires NCIS or law enforcement to investigate, allow them to take custody as
they each are experts at chain of custody.
TIP 3: Ensure you have clear guidance in your unit’s Mishap Action Plan regarding the need to take
custody of certain physical evidence (i.e. weapons, parts of tactical vehicles, etc.) needed for an
Engineering Investigation (EI). An EI can provide an in-depth analysis of equipment function or
malfunction. When the investigator desires an EI, submit a request to the appointing authority. EIs are to
be conducted at the local installation whenever possible or contact the COMNAVSAFECOM for the
closest appropriate facility. Marine Corps units should contact MARCORSYSCOM and CMC(SD) for
assistance. The investigator or representative may accompany the part(s) in question and may be present
during all examinations. The request will include the material for the EI description of the physical
circumstances of the mishap, and description of the parts as found in the wreckage or damaged
configuration. Do not include privileged information. Do not tamper with, adjust, remove parts from, or
clean the material subject to the EI. EIs are an important source of factual information not only for the
SIREP but other reports as well and maybe required by other directives.
e. Step 5 – Collect Documentary Evidence: Any evidence that paper or electronic form, excluding
medical records. (Includes photos, video, technical manuals, emergency action plans, operational plans
(OPLANS), regulations, SOPs, letter of instruction (LOI), training records, maintenance records, safety data
sheets, job hazard analysis sheets or RM worksheets, safety committee minutes, weather reports, duty logs,
past mishap reports, diagrams, charts, maps, mishap site diagrams, investigator notes, etc.)
f. Step 6 – Collect Medical Evidence: Medical information about the operator and/or other team
members that may provide insight to preconditions that contributed to the actions of the operator, team
members and/or immediate supervisor. This includes medical records, lab results, pathological / autopsy
reports and the 72 hour profile beginning with the mishap operator.
1) 72 Hour Profile: A 72-hour profile traces the chronological actions and activities of individuals
directly involved in the mishap. The information may be valuable to help determine preconditions
that may have affected mental awareness, physical problems, mental problems, sensory
misperceptions and/or the state of mind. The following information is important to develop the
profile:
 Hours continuous awake prior to the mishap:
 Hours continuous duty prior to the mishap:
 Hours between the last meal and the mishap:
 Hours slept in last 24 hours, last 48 hours, and last 72 hours:
 Hours worked in last 24 hours, last 48 hours, last 72 hours:
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 Duration of last sleep period:
 Type of last sleep (broken or continuous):
 Distance in miles driven: (For MV operators)
 Duration (hours) of time driving:
TIP: The 45 Code of Federal Regulation provides conditions to overcome potential HIPPA concerns during
mishap investigations.
45 CFR 164.512 Uses and disclosures for which an authorization or opportunity to agree or object is
not required. A covered entity may use or disclose protected health information without the written
authorization of the individual, as described in § 164.508, or the opportunity for the individual to agree or object
as described in § 164.510, in the situations covered by this section, subject to the applicable requirements of
this section. When the covered entity is required by this section to inform the individual of, or when the individua
may agree to, a use or disclosure permitted by this section, the covered entity's information and the individual's
agreement may be given orally.
(a) Standard: Uses and disclosures required by law.
(1) A covered entity may use or disclose protected health information to the extent that such use or
disclosure is required by law and the use or disclosure complies with and is limited to the relevant
requirements of such law.
(2) A covered entity must meet the requirements described in paragraph (c), (e), or (f) of this section for
uses or disclosures required by law.
(b) Standard: uses and disclosures for public health activities.
(1) Permitted disclosures. A covered entity may disclose protected health information for the public health
activities and purposes described in this paragraph to:
(v) An employer, about an individual who is a member of the workforce of the employer, if:
(A) The covered entity is a covered health care provider who is a member of the workforce of such
employer or who provides health care to the individual at the request of the employer:
(1) To conduct an evaluation relating to medical surveillance of the workplace; or
(2) To evaluate whether the individual has a work-related illness or injury;
(B) The protected health information that is disclosed consists of findings concerning a work-related
illness or injury or a workplace-related medical surveillance;
(C) The employer needs such findings in order to comply with its obligations, under 29 CFR parts
1904 through 1928, 30 CFR parts 50 through 90, or under state law having a similar purpose, to
record such illness or injury or to carry out responsibilities for workplace medical surveillance;
and
(D) The covered health care provider provides written notice to the individual that protected health
information relating to the medical surveillance of the workplace and work-related illnesses and
injuries is disclosed to the employer:
(1) By giving a copy of the notice to the individual at the time the health care is provided; or
(2) If the health care is provided on the work site of the employer, by posting the notice in a
prominent place at the location where the health care is provided.
g. Step 7 - Conduct Detailed Cognitive Witness Interviews. The importance of a witness varies with
the mishap. In some cases, witnesses are absolutely vital when there is no recoverable wreckage, no
survivors or no recorded information. In other cases, witness’s statements are merely corroborative. In these
cases, it is interesting to note the differences between what the witnesses say and what the facts support.
Often personnel inexperienced in conducting “safety” interviews tend to be technicians who suddenly find
themselves in the interviewing business without any particular background or training in interviewing
techniques. The challenge for personnel (e.g. collateral duty safety personnel) inexperienced in conducting
a witness interview is they tend to conduct an interview “as seen on TV” or assert their rank or position in a
manner that is adversarial vs cooperative.
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People in some professions (clergy, medicine, psychiatry, etc.) tend to develop good interviewing skills
because they use them often. Also, those same professions typically attract people who are naturally
empathetic to other people.
Consider this: For those witnesses that saw or heard “what happened”, we are asking an eye witness to
convert the visual image they have in their mind into words that we can use to recreate the image and see
what he or she saw. The witness must translate what he/she saw into words which, we hope, have the
same meaning to him/her that they do to us. We might call this a "double translation" problem. The witness
must use words as they have meaning to him. We must use those same words as they have meaning to us
and come up with the same image.
The witness had only a fleeting glimpse of the mishap or he/she really wasn't in the right place to see
what we wish he/she may have seen. Frequently, the witness really didn't see the mishap; he or she saw
the results of it (i.e. the crash) which is not what we need. Determining what a witness saw is significantly
more difficult than determining what he or she did. Whatever the reason, we should do what we can to
improve our own techniques and increase the amount of information recovered.
Seasoned investigators from law enforcement and safety as well as the psychiatric community identify
there are two important truths about witness memory; it is fallible and confidence has little correlation with
accuracy. This section will identify common factors which make recall more or less accurate and the best
methods of eliciting the most reliable reports.
NOTE: For unit or command safety investigations, a safety officer conducting a safety investigation will not
take written witness statements. (Ref: Appendix C, paragraph 1)
1) Barriers that Affect Memory Recall: There are two types of memory retrieval that eyewitnesses
perform. First there is “Recall Memory” which is reporting details of a previously witness event or
person. Second there is “Recognition Memory” which is reporting whether what the witness is
currently viewing or hearing is the same as that previously witnessed.
Eyewitness testimony relies on storing and recalling information. The psychiatric community divide
memory into three phases: encoding, storage, and retrieval (Melton 1963).
For various reasons, not all memories pass successfully through these stages and problems may
occur at each stage. In the past, a great deal of credibility has been given to eyewitness testimony,
but its reliability has recently come into question. Increasing evidence shows that memories and
individual perceptions are unreliable, biased, and can be manipulated. Some key barriers as
illustrated in figure 7-5 to accurate memory recall include:
 Perceptual Factors: Human memory does not exist so that an observer may accurately report
previously seen events. The actual, physical events are merely grist for the mill of interpretation.
Each witness perceives the event somewhat differently; therefore, each witness extracts an
interpretation that is meaningful in terms of his/her own beliefs, experiences and needs. Once
the interpretation occurs, the events themselves become relatively unimportant. Moreover, since
each person interprets the events in terms of his/her own world view, different eyewitnesses
observing the same event may have different interpretations and different memories. (Marc
Green Ph.D ,2008) To put it succinctly:
"We do not see what we sense. We see what we think we sense. Our consciousness is
presented with an interpretation, not the raw data. Long after presentation, an unconscious
information processing has discarded information, so that we see a simulation, a hypothesis, an
interpretation; and we are not free to choose" (Norretranders, 1999).
Green points out that although Norretranders was talking about perception, the same basic
operation applies to memory: it is an interpretation, the raw sensory data is largely discarded,
and we are not free to choose, meaning that the transformation from raw data to interpretation
occurs automatically and outside volition. This is why people can be so certain despite the
distortion - they were not aware of having "altered the facts."
 Environmental Factors / Event Characteristics: factors that interfere with a witness's ability to get
a clear view of the event—like time of day, weather, and poor eyesight—can all lead to false
recollections. (Boundless, 2016)
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 Time: One factor that influences the encoding of memory is the duration of the event being
witnessed. Scientific studies suggests that recall is better for events that last longer.
Additionally, the accuracy of eyewitness memory degrades swiftly after initial encoding.
Scientists have documented that memory begins to drop off sharply within 20 minutes following
initial encoding, and begins to level off around the second day at a dramatically reduced level of
accuracy. Unsurprisingly, research has consistently found that the longer the delay between
encoding and recall, the worse the recall will be. There have been numerous experiments that
support this claim. Malpass and Devine (1981) compared the accuracy of witness identifications
after 3 days (short retention period) and 5 months (long retention period). The study found no
false identifications after the 3-day period, but after 5 months, 35% of identifications were false.
 External Factors: There are a wide number of external influences to memory and memory recall
such as introducing false facts into a person’s memory by a third-party (e.g. news media, friends,
social media, co-workers, etc.). In the mid-70s, Elizabeth Loftus did experiments that showed the
effects of third-party information effecting accuracy of recall. The results reveal that some of the
subjects false remembered seeing images that were not there during a particular incident. The
experiments also involved injecting words in certain questions that lead the subjects to
incorrectly provide accounts of what they saw. All of this show that sometimes eyewitness
testimonies may not be accurate.
TIP: Keep witnesses separated while waiting to interview them. That way they can't confer with other
witnesses and mentally fill in parts of their observations based on what someone else may have seen or heard.
 Interviewer Questioning Techniques: Research has consistently shown that even very subtle
changes in the wording of a question can influence memory. Questions whose wording might
bias the responder toward one answer over another are referred to as leading questions. One
classic study was conducted in 1974 by Elizabeth Loftus, a notable researcher on the accuracy
of memory. In this experiment,
Fisher and
Geiselman
participants watched a film of a car
1992
mishap and were asked to estimate the
speed the cars were going when they
"contacted" or "smashed" each other.
Results showed that just changing this
one word influenced the perception of
speed estimated by the participants: The
group that was asked the speed when
the cars "contacted" each other gave an
average estimate of 31.8 miles per hour,
whereas the average speed in the
"smashed" condition was 40.8 miles per
hour.
 Age: Age has been shown to impact the
accuracy of memory; younger witnesses
are more suggestible and are more
easily swayed by leading questions and misinformation.
Figure 7-5
 Personality Barriers (3 Types) (Fisher and Geiselman 1992)
o Motivational Barrier: The underlying problem with this type of a witness is that he/she thinks
only about his/her personal problem and does not go beyond personal influence to larger
implications. This is often exacerbated by media and/or advisors. This person does not
believe you can reasonably identify with his/her problem. This may also include the person
who is trying to protect themselves or someone else from disciplinary action.
o Cognitive Barrier: This is the witness does not know the “rules of the game”; no prior
experience with an interview process. His/her only relevant experience may likely derive from
TV or social media which is completely inappropriate. Also, when we see Event A, we apply
our experiences and we expect it to result in Event B, because that is normally what happens
or what makes sense after event A.
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1992
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Witnesses can experience temporal time distortion where time seems to stand still and the
mishap seems to happen in slow motion. Because of this misperception, witnesses will
consistently tend to overestimate time. In addition, the witness' attention just naturally follows
the most dramatic part of the mishap; the biggest piece or the one that is burning. He/she
may not even notice that a wheel was loose or a tire went flat. The human mind is
programmed to relate order of occurrence with order of perception. If we saw or heard it first,
it must have happened first. Because of the difference in the speed of light and the speed of
sound, this is not necessarily true. Even though you know what's happening, your brain will
still tell you that the events are occurring in the wrong order.
Lastly, we are influenced by everything we hear and read about the event after it happened.
There is another phenomena called "Retroactive Amnesia." When we witness a very
dramatic event, a crash for example, there is a tendency for the details immediately preceding
the event to be blotted out of our memory. The longer the time from the event and the more
external influences we see and hear, the less likely we are able to recall accurate details.
o Emotional Barrier: The emotional tone of the event can have an impact: for instance, if the
event was traumatic, exciting, or just physiologically activating, it will increase adrenaline and
other neurochemicals that can damage the accuracy of memory recall.
Nervousness, or fear can also affect a person’s memory. Some people feel pressured when
everyone else in the room is counting on them. This might lead them into saying something
that is wrong or inaccurate. Oftentimes, emotions get the best of us. When that happens,
people might remember things or events differently. They might not be able to accurately
recall the sequence of events or crucial details that will help prevent future events.
For some people, giving an official statement is an unpleasant experience. They feel
intimidated by the surroundings or the person(s) conducting the interview. If you want to get
the best statement, you should remove as many of these intimidating influences as possible.
A witness is likely to be more at ease and comfortable in his own surroundings; not yours.
This witness may also be in fear of reprisal. You cannot expect a witness to tell you things
that are likely to result in some inappropriate action.
2) Cognitive Witness Interview Techniques to Promote Active Witness Participation. Most people’s
impression of witness “interview” is what they see on TV or in the movies. The common belief is that
interviews are accusatory, they last a couple of minutes and the interviewer will solve the case. You
must disabuse them of the belief the interview will be short and that you will solve the case.
When the testimony is obtained and reported right after the event took place, the witness’ memory
is still fresh, which means that there is a higher chance that his/her account of the incident is still
vivid in his/her mind. This makes his or her testimony more valuable and investigators will be able
to better understand and envision exactly ”what” occurred and help to postulate “why” the mishap
occurred.
GOAL: To elicit the witness’s ______________ participation to help solve the problem / prevent
future mishaps. This is achieved by adherence to three key practices.
 First - Build Rapport: Developing rapport and actively listen. (Interviewers do not spend enough
time developing rapport. This is exacerbated by panel of interviewers.)
o Present yourself as a person and develop a personal rapport with the witness.
o Chat for a few minutes. (NOTE: For the “Motivational Barrier” witness, be sure to identify with
the witness’s problem. If the witness is focused only on his/her problem with the mishap, then
make it about him/her. Develop a rapport with understanding and self-disclosure.)
o Find something in common with witness. (E.g. Sports, recreational activities, units/commands
served, deployments, home states or towns, entertainment, etc.)
o Give the witness a chance to relax. Ask some routine questions for basic information such as
the correct spelling of their name, their current job and a brief job description. Also ask if
there were any previous jobs having a bearing on the mishap. (NOTE: These type of
questions can also provide you valuable information on the validity of their statement.)
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TIP: While the witnesses are waiting for the interview, keep them busy outlining the sequence of events or
making a sketch of the mishap site. Both will help the witnesses remember important information about the
mishap. (Remember - The witness outline or sketches are not privileged.)
 Second - Supportive Interviewer Behavior: Provide a non-judgmental, non-threatening,
empathetic, and cooperative environment.
Fisher and
Geiselman
1992
o Completely explain who you are and the purpose of a mishap investigation. The perception of
an “investigation” is that all investigations are legal/collateral investigations. You must ensure
the witness understands the difference between a safety investigation and a non-safety
investigation.
o Display an attitude of concern over finding the mishap causes and preventing it from
happening again.
o Encourage the witness to provide specifics about what s/he is thinking. If the interviewee
appears to be having difficulty thinking aloud, use such prompts as: “Tell me what you’re
thinking.” or “What are you thinking about right now?”
o Do not interrupt but provide non-verbal reinforcement to let the interviewee know that you are
listening. (i.e. non-verbal acknowledgement such as nodding your head, saying ‘mm hmm,’ or
saying ‘okay,’ or ‘I understand”)
 Third - Transfer of Control: Resolving any apparent conflict is crucial for a successful interview.
Therefore, after developing rapport, the interviewer will in effect transfer control of the interview
to the witness. The interviewer generally has higher social or expert status, which normally
dictates that that the interviewer should control the interview; however, the witness has first-hand
knowledge of the mishap or something related to the mishap, which dictates that:
o The witness is the central character in the interview, because he/she has event-related
information.
o The interview process revolves around the witness’s knowledge.
o The witness should play an active role in the interview.
o The witness, not the interviewer, should do most of the mental work.
o Explicitly instruct witness of his/her role. Interviewers should openly acknowledge that s/he
was not at the scene and that the witness must play an active role in the interview. This
clarifies for the witness the role that s/he will be playing during the interview, and that s/he
should not wait for the interviewer to ask questions. It is commonly desired that the
interviewer contribute only 20% of the talking during an investigative interview (Snook &
Keating, 2010), thus preserving the “80-20” rule.
TIP: As the investigator/interviewer – DO NOT…
- Make regular direct eye contact.
- Use a negative attitude, intimidate or threaten.
- Rush the witness
- Use inflammatory words (killed, lied, stupid, failure, etc.)
- Interrupt or cut the witness off
- Dominate the witness
- Judge or blame the witness
- Make promises you can’t keep
- Suggest answers
- Re-teach witness what they should have done.
- Omit questions
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Witness Interview Key Points: In accordance with OPNAV M-5102.1_/MCO P5102.1_ (Appendix A &
C) and OPNAVINST 3750.6_.
 A witness shall _____ testify under oath.
 A witness shall _____ give a sworn statement.
 Witnesses shall provide personal opinions and speculations.
 Interviewers shall use investigator (safety officer) notes as the ___________ written record.
 Interviewers shall not include witness names in notes.
 Interviewers shall not have witnesses sign a summary.
3) Techniques to Maximize Recall: There are several techniques to maximize a witness’s memory
recall of events leading up to and during the mishap. They include:
Fisher and
Geiselman
1992
 Warm-up Question. A technique used by some seasoned interviewers is to ask a “warm-up”
question. The purpose is to help the witness better understand the process and the level of
detail you expect. An example question is: “Before we begin the actual, I’d like to ask you a
‘warm-up’ question to introduce you to the think aloud process.”
 Questionless Interview (Open-Ended Questions). The “open-ended” question is the primary tool
to solicit the best response. The goal is to have the witness provide a complete verbal account
while you take notes. The most successful interviewers ask the fewest questions to avoid placing
heavy demands on themselves and disrupting the witness’s thought process. Additionally,
idiosyncratic information cannot be generated from questions, but only from active witness. (See
figure 7-6)
 Closed Eyes Recall Method: To promote a more focused concentration, encourage the witness
to close their eyes, ask them to place themselves in that time and space, and re-tell the story.
 Drawing Diagrams: Provides the witness an opportunity to draw the scene and narrate. This too
promotes focused concentration.
 Power of the Pause: For the interviewer a pause is a passive yet excellent tool for eliciting more
information. After a subject answers a question or finishes recalling his/her version of a
sequence of events, try waiting a few seconds before you respond. As this silence naturally
presents an awkward moment, your pause can give the witness the impression that you may
know more than they realize and you expect them to be forthcoming.
 Re-Enactment: The main challenge for the investigator(s) is to distinguish between accurate and
erroneous information. You may encounter conflicting information while examining evidence. If
the witness accounts are conflicting, then significant new information can be gained from a
reenactment. Having witness and/or participants re-enact their actions during the interview
process may be useful as memory is not as clouded as it would be later. However, investigators
may also need to use this technique during the analysis phase as the re-enactment can either
provide a key to prevent recurrence or verify theories and opinions of the investigator(s).
If possible, use the original personnel involved in the mishap however, re-enactment is not
advisable if the participants are emotionally upset, tense, or agitated. When reenacting mishap:
o Ensure qualified supervisory personnel monitor the progress of the re-enactment.
o Brief the participants to use a talk-and-walk method of re-enactment.
o Warn the participants not to repeat the act or unsafe practice that caused the mishap. Be
prepared to stop the re-enactment if the participants are about to take an unnecessary risk.
o Ask participants to demonstrate their actions slowly and deliberately, explaining as they
demonstrate.
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Examples of OPEN ended Questions:
• What was the first thing that attracted your attention to the mishap?
• What can you tell me about…..?
Or what do you think about……..?
• Describe what you remember about the area and the people just before the mishap?
• Can you describe everything you remember about your day leading up to the mishap?”
• How exactly did it start?
• What is the normal process for ……?
• Tell me exactly what happened and how you handled it.
• What types of things have made you angry?
How did you react to those situations?
• In your experience, tell me about a time when you stuck to company policy to solve a problem when it
might have been easier or more immediately effective not to. Give me an example of a time when
communicating with a fellow work was difficult and give me an example of how you handled it.
• What experience have you had with a miscommunication with a fellow employee / Marine / Sailor?
How did you solve the problem?
• Tell me about a time when an upper-level decision or a policy change held up your work.
• Have you ever had to make a sticky decision when no policy existed to cover it? Tell me what you did.
• Describe a time when you communicated some unpleasant news or feelings to a supervisor.
What happened?
• What has been your experience in dealing with poor performance of subordinates? Give me an
example.
• In your current (or most recent) position, what types of decisions do you make without consulting your
boss / supervisor?
• Give me an example of a time when you got really motivated at work.
• What have been major obstacles which you have had to overcome on your most recent (or current)
job. How did you deal with them?
• Describe a situation in your last (or current) job where you could structure your own work schedule.
What did you do?
• Describe for me a time when you made a mistake where you feel a need for improvement in a certain
area.
• You have heard the expression, "being able to roll with the punches"? Describe a time when you had
to do that.
• Why do you think this mishap occurred?
• On the day of the mishap, was there anything different in the process or that anyone was doing
from other times? Can you describe what was different?
• If you could be the “Boss/CO”, "Commandant / CNO” or “Sgt.Maj. / MCPON” for a day, what
changes would you make to prevent this mishap from happening again?
Figure 7-6
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4) Wrapping up the Interview:
 Summarize / Rephrase: Once you and the witness feels he/she has provided all information, a
good technique is to read back what you have written. This gives the witness another
opportunity to fill any gaps and to ensure you (the interviewer) interpreted all information
correctly.
 Ask Closed-ended Questions: The use of “closed questions” should be strategic and only used
at the end of an interview to help fill in the gaps or solicit specific responses. The interviewer
should have a list of well-prepared closed questions to ask if needed. (I.e. information to
complete the 72 hour profile). The DoD HFACS is an excellent tool to develop interview
questions such as those required for the 72 hour profile. (See Unit 8-9 “Compliance / NonCompliance Tool” of this handbook)
 Share contact Information: Personnel involved will continue to think about the mishap even after
the interview has terminated—and thereby recall new details. A best practice is to contact the
witness after the interview and ask if he/she has any new recollections. Such a post-interview
follow-up should help to reassure personnel of the interviewer’s concern about the witness as a
person and not merely as a “fact generator”. These post-interview contacts are particularly
important to the public relations component of safety.
5) Post Interview Actions. Write a summary and store your notes/summaries in a safe or lockable file
cabinet. Nothing can destroy your credibility or effectiveness as a safety investigator more quickly
than for word to spread safety is giving information to people after you promised the witness you
would not. Once complete –TRANSCRIBE all witness notes & recordings and DESTROY all
WITNESS WRITTEN MATERIAL.
Note: “the only written record should be notes taken by the investigator.” (Ref: Appendix C,
para2)
Evidence Collection Priorities review Questions
Q: What are the four types of evidence collected in a DON mishap investigation?
A: ______________________________________________________________________________
Q: (True or False) Before the interview begins, the witness should be read their Miranda rights and/or
make a sworn statement.
A: ___ Why? ______________________________________________________________________
Q: According to Fisher and Geiselman 1992, what are three personality barriers the interviewer may
encounter and likely have to overcome during witness interviews?
A: _______________________________________________________________________________
Q: IAW Navy and Marine Corps policy, what should be the ONLY written record from witness interviews?
A: _______________________________________________________________________________
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Unit 8:
Causal Factor Analysis (Why It Happened)
8-1. INTRODUCTION
a. Overview. The reasons why people make errors, or materiel fails, or injuries occur in a mishap are the
keys to mishap prevention. Identification of contributing active and latent failures by individuals, supervisors
and/or the organization can be particularly challenging.
Analyzing causal factors is a process that allows the mishap investigator(s) (unit/command or a SIB) to
probe, discover and ponder through use of facts to test presumptions and scenarios to determine mishap
causes. The systemic analysis of data collected during the investigation allows investigators to deduce
causes and develop recommendations for corrective actions. With few exceptions (E.g. insufficient
data/evidence to make conclusive findings), the conclusions and recommendations are directly supported by
the analysis of data. Formal analysis begins when the unit/command investigator or the SIB determines
sufficient data has been collected to pursue analysis.
The objective of the causal factor analysis process is for the DON safety community to identify the facts,
reconstruct and sequence the true course of events (“what” happened), then use a detailed and methodical
process to identify the multiple and interrelated causes (“Why” did it happened).
b. Preparation. The facility used to conduct the analysis and deliberations should be secure, free from
distractions, and allow for complete privacy. The investigator(s) (i.e. Unit/Command or members of a
SIB/AMB) must be able to facilitate and record the analysis and deliberations. It is important for privacy and
ability to protect all evidence and investigator analysis products. Mishap unit commanders must allow his/her
safety team or a SIB/AMB to operate in an area that ensures accuracy and completeness of analysis as well
as safeguarding of privileged safety information.
c. Methodology – Analysis Tools. Caution must be taken in applying analytic methods. First, no
single method will provide all the analyses required to completely determine the causal factors of a mishap.
A structured and meticulous analysis of the data provides the best opportunity for the investigators to reach
accurate conclusions. A number of mishap analysis methods are used by seasoned Navy and Marine Corps
safety personnel to determine causes of a mishap (see figure 8-1 below and Table 8-1). Each method has
different areas of application and the investigator should be prepared to use several to ensure a
comprehensive investigation. This section provides an understanding of how to utilize some commonly used
methods for investigating mishaps and certain near-mishaps.
Is there a possible failure of a system or process?
Can a deductive approach be useful?
Begin with an analytical method
(CFAM, MORT, PET, Fault Tree Analysis, etc.)
Was there a change in a
process?
Was there a materiel failure?
Was there a failure of a
barrier/control?
Change Analysis
Materiel Analysis (E/I)
Barrier Analysis
Did human error or human-machine or human-environment interaction affect the mishap?
DoD Human Factors Analysis
Compliance / Non-Compliance Analysis
Figure 8-1
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MISHAP ANALYTICAL TOOLS
Method
When to Use
Advantages
Easy to apply and
provides a
To help identify all the
Causal
comprehensive
Factors
reasons why a process
overview of how a
Analysis
went out of control.
single quantity depends
Mapping
For multifaceted problems on other quantities.
(CFaM)
with long or complex
Provides visual display
AKA: Cause causal factor chains.
of analysis process.
and Effect To visually depict error
Identifies contributing &
Analysis
pathways.
causal factors to any
event.
Disadvantages
Time consuming
and requires
familiarity with the
process to be
effective.
Remarks
Identifies many possible
causes of a problem.
It can be used to structure a
“Risk Assessment” session
during a pre-event Planning
Process.
Makes the distinction between
conditions that allow other
conditions to exist or affect
events. Helps to identify where
deviations occurred from
acceptable methods.
When problems involve
human factors or
interactions.
Determine relationships
between causes.
Simplest of tools without
statistical analysis.
Causal factors
may not be
identified w/o all
facts.
Excellent tool to use in
conjunction with CFAM to ask
“why did an event occur?” or
“why did a specific condition
exist?”
Barrier
Analysis
Identify barrier equipment
failures and procedural or
admin problems
Provides systemic
approach.
Requires
familiarity with
process to be
effective.
This process is based on the
MORT Hazard / Target
concept and may require input
from systems safety engineers.
Change
Analysis
Use when cause is
obscure. Especially useful Simple Six-step
in evaluating equipment
process.
failures.
Limited value:
Danger of
accepting wrong.
“Obvious” answer.
A singular problem technique
that can be used in support of
a larger investigation. Causal
Factors may not be identified.
Analysis and long
term corrective
measures will
likely take more
than 30 days.
Engineering investigations are
to be conducted at the local
installation whenever possible.
An engineering investigation
(EI) can provide an in-depth
analysis of equipment function
or malfunction. When the
investigator desires an EI,
submit a request to the
appointing authority.
Likely will not
achieve positive
Inter-rater
reliability without
effective
understanding of
applicability.
Nano-codes may apply directly
to the “unsafe act” or to
another nano-code that applies
directly to the “unsafe act”.
The categories within each
major tier may be used to
assist in risk analysis and the
planning process.
Limited use
without using the
DoD HFACS.
This technique compares
evidence collected against
three categories of
noncompliance to determine
the deeper causes of a
noncompliance issue.
Five Whys
Materiel
Analysis
DoD HFACS
When there is a suspected
failure of equipment,
weapons systems,
Improve engineering
vehicles systems,
controls as well as fit,
communications systems form, and function.
or components of a
system.
In conjunction with causal
factors analysis mapping
Structured analysis of
error pathways.
Applicable to all
mishaps & near
mishaps.
Targets the need for
specific intervention
(RM controls) - better
command decisions
Helps develop closedended interview
questions.
Helps determine if acts
Compliance When investigators
/ Nonsuspect noncompliance to are error or violation.
Compliance be a causal factor.
Also helps determine
preconditions and
potential organizational
influences.
Table 8-1
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TIP: These tools best apply to “High Potential” on-duty mishaps (HIPOM) that require more level of
scrutiny. These are mishaps meet the DoD and DON criteria of first-aid injury, class D or C injury or
damage. Unlike some reportable mishaps such as off-duty/recreational mishaps or the twisted ankle during
PT, a HIPOM is an on-duty mishap which had the potential to result in a more severe loss or significantly
degrade mission capability and readiness). (See Appendix C of this handbook for definitions of HIPOM)
8-2. CAUSAL FACTORS ANALYSIS MAPPING (CFaM). CFaM is the PRIMARY analysis tool
used by investigators of CMC (Safety Division) and the Naval Safety Center. The CFaM (see figure 3-7) is a
hybrid of other analytical tools from many agencies and/or academic studies (e.g. The Management
Oversight and Risk Tree (MORT) developed by US Department of Energy, Lean-Six-Sigma, Events and
Conditions analysis and “Cause Mapping” by Think Reliability”)
The CFAM is easy to develop and provides a clear depiction of the data. Investigators use either “post-it”
notes or MS Excel or a mapping software to provide a graphical depiction of the mishap’s sequence of
events (what) and the layers of conditions (why) that allowed significant events to occur. Keeping the map
up-to-date helps ensure the investigation proceeds smoothly and investigators have a clear representation of
the cause and effect relationships.
a. Key benefits of the CFaM
1) Provides a structured method for organizing and integrating the collected evidence;
2) Graphically depicts the triggering conditions to events necessary for the mishap to occur;
3) Identifies information gaps to collect additional data for analysis;
4) Identifies hazardous trends of systemic deficiencies and oversights;
5) Links facts to organizational issues and/or management systems that trigger a chain of conditions
and events;
6) Identifies relationships between organizational influences that had a cascading effect to individual
actions;
7) Provides the investigator with an effective visual aid when writing the mishap investigation report;
8) Provides a visual representation of accurate information to aid in briefing commanders.
b. CFaM Process.
1) CFaM Process STEP 1 – Establish a Sequence of Events. The chain of events may have begun
days, weeks, months or years before the mishap even occurred. You must take all the events
surrounding the mishap and put together like a jigsaw puzzle. Developing a time line may be
accomplished by looking at each piece of evidence (documents, photos, witness interviews, logs,
records, etc.) and documenting each event on a self-stick note pad or in software. (See figure 8-2).
Event: A point in time defined by a specific _______________ (1 Noun, 1 Verb)
“An occurrence; something significant that happens in real-time. A mishap involves a sequence of events
occurring in the course of work activity and culminating in unintentional injury or damage (DOE 2012).”
Primary Event Line: The key sequence of occurrences that led to the mishap. The primary event line
provides the basic logical progression, but it does not provide all of the contributing causes. This line
always contains the mishap, but it does not necessarily end with a mishap event. The primary event line
can contain events that may likely become conditions later in the sequence nearing the mishap.
Secondary Event Lines. The sequences of occurrences that occurred at the same time as primary
events and together are both relevant to the mishap as they converge.
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A “Best Practice” is to use “Self-stick note pads”. One may also use a computerized charting
capability and graphic programs are if available. MS Excel is an excellent tool to use.
EVENT
(Noun + Action Verb)
Example of “post-it note”
Individual did x
Team did x
Weather did x
Equipment did x
(Example: Mishap driver
began to back the mishap
vehicle)
Date
Source
Source Info may be
written on the back if
needed
Time
Figure 8-2
EVENT
(Noun + Action Verb)
Individual did x
Team did x
Weather did x
Equipment did x
(Example: Mishap ground
guide tripped on the gripe)
Source
BEST PRACTICE TIP: By writing the date, time and sources of the information on the “Post-it” note,
investigators will be able to better retrieve evidence to validate facts during the analysis and
deliberation process.
Once events are documented, the next step is sequencing the events. Working backwards to
minutes, hours, days, weeks, months, perhaps years helps identify significant events, unit
milestones, unit SOPs, and other activities that could have allowed a cascading effect of latent
conditions to exist thus leading to the mishap. These timelines allow the investigators to analyze
policies and events in the proper context and weigh the role each may have played in the resulting
mishap. (See figure 8-3).
Look as far back as needed to find a cause that could prevent recurrence. (For example,
maintenance done on a tactical vehicle six weeks ago could be a contributing cause to a crash.
Disconnecting a backup warning bell on a fork truck last year may have contributed to a worker
being run over last week.)
Fig 8-3 (Sequence of events)
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2) STEP 2 – Determine which Events were Significant. The main challenge for the investigator(s) is to
distinguish between accurate and erroneous information in order to focus on areas that will lead to
identifying the causal factors. You may encounter conflicting information while examining evidence
(documents, physical evidence and witness interviews). Constantly review the facts for relevance
and accuracy to ensure only truly factual information is considered.
Begin with the first event that immediately precedes the mishap. Evaluate its significance in the
mishap sequence by asking, “If this event had not occurred, would the mishap have occurred?” If
the answer is, “The mishap would have occurred with or without this event happening” (e.g., the
individual reported for duty/work at 0700), then the event is not significant. Proceed to the next
event in the sequence, working backwards from the mishap.
 If the answer to the evaluation question is, “The mishap would not have occurred without this
event,” then determine whether or not the event represented normal activities with the expected
consequences.
 If the event was intended and had the expected outcomes, then it is not significant to the
negative outcome.
 However, if the event deviated from what was intended or had unwanted consequences, then it
is a significant event.
3) STEP 3 - Determine “why” each event occurred. Using all collected evidence, carefully examine
each significant event to assess what “condition(s)” existed for the event to occur. You may find that
more than one condition either existed or had to exist for the event to occur. (See figures 8-4 & 8-5)
A Condition is a distinct state that facilitates the occurrence of an event or other conditions leading to
the event. Such as :

_____________________status / conditions,

conditions of ______________ (team members) and

______________________ conditions.
Presumed Conditions are conditions investigators believe affected the mishap sequence, but the effect
could not be substantiated with hard evidence. However, for the event or other condition(s) to exist, the
presumed condition is the most logical in the sequence of cause and effect. Often, presumed conditions
require further collection of evidence in an attempt to provide reasonable proof of the existence of the
condition.
TIP: Triangulation Method: Triangulation is a powerful technique that facilitates validation of data
through cross verification from two or more sources. In particular, it refers to the application and
combination of several research methodologies in the study of the same phenomenon. In the social
sciences, triangulation is often used to indicate that two (or more) methods are used in a study in order to
check the results.
Minimum of three (3) pieces of factual evidence that supports a hypothesis. This may include any
combination of each type of evidence such as:
 Witness Statements
 Physical Evidence
 Documentary Evidence
 Medical Evidence
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Once the initial conditions are identified, then continue to assess each condition separately and
identify each layer of conditions that allowed other conditions to exist until the evidence ends. This
is achieved by asking a series of questions (See section e. The Five Whys, below and figure 38). One can frame their questions in several manners, such as:
 Why did this event happen / what condition or conditions existed to allow the event to occur?
 Why did this condition exist or what other conditions allowed this condition to exist?
 Are there other conditions that allowed these conditions to exist?
 How did this event or all these conditions originate?
 Are there any relationships between what went wrong in this event chain and other events or
conditions in the mishap sequence?
 Is the significant event linked to other events or conditions that may indicate a more general or
larger deficiency at the organizational level?
Figure 8-4 (Causal Factor Analysis Map)
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Unit 8:
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Sequence of Events (i.e. Points in time defined by specific actions)
Mental Fatigue is one of
four “Contributing Causes”
in this example
Why did the fatigue
condition exist?
Compounding Conditions generated by use of the “5-Whys” tool.
Why did the Mishap
Operator drink a 4th
“Monster” energy drink?
Mapping shows trends of causal factors
Two separate “ Causal Factors” in this example
Figure 8-5 (CFAM Example)
4) STEP 4 – Use other analysis tools to refine causal factors. If warranted, investigators may choose
to also use other tools (i.e. “5-Whys” Change Analysis, Barrier Analysis, Materiel Analysis) to
provide more details into specific factors and help discover more effective solutions. Whichever
alternate analysis tools are used to help develop the CFAM, once the CFAM is complete,
investigators must apply the DoD HFACS taxonomy to analyze the pathways or series of human
influence.
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8-3. THE FIVE WHYS ANALYSIS. The “Five Whys” began at the Toyota Motor Company and
became a component of Six Sigma. This simple technique is used to explore the cause & effect relationships
underlying a specific problem and is a valuable tool when used in conjunction with other analytical tools (i.e.
CFAM, Barrier Analysis, Change Analysis, etc.).
The goal of applying the five whys method is to determine a root cause of a defect or problem. By asking
a “why” question, it identifies conditions/causes that allowed certain events and other conditions to occur.
Often the answer to the first “why” uncovers another reason and generates another “why.” In actual practice,
investigators will probably find that one will ask more or less than five whys. Some root causes can be
discovered after only three “whys” while others may take asking “why” up to seven or eight times. On
average, one will discover a root cause of a problem after five why questions.
The 5 Whys process involves selecting one event associated within a mishap and asking “why did this
event occur?” (See figure 8-6) Once the condition(s) are identified that lead to the event, the investigator
continues to follow each “condition” and ask “Why was this condition allowed to exist?” This produces the
most direct path for each of the sub-events or conditions affected other conditions and/or events. Repeat the
process for the other events associated with the mishap.
a. Benefits: The 5 Whys offers some real benefits at any maturity level: It is easy to use and requires no
advanced mathematics or tools; It is effective to help quickly separate symptoms from causes and identify
the root cause of a problem; It is comprehensive in that it aids in determining the relationships between
various problem causes; It’s flexibility as it works well alone and when combined with other troubleshooting
techniques. It is engaging in nature as it fosters and produces teamwork and teaming within and without the
organization and is a guided, team focused exercise.
b. Limitations. Without good evidence: A team consensus may not be reached; Results are not
reproducible or consistent if multiple personnel are analyzing the same data. Without the same evidence or
information, another team analyzing the same issue may reach a different solution; Factors may not be
identified if used as a stand-alone technique. It MUST be used as an additional tool to the CFAM.
Figure 8-6
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8-4. BARRIER ANALYSIS. This tool is based on the premise that hazards are associated with all
mishaps. Barriers (aka control, defense, stop-gap, etc.) are developed and integrated into a safety
management system (SMS) or work process such as a job hazard analysis (JHA) or pre-mission deliberate
risk assessment. The goal is to protect equipment and personnel from hazards and ensure a mishap free
task, job, training event or mission. For a mishap to occur, there must be a hazard which comes into contact
with a target, because one or more barriers (or controls) were unused or failed. (see figures 8-7 and 8-8)
Target
Hazard
Hazard
TIP: Barriers / Controls are:
- Engineering
• Materiel Design
Barrier
- Administrative
• Regulations, Policies, SOPs
Hazard
• Workplace Practices
• JHAs or Risk assessments
Figure 8-7
• Signs
• Training, Rehearsals, Briefings
- Physical
• Guards, Covers, Fencing, PPE
Figure 8-8
a. Benefits.
1) Requires minimal resources; Works well in combination with other methods; and Results translate
naturally into corrective action recommendations.
2) Barrier analysis helps investigators to determine if an Engineering Investigation (E/I) is required, or
further support human factors analysis and ultimately helps develop more effective
recommendations for corrective actions.
b. Limitations. Sometimes promotes linear thinking and subjective in nature; Can confuse causes and
countermeasures; Reproducibility can be low for cases that are not obvious or simple.
c. Barrier Analysis Process. This tool is used in conjunction with the CFaM when an investigator
desires to know why a barrier was either not used, failed or did not exists. The process is to use the
evidence to develop a worksheet. (See Table 8-2)
1) List the barrier. (On paper, dry erase board, etc.);
2) State the barrier type. (engineering, administrative or physical);
3) Describe the purpose of the barrier. (You may require a technical manual, user’s manual, SOP,
etc.):
4) Determine the performance of the barrier. (Did if Fail, was it Not Used, was it Not Used Properly, or
did it Not Exist?):
5) State the effect the performance. (or lack of) had on the mishap:
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BARRIER ANALYSIS WORKSHEET
Name of
BARRIER
TER
Electrical
safety Pin
Procedure to
connect
pigtail and
remove TER
pin
Trained
Firefighting
Teams
BARRIER
TYPE
(Engineering,
Admin, Phys.)
PURPOSE OF BARRIER
PERFORMANCE OF
BARRIER
(Failed, Not Used, Did Not
Exist)
Effect on Mishap?
RAC
Engineering
Prevent electrical circuit
completion and an
inadvertent rocket launch.
Failed. Pins were
known to be pulled
out prematurely due
to high winds.
Allowed rocket to
fire
H (IC)
Administrative
To incorporate safety
measures to ensure safe
flight deck operations and
protect personnel and
equipment.
Not used properly.
Sailors violated policy
and SOP when the
connected pigtails on
the fantail while
planes were facing
each other.
Allowed charge to
reach rocket pod
H (IC)
Administrative
To ensure all personnel
assigned to a team are
properly trained to
extinguish fires and
protect personnel and
equipment
Failed. Only (1)
trained team was
available which was
eliminated after
explosion resulting in
untrained personnel
fighting a fuel fire.
Washed away
foam.
Washed burning
fuel below decks –
exacerbating
human loss.
EH (IIA)
Table 8-2
NOTE: If erroneous instructions or discrepancies found in the content of technical publications that would
jeopardize operation, maintenance, or performance of the item or equipment supported are discovered,
these shall be reported per SECNAV M 5210.1_, OPNAV 5215.17 and MCO P5215.17_.
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8-5. CHANGE ANALYSIS. Change is anything that disturbs the “balance” of a system operating as
planned. Change is often the source of deviations in system operations. Change can by planned, anticipated,
desired, or it can be unintentional, unforeseen and unwanted.
Change analysis examines planned or unplanned changes that caused undesired outcomes. The
investigator performing the change analysis identifies specific differences between the mishap free situation
and the mishap scenario. These differences are evaluated to determine whether the differences caused or
contributed to the mishap. For example, why would something that operates correctly 99 times out of 100 fail
to operate as expected one time?
This tool is used in conjunction with the CFaM when an investigator desires to know the differences between
what has occurred before or what was expected to occur and the actual sequence of events. The benefits of
this method are that it is particularly useful in identifying obscure contributing causes of mishaps; it is easy to
use and apply with minimal resources and it works well in combination with other methods.
a. Change Analysis Process. The process is to evaluate three areas of PERSONNEL (staff, training
qualifications, supervision, etc.); PLANT/HARDWARE (equipment, location of activities, etc.) and
PROCEDURES & MANAGEMENT Controls (Policies, SOPs, training, etc.). (See Table 8-3)
1) List the area in need of analysis. (Personnel, Plant/Hardware, or Procedure & Management) on
paper, dry erase board, etc.;
2) State the mishap situation. (E.g. Personnel conducting a task outside their expertise, crew was
forced to use dead-lined equipment, unofficial change to training methods, etc.);
3) State the mishap free or ideal situation. (E.g. Only use competent & trained personnel, prevent use
of dead-lined equipment, use only approved training methods, etc.):
4) State the difference the change affected the mishap. (Untrained personnel conducting high risk
task, dead-lined equipment created unnecessarily greater risk of injury, unofficial SOP change
created an unreasonably high risk situation to students and instructors):
5) State the effect or impact on the mishap. (Untrained personnel conducting high risk task increased
the severity of injuries; use of dead-lined equipment caused loss of personnel; unofficial SOP
change failed to consider new hazards and resulted in loss of humans and training mission)
CHANGE ANALYSIS WORKSHEET
Factors
Mishap Situation
What is the
Ideal or
Mishap Free
Situation?
Difference
Effect or Impact on
Mishap
RAC
Personnel
(Staff, Training
Qualification,
Supervision, etc.)
(1) Trained Fire
crew
Multiple
trained fire
crews
Untrained Sailors
fighting fire
Increased the severity
of loss to personnel and
ship.
2(IIB)
Or
H(IIB)
Loose safety
pins in rocket
pod
Push-Pull
Safety pins
Plant /
Hardware
(Conditions,
equipment,
location,
activities, etc.)
Procedures &
Management
Controls
(Hazard analysis,
SOP, Policy,
training, etc.)
Outdated an
inappropriate
ordnance
Unofficial SOP
change to arm
rocket pods
while starting up
planes.
Modern /
correct
ordnance
Arm rockets
on catapult
per SOP
 Suspected to have
come out w/ high
winds.
 Bombs not designed
for cradle
 Old bombs were
unstable, with short
“cook off” time.
Unofficial change in
procedure without
approval from CO.
 Allowed current to
reach rocket pod
 Bombs fell from
cradles with ease
 Quicker explosion
 Pigtail connected with
missing safety pin
allowed current to flow
to rocket.
Table 8-3
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8-6. MATERIEL FACTORS ANALYSIS: The condition of equipment involved in the incident may
provide value data to one or more causes. Materiel factors are related to materiel failures or malfunctions
that may be the result of a defect or design flaw.
Materiel factors analysis is primarily concerned with evaluating the performance of the aircraft, vehicle,
weapons system, ground support equipment, or other support material. This usually requires the assistance
of key personnel with expertise of specific components or systems.
a. General Process. Determine if the equipment functioned as designed, and if the design was
adequate/appropriate for use (Fit, Form and Function). Consider whether materiel failures or malfunctions
occurred because of normal or abnormal means. Also examine if the required equipment was available, if it
was used, and if it was used correctly. To describe fully and to understand material factors requires safety
personnel to identify the elements: component, mode (what), and agent (why) in each occurrence. (See
Table 8-4)
1) Component. Is the smallest, most specific part, assembly, or system that can be identified as having
failed.
2) Mode (What). Is the manner in which the component failed. Typical examples include brake master
cylinder failure, hose failure, stress fractures, and part not secured correctly (e.g., wrong bolt, nut,
cotter pin reused causing weakness, or cotter pin end not opened).
3) Agent (Why). Is the act or event leading to the failure. Typical examples include lack of
maintenance, improper installation, fire, and overloading. Uncommon examples include an
engineering design flaw or manufacturing defect.
TIP: If the equipment was not used appropriately it is not a materiel failure and is assessed as human error.
Data concerning how operational conditions affected the vehicle / system / equipment performance is
also collected. In the event you determine there is a materiel or material factor, then an Engineering
Investigation (EI) can provide an in-depth analysis of equipment function or malfunction. When the
investigator desires an EI, request assistance from the appropriate authority and/or systems command.
MATERIAL FACTORS ANALYSIS SHEET
COMPONENT
MODE
(What
Happened)
Triple Ejector
Rack (TER)
Electrical Safety
Pin on Zunni
Rocket Pod
Fell out with
minimal force
Normal or
Abnormal?
Abnormal
AGENT
(Why it happened)
(The act or event leading to the
failure)
- High Winds?
- Improper use?
- Worn?
Factors
RAC
 Ineffective
Design?
 Inadequate PMs?
Table 8-4
NOTE 1. In accordance with DLAR 4155.24/AR 702-7/SECNAVINST 4855.5C/AFI 21-2115/DCMAINST 305
(19 Sept 18), a Priority Quality Deficiency Report (PQDR) must be submitted to address materiel failures
found during the investigation, even if it is suspected. The owning unit is responsible for completing the
PQDR and a copy is submitted with the mishap investigation report.
NOTE 2. Ammunition deficiencies shall be reported to NOSSA and MARCORSYSCOM per OPNAV M8000.16 and MCO 8025.1_.
NOTE 3. Aeronautical equipment deficiencies shall be reported per OPNAVINST 4790.2_.
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b. Ground EI Process (Includes all USN-USMC ground tactical training and operations): Contact
the appropriate supporting SYSCOM if any of the following malfunction and might require engineering
investigation:
 Weapons system components
 Ammunition (cracked casings, malfunction, etc.)
 Explosives (damage, cracked casings & post blast analysis)
 Live Fire Ranges (call TECOM RTAM)
 Seats, turrets, hatches, doors of tactical MV systems
 Warning system components (audible, visual, etc.)
 Restraint systems
 Helmet / cranial
 Pressurized system components (i.e. pneumatic, hydraulic, etc.)
 Parachute components
 Suspension and / or Brake system components
 Engine components (If malfunction)
 Technological system components (navigation, targeting, etc.)
 Position of controls (engine, weapons) at impact
 Tactical vehicle system junction boxes
 Electrical sources of fire ignition
 Bilge pumps
 Communications mount & equipment
 Material Handling Equipment components
 Instrument reading malfunctions
 Fluid contamination and type
 Component operating at time of impact or explosion
 Type/source of combustible material
 Heat-distressed items
 Latching or fastening devices on tactical MV systems
 Rigging and Sling components
NOTE 1. (MARINE CORPS ONLY) IAW MCO 5100.34A, all Marine Corps units shall immediately
contact MARCORSYSCOM for any hazards found with weapons or tactical vehicle systems.
NOTE 2. Components (engines, seats, hydraulic components, turrets, hatches, gun breach, etc.)
should not be dismantled in the field without appropriate maintenance experts and/or cognizant engineer
present to direct disassembly. Field disassembly risks losing evidence and might spoil opportunity to conduct
functional tests.
c. Afloat EI Process: Contact the appropriate supporting SYSCOM (E.g. NAVSEASYSCOM) if any of
the following malfunction and might require engineering investigation:
 Most of the same components or systems listed for ground. (above)
 Add steam production/delivery system components.
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d. Installation / Ashore EI Process: Contact the appropriate supporting SYSCOM if any of the following
malfunction and might require engineering investigation:
 All of the same components or systems listed for ground and afloat. (above)
e. Aviation EI Process: The following, if not evident in field examination, might require engineering
investigation:
 Position of controls and instrument reading (flight, engine) at impact,
 Fluid contamination and type,
 Ejection attempted, sequence interruption,
 Component operating at impact,
 Electrical sources of fire ignition,
 Type/source of combustible material,
 Temperature of heat-distressed items,
 Light bulb illumination at impact,
 Trim setting,
 Engine condition, or malfunction,
 Propeller, and/or rotor blade pitch)
NOTE: Components (engines, ejection seats, hydraulic components, etc.) should not be dismantled in
the field without a Fleet Support Team (FST) engineer present to direct disassembly. Field disassembly risks
losing evidence and might spoil opportunity to conduct functional tests. Also, memory content can be
affected by electrical impulse (static charge).
TIP: If components will be retrieved from wreckage or damaged equipment, consult with
COMNAVSAFECOM investigations branch and request support from the cognizant engineering support
activity BEFORE manipulating parts.
The Program Managers will help you develop a collection and delivery plan. Engineering investigations
are to be conducted at the local installation whenever possible.
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8-7. RISK ASSESSMENT CODING: Each hazard /condition as well as causal factors require a risk
assessment code (RAC). Use the below matrix. (Table 8-6)
a. Probability Categories:
1) Subcategory A: Frequent to occur. Continuously experienced to an individual item or person; or
continuously over a service life for an inventory of items or group.
2) Subcategory B: Likely to occur, immediately or within a short period of time. Expected to occur
frequently to an individual item or person; or continuously over a service life for an inventory of
items or group.
3) Subcategory C: Occasionally will occur in time. Expected to occur several times to an individual
item or person; or frequently over a service life for an inventory of items or group.
4) Subcategory D: Seldom may occur in time. Can reasonably be expected to occur sometime to an
individual item or person; or several times over a service life for an inventory of items, or group.
5) Subcategory E: Unlikely it will occur in time. Unlikely to occur, but possible in the service life for an
inventory of items, or group.
b. Severity Categories: An assessment of the worst credible consequence that can occur as a result of
a hazard.
1) Catastrophic I: Loss of the ability to accomplish the mission. Death or permanent total disability.
Loss of a mission-critical system or equipment. Major facility damage. Severe environmental
damage. Mission-critical security failure. Unacceptable collateral damage.
2) Critical II: Significantly degraded mission capability or unit readiness. Permanent partial disability or
severe injury or illness. Extensive damage to equipment or systems. Significant damage to property
or the environment. Security failure. Significant collateral damage.
3) Moderate III: Degraded mission capability or unit readiness. Minor damage to equipment, systems,
property, or the environment. Minor injury or illness.
4) Negligible IV: Little or no adverse impact on mission capability or unit readiness. Minimal threat to
personnel, safety, or health. Slight equipment or systems damage, but fully functional and
serviceable. Little or no property or environmental damage.
Risk Assessment Code (RAC) Matrix
OPNAVINST 3500.39D
(29 March 2018)
PROBABILITY (Frequency of Occurrence over time)
D
E
A
B
C
Seldom
Unlikely
Frequent
Occasional
Likely
(Can be
(Improbable
(Continuously
experienced)
(Will likely
occur)
(Will occur
several times)
expected to
occur
sometimes)
, but
possible to
occur)
EH
(1)
EH
(1)
H
(2)
H
(2)
M
(3)
EH
(1)
H
(2)
H
(2)
M
(3)
L
(4)
H
(2)
M
(3)
M
(3)
L
(4)
L
(4)
M
(3)
L
(4)
L
(4)
L
(4)
L
(4)
SEVERITY (Effect of Hazard)
Catastrophic
I
(Includes Death, PTD, total loss of
equipment, mission capability or unit
readiness)
Critical
II
(Includes, Severe Injury (PPD),
damage, significantly degraded
mission capability or unit readiness
Moderate
III
(Minor Injury or damage, Degraded
mission capability or unit readiness)
Negligible
IV
(Minimal injury or damage, little to no
impact to mission capability or unit
readiness)
Risk Assessment Levels
EH = Extremely High (1)
H = High (2)
M = Medium (3)
L = Low (4)
Table 8-6
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8-8. DEPARTMENT OF DEFENSE HUMAN FACTORS ANALYSIS AND
CLASSIFICATION SYSTEM (DOD HFACS).
a. Introduction. The last part of mishap analysis is focused on determining the level or depth of human
error. There are several reasons for this focus. First, academic studies prove human error is involved in over
85 percent of all mishaps. Second, identifying human error is the least objective of all the causal factors.
Third, human error is often present in mishaps where environmental factors and materiel failures are
involved. Finally, the complex nature of human behavior and organizational culture that influences human
behavior mandates a systematic approach to investigations to ensure that all areas are thoroughly
addressed.
Mishap or event investigation can be extremely difficult, time-consuming and stressful, but it is rewarding
when we recognize the contributions made to improve safety through methodical root cause analysis. The
DoD HFACS tool was designed specifically for the DoD components and intended for use to determine
potential hazards and risk during Risk Management (RM) in operational planning, develop interview
questions during mishap investigations and guiding root cause analysis of human error pathways. This tool
provides the mishap investigator with a proven template that aids in providing a detailed analysis of human
error during the analysis process, revealing previously unidentified trends of human-error and hazards.
Simply writing off mishaps to "operator error" is a simplistic, if not naïve, approach to mishap causation
and hazard identification. Further, it is well established that mishaps are rarely attributed to a single cause or
a single individual. Rather, mishaps are the end result of myriad latent conditions or failures that precede
active failures (Shappell). As human error continues to plague both military and civilian mishaps, the goal of
a applying the DoD HFACS tool to mishap investigations is to identify the layers of failures and conditions in
order to understand why the mishap occurred and how to implement better mishap prevention strategies.
There are myriad potential human factors, all of which need to be assessed for relevancy during a mishap
investigation. Regardless of education or experience, no investigator, physician, physiologist, human factors
consultant or psychologist can be expected to be fully familiar with all potential human factors. However, the
DoD HFACS taxonomy provides a system for mishap investigators to consider multiple layers of conditions
that lead to unwanted events.
b. History of DoD HFACS. In May 2003, the Secretary of Defense published a memorandum
challenging the services to reduce mishaps by 50% over a 2 year period. The desired end state was to
increase operational readiness. The memorandum resulted in the creation of the DoD Safety Oversight
Committee (DSOC) to provide guidance to the DoD service components of best practices and methods to
accomplish this mandate. As a result, the Aviation Safety Improvement Task Force (ASI-TF) was established
to meet these DoD requirements. The ASI-TF subsequently established the DoD Human Factors Working
Group (DoD HFWG) with a charter to identify data-driven, benefit focused, human-factor and humanperformance safety strategies designed to identify hazards, mitigate risk and reduce mishaps inherent in
operations throughout the DoD.
Drawing upon Reason's (1990) “Swiss Cheese” model, a human factors analysis taxonomy called the
DoD Human Factors Analysis and Classification System (DoD HFACS) was developed by Doctors Shappell
and Wiegmann of the Naval Safety Center.
This classification system specifically defines the
"holes (hazards) in the Dr Reason’s “Swiss Cheese".
Shappell and Wiegmann’s classification system provided the
DoD HFWG the model to not only allow DoD safety
personnel to more effectively identify hazards and error
pathways that lead to a mishap, but it also provides leaders
and safety practitioners with a proactive hazard identification
tool. In other words, if you know what these system
failures/hazards or "holes" are, you can better identify their
roles in mishaps -- or better yet, detect their presence and
develop a risk mitigation strategy correcting them before they
can “set the stage” for a mishap to occur.(See Figure 8-7)
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Each service Safety Chief signed a joint memorandum of agreement (MOA) on 10 May 2005
establishing a joint “policy on the collection and analysis of mishap human factors data.” Though revisions
have been made to the taxonomy by the DoD HFACS working group, the joint MOA remains effective.
The DOD HFACS taxonomy supports DoDI 6055.07, (Mishap Investigation, Reporting, and Record
Keeping), June 2011, which directs DoD components to “Establish procedures to provide for the cross-feed
of human error data using a common human error categorization system that involves human factors
taxonomy accepted among the DoD Components and U.S. Coast Guard.” This guide is designed to ensure
uniformity of inter-service human factors definitions and data driven analysis. It is an adjunct to formal
instructions that govern mishap investigation and is not meant to replace service-specific guidance for
mishap investigations.
c. Benefits. The DoD HFACS taxonomy provide many benefits from the safety officer level to the DoD.
1) For the DoD. The DoD HFACS taxonomy creates a standard, data-driven approach which meets
the intent of DoDI 6055.07 to “Establish procedures to provide for the cross-feed of human error
data using a common human error categorization system that involves human factors taxonomy
accepted among the DoD Components and U.S. Coast Guard.” Which if adapted effectively, the
data from a standardized data collection tool supports better research across the DoD.
2) For the safety investigator (Unit level and SIB). The DoD HFACS taxonomy has a more immediate
return it is easily applied to all mishaps & near mishaps. For investigators, it aids in the development
of interview questions; provides a structured analysis of human error; detects error patterns and the
pathways from organization to individual; and provides a framework of providing a more insightful
root cause determination when used in conjunction with a casual factors analysis map.
3) For unit level leaders. The DoD HFACS taxonomy targets the need for specific intervention (RM
controls) and better command decisions and once proficient in its use, the DoD HFACS system
provides more in-depth hazard analysis during RM process for planning training events or premission planning (I.e. METT-TC, BAMCIS, MCPP, NPP).
Figure 8-7
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SI 001
CMC (Safety Division) Mishap Investigation & Causal Factor Analysis Course
Figure 8-8
EXAMPLE: DoD HFACS overlay onto the CFaM
TIP: This process is highly useful
when determining relationships of
causes and in writing the
investigation report.
OP 004
SI 003
SP 003
OR 005
OR 009
SI 001
OS 002
OP 001
AE 201
AE 206
OC 001
PC 209
SI 001
SP 001
SI 001
OS 002
PC 207
d. How to Apply the DoD HFACS to a Mishap Investigation. After completion of mapping the mishap,
investigators will use the latest version of the DoD HFACS taxonomy.
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Unit 8:
Causal Factor Analysis (Why It Happened)
TIP: Ground rules for application of DoD HFACS taxonomy. The following are best practice tips
based on the experience of seasoned mishap investigators.
 Read definitions completely, not just titles. One word in the definition may make the code
inappropriate.
 Don’t try to paint stripes on a horse and try to call it a zebra. Avoid personal bias, let the
evidence and/or your “CFAM” guide you to the appropriate code. (When in doubt – refer to the
evidence and your CFAM) (See example on Figure 3-9)
 Avoid the rabbit holes. Be willing to move on – come back. It is very easy to become distracted
from the facts by debating with yourself or the investigation team whether or not a specific code
applies. A best practice is to tick-mark the code and move on. You or the team will go through two or
more iterations of “scrubbing” and validating each code.
 Choose the MOST applicable codes to support causal factors and mitigating hazards.
Some codes may seem similar, yet as you “scrub” the codes, you will find that certain codes are more
applicable than others. Be willing to deselect codes that are contentious.
 There are no minimums or limitations on number of nano-codes. If the code fits – it fits.
 Nano-codes may apply directly to the “unsafe act” or to other nano-codes that
applies directly to the “unsafe act”. It sometimes becomes confusing as to how a “supervisory”
code or an “organizational” code is applicable to the individual’s “Unsafe Act”. If supervisory and/or
organizational codes had any influence on one or more preconditions to the unsafe act – then you are
correct.
 Each selected nano-code MUST be supported by evidence. Again – let the evidence be
your guide. A best practice is to support each selected code with a brief statement. This aids in the
preparation of recommendations and the SIREP.
 When in doubt – Follow your CFAM. A simple way to understand how codes are traced back to
code at the supervisory or organizational levels is to ALWAYS refer back to the “CFAM” and follow
the error pathways.
(See example Figure 8-8)
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UNSAFE ACTS: Acts are those factors that are most closely tied to the mishap, and can be described
as active failures or actions committed by the operator that result in human error or unsafe situation. We
have identified these active failures or actions as Errors and Violations. Unsafe Acts include; Performance /
Skill-Based Errors, Judgment and Decision-Making Errors and Violations. Using this error analysis process,
the investigator must first determine if an individual or team committed an active failure. (See figure 8-9)
Errors are factors in a mishap when mental or physical activities of the operator fail to achieve their
intended outcome as a result of performance-based or judgment and decision making errors, leading to an
unsafe situation. Errors are unintended. (e.g., made a decision error, did not follow procedure, pushed the
wrong button, over corrected, over reacted, etc.)
Violations are factors in a mishap when the actions of the operator represent willful disregard for rules and
instructions and lead to an unsafe situation. Unlike errors, violations are deliberate. (E.g. knowingly violated
policy, regulations or orders)
Figure 8-9
1) STEP 1 - Determine the Unsafe Act(s).
 Begin by with asking “WHAT did the person / operator do, or not do, to cause the mishap?”
 Determine if the last Unsafe Act was an Error or Violation.
o If determined to be an Error, proceed to determine which of the AE codes apply.
o If determined to be a Violation, proceed to determine which of the AV codes apply.
NOTE: There may be more than one unsafe act committed by the individual/operator/team. You may
determine that some acts to be errors and some to be violations. Be sure to focus on the last act and
remember, the “act” CANNOT be an error and a violation - It must be one or the other.
TIP: Another tool that is useful in determining if the act was an “error” or a “violation” is the
Compliance/Non-compliance tool. (See Unit 8 section 9 below)
This technique compares evidence collected against three categories of noncompliance to determine the
roots of a noncompliance issue. As discussed in unit 8-9 below, these are: “Don’t Know,” “Can’t Comply,”
and “Won’t Comply.” Examining these three areas independently without applying DoD HFACS will limit
the application of this technique; however, the technique is highly useful in determining if the act is an
error or violation, then determining the preconditions (why) as well as supervisory and/or organizational
influences (why).
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Causal Factor Analysis (Why It Happened)
Performance / Skill - Based Errors (AE): are factors that occur when a specific action is performed in
a manner that leads to a mishap. (In other words, when errors occur in the operator’s execution of a routine,
highly practiced task relating to procedure, training or proficiency and result in an unsafe a situation.)
• AE101 Unintended Operation of Equipment: is a factor when an individual’s movements
inadvertently activate or deactivate equipment, controls or switches when there is no intent to operate
the control or device. This action may be noticed or unnoticed by the individual.
• AE102 Checklist Not Followed Correctly: is a factor when the individual, either through an act of
commission or omission makes a checklist error or fails to run an appropriate checklist.
• AE103 Procedure Not Followed Correctly: is a factor when a procedure is accomplished incorrectly
or in the wrong sequence or using the wrong technique.
• AE104 Over-control / Under-control of the Vehicle or System: is a factor when an individual
responds inappropriately to conditions by either over controlling or under controlling the aircraft/vehicle
or system. The error may be a result of preconditions or a temporary failure of coordination.
• AE105 Breakdown in Visual Scan: is a factor when the individual fails to effectively execute learned
/ practiced visual scan patterns.
• AE107 Rushed or Delayed a Necessary Action: is a factor when an individual takes the necessary
action as dictated by the situation but performs these actions too quickly or too slowly. (Formerly AE
203)
Judgment and Decision-Making Errors (AE): are factors that occur when an individual proceeds as
intended, yet the plan proves inadequate or inappropriate for the situation, “An honest mistake.”
• AE201 Inadequate Real-Time / Time-Critical Risk Assessment: is a factor when an individual fails
to adequately evaluate the risks associated with a particular course of action and this faulty evaluation
leads to inappropriate decision-making and subsequent unsafe situations.
• AE202 Failure to Prioritize Tasks Adequately: is a factor when the individual does not organize,
based on accepted prioritization techniques, the tasks needed to manage the immediate situation.
• AE205 Ignored a Caution / Warning: is a factor when a caution or warning is perceived and
understood by the individual but is ignored by the individual.
• AE206 Wrong Choice of Action during Operation: is a factor when the individual, through faulty
logic or erroneous expectations, selects the wrong course of action.
Violations (AV): are factors when an individual intentionally (willful disregard) breaks the rules and
instructions. Violations are deliberate.
• AV001 Performs Work-around Violation: is a factor when the consequences/risk of violating
published procedures was recognized, consciously assessed and honestly determined by the
individual, crew or team to be the best course of action. Routine “work-arounds” and unofficial
procedures that are accepted by the community as necessary for operations are also captured under
this code.
• AV002 Commits Routine / Widespread Violation: is a factor when a procedure or policy violation is
systemic in a unit/setting and not based on a risk assessment for a specific situation. It needlessly
commits the individual, team, or crew to an unsafe course-of-action. These violations may have
leadership sanction and may not routinely result in disciplinary/administrative action. Habitual violations
of a single individual or small group of individuals within a unit can constitute a routine/widespread
violation if the violation was not routinely disciplined or was condoned by supervisors.
• AV003 Extreme Violation - Lack of Discipline: is a factor when an individual, crew or team
intentionally violates procedures or policies without cause or need. These violations are unusual or
isolated to specific individuals rather than larger groups. There is no evidence of these violations being
condoned by leadership. These violations may also be referred to as “exceptional violations.” (NOTE:
These violations may also carry UCMJ consequences. Safety investigators should consult the Judge
Advocate of the convening authority.)
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PRECONDITIONS TO UNSAFE ACTS: Preconditions are factors in a mishap where active and/or
latent conditions such as conditions of the operators, environmental or personnel factors affect practices,
conditions or actions of individuals and result in human error or an unsafe situation. In this error analysis
model preconditions include:
Figure 8-10
2) STEP 2 - Determine all the Preconditions that allowed the individual / operator / team to commit the
unsafe act. (See figure 8-10)
 Begin by asking “WHY did the individual/team commit the unsafe act?”
 What was the Physical and Mental condition of the individual/operator/team involved? (E.g.
Trouble in their personal life, complacency, trying too hard to complete the task, lack of sleep,
overworked, illness, effects of prescribed medications, Nutrition, lack of proper rest and PT,
alcohol, misperception, etc.) Select all codes that apply.
 Did any environmental factors impact the person’s decision to error or disregard policy? (E.g.
Bad weather, visibility restrictions from dust, smoke or blind spot, location of controls or
switches, etc.) Select all codes that apply.
 Did poor communication and/or planning impact the person’s decision making process? (E.g.
poor communications, ineffective pre-mission planning, pre-mission/activity briefing, etc.) Select
all codes that apply.
NOTE: Preconditions will account for approx. 67% of applicable HFACs nanocodes.
Condition of Individuals / Physical or Mental State (PC): Are factors in a mishap if cognitive,
psycho-behavioral, adverse physical state, or physical/mental limitations affect practices, conditions or
actions of individuals and result in human error or an unsafe situation.
Mental Awareness (Cognitive Factors): Are factors in a mishap if cognitive or attention management
conditions affect the perception or performance of individuals.
•
PC101 Not Paying Attention: is a factor when there is a lack of state of alertness or a readiness to
process immediately available information. The individual has a state of reduced conscious attention
due to a sense of security, self-confidence, boredom or a perceived absence of threat from the
environment. This may often be a result of highly repetitive tasks.
•
PC102 Fixation: is a factor when the individual is focusing all conscious attention on a limited number
of environmental cues to the exclusion of others.
•
PC103 Task Over-Saturation / Under-Saturation: is a factor when the quantity of information an
individual must process exceeds their mental resources in the amount of time available to process the
information.
•
PC104 Confusion: is a factor when the individual is unable to maintain a cohesive and orderly
awareness of events and required actions and experiences a state characterized by bewilderment,
lack of clear thinking or (sometimes) perceptual disorientation.
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•
PC105 Negative Habit Transfer: is a factor when the individual reverts to a highly learned behavior
used in a previous system or situation and that response is inappropriate for current task demands.
•
PC106 Distraction: is a factor when the individual has an interruption of attention and/or
inappropriate redirection of attention by an environmental cue or mental process.
•
PC107 Geographically Lost: is a factor when the individual is at a different location from where one
believes they are.
•
PC108 Interference / Interruption: is a factor when an individual is performing a highly
automated/learned task and is distracted by another cue/event that results in the interruption and
subsequent failure to complete the original task or results in skipping steps in the original task.
•
PC109 Technical or Procedural Knowledge Not Retained after Training: is a factor when the
individual fails to absorb/retain required information or is unable to recall past experience needed for
safe task completion. (Formerly PC405)
•
PC110 Inaccurate Expectation: is a factor when the individual expects to perceive a certain reality
and those expectations are strong enough to create a false perception of the expectation.
State of Mind (Psycho-Behavioral Factors): Are factors when an individual’s personality traits,
psychosocial problems, psychological disorders or inappropriate motivation creates an unsafe situation.
• PC202 Psychological Problem: is a factor when the individual met medical criteria for a psychiatric
disorder.
• PC203 Life Stressors: is a factor when the individual’s performance is affected by life circumstance
problems (includes relationship issues, financial stressors, recent move, etc.).
• PC204 Emotional State: is a factor when the individual is under the influence of a strong positive or
negative emotion and that emotion interferes with duties.
• PC205 Personality Style: is a factor when the individual’s personal interaction with others creates an
unsafe situation. Examples are authoritarian, over-conservative, impulsive, invulnerable, submissive or
other personality traits that result in degraded performance.
• PC206 Overconfidence: is a factor when the individual overvalues or overestimates personal
capability, the capability of others or the capability of aircraft/vehicles or equipment.
• PC207 Pressing: is a factor when the individual knowingly commits to a course of action that
excessively presses the individual and/or their equipment beyond reasonable limits (e.g., pushing self
or equipment too hard).
• PC208 Complacency: is a factor when the individual has a false sense of security, is unaware of, or
ignores hazards and is inattentive to risks.
• PC209 Motivation: is a factor when the individual’s motivation to accomplish a task/mission is
excessive, weak, indecisive or when personal goals supersede the organization’s goals.
• PC215 Motivational Exhaustion (Burnout): is a factor when the individual has the type of exhaustion
associated with the wearing effects of high OPTEMPO and/or lifestyle tempo in which operational
requirements impinge on the ability to satisfy personal requirements and leads to degraded
effectiveness.
TIP: PC215 is one’s “give a crap” meter. These are excessive, prolonged stressors. It occurs when one
feels overwhelmed, emotionally drained, and unable to meet constant demands. This may be the result
of mundane repetitive tasks, or taking on too many tasks at work and off-duty where one is so physically
and/or mentally tired that s/he no longer cares about what is going on around them and is accepting of a
higher level of risk. This is more about “attitude” instead of “mental fatigue”.
For this to be selected, we must PROVE that an individual was emotionally burned out from doing
repetitive tasks or in a poor command climate. (E.g. Double ITX, or “So tired of the BS, I did not care
what happens.” or “TERMINAL LANCE SYNDROME” or the “R.O.A.D. Program”
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Physical Problems: Are factors when an individual experiences a physiologic event that compromises
human performance and this decreases performance and results in an unsafe situation.
•
PC302 Substance Effects (alcohol, supplements, medications, drugs): is a factor when the
individual uses legal or illegal drugs, supplements, energy drinks, or any other substance with
measurable effect that interferes with performance.
•
PC304 Loss of Consciousness (sudden or prolonged onset): is a factor when the individual has
a loss of functional capacity/consciousness due to G-LOC, seizure, trauma or any other cause.
•
PC305 Physical Illness / Injury: is a factor when a physical illness, injury, deficit or diminished
physical capability causes an unsafe situation. This includes pre-existing and operationally-related
medical conditions, over-exertion, motion sickness, etc.
•
PC307 Fatigue: is a factor causing diminished physical / mental capability resulting from chronic or
acute periods of prolonged wakefulness, sleep deprivation, jet lag, shift work or poor sleep habits.
TIP: Fatigue MUST be quantified. The 72 hour profile is a rudimentary tool to help identify the potential
for mental fatigue. If fatigue is in question, it is highly recommended to contact the “Physiologist” at
CMC(SD) or the “Research Psychologist” at the Naval Safety Center.
Be sure to clearly identify the source of fatigue (physical vs mental) and state it in your report. You must
also indicate circadian rhythm issues (i.e. shift-lag or jet-lag) if one is contributory to the fatigue.
•
PC310 Trapped Gas Disorders: is a factor when gasses in the middle ear, sinuses, teeth or
intestinal tract expand or contracts. Also capture alternobaric (dizziness from unequal pressures)
vertigo for diving or aviation under this code.
•
PC311 Evolved Gas Disorders: is a factor when inert-gas evolves in the blood causing an unsafe
situation. This includes chokes, CNS, bends, paresthesia (a sensation of pricking, tingling, or
creeping on the skin) or other conditions caused by inert-gas evolution.
•
PC312 Hypoxia / Hyperventilation: is a factor when the individual has insufficient oxygen supply to
the body and/or breathing above physiological demands causes impaired function.
•
PC314 Inadequate Adaptation to Darkness: is a factor when the normal human limitation of darkadaptation rate affects safety, for example, when transitioning between aided and unaided night
vision.
•
PC315 Dehydration: is a factor when the performance of the individual is degraded due to
dehydration as a result of excessive fluid losses due to heat stress or due to insufficient fluid intake.
•
PC317 Body Size / Movement Limitations: is a factor when the size, strength, dexterity, mobility or
other biomechanical limitations of an individual creates an unsafe situation. It must be expected that
the average individual qualified for that duty position could accomplish the task in question.
(Formerly PC403)
•
PC318 Physical Strength & Coordination (inappropriate for task demands): is a factor when the
relative physical strength and/or coordination of the individual is not adequate to support task
demands. (Formerly PP201)
•
PC319 Nutrition/Diet: is a factor when the individual’s nutritional state or poor dietary practices are
inadequate to fuel the brain and body functions resulting in degraded performance. (Formerly
PP204)
Sensory Misperception: are factors resulting in degraded sensory inputs (visual, auditory or vestibular)
that create a misperception of an object, threat or situation.
•
PC501 Motion Illusion – Kinesthetic: is a factor when physical sensations of the ligaments, muscles
or joints cause the individual to have an erroneous perception of orientation, motion or acceleration. (If
this illusion leads to spatial disorientation you must code PC508.)
•
PC502 Turning/Balance Illusion – Vestibular: is a factor when stimuli acting on the balance organs
in the middle ear cause the individual to have an erroneous perception of orientation, motion or
acceleration. (If this illusion leads to spatial disorientation you must code PC508.)
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•
PC503 Visual Illusion: is a factor when visual stimuli result in an erroneous perception of orientation,
motion or acceleration. (If this illusion leads to spatial disorientation you must code PC508.)
•
PC504 Misperception of Changing Environment: is a factor when an individual misperceives or
misjudges altitude, separation, speed, closure rate, and road / sea conditions, or vehicle / aircraft
location within the performance envelope or other operational conditions.
•
PC505 Misinterpreted / Misread Instrument: is a factor when the individual is presented with a
correct instrument reading but its significance is not recognized, it is misread or is misinterpreted.
•
PC507 Misinterpretation of Auditory / Sound Cues: is a factor when the auditory inputs are
correctly interpreted but are misleading/disorienting or, when the inputs are incorrectly interpreted and
cause an impairment of normal performance.
•
PC508 Spatial Disorientation: is a factor when an individual fails to correctly sense a position,
motion or attitude of the aircraft/vehicle/vessel or of oneself. Spatial Disorientation may be
unrecognized and/or result in partial or total incapacitation.
•
PC511 Temporal / Time Distortion: is a factor when the individual experiences a compression or
expansion of time relative to reality. This is often associated with a “fight or flight” response.
Preconditions - Environmental Factors (PE): Are factors in a mishap if physical or technological
factors affect practices, conditions, and actions of an individual and result in human error or an unsafe
situation. Environmental factors include both physical and the technological environments,
Physical Environment: Are physical factors in a mishap to which the individual members are exposed
such as weather, climate, fog, brownout (dust or sand storm) or white out (snow storm) that affect the
actions of individuals.
•
PE101 Environmental Conditions Affecting Vision: is a factor that includes obscured windows;
weather, fog, haze, darkness; smoke, etc.; brownout/whiteout (dust, snow, water, ash or other
particulates); or when exposure to windblast affects the individual’s ability to perform required duties.
•
PE103 Vibration Affects Vision or Balance: is a factor when the intensity or duration of the vibration
is sufficient to cause impairment of vision or adversely affect balance.
•
PE106 Heat / Cold Stress Impairs Performance: is a factor when the individual is exposed to
conditions resulting in compromised performance.
•
PE108 External force or Object Impeded an Individual’s Movement: is a factor when acceleration
forces of longer than one second cause injury, prevent or interfere with the performance of normal
duties. Do not use this code to capture G-induced loss of consciousness
•
PE109 Lights of Other Vehicle / Vessel / Aircraft Affected Vision: is a factor when the absence,
pattern, intensity or location of the lighting of other vehicle/vessel/aircraft prevents or interferes with
safe task accomplishment.
•
PE110 Noise Interference: is a factor when any sound not directly related to information needed for
task accomplishment interferes with the individual’s ability to perform that task.
Technological Environment: Are factors in a mishap when cockpit / vehicle / control station /
workspace design factors or automation affect the actions of individuals and result in human error or an
unsafe situation.
•
PE201 Seat and Restraint System Problems: is a factor when the design of the seat or restraint
system, the ejection system or seat comfort has poor impact-protection qualities.
•
PE202 Instrumentation and Warning System Issues: is a factor when instrument factors such as
design, reliability, lighting, location, symbology, size, display systems, auditory or tactile situational
awareness or warning systems create an unsafe situation.
•
PE203 Visibility Restrictions (not weather related): is a factor when the lighting system,
windshield/windscreen/canopy design, or other obstructions prevent necessary visibility. This
includes glare or reflections on the windshield/windscreen/canopy. Visibility restrictions due to
weather or environmental conditions are captured under PE101.
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•
PE204 Controls and Switches are Inadequate: is a factor when the location, shape, size, design,
reliability, lighting or other aspect of a control or switch are inadequate.
•
PE205 Automated System Creates an Unsafe Situation: is a factor when the design, function,
reliability, symbology, logic or other aspect of automated systems creates an unsafe situation.
•
PE206 Workspace Incompatible with Operation: is a factor when the workspace is incompatible
with the task requirements and safety for an individual.
•
PE207 Personal Equipment Interference: is a factor when the individual’s personal equipment
interferes with normal duties or safety.
•
PE208 Communication Equipment Inadequate: is a factor when communication equipment is
inadequate or unavailable to support task demands. This includes electronically or physically blocked
transmissions. Communications can be voice, data or multi-sensory.
Preconditions - Personnel Factors (PP): Personnel factors are factors in a mishap if crew resource
management affects practices, conditions or actions of individuals, and result in human error or an unsafe
situation.
Teamwork: Refer to interactions among individuals, crews, and teams involved with the preparation and
execution of a mission that resulted in human error or an unsafe situation.
•
PP101 Failure of Crew / Team Leadership: is a factor when the crew/team leadership techniques
failed to facilitate a proper crew/team climate, to include establishing and maintaining an accurate and
shared understanding of the evolving task and plan on the part of all crew/team members.
•
PP103 Inadequate Task Delegation: is a factor when the crew/team members failed to actively
manage the distribution of tasks to prevent the overloading of any individual member.
•
PP104 Rank / Position Intimidation: is a factor when the differences in rank of the team/crew
caused the task performance capabilities to be degraded. Also, conditions where formal or informal
authority gradient is too steep or too flat across a crew/team and this condition degrades collective or
individual performance.
•
PP105 Lack of Assertiveness: is a factor when an individual failed to state critical information or
solutions with appropriate persistence and/or confidence.
•
PP106 Critical Information Not Communicated: is a factor when known critical information was not
provided to appropriate individuals in an accurate or timely manner.
•
PP107 Standard / Proper Terminology Not Used: is a factor when clear and concise terms,
phrases, hand signals, etc. per service standards and training were not used.
•
PP108 Failed to Effectively Communicate: is a factor when communication is not understood or is
misinterpreted as the result of behavior of either sender or receiver. Communication failed to include
backing up, supportive feedback or acknowledgement to ensure that personnel correctly understood
announcements or directives.
•
PP109 Task/Mission Planning/Briefing Inadequate: is a factor when an individual, crew or team
failed to complete all preparatory tasks associated with planning/briefing the task/mission.
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UNSAFE SUPERVISION: Supervision is a factor in a mishap if the methods, decisions or policies of
the supervisory chain of command directly affect practices, conditions or actions of the individual(s). The
DoD Human Factors Working Group has determined that a mishap event can often be traced back to the
supervisory chain of command. Unsafe Supervision is divided into three major categories of Inadequate
Supervision, Planned Inappropriate Operations, and Supervisory Violations. (See figure 8-11)
Figure 8-11
3) STEP 3 - Determine the role of first line supervisors (what (if any) supervisory conditions influenced
either one or more of the preconditions or the unsafe act(s)).
 Begin by asking “Who knew about the person’s/team’s preconditions but did not take proper
steps to avoid the unsafe act?”
 Was the first line supervisor(s) guidance or training inadequate/ineffective and contributed to
either the precondition(s) or directly to the unsafe act(s). Select all codes that apply.
 Determine if the first line supervisor(s) failed to adequately assess hazards and risks during the
planning of the task/event/mission and contributed to either the precondition(s) or directly to the
unsafe act(s). Select all codes that apply.
 Determine if the first line supervisor(s) violated policies or standards in the planning or execution
of the task/event/mission which either contributed to the precondition(s) or directly to the unsafe
act(s).
Inadequate Supervision (SI): are factors when section / department / platoon level or unit / command
level supervision proves inappropriate or improper and/or fails to identify hazards, recognize and control
risk, provide guidance, training and/or oversight and results in human error or an unsafe situation.
The role of supervisors is to provide their personnel with the opportunity to succeed. To do this, supervisors
must provide guidance, training opportunities, leadership, motivation, and the proper role model, regardless
of their supervisory level. Unfortunately, it is easy to imagine a situation where adequate Risk Management
training was not provided to an operator or team member. Conceivably, the operator's coordination skills
would be compromised, and if put into a non-routine situation (e.g., emergency), would be at risk for errors
that might lead to a mishap. Therefore, the category Inadequate Supervision accounts for those times when
supervision proves inappropriate, improper, or may not occur at all.
•
SI001 Supervisory / Command Oversight Inadequate: is a factor when the availability, competency,
quality or timeliness of leadership, supervision or oversight does not meet task demands. Inappropriate
supervisory pressures are also captured under this code.
•
SI002 Improper Role-Modeling: is a factor when the individual’s learning is influenced by the
behavior of supervisors and when that learning manifests itself in actions that are either inappropriate
to the individual’s skill level or violate standard procedures.
•
SI003 Failed to Provide Proper Training: is a factor when one-time or recurrent training programs,
upgrade programs, transition programs or any other local training is inadequate or unavailable, etc.
(Note: the failure of an individual to absorb the training material in an adequate training program does
not indicate a training program problem.)
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•
SI004 Failed to Provide Appropriate Policy / Guidance: is a factor when policy/guidance or lack of a
policy/guidance leads to an unsafe situation.
•
SI005 Personality Conflict with Supervisor: is a factor when a supervisor and individual member
experience a "personality conflict" that leads to a dangerous error in judgment/action.
•
SI006 Lack of Supervisory Responses to Critical Information: is a factor when information critical
to a potential safety issue was provided but supervisory/management personnel failed to act upon it
(failure to close the loop).
•
SI007 Failed to Identify / Correct Risky or Unsafe Practices: is a factor when a supervisor fails to
identify or correct risky behaviors or unsafe tendencies and/or fails to institute remedial actions. This
includes hazardous practices, conditions or guidance. (Formerly SF001)
•
SI008 Selected Individual with Lack of Proficiency: is a factor when a supervisor selects an
individual that is not proficient in a task, mission or event. (Formerly SP005)
Planned Inappropriate Operations (SP): Is a factor in a mishap when supervision fails to adequately
assess the hazards associated with an operation and allows for unnecessary risk.
It is also a factor when supervision allows non-proficient or inexperienced personnel to attempt missions
beyond their capability or when crew or flight makeup is inappropriate for the task or mission.
Occasionally, the operational tempo or schedule is planned such that individuals are put at unacceptable
risk, crew rest is jeopardized, and ultimately performance is adversely affected. Such “Planned
Inappropriate Operations”, though arguably unavoidable during emergency situations, are not acceptable
during normal operations.
Included in this category are issues of crew pairing and improper manning. For example, it is not surprising
to anyone that problems can arise when two individuals with marginal skills are paired together. During a
period of downsizing and/or increased levels of operational commitment, it is often more difficult to manage
crews. However, pairing weak or inexperienced operators together on the most difficult missions may not
be prudent
• SP001 Directed Task Beyond Personnel Capabilities: is a factor when supervisor/management
directs personnel to undertake a task beyond their skill level or beyond the capabilities of their
equipment.
• SP002 Inappropriate Team Composition: is a factor when the makeup of the crew/team should have
reasonably raised safety concerns in the minds of members involved in the task, or in any other
individual directly related to the scheduling of this task.
• SP003 Selected Individual with Lack of Current or Limited Experience: is a factor when the
supervisor selects an individual whose experience is not sufficiently current or proficient to permit safe
task execution.
• SP006 Performed Inadequate Risk Assessment – Formal: is a factor when supervision does not
adequately evaluate the risks associated with a task or when pre-mission risk assessment
tools/programs are inadequate. (I.e. Deliberate Risk Assessment (ORM/RM) and worksheet, METTTC, BAMCIS, Marine Corps Planning Process, Navy Planning, etc.)
TIP: If any aspect of the risk assessment or overall planning process was deficient and contributory or
causal to any precondition or unsafe act, this code is applicable.
•
SP007 Authorized Unnecessary Hazard: is a factor when supervision authorizes an activity or task
that is unnecessarily hazardous without sufficient cause or need.
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Supervisory Violations (SV): Is a factor in a mishap when supervision willfully disregards instructions,
guidance, rules, or operating instructions and this lack of supervisory responsibility creates an unsafe
situation.
For instance, a supervisor knowingly permits an individual to operate a vehicle or piece of equipment without
being qualified is a flagrant violation that invariably sets the stage for the tragic sequence of events that
predictably follow.
•
SV001 Failure to Enforce Existing Rules (supervisory act of omission): is a factor when unit
(organizational) and operating rules have not been enforced by a supervisor
•
SV002 Allowing Unwritten Policies to Become Standard: is a factor when unwritten or “unofficial”
policy is perceived and followed by the individual, although it has not been formally recognized by the
organization.
•
SV003 Directed Individual to Violate Existing Regulations: is a factor when a supervisor directs a
subordinate to violate existing regulations, instructions or technical guidance.
•
SV004 Authorized Unqualified Individuals for Task: is a factor when an individual has not met the
general training requirements for the job/weapon system and is considered non-current but
supervision/leadership inappropriately allows the individual to perform the task for which the individual
is non-current.
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ORGANIZATIONAL INFLUENCES: Are factors in a mishap where “command level” and/or “upperlevel management” may have contributed to the mishap. Fallible decisions of upper-level management
directly affect supervisory practices, as well as the conditions and actions of operators. These latent
conditions generally involve issues related to the following four major categories of Organizational Climate /
Culture Influences, Organizational Policy & Process Issues, Resource Problems and Personnel Selection &
Staffing. (See figure 8-12)
Figure 8-12
4) STEP 4 - Determine the role of the organization. (Did any organizational conditions influence either
supervisory conditions or the precondition(s) or the unsafe act(s))?
 Begin by asking “Are there any organizational vulnerabilities that affected supervisory practices
and/or preconditions, and/or directly to the unsafe act(s)?”
 Determine if climate and/or culture (unit level or higher) influenced first line supervisor(s)
guidance, training or role modeling, the precondition(s) or directly to the unsafe act(s). Select all
codes that apply.
 Determine if policies and/or processes (unit level or higher) influenced either first line
supervisor(s) guidance, training or role modeling, the precondition(s) or directly to the unsafe
act(s). Select all codes that apply.
 Determine if resource problems (installation or higher command) influenced either first line
supervisor(s) guidance, training or role modeling, the precondition(s) or directly to the unsafe
act(s). Select all codes that apply.
 Determine if personnel selection (recruiting) and/or staffing problems (Big Navy or Marine Corps)
influenced either first line supervisor(s) guidance, training or role modeling, the precondition(s) or
directly to the unsafe act(s). Select all codes that apply.
Organizational Climate / Culture (OC): Are factors where the working atmosphere within the
organization influences individual actions resulting in human error. (E.g. command structure, policies, and
working environment). Organizational Climate refers to a broad class of organizational variables that
influence worker performance. It can be defined as the situational consistencies in the organization's
treatment of individuals. In general, Organizational Climate is the prevailing atmosphere or environment
within the organization. Within the present classification system, climate is broken down into three
categories--structure, policies, and culture.
The term “structure” refers to the formal component of the organization. The “form and shape” of an
organization are reflected in the chain-of-command, delegation of authority and responsibility,
communication channels, and formal accountability for actions. Organizations with maladaptive structures
(i.e., those that do not optimally match to their operational environment or are unwilling to change) will be
more prone to mishaps.
“Policies” refer to a course or method of action that guides present and future decisions. Policies may refer
to hiring and firing, promotion, retention, raises, sick leave, drugs and alcohol, overtime, mishap
investigations, use of safety equipment, etc. When these policies are ill-defined, adversarial, or conflicting,
safety may be reduced.
Finally, “culture” refers to the unspoken or unofficial rules, values, attitudes, beliefs, and customs of an
organization ("The way things really get done around here."). Other issues related to culture include
organizational justice, psychological contracts, organizational citizenship behavior, esprit de corps, and
union / management relations. All these issues affect attitudes about safety and the value of a safe working
environment.
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•
OC001 Organizational Culture (attitude/actions) Allows for Unsafe Task/Mission: a factor when
explicit/implicit actions, statements or attitudes of unit leadership set unit/organizational values
(culture) that allow an environment where unsafe task/mission demands or pressures exist.
•
OC003 Organizational Over-confidence or Under-confidence in Equipment: is a factor when there
is organizational over- or under-confidence in an aircraft, vehicle, device, system or any other
equipment.
•
OC004 Unit Mission/Aircraft/Vehicle/Equipment Change or Unit Deactivation: is a factor when the
process of changing missions, aircraft/vehicle/equipment or an impending unit deactivation creates an
unsafe situation.
•
OC005 Organizational Structure is Unclear or Inadequate: is a factor when the chain of command
of an individual or structure of an organization is confusing, non-standard or inadequate and this
creates an unsafe situation.
Organizational Policy and Processes Issues (OP): Are factors if organizational processes
negatively influence performance and result in an unsafe situation or human error. This includes
operational risk management practices, procedures, and oversights which negatively influence individual,
supervisory, and/or team performance and results in unrecognized hazards and/or uncontrolled risk. This
category refers to the formal process by which “things get done” in the organization. It is subdivided into
three broad categories--operations, procedures, and oversight. The term “operations” refers to the
characteristics or conditions of work that have been established by management. These characteristics
include operational tempo, time pressures, production quotas, incentive systems, and schedules. When set
up inappropriately, these working conditions can be detrimental to safety.
“Procedures” are the official or formal procedures as to how the job is to be done. Examples include
performance standards, objectives, documentation, and instructions about procedures. All of these, if
inadequate, can negatively impact employee supervision, performance, and safety.
Finally, “oversight” refers to monitoring and checking of resources, climate, and processes to ensure a safe
and productive work environment. Issues here relate to organizational self-study, risk management, and the
establishment and use of safety programs.
•
OP001 Pace of Ops-tempo/Workload: is a factor when the pace of deployments, workload,
additional duties, off-duty education, PME or other workload-inducing conditions of an individual or unit
creates an unsafe situation.
•
OP002 Organizational Program/Policy Risks not Adequately Assessed: is a factor when the
potential risks of a large program, operation, acquisition or process are not adequately assessed and
this inadequacy leads to an unsafe situation.
•
OP003 Provided Inadequate Procedural Guidance or Publications: is a factor when written
direction, checklists, graphic depictions, tables, charts or other published guidance is inadequate,
misleading or inappropriate.
TIP: Selection of OP003 means there is evidence of organizational policies, SOPs, LOIs, TMs etc. meet one
of the following criteria:
 Too Complex: The document is difficult for the average person to follow or too difficult to understand.
 Not Available: The document either does not exist or was not received by the unit or the supervisors of
the individual who committed the unsafe act.
 Incorrect: The document is out of date and no longer valid or; it is missing steps in a sequence, or the
steps are out of sequence.
Remember: Not following a written document that is available and correct and/or simple to understand is a
supervisory or individual level factor and does not apply to this code.
•
OP004 Organizational (formal) Training is Inadequate or Unavailable: is a factor when one-time
or initial training programs, upgrade programs, transition programs or other training that is conducted
outside the local unit is inadequate or unavailable, etc.
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•
OP005 Flawed Doctrine/Philosophy: is a factor when the doctrine, philosophy or concept of
operations in an organization is flawed or accepts unnecessary risk which leads to an unsafe situation
or unmitigated hazard.
•
OP006 Inadequate Program Management: is a factor when programs are implemented without
sufficient support, oversight or planning.
•
OP007 Purchasing or Providing Poorly Designed or Unsuitable Equipment: is a factor when the
processes through which aircraft, vehicle, equipment or logistical support are acquired allows
inadequacies or when design deficiencies allow inadequacies in the acquisition. (Formerly OR004)
Resource Problems (OR): Is a factor in a mishap if resource management, processes, or policies,
directly or indirectly, influence system safety and results in inadequate management or creates an unsafe
situation. This category refers to the management, allocation, and maintenance of organizational resources,
monetary, and equipment / facilities. “Funding” issues refer to the management of nonhuman resources,
primarily monetary resources. For example, excessive cost cutting and lack of funding for proper equipment
have adverse effects on operator performance and safety. Finally, “equipment” refers to issues related to
equipment design, including the purchasing of unsuitable equipment, inadequate design of workspaces, and
failures to correct known design flaws. Management should ensure that human-factors engineering
principles are known and utilized and that existing specifications for equipment and workspace design are
identified and met.
•
OR001 Command and Control Resources are Deficient: is a factor when installation resources are
inadequate for safe operations. Examples include: command and control, airfield services, battle-staff
or battle-group management, etc.
•
OR003 Inadequate Infrastructure: is a factor when support facilities (dining, exercise, quarters,
medical care, etc.) or opportunity for recreation or rest are not available or adequate. This includes
situations where leave is not taken for reasons other than the individual’s choice.
TIP: This may also apply to installation road maintenance, traffic signs, etc.
•
OR005 Failure to Remove Inadequate/Worn-Out Equipment in a Timely Manner: is a factor when
the process through which equipment is removed from service is inadequate.
•
OR008 Failure to Provide Adequate Operational Information Resources: is a factor when
weather, intelligence, operational planning material or other information necessary for safe operations
planning are not available.
•
OR009 Failure to Provide Adequate Funding: is a factor when an organization or operation does
not receive the financial resources to complete its assigned task/mission.
Personnel Selection & Staffing (OS): are factors if personnel management processes or policies,
directly or indirectly, influence system safety and results in inadequate error management or creates an
unsafe situation. Issues that directly influence safety include selection (e.g. background checks), training,
and staffing / manning.
• OS001 Personnel Recruiting and Selection Policies are Inadequate: is a factor when the process
through which individuals are screened, brought into the service or placed into specialties is
inadequate. (Formerly OR006)
• OS002 Failure to Provide Adequate Manning/Staffing Resources: is a factor when the process
through which manning, staffing or personnel placement or manning resource allocations are
inadequate for task/mission demands. (Formerly OR007)
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Table 8-7
Unit 8:
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8-9. COMPLIANCE / NON-COMPLIANCE TOOL (DOE 1999)
a. Introduction. The compliance / noncompliance technique is useful when investigators suspect
noncompliance to be a causal factor. This technique compares evidence collected against three categories
of noncompliance to determine the root cause of a noncompliance issue. As discussed in Table 8-8, these
are: “Don’t Know,” “Can’t Comply,” and “Won’t Comply.”
NOTE: Examining these three areas independently without applying the DoD HFACS tool will limit the
application of this technique; however, the technique is highly useful in determining if the act is an error or
violation. Additionally, this tool is also highly applicable in determining the preconditions (why) as well as
understanding how supervisory and/or organizational influences (why) impacted the individuals unsafe act.
For example, investigators may use this technique to determine whether an individual was aware of
particular safety requirements, and if not, why he or she was not (e.g., the worker didn’t know the
requirements, forgot, or lacked experience). If the worker was aware but was not able to comply, a second
line of questioning can be pursued. Perhaps the worker could not comply because the facility did not supply
personal protective equipment. Perhaps the worker would not comply in that he or she refused to wear the
safety equipment.
b. Steps. The basic steps for applying the compliance/noncompliance technique are:
1) Have a complete understanding of the facts relevant to the event.
2) Broadly categorize the non-compliance event.
3) Determine why the non-compliance occurred (i.e. what were the preconditions? Was there a
supervisory and/or organizational influence?)
c. Application to a Witness Interview. Lines of inquiry are pursued until investigators are assured that
a sources of a non-compliance are identified. Lines of questioning pertaining to the three
compliance/noncompliance categories follow. However, it should be noted that these are merely guides;
mishap investigators should tailor the lines of inquiry to meet the specific needs and circumstances of the
mishap under investigation.
1) Don’t Know. Questions focus on whether an individual was aware of or had reason to be aware of
certain procedures, policies, or requirements that were not complied with.
2) Can’t Comply. This category focuses on what the necessary resources are, where they come from,
what it takes to get them, and whether personnel know what to do with the resources when they
have them.
3) Won’t Comply. This category focuses on conscious decisions to not follow specific guidance or
perform to a certain standard.
NOTE: “Won’t Comply” will include DoD HFACS unsafe act codes of AV 00x before assessing the
preconditions, unsafe supervision and organizational influences.
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COMPLIANCE / NON-COMPLIANCE TOOL
Don’t Know
This is often an indication of
poor training or failure in a
work system to disseminate
guidance to the working
level.
Never (Carefully assess DoD
Knew HFACS Preconditions,
Unsafe Supervision &
Organizational Influences to
develop questions)
This is usually a local,
personal error. It does not
reflect a systemic deficiency,
but may indicate a need to
Forgot increase frequency of
How training or to institute
refresher training.
(Carefully assess DoD
HFACS Preconditions to
develop questions)
This is often a result of lack
of experience or lack of detail
in guidance.
(Carefully assess DoD
HFACS Preconditions and
Unsafe Supervision to
Tasks develop questions)
Implied
Can’t Comply
Lack of funding is a
common rebuttal to
questions regarding noncompliance. However,
resource allocation
requires decision-making
Scarce
and priority setting at
Resources some level of command.
(Carefully assess DoD
HFACS Organizational
Influences - OR 00x
codes to develop
questions)
This issue focuses on
lack of knowledge (i.e.,
the know-how to get a job
done).
Don’t know (Carefully assess DoD
how
HFACS Preconditions,
Unsafe Supervision &
Organizational Influences
to develop questions)
Won’t Comply
An investigator may have to
determine whether there is
a benefit in complying with
requirements or doing a job
correctly. Perhaps there is
no incentive to comply.
No
Reward (Carefully assess DoD
HFACS AV codes,
Preconditions, Unsafe
Supervision &
Organizational Influences
to develop questions)
This issue focuses on
whether sanctions can
force compliance, if
enforced.
No
(Carefully assess DoD
Penalty HFACS AV codes,
Preconditions, Unsafe
Supervision &
Organizational Influences
to develop questions)
This issue requires
investigators to determine
In some cases, individuals
whether a task can be
refuse to perform to a
standard or comply with a
executed. Given
requirement that they
adequate resources,
disagree with or think is
knowledge, and
impractical.
willingness, is a worker or
Impossibility group able to meet a
Disagree
(Carefully assess DoD
certain requirement?
HFACS AV codes,
(Carefully assess DoD
Preconditions, Unsafe
Supervision &
HFACS Preconditions,
Organizational Influences
Unsafe Supervision &
to develop questions)
Organizational Influences
to develop questions)
Table 8-8
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Factor Statements, Findings, Recommendations
9-1. DELIBERATIONS - FINALIZING CONCLUSIONS.
a. Overview. Deliberations are the final stage of analysis and result in the development of findings and
recommendations. Using the weight of evidence, professional knowledge and good judgement, the
investigator(s) must decide on the most likely reasons for the mishap and develop a concise conclusion
statement, factor statements and findings. If the mishap evidence was thoroughly analyzed with all analytical
tools this phase of the investigation should be simplified.
The investigator(s) must analyze the relationships of event causes to each other and base conclusions on
their deductions from all available evidence as to which factors caused the mishap, which factors contributed
(increased the likelihood) to the mishap, and which factors caused further damage or injury during the
mishap or during the response.
b. Factor Statement: A factor statement is a significant deduction derived from the investigation’s
analytical results. They are derived from and supported by the facts and results of various analyses. Writing
down the factors and what they led to helps tie everything together, develop effective recommendations and
write a report that allows readers to clearly visualize the mishap sequence and all the reasons why the
mishap occurred. As a best practice factor statements should meet the following criteria.
1) Be organized sequentially.
2) Be supported by facts/evidence and analysis of the facts/evidence.
3) Differentiate cause type (material or human).
4) Be clear statements for each factor that bear directly on the mishap, and that reiterate significant
facts and relevant analytical results leading to the causes of the mishap.
5) Be statements that identify “Other Causes Considered, but Rejected” to alleviate potential confusion
on issues that were originally suspected.
6) Address significant concerns that may be inconclusive.
TIP: Factor statements may be used to highlight positive performance.
c. Process. Once Investigators (Unit/Command or SIB) agree to the factors they believe caused the
mishap, contributed to injuries, or had other significance, the next step is to determine each factor’s
relationship to other factors and the level of significance each causal factor played in the outcome. This helps
in placing each causal factor in its proper perspective and relation to the other events which will help
prioritize corrective actions.
1) STEP 1: List all factors that definitely allowed the mishap to occur.
2) STEP 2: Identify the factors suspected to have contributed to the mishap. (These are commonly
referred to as “suspected present and contributing”) This category is used when the mishap
investigator(s) or SIB cannot positively determine or reasonably conclude all causal factors of the
mishap. In these cases, investigators must develop a hypothetical explanation for why the mishap
occurred based on the evidence available. It is acceptable for the mishap investigator(s) to deduce
that a certain event most likely occurred as the result of specific conditions that had to exist for the
event to occur. The discussion in the analysis must be very detailed and must discount any other
plausible explanations of why the mishap occurred and support the suspected cause.
For example, a rocket from an aircraft rocket pod on the aft end of the flight deck and strikes an
aircraft across the deck. The only plausible cause is that the rocket pod was armed/connected to
the aircraft systems, and the safety pins removed, yet key witnesses did not survive and the aircraft
was jettisoned overboard during ship firefighting activities. The only evidence are witness
statements. The pilot stated he only actuated one switch (per procedure) to transfer the aircraft
from external power to internal power. He did not activate any other switches. Several Aviation
Ordnance personnel stated they were operating on unofficial changes in arming procedures to
streamline the launch sequence. The only other evidence is a flight deck video showing the rocket
launching and striking the adjacent aircraft.
3) STEP 3: Identify the factors that did not contribute to the mishap but contributed to the severity of
the injuries. (These are commonly referred to as “present and contributing to the severity of
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injury/extent of property damage”) This category covers factors that did not cause or contribute to
the mishap, but contributed to the severity of the injuries or damage. These may include
unrestrained humans or gear during a collision or rollover. Personnel injuries attributable to defects
in life support equipment, personal protective clothing/equipment, or aircraft/vehicle
crashworthiness design should also be summarized as findings in this category. These findings are
written in the same format as the present and contributing finding using the applicable elements for
the three causal factors (human and materiel). These findings are preceded by the following
statement. “THE FINDING LISTED BELOW DID NOT DIRECTLY CONTRIBUTE TO THE CAUSE
FACTORS INVOLVED IN THIS ACCIDENT; HOWEVER, IT DID CONTRIBUTE TO THE
SEVERITY OF INJURIES AND DAMAGE.”
NOTE: At times you may identify factors that in no way contributed to the mishap but identify local
conditions or practices that should be corrected. These factors should not be addressed in the
mishap investigation report however, unit/command safety officers should consider submitting a
HAZREP.
4) STEP 4: Determine Cause Type: (Human or Materiel). Department of the Navy Cause types are
defined as either Human or Materiel.
NOTE: Factors related to environmental or procedural document factors are captured under Human
as part of the DoD HFACS analysis.
5) STEP 5: Determine relationships of causes to each other (Causal, Contributing). Although the direct
causal factor is obvious, sometimes the contributing and other causal factors may not be completely
clear. Investigators must consider their “cause and effect” relationship. A good practice is to take
each causal factor and ask “Which of the other factors directly influenced this factor?” A cause that
has only one or no cause that influenced / effected its existence will be a causal factor.
Investigators can also remove the causal factor from the mishap to see if it would prevent the
mishap (see figure 9-1 below). The CFaM process, if completed effectively, will streamline this
process. Most causal factors will exist on the ends of the pathway. Cause definitions are as follows:
 Contributing Factors: Contributing causes are events or conditions that collectively with other
causes increased the likelihood of a mishap but that individually did not cause the mishap.
Contributing causes may be longstanding conditions or a series of prior events that, alone, were
not sufficient to cause the mishap, but were necessary for it to occur. Contributing causes are
the events and conditions that “set the stage” for the mishap and, if allowed to persist or reoccur, increase the probability of future mishaps. (DOE 1999)
 Causal Factors: if corrected, would prevent recurrence of the same or similar mishaps. Causal
factors may be derived from or encompass several contributing causes. In many cases, they are
higher-order, fundamental causal factors that address classes of deficiencies, rather than single
problems or faults. Correcting root causes would not only prevent the same mishap from
recurring, but would also oversight at the first line supervisors (NCO, SNCO, PO, CPO, etc.),
and organizational management system deficiencies (immediate command or higher) that could
cause or contribute to other mishaps. In many cases, root causes are failures to properly
implement the principles and core functions of integrated safety management. Causal factors
can include failures in management systems to:
o Ensure that personnel are competent and current to perform their duties / task / mission;
o Ensure that resource use is balanced to meet critical mission and safety goals;
o Ensure that standards and requirements are known and applied to work activities;
o Define clear roles and responsibilities for safety;
o Ensure that hazard controls are tailored to the work or mission being performed
o Ensure that work is properly reviewed and authorized.
NOTE: Causal Factors can be found at more than one level of an organization. (For example, one
root cause may be attributable to first line supervision, while two other root causes are attributable
to immediate command or higher organizational influences.)
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Causal Factors are generally attributable to an action or lack of action by a particular group or
individual in the organizational chain of command.
Each “corporate” organization (i.e. immediate command, supporting commands, higher command,
etc.) is considered separately for its responsibility in the mishap. (For example, in DON, the
immediate commander (BN/SQDRN/Ship/Installation) would be considered as one organization,
and a systems command would be considered as a second organization.) Consequently, the results
of one causal factor may be the input of another. (For example, if the command was responsible for
a particular root cause, echelon 2 commands or big Navy or Marine Corps may share responsibility
for that particular causal factor — there may be a deficiency in the directives given from the echelon
2 command or higher, or insufficient oversight from that level, or some other responsibility that was
inadequately fulfilled).
TIP: Causal Factors are generally found in higher tiers/outer edge because that is where leaders & managers are
most responsible for directing and overseeing activities. However, they may be found closer to individual acts.
The root cause of a mishap can be found at the worker level if, and only if, the following conditions are found to
exist:
 Safety management systems were in place and functioning, and provided leadership with feedback on system
implementation and performance.
 The chain of command took appropriate actions based on the feedback.
 The chain of command could not reasonably have been expected to take additional actions based on their
responsibilities and authorities.
Direct Causal Factor: “Power Surge – Rocket Launch into Aircraft”
(Influenced by: Normalization of Deviance from SOP, Ineffective Deliberate
Risk Assessment, OPTEMPO, Missing TER safety pin.)
Contributing Factor:
“Inadequate number of
Trained Firefighters”
(Influenced by Inadequate
formal training program)
Contributing Factor:
“Unsafe use of TER
safety pin”
(Influenced by: Ineffective
hazard reporting training
and Design Flaw)
Causal Factor:
“Inadequate Formal
Training Programs”
(Influenced by: Ineffective
assessment of training
requirements)
Contributing Factor:
“Connected Pigtails”
(Sailors deviating
from SOP)
(Influenced by:
Supervisory acceptance
of deviation, unit culture)
Causal Factor:
“Design Flaw”
(Influenced by: Ineffective
safety management systems /
hazard reporting program)
Contributing Factor:
“Use of high risk
ordnance” (short cook-off
& incompatibility)
(Influenced by:
OPTEMPO, ineffective
planning, normalization of
deviance)
Causal Factor:
“Normalization of
Deviation”
(Influenced by: Culture of
ineffective risk management
and lack of enforcing
standards)
Figure 9-1 (Example of Causal Factor “cause and effect” Relationships)
STEP 6: Prepare Factor Statements. The factor statement answers the why of the mishap while associating
the why to facts, evidence and finally connecting to findings. The most common error in a mishap
investigation report is an improperly written conclusion/finding statement.
TIP: Even though investigators (unit/command or board) should avoid placing individual blame for a mishap, the
investigators have an obligation to seek out and report ALL causal factors, including deficiencies in organizational
policies or training programs, local management, or first line supervisory (safety) oversight.
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Factor Statements, Findings, Recommendations
The causal and contributing factors are an integral part of the mishap reporting process and are
imperative in identifying the unsafe act (what happened) and system inadequacies (why it
happened).
If the findings’ author does not clearly identify “why” the mishap occurred, he/she cannot formulate
effective directed recommendations (what to do about it) to address the causes of the mishap.
Whether the investigation is at the SIB level or the unit/installation level, a best practice is that factor
statements should be written using the four elements described below which give the investigator a
standardized way to present the causes.
(See Examples in Tables 9-1 through 9-10)
 Element 1: State the causal factor by number, cause type, name of cause, and relationship to
the mishap.
 Element 2: Identify WHO failed by duty position (e.g. operator/driver/pilot, team, supervisor(s),
command) or WHAT failed (materiel part, component, or system) or WHAT environmental
condition.
 Element 3: Identify the action or inaction (mistake/error made by humans. or the name and part,
component or system that failed, or the environmental condition, as appropriate.
If possible, include guidance (Directive, Order, Instruction, Policy SOP, TM, etc.) or common
practice governing performance of task/activity or function
For materiel failures, be sure to include the part number (PN) or national stock number (NSN).
 Element 4: Identify the consequences of the action / inaction / failure or environmental condition.
CRITICAL NOTE: Each factor statement must be followed by a narrative explaining the
“analysis” of why the causal factor was selected. This includes stating each selected DoD
HFACS code and a sentence linking the code to the causal factor.
Factor Statement Example - Ground Training Mishap
(Human Factor – Ineffective Supervision)
1. State the causal factor by number, cause type, name
of cause, and relationship to the mishap.
CAUSAL FACTOR-4: (Human Factor Ineffective Planning – Root Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The unit leadership. . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental),
as appropriate.
did not effectively conduct a deliberate risk
assessment during the planning phases of the
training mission IAW MCO xxxx and
OPNAV M- xxxxxxx . . .
4. Consequences of the action / inaction / failure or
environmental condition.
which allowed numerous uncontrolled
hazardous conditions to exist that significantly
increased the team’s risk.
Table 9-1
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Factor Statement Example - Ground Training Mishap
(Human Factor)
1. State the causal factor by number, cause type, name of
cause, and relationship to the mishap.
CAUSAL FACTOR-2: (Human Factor –
Biomechanical Limitation – Contributing
Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The mishap operator’s . . . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental), as
appropriate.
body size contributed to the mishap. . .
4. Consequences of the action / inaction / failure or
environmental condition.
as his below average size limited effective
vision and operation of controls.
Table 9-2
Factor Statement Example - Afloat Mishap
(Human Factor)
1. State the causal factor by number, cause type, name of
cause, and relationship to the mishap.
CAUSAL FACTOR-2 (Human Factor Fatigue – Contributing Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The mishap operator’s . . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental), as
appropriate.
duty/work related mental fatigued (awake
greater than 26 hours) . . .
4. Consequences of the action / inaction / failure or
environmental condition.
contributed to the degraded performance and
the unsafe act.
Table 9-3
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Unit 9:
Factor Statements, Findings, Recommendations
Factor Statement Example - Afloat Mishap
(Human Factor – Ineffective Supervision)
1. State the causal factor by number, cause type, name
of cause, and relationship to the mishap.
CAUSAL FACTOR-5: (Human Factor Ineffective Supervision – Root Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
Unit leadership. . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental),
as appropriate.
did not effectively assess risks and knowingly
allowed an ineffectively trained, non-proficient
and fatigued individual . . .
4. Consequences of the action / inaction / failure or
environmental condition.
to operate the craft in a high risk environment.
Table 9-4
Factor Statement Example – Ashore / Industrial Mishap
(Materiel Factor – Environmental Conditions)
1. State the causal factor by number, cause type, name
of cause, and relationship to the mishap.
CAUSAL FACTOR-3 (Materiel Factor Inadequate illumination - Contributing
Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
Inadequate illumination in the area of the
platform . . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental),
as appropriate.
created visibility problems for the crew . . .
4. Consequences of the action / inaction / failure or
environmental condition.
and contributed to the mishap victim’s fall
from the platform.
Table 9-5
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Factor Statement Example - Ashore Mishap
(Human Factor - Organizational Influences)
1. State the causal factor by number, cause type, name of
cause, and relationship to the mishap.
CAUSAL FACTOR-3 (Human Factor –
Insufficient Program Funding - Root
Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The lack of MWR/MCCS funding to support
operations in the base hobby shop. . .
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental), as
appropriate.
forces hobby shop employees to
unnecessarily improvise to try and overcome
serious hazards to both military and civilian
customers . . .
4. Consequences of the action / inaction / failure or
environmental condition.
resulting in risky use of equipment that
resulted in the mishap.
Table 9-6
Factor Statement Example - Aviation Mishap
(Human Factor – Team Failure)
1. State the causal factor by number, cause type, name of
cause, and relationship to the mishap.
CAUSAL FACTOR-1: (Human Factor Crew/Team Failure – Root Cause)
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The Pilot in Command (PC) and Pilot (PI) of
the UH-60…
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental), as
appropriate.
both became visually fixated on an animal on
the ground and did not properly scan for
obstacles when they …
4. Consequences of the action / inaction / failure or
environmental condition.
which resulted in the aircraft main rotor
blades making contact with a tree at
approximately 50 feet AGL. There were no
injuries.
Table 9-7
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Factor Statement Example - Aviation Mishap
(Materiel Factor – Manufacturer Influence)
1. State the causal factor by number, cause type, name
of cause, and relationship to the mishap.
CAUSAL FACTOR-1 (Materiel Factor –
Improper component – Contributing
Cause)
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
During engine run-up of the MH- 60R with
rotor blades turning…
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental),
as appropriate.
the retention bolts (P/N BR549-X) securing
the fixed droop stop to the aft rotor system red
blade pitch shaft failed . . .
4. Consequences of the action / inaction / failure or
environmental condition.
causing the aircraft red main rotor blade to
contact the fuselage
Table 9-8
Factor Statement Example – Off Duty Mishap
(Human Factor – Individual failure)
1. State the causal factor by number, cause type, name
of cause, and relationship to the mishap.
CAUSAL FACTOR-1: (Human Factor Individual Failure – Direct and Root
Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The mishap Marine/Sailor…
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental),
as appropriate.
while driving drowsy, over reacted with
excessive steering and braking inputs . . .
4. Consequences of the action / inaction / failure or
environmental condition.
causing the PMV to swerve uncontrollably,
skid across the road, strike a guardrail, and
barrel roll multiple times resulting in severe
spinal trauma.
Table 9-9
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Factor Statement Example – Off Duty Mishap
(Human Factor – Individual failure)
1. State the causal factor by number, cause type, name of
cause, and relationship to the mishap.
CAUSAL FACTOR-1: (Human Factor Individual Failure – Root Cause):
2. Identify WHO or WHAT.
- Who failed (by duty position) or
- What materiel failed (part, component, or system) or
The mishap Marine/Sailor…
- What environmental condition
3. Identify the action or inaction (mistake/error made by
humans. (I.e. individual, supervisors, unit/command) or
the name and part, component or system that failed (by
part number (PN) or national stock number (NSN); or a
description of the condition (human or environmental), as
appropriate.
failed to prioritize personal task. Instead of
scanning for hazards while crossing a busy
street, s/he fixated on his/her cell phone . . .
4. Consequences of the action / inaction / failure or
environmental condition.
causing him/her to walk into the path of an
oncoming truck.
Table 9-10
9-2. DEVELOPING FINDINGS.
a. Overview. Findings connect the factors to the timeline and occurrence of the mishap, commonly
known as the mishap sequence. Similar to factors, findings are based on mishap evidence, professional
knowledge and judgement of the investigator.
b. Guidelines for development.
1) Arrange in chronological order
2) Each finding is a single event or condition and cites an essential step in the mishap
sequence.
3) Findings are concise (one sentence) and only contain information necessary to explain the
mishap sequence.
4) Each finding requires a logical connection to the preceding finding.
5) Each factor must be associated with at least one finding, but not every finding requires
connection to a factor.
9-3. DEVELOPING RECOMMENDATIONS FOR CORRECTIVE ACTIONS.
a. Overview. Every near-miss or mishap investigation report requires some corrective action to be taken
throughout the unit/command or chain of command. When developing and writing recommendations,
investigators should use the following guidelines, and test these recommendations with the question:
"If this had been done before the mishap, would these additional hazards have been eliminated?"
Do not include any recommendations that fail this test; rather, include them in a HAZREP. If in doubt,
contact Naval Safety Command / CMC(SD) mishap investigations team at (757) 444-3520 extensions
7137, 7139, 7161, 7170, 7173, or 7198.
b. Preparation Guidelines. In accordance with OPNAVINST 5102.1_/MCO P5102.1_, the following
guidelines shall be used in the composition of recommended corrective actions:
1) Recommendations shall NOT refer to disciplinary or administrative action.
2) Each causal factor shall have at least one recommendation, yet the number of recommendations
per causal factor are not limited.
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3) Recommendations should be stated in the same sequence as the causal factors.
4) Each recommendation must be assigned an “Action Agency” to complete the corrective action
("who" should do exactly "what.") Sometimes, "how," "where" and "when" are also appropriate.
Direct each recommendation at the unit, command, or activity having responsibility for and which is
best capable of implementing the actions contained in the recommendation.
Most actions are required at the mishap “Unit/Command Level” (i.e. Battalion / Squadron / Ship /
Installation). However, sometimes unit level or board level investigators will determine that certain
corrective actions can only be implemented by “Higher Level” Command (i.e. One and Two star
Flag/General Officer Commands as well as three star regional commands), and/or the “CNO or
CMC Level” to include supporting agencies such as TECOM, NETC, NAVFAC, the appropriate
SYSCOM, LOGCOM, BUMED, NAVSUP, NAVSAFECOM, CMC(SD), etc.
5) Recommendations must be expressed in a complete, self-explanatory statement. They must stand
alone. Recommendations are often included in endorsements and separate from the detailed
analysis of the deductive process. This is especially true for SIBs.
6) Recommendations must be confined to the investigated mishap or hazard. Ensure that
recommendations are pertinent to hazards detected in the investigation. Do not make
recommendations that are a community agenda item that is not attached to a causal factor of the
mishap.
7) State only one recommendation at a time.
8) Address only one subject in each recommendation. Avoid dual recommendations (do this and do
that), and alternative recommendations (do this or do that). If alternatives are apparent, select and
recommend the optimum or include a second recommendation that does not conflict with the first.
9) Be practical / realistic. Avoid vague wishful thinking which usually includes terms such as "all crew
members read and comply", "all personnel do XYZ," "good seamanship is to be re-emphasized," or
"safety compliance is to be stressed." Describe precisely how the desired end is to be
accomplished, and by whom. The exception to this rule is recommendations to brief the contents
the “Lessons Learned” to an identifiable group (e.g. “all team members, all maintenance personnel,
or all operators”) as a means to raising awareness about the hazards encountered in mishap.
TIP: To ensure your recommendations do not fall into the “good idea fairy” category and you lose
credibility, you will need to spend some time to ensure each recommendation meets ALL of the following
criteria.
Think S.A.F.E.
 Suitable: Will the corrective action remove or mitigate the hazard(s) to a level acceptable by the
chain of command?
 Acceptable: Is it accepted by USN-USMC standards & core values?

The benefit gained by implementing the control justifies the cost in resources and time. The
assessment of acceptability is largely subjective. Past experience, the commander’s guidance,
or other external restrictions influence the assessment.
 Feasible: Does the commander has the capability to implement the control / corrective action?

Does the mishap commander have the resources?

Does the higher command have the resources?

Does the USN, USMC, or DoD have the resources?
 Enduring: Will the solution last beyond a change of command?

Guidance and procedures for implementing the control are clear, practical, and specific.

Leaders are ready, willing, and able to enforce standards necessary to implement the control.
NOTE: If the recommendation does not meet all these criteria, you must continue to research for an
effective solution.
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10) Be comprehensive. See the “tip” box above. When a hazard is common to an entire community
and the recommended corrective action could benefit all, do not limit a recommendation to local
actions. Write it so that it applies to all who could benefit, and assign the action to the command in
the best position to act on the recommendation.
11) Recommend final, definitive solutions. See the “Tip” box above. Avoid recommending interim
steps toward a desired end. Recommend final, definitive solutions, rather than half-measures
such as "study," "review," "research," "evaluate," "vigorously explore," or "pursue." Ensure the
recommendation provides a mechanism to “Close the Loop”
12) Be uninhibited. Do not suppress valid recommendations because they appear to be too
expensive, too difficult, or imply criticism. A decision in favor of the desired action may be pending
only the incentive of a recommendation.
13) Do not include extraneous material. Analysis, conclusions and justification belong elsewhere in
the report.
14) Recommend use of established procedures for changes of publications. When appropriate,
recommend "who" (usually the reporting command/custodian that sustained the mishap) should
submit exactly "what" change to the applicable publication (e.g., NWPs, MCOs, maintenance
program directives, SOP’s, safety publications, etc.).NOTE: When possible, include a verbatim
draft of the recommended change to show exactly what is intended.
TIP: Many “Off-duty” mishaps that are the result of poor judgment and decisions, it may not be realistic
to ensure that recommendations meet all the above stated criteria. However, one can reasonably expect
to meet the criteria for all on-duty mishaps.
c. Elements of a Recommendation. In accordance with OPNAV M-5102.1_/MCO P5102.1_, the
following guidelines shall be used in the composition of recommended corrective actions (See Figure 9-2):
1) Element 1: Action Agency. Identify who the recommendation “applies to”. Repeat this for every
action agency.
NOTE: For unit level mishap investigations within operational units/commands, most
recommendations will “Apply to” only the mishap unit commander.
2) Element 2: Re-state the causal factor by number, category, cause type, name of cause, and
relationship to the mishap. (Example: HUMAN FACTOR 4: Ineffective Planning – Root Cause)
3) Write each recommendation that meets the criteria of S.A.F.E. and all above stated guidelines. For
unit / Installation Level mishap report. Sometimes the corrective actions have already been
identified and completed before the writing of your report. Ensure you identify the corrective action
taken by the commander and its status (i.e. complete, in progress, etc.)
NOTE: For SIB reports Only: After each recommendation, reference which causal factor(s)
paragraph(s) they address. (e.g., REFS 4E(1) and 4E(2). Reference accepted causal factors 4.E.1
and 4.E.2)
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Example Factor Statement - Ashore Mishap
(Human Factor - Organizational Influences)
Accepted Causal Factors:
HUMAN FACTOR - 3: CAUSAL FACTOR-3 (Human Factor – Insufficient Program Funding - Root
Cause): The lack of MWR/MCCS funding to support operations in the base hobby shop forces hobby shop
employees to unnecessarily improvise to try and overcome serious hazards to both military and civilian
customers resulting in risky use of equipment that resulted in the mishap.
ANALYSIS: (This paragraph follows the conclusion statement – See Unit 10, section 3, paragraph I, in
this manual for details.)
Example Recommendation
APPLIES TO: Director, MWR/MCCS, xxxxx Base.
HUMAN FACTOR - 3: (Insufficient Program Funding – Root Cause)
1. Recommend conducting an organizational level operational planning team (OPT) or working group
(WG) to create a prioritized list of MWR/MCCS equipment / materiel which are in greatest need of repair
or replacement. The OPT or WG should include supervisors, employees, and safety reps from various
MWR/MCCS functions. The purpose is to identify and assess equipment/materiel that create health or
injury hazards for both employees and patrons. The goal is to create a prioritized list of equipment/materiel
that require more effective hazard mitigation efforts to include replacement. The OPT or WG should then
prioritize the hazards based on levels of frequency and risk then place each hazard into the following
categories: high-frequency/high-risk; high-frequency/low-risk; Low-frequency high-risk; Low-frequency/
low-risk. The term “frequency” refers to the amount of hours an employee and patron are exposed to the
hazardous activity and/or equipment. The term “risk” refers to the definition of risk defined in DoDI
6055.01, DoDI 6055.07, and OPNAVINST 3500.39 series. This should be completed within 15 business
days with courses of action provided to the Base Commander and all tenant commanders.
2. Recommended immediate removal from service of all damaged or outdated equipment/materiel
identified to have the highest risk to injury or illness and highest frequency of use. (COMPLETE)
3. Recommend immediate funding to repair or replacement of all damaged or outdated
equipment/materiel identified to have the highest risk to injury or illness and highest frequency of use,
4. Recommend replacement or repair of remaining materiel based on frequency of use & risk
categories.
5. Recommend periodic OPT or WG reviews of all identified and newly identified hazards every six
months to reassess and reprioritize the repair or replacement of materiel.
Recommendation Validation Checklist - Do the above stated recommendations meet the guidelines?
 Do the recommendations refer to disciplinary or administrative action? NO
 Is there at least one recommendation per causal factor? YES (multiple)
 Is/Are the recommendation(s) stated in the same sequence as the causal factor?. YES (Causal Factor -3)
 Do the recommendations have an “Action Agency” (who, do what by when). YES (Director of
MWR/MCCS create OPT/WG to complete a task w/in 15 business days; Immediately take action on high
risk items; and conduct audits every 6 months)
 Is each recommendation expressed in a complete, self-explanatory statement? YES
 Is the recommendation confined to the investigated mishap or hazard? YES
 Is each recommendation separated by subject (no this and that or this or that)? YES
 Is/are the recommendations practical and realistic (S.A.F.E.)? YES
Suitable: Removing most risky equipment from service and replacing equipment significantly reduces risk
and liability.
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Acceptable: Honors the intent of a “safe and healthful work environment”. They create good business
practices that are not invasive on the organization or patrons. By including supervisors, employees and
safety representatives, fosters ownership (buy-in), teamwork, effective communication, and a positive
organizational culture.
Feasible: Organizational supervisors have plenty of personnel who can easily tag-out and remove most
hazardous items from service. MWR/MCCS has the funds to replace or repair items/materiel of highest risk.
Enduring: Periodic reviews / assessments with an established metric sustains a best practice to ensure a
safe and healthful working environment.
 Is each recommendation comprehensive (can they benefit an entire community)? YES (Each
recommendation fosters a best practice across the installation as well as across all MWR/MCCS activities
around the globe)
 Is/Are the Recommendation(s) a definitive solutions? YES (Provides a pathway to improve program
management to audit/assess, prioritize, repair, and replace with the end state focused on mishap
prevention.)
 Do any recommendations include extraneous material? NO
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Unit 10:
Preparation of Safety Reports
PART III
Safety Investigation Reports and Corrective Action
Process
Unit 10 –Preparation of Safety Reports
Unit 11 – Unit Safety Officer’s Role to a Safety Investigation
Board
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10-1. INTRODUCTION AND OVERVIEW. Record keeping and reporting is vital to provide safety
information to Department of the Navy (DON) and Department of Defense (DoD). These records and reports
are required by federal law and provide information to identify unsafe acts, influencing conditions, and apply
corrective measures. Mishaps or incidents that previously were only locally recordable, and not reportable
outside the command, are reportable to the DON, since all electronic entries are mandated by the Chief of
Naval Operations (CNO) and the Commandant of the Marine Corps (CMC) to be transmitted to the
Commander, Naval Safety Command (COMNAVSAFECOM) mishap database (currently Risk Management
Information (RMI)). This includes not only material damage but also near mishaps and mishaps that result in
injuries and occupational illnesses that cause death, time away from work, light-duty, limited duty, or
restricted duty. Therefore all OSHA “recordable” mishaps along with Naval “near-mishaps” and hazards
effecting a community are mandated to be reported electronically to COMNAVSAFECOM.
NOTE: Submitting hazard and mishap reports in the mandated DON reporting database meets the
requirement for organizations and commands to maintain mishap “injury and illness logs” per OSHA 1904,
DoDI 6055.07 and all Navy and Marine Corps policies
10-2. HAZARD REPORT (HAZREP).
a. Purpose. A HAZREP is intended to be submitted when the elimination and control of a given hazard
has community-wide implication in reducing mishaps. The HAZREP is to be used for all Navy/Marine Corps
reportable hazards, as detailed in OPNAV M-5102.1_/MCO P5102.1_.
b. Required Reports. HAZREPs are submitted electronically, using the current mandated DON program
of record reporting system for the following:
1) A hazard or near-mishap and the recommended remedial or corrective action taken to eliminate the
hazard.
2) A previously unrecognized hazard so that another agency may determine appropriate corrective
action to eliminate the hazard.
3) A significant, unexpected, or unusual occupational overexposure, as the result of industrial hygiene
assessments of industrial processes or operations, to bring that potential exposure to the attention
of medical and safety authorities and others.
4) Electrical shock incidents (afloat, ashore, ground, aviation) where the mishap did not result in any
medical treatment or injury/fatality and where it was determined that the shock was caused by
equipment design.
5) Afloat man overboard mishaps while underway where the mishap did not result in a
recordable/reportable injury/fatality.
6) Any unusual hazard discovered during maintenance, repair, inspections, or evolutions where
notifying other activities may prevent future mishaps.
7) Any hazard discovered during the conduct of a safety investigation (unit/installation or SIB) that
warrants immediate widespread dissemination.
c. Guidelines. In accordance with OPNAV M-5102.1_/MCO P5102.1_, the following guidelines shall be
used regarding the submission of HAZREPS:
1) HAZREPS must be released immediately upon finding a hazard.
2) Near-mishaps should be investigated and reported via a HAZREP, as outlined in OPNAV
M-5102.1_/MCO P5102.1_.
3) HAZREPs are submitted electronically using the DON (CNO & CMC) approved reporting system.
(I.e. RMI) (Not Echelon II or regionally approved – must be a DON program of record).
4) HAZREPs do not replace Hazard Abatement Program requirements.
5) HAZREPs related to aviation are reported per OPNAVINST 3750.6R.
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6) HAZREP is usually unclassified and “Factual” information.
7) HAZREPs are For Official Use Only (FOUO) per SECNAVINST 5510.36.
8) Re-addressing and redistributing HAZREPs is at the discretion of COMNAVSAFECOM, CMC (SD),
and the originating command’s chain of command.
NOTE: USMC ONLY: Hazards associated with the operation of Marine Corps ground tactical equipment
and/or weapons systems, units must submit the hazard to MARCORSYSCOM in accordance with MCO
5100.34A. This is an addition to the HAZREP submitted in the COMNAVSAFECOM reporting database.
d. HAZREP Format / Elements. Seven basic elements of the HAZREP are:
1) General Information. Includes hazard type, reporting activity, time, date, narrative of the hazard,
training or other,
2) Draft Participants. List names of safety personnel having authority to submit and edit the report.
3) Location of the hazard.
4) Involved Commands.
5) Involved Personnel. (Job, activity, duty status, location, etc.)
6) Involved Property (Gov and/or Non-Gov)
7) Factors and Recommendations.
10-3. SAFETY INVESTIGATION REPORT (SIREP).
a. Purpose. The use of standardized mishap reports allows for consistent mishap trending, efficient
hazards analysis, and more effective sharing of lessons learned across the DON and the DoD. All
“reportable” and “recordable” mishaps or near-mishaps that occur within the United States Navy and Marine
Corps shall be reported to the Naval Safety Center using the electronic program of record mandated by the
CNO and CMC. Reports of the “work related illness and injury log” are captured in the NAVSAFECOM’s
reporting tool and meet the requirements of 29 CFR, DoDI 6055.07, and subordinate Navy and Marine Corps
policies.
TIP: In accordance with DoDI 6055.07 and OPNAV M-5102.1_/MCO P5102.1_ upon completion of any safety
investigation, activities and commands shall destroy any privileged materials gathered during that investigation.
b. Guidelines. In accordance with OPNAV M-5102.1_/MCO P5102.1_, SIREPS prepared generated
from either unit/command level or board level investigations shall not:
1) Refer to disciplinary or administrative action in connection with the mishap.
2) Include witness statements from a JAGMAN or NCIS investigation.
3) Be released to the Office of the Judge Advocate General (OJAG) and Staff Judge Advocate (SJA).
4) Be released to individuals outside the privileged safety chain.
5) Be released in public forum.
6) Be released to commands outside designated endorsees and action agencies.
c. Completion and Release Timelines.
1) Unit/Command safety officers / civilian SOH specialists have 30 days from the time of the mishap to
complete and submit the SIREP for all reportable and “recordable” mishaps and near-mishaps.
2) Senior members of a SIB have 30 days from the convening of the board to submit the SIREP.
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d. Report Format. Although there is minor differences between the unit/command level report and the
SIB report submitted into the DONs reporting system, the general elements are as follows:
1) Part A. This section contains factual / non-privileged) Information about the mishap,
units/commands involved, materiel involved, personnel involved, etc. This section is for official use
only (FOUO) and cannot be released to any individual, activity or organization, or used for any
purpose other than safety without the written permission of Commander, Naval Safety Command,
(Ref: SECNAVINST 5720.42, OPNAV M-5102.1 Series.)
2) Part B. This section is the MOST CRITICAL section of the report as it captures the privileged
information to include:
 List of evidence, (Required for SIB only. Recommended for Non-SIB (unit / command /installation
investigations)
 Chronological sequence of events, (Required for SIB only. Recommended for Non-SIB (unit /
command / installation investigations)
 Narrative, (Required for ALL SIREPS)
 Causal factors, (Those rejected and those selected are required for ALL SIREPS)
 Detailed analysis of the causal factors to include DoD HFACS codes and sentences linking each
code to the analysis, (Required for ALL SIREPS)
 Recommendations for Corrective Actions, (Open and complete – Required for ALL SIREPS)
 Senior Member comments (Only for SIBs)
NOTE: Unauthorized disclosure of the information in a mishap investigation report by military personnel
is a criminal offense punishable under Article 92, Uniform Code of Military Justice. Unauthorized disclosure
of the information in a mishap investigation report by civilian personnel will subject them to disciplinary action
under the DON Civilian Human Resources Manual, Subchapter 752.
e. Part B, Paragraph A: Evidence. Identify all documents used by the investigation that form the basis
for analysis and referred to as evidence. Identify non-privileged information in paragraph A. Identify
privileged evidence in paragraph B by using the symbol "(P)" prior to each document. Identify evidence
available to all in paragraph C. (See example in figure 10-1)
NOTE: All physical evidence should be held by the owner of the mishap. If any evidence is classified, it
must be clearly identified in paragraph A, B or C.
EXAMPLE using an “On-duty PT” mishap:
A. EVIDENCE
(1). PRIVILEGED EVIDENCE
(A) (P) Interview Notes Witness 1 (W1)
Figure 4-1
(B) (P) Interview Notes Witness 2 (W2)
(C) (P) Interview Notes Witness 3 (W3)
(2). NON-PRIVILEGED EVIDENCE
(A) Deck Log (CONFIDENTIAL)
(B) EMS Report
(C) Medical Record (SENSITIVE)
(3). EVIDENCE AVAILABLE TO ALL
(A) SECNAVINST xxxx.x
(B) OPNAVINST xxxx.xx
(C) MCO xxxx.xx
Figure 10-1
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f. Part B, Paragraph B: Chronological Sequence of Events Leading up to and through the Mishap.
Paragraph B. CHRONOLOGICAL SEQUENCE OF EVENTS LEADING UP TO AND THROUGH THE
MISHAP (in local time). State the date and time of each event, followed by the event, then the paragraph
number of the evidence in the “Evidence” section above. Insert “(P)” prior to each event when citing
information taken from privileged evidence. (See example in Figure 10-2 that references figure 10-1)
NOTE: This section is required for all mishap investigation boards. This section is currently not required
for non-SIB reports however, is a best practice and should be included in to the “Narrative” section of the
reporting database
EXAMPLE using the “on-duty PT” mishap:
B. CHRONOLOGICAL SEQUENCE OF EVENTS LEADING UP TO AND THROUGH THE MISHAP IN
LOCAL TIME (APPROXIMATE):
26 FEB 06: At age 15, Mishap victim was diagnosed with elevated blood pressure and a heart
murmur. (PART B, ALPHA (2)(C))
(P) 29 OCT 11: Mishap victim informed Officer in Charge of chest wall pain. (PART B, ALPHA (1)(C))
01 MAY 12: Medical Officer (Cardiologist) clears mishap victim to participate in spring physical fitness
testing. (PART B, ALPHA (2)(C))
20 MAY 12:
(P) 1005: Mishap victim stops running and falls down grasping chest. (PART B, ALPHA (1)(A))
(P) ~1006: Fellow runners yell to monitor to call 911 and begin first aid. (PART B, ALPHA (1)(C))
(P) ~1008: W3 and W6 begin cardiopulmonary resuscitation. (PART B, ALPHA (1)(C), ALPHA
(1)(E), ALPHA (1)(F), and ALPHA (1)(G)
1010: Ambulance dispatched from Naval Hospital Xxxxxxxx. (PART B, ALPHA (2)(A) and (2)(B))
1020: Dispatched ambulance arrives on scene. EMS personnel assist in ventilation, begin EKG
monitoring and take over cardiopulmonary resuscitation (PART B, ALPHA (2)(A) and ALPHA
(2)(B)
Figure 10-2
TIP: Listing the evidence is required for all investigation boards. Although not required for a non-SIB at
the unit / command level, it is a best practice to improve lessons learned and trend analysis
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g. Part B, Paragraph C: Narrative. Describes detailed narrative of events leading up to and through the
mishap that describes facts about Who, What, When and Where. Avoid the “Why” as this will be detailed in
“Accepted Causal Factors” section. Ensure all information is based on analyzed evidence. Do not include
Privacy Act protected information or personal identifiers, instead, use positional identifiers (E.g. MOOD for
Mishap Officer of the Deck/Day, W5 for witness number 5, MD for mishap driver, MSM for Mishap Service
Member, etc.)
NOTE: This section applies to both unit/command investigations and SIBs. (See figure 10-3)
EXAMPLE using an “on-duty, shore/ground tactical GVO” mishap:
C. PRIVILEGED NARRATIVE:
On the afternoon of DD MMM YYYY at ~1655, a Class-C mishap occurred onboard Xxxxxxxx Base
Xxxxxxx, Nowhereville, USA when a M-Xxxx tactical motor vehicle crash resulted in injuries to three
active duty personnel and damage to the tactical vehicle.
While driving in a convoy of six tactical vehicles to a training site on Xxxxxxxxxxx road the mishap
driver (MD) lost control of the mishap vehicle (MV) as the MD over reacted with excessive braking and
steering inputs causing the MV to roll over approximately three-quarter (3/4) of a full rotation. The MV
came to rest on the driver’s side, XX feet from the road surface. Unit personnel responded with first aid
measures for three injured personnel until emergency services arrived. Three injured personnel were
transported to a Military Treatment Facility onboard Xxxxxxxx Base Xxxxxxx, Nowhereville, USA. One
service member was placed on light duty after being treated and released from the Emergency Room.
Two service members were admitted to inpatient care for injuries that required surgery and an extended
hospital stay that will include rehabilitative physical therapy.
The direct cause (crash/rollover) of the mishap was the result of numerous contributing and root
causes stemming from supervisory and organizational factors which are detailed in paragraph E
(Accepted Causal Factors) of this report.
This mishap Investigation was conducted by the command Safety Officer, the command Safety Chief
with assistance from the Executive Officer. The conclusions of the findings below are derived from the
utilization of various analytical methods to determine the causal factors of the mishap. These tools
include: Cause mapping analysis, barrier analysis, change analysis, materiel analysis and the DoD
Human Factors Analysis and Classification System (DoD HFACS 7.0)
Figure 10-3
TIP: OPNAV M-5102.1_/MCO P5102.1_ requires investigators to document the methodologies used to
deduce the causal factors. As a “best practice” it is recommended state the analytical methodologies at t
he end of the “Narrative”.
h. Part B, Paragraph D: Rejected Causal Factors. Provide a description of the causal factor followed
by summary of the investigators analysis of why it wasn’t causal. This is repeated for each rejected causal
factor. (See figure 10-4) NOTE: This section applies to only SIBs.
EXAMPLE (on-duty, live fire training mishap):
D. REJECTED CAUSAL FACTORS:
(1) HUMAN FACTOR - 1: Negligent discharge or weapon (Mishap shooter unintentionally
discharged the weapon.)
(A) ANALYSIS: Based on witness accounts with several personnel and with the mishap
shooter, the mishap shooter intended to fire the weapon at the target identified by the team
leaders; however, the mishap shooter was confused on locations of targets versus personnel as
targets and personnel night markings looked the same when viewed through the AN/PVS-14.
(2) MATERIAL FACTORS: N/A
(A) ANALYSIS: N/A
Figure 10-4
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i. Part B, Paragraph E: Accepted Causal Factors. Provide a description of the causal factor (i.e.
factor statement) followed by analysis paragraphs describing the role of the causal factor in relation to other
causal factors and the mishap. Each causal factor will be either human or material. This is repeated for each
accepted causal factor (See Figure 4-5). This section is broken down into multiple sub paragraphs that
provide detailed descriptions of the analysis of each causal factor. Below are outlines of the required
sections of the analysis paragraph for all investigations (aviation, ground, ashore, afloat, etc.).
1) Subparagraph (1) HUMAN FACTOR: Enter conclusion statement here as discussed in Unit 9-1
“Deliberations – Finalizing Conclusions”.
NOTE: Repeated for every identified causal factor that fits in the human factor category.
 Human Factor (A) ANALYSIS: The analysis presents all relevant data that links the causal factor
to other causal factors and recommendations. Provide a detailed description that clearly
delineates the cause and effect relationship of the causal factor to other factors of the mishap.
(See figures 10-5 and 10-6 which are based on figure 10-7).
TIP – For Human Factors Analysis Statement: To ensure the analysis paragraphs are complete, a best
practice ensure the analysis includes:
a) Identification of the task, function, precondition or environmental factor and how the task/function was
performed improperly or how the precondition or environmental factor affected human performance. If
the stated cause is at the individual/team level (e.g., a performance-based error, judgment and decision
making error or a violation), identify the direct cause and how was performed improperly. If the cause is
a contributor (i.e. environmental or a precondition such as fatigue), include an explanation of how the
factor contributed to the human performance. If the stated cause is at the supervisory or organizational
level (typically root causes), ensure you describe how the cause factor was incorrect, ineffective, or
improper.
b) Identification of the directive, (i.e., OPNAVINST, MCO, NAVMC, SOP, FM, TM, etc.) or common
practice governing the performance of the task or function. In lieu of a written directive, the error may
represent performance that is contrary to common practice which is identified using the DoD HFACS
taxonomy.
c) An explanation of the consequences of the causal factor. Describe how the action (individual,
supervisory, or organizational) influenced other actions or conditions
d) Explanation of the reasons for the causal factor.
e) Explanation of how each reason contributed to the individual’s or team’s unsafe act(s).
The analysis paragraph is followed by listing all DoD HFACS codes that support the analysis
paragraph as follows:
o 1. UNSAFE ACTS: State each DoD HFACS code followed by a sentence linking the code to
analysis. NOTE: This is used if describing the “Direct Cause”. If the stated causal factor is at
the supervisory level or organizational level, these codes will not be applicable.
o 2. PRECONDITIONS TO UNSAFE ACTS: State each DoD HFACS code followed by a
sentence linking the code to the “unsafe acts” and analysis. NOTE: Each precondition must
support an “unsafe act”. If the stated causal factor is at the supervisory or organizational level,
these codes will not be applicable.
o 3. SUPERVISION: State each DoD HFACS code followed by a sentence linking the code to
analysis. NOTE: The sentences must describe how the supervisory code affected
“preconditions” and/or the “unsafe act”.
o 4. ORGANIZATION: State each DoD HFACS code followed by a sentence linking the code
to analysis. NOTE: The sentences must describe how the organizational code affected the
“supervisory” actions and/or the “preconditions” and/or the “unsafe act”.
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2) Subparagraph (2) MATERIEL FACTOR: Enter conclusion statement here as discussed in Chapter
3-6 “Deliberations – Finalizing Conclusions”.
 Materiel Factors (A) ANALYSIS: Provide a detailed description that clearly delineates the cause
and effect relationship of the causal factor to other factors of the mishap. The material factor
statement is supported by the following subsets.
o 1. COMPONENT: Described what failed.
o 2. MODE: Describe how the component failed (e.g., stripped, cracked, bent, twisted,
shattered, etc.).
o 3. AGENT: Describe why the component failed (e.g., fatigued, overloaded, corrosion,
decayed, etc.).
NOTE: A materiel failure may have an immediate effect on equipment or its performance, or it may
create circumstances that cause unsafe acts resulting in further damage, injury or occupational
illness.
EXAMPLE (blank format):
E. ACCEPTED CAUSAL FACTORS:
(1) HUMAN FACTOR-1: (State the causal factor by number, cause type, name of cause, and
relationship to the mishap.)
(A) ANALYSIS: (Provide a detailed description that clearly delineates the cause and effect
relationship of the causal factor to other factors of the mishap.)
1. UNSAFE ACTS: (DoD HFACS code followed by description of applicability.)
2. PRECONDITIONS: (Repeat)
3. SUPERVISION: (Repeat)
4. ORGANIZATIONAL: (Repeat)
(2) MATERIAL FACTORS: (State the causal factor by number, cause type, name of cause, and
relationship to the mishap.)
(A) ANALYSIS: (detailed narrative of accepted materiel factor)
1. COMPONENT: (Describe what failed)
2. MODE: (Describe how the component failed)
3. AGENT: (Describe why the component failed)
NOTE: This format is repeated for every selected causal factor.
Figure 10-5
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EXAMPLE using an “on-duty, shore/ground tactical GVO” mishap:
E. ACCEPTED CAUSAL FACTORS:
(2) HUMAN FACTOR - 2: (Mental Fatigue – Contributing Cause): The mishap driver (MD) was forced
to operate the mishap vehicle (MV) in a severe fatigued state which contributed to the degraded
performance, the unsafe act and the mishap.
(A) ANALYSIS: The MD’s mental fatigue (eight (8) hours of broken sleep in the 72 hours prior to
the mishap) was the most significant precondition contributing to the MD’s unsafe act of overcorrecting
steering. The MDs fatigue was the result of a combination of factors which included circadian rhythm desynchronization, being directed to stand duty the evening prior to driving, improper hydration and nutrition
prior to and the day of the mishap. These conditions stemmed from numerous supervisory errors,
omissions, and oversights beginning with ineffective pre-mission planning and ending with ineffective
time-critical risk management. The unit leadership conducted pre-mission planning 45 days prior to the
mishap. Evidence proves the planning team did not effectively assess and manage risk of personnel leave
and duty status prior to execution of the convoy. Rather than mandate all drivers and enablers to take the
first block leave period, the MD’s supervisors authorized the MD to take the second block leave period
with a location eight (8) time zones from the command and a return date of 30 hours prior to execution of
the convoy operations. Additionally, the MD was assigned to the watch-bill/duty roster the day prior to the
mishap in contravention of Big policy Xxx-x.
According to interviews with enlisted and officers, there were two reasons the MD was placed on
the watch bill / duty roster. First, there is a command policy that all duty positions require a primary,
alternate, and a second alternate. Second, the unit was at half strength due to the “port-starboard” block
leave period. Therefore, the supervisors felt that since the second alternate has never been pulled for
duty, by placing the MD as the second alternate, they would remain in compliance with the command
policy while mitigating the likelihood the MD would stand duty.
On the day before the mishap, the primary duty became ill, the OOD stated that he could not
locate the first alternate thus directing the MD to assume the duty at 2000. After the MD informed the
OOD of his driving duties the next day, the OOD did not take action to contact the MD’s supervisor due to
the OOD’s misinterpretation of the Big-Navy/Big Marine Corps policy Xxxxxx. On the day of the mishap,
the OOD relieved the MD of duty at 0700 who immediately reported to supervisors of being extremely
tired and should not drive. At this point the MD was directed by the unit enlisted leadership to operate the
MV and prepare for a departure time of 0900. After a delayed departure by two hours, the MD tried and
overcome his fatigued state by drinking a third and fourth “Monster” energy drink yet did not acquire
proper nutrition to fuel the brain and body functions.
Throughout the 40 mile trip to the training area, the convoy made two scheduled stops and one
unscheduled stop to assess an overheating issue of one of the vehicles. During this time, the MD drank a
fifth “Monster” energy drink try and overcome his degraded performance. The MD’s vehicle commander
(VC) was fully aware of the MD’s fatigue, yet failed to request a change in operators/drivers from the
senior enlisted and officer in charge.
This combination of lack of effective sleep combined with a circadian rhythm de-synchronization
(jet-lag) and poor dietary practices resulted in a mentally fatigued state that degraded the MD’s
performance which significantly increased the overall risk of this mishap. Had the supervisory team
mandated the MD take the first block leave period, the MD would have had plenty of time to reset his
circadian rhythm and avoid prepare for the mission.
1. UNSAFE ACTS: (See Human Factor-1 above)
2. PRECONDITIONS:
a. PC 307 (Fatigue): An analysis of the MD’s 72 hour profile revealed the mishap driver
had only eight (8) hours of broken sleep in the 72 hours prior to the mishap, one good meal the day prior,
with trail mix and energy drinks versus a full meal and water on the day of the mishap.
b. PC 302 (Substance effects): On the day of the mishap, the MD tried and overcome his
fatigued state by drinking five (6) Monster energy drinks within 12 hours (yet only drank 32 oz. of water.
Figure 10-6
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(A) ANALYSIS (continued):
3. SUPERVISION:
a. SI 001 (Inadequate Supervision): The MD’s first line and second line supervisors
continuously failed to identify the risk of the MDs degraded condition and take action to replace the MD
with another driver.
b. SP 006 (Inadequate Risk Assessment-Formal Planning): The supervisory team did not
effectively recognize key conditions. These numerous errors during the Marine Corps Planning Process
for this event allowed a number of latent conditions to exist and set the stage for a severely fatigued driver
to be behind the wheel thus placing all occupants in danger and allowing a mission failure.
c. SV 001 (Failure to enforce existing rules): The MDs first line supervisors failed to enforce
existing policies to prevent unsafe Government motor vehicle operations.
d. SV 003 (Directed Individual to Violate Existing Regulations): The MD was directed to
stand duty the night prior to operating a tactical GVO in contravention of Xxx-x policy. Also, the MD was
directed to drive by the second line supervisor after the MD informed the leadership of being extremely
tired.
4. ORGANIZATIONAL:
a. OP 003 (Inadequate Procedural Guidance or Publication): The command watch-bill/duty
policy creates increase risk of supervisory errors during times of reduced command strength.
(2) MATERIAL FACTORS: N/A
(A) ANALYSIS: N/A
1. COMPONENT: N/A
2. MODE: N/A
3. AGENT: N/A
Figure 10-6 (continued)
Direct Causal Factor: “Loss of Control - overcorrection”
(Influenced by: Speed to fast for conditions, fatigue, poor visibility, ineffective operator’s training, ineffective TCRM of
supervisors (directed to operate the vehicle / craft), ineffective pre-mission planning/deliberate risk assessment.)
Contributing Factor: “Operator
Inexperience”
(Influenced by: ineffective execution of
operator’s training program, ineffective
pre-mission planning/deliberate risk
assessment)
Contributing Factor: “Speed”
Contributing Factor: “Fatigue”
(Influenced by: fatigue, poor visibility,
operator experience, ineffective TCRM
of supervisors)
(Influenced by: ineffective TCRM by
supervisors, ineffective pre-mission
planning/deliberate risk assessment)
Causal Factor:
“Ineffective Planning / DRM”
Causal Factor:
“Ineffective Supervision”
(Influenced by: ineffective supervision & unsafe unit
culture prioritizing time over effectiveness)
(Influenced by: unsafe unit culture prioritizing time over
effectiveness)
Causal Factor:
“Unsafe Unit Culture”
Figure 10-7 (Example of Causal Factor “cause and effect” Relationships)
j. Part B, Paragraph F: Recommendations. List recommendations as detailed in Unit 9, section 2 and
figure 9-2 of this manual.
k. Part B, Paragraph G: Senior Member Comments. This section is reserved for comments of a SIB
Senior Member (if desired).
NOTE: Paragraph G applies only to investigation boards.
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10-4. ENTERING THE SIREP INTO THE CNO/CMC APPROVED PROGRAM OF
RECORD DATABASE.
a. Mandate. All “reportable” and “recordable” mishaps or near-mishaps that occur within the United
States Navy and Marine Corps shall be reported to the Naval Safety Center using the electronic program of
record mandated by the CNO and CMC. Currently the only authorized mishap reporting system recognized
by the CNO and CMC is the Risk Management Information system (aka: RMI).
b. RMI SIREP Entry Steps. Once all steps are complete, ensure to validate your data and RMI will
determine any errors before submitting.
1) Create new event investigation
2) Add investigator(s); Add/modify SIB Members
3) Enter general information, location, environment
4) Enter Risk Management (if applicable, dependent on mishap class)
5) Enter Object(s), Person(s), Interviewed Persons, Vehicle Occupants, Injuries, Costs
6) Enter Narrative
7) Enter Factors and/or HFACS
8) Enter Findings
9) Associate Factors to Findings
10) Enter Investigation Conclusions (BLUF)
11) Enter Recommendations
12) Validate
13) Authenticate
14) Create Final Message
c. Best Practices for RMI SIREP entry.
1) Narrative: Narrative should be detailed enough to give complete context of the mishap to the reader
and answer who, what, where, when, why and how.
2) PII/Pronouns: PII and personal pronouns should be avoided in all narrative portions of the report
(i.e. First and last name, he/she/his/hers, rank/grade, age, gender and Unit/Command)
3) Validate: Using the validation tool will quickly alert the user to any sections that haven’t been filled
out or need to be fixed.
d. RMI SIREP Entry Method. Use the following figures and the above steps to guide you through RMI
SIREP entry.
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Click to create new
event
Figure 10-8
Figure 10-9
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Figure 10-10
Figure 10-11
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Enter information in
objects and persons
tabs as applicable
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Figure 10-12
Figure 10-13
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Figure 10-14
Figure 10-15
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11-1. MISHAP UNIT - SAFETY OFFICER’S ROLE TO A SIB: In the event your unit has a
mishap that requires a SIB, the GSO/GSM/ Civilian GS-0018 still plays a critical role in the SIB process.
Besides advising your commander of the requirements and proper course of action, you have other
responsibilities that are outlined in Chapters 1, 3, 4, 5, 7 and Appendix A of the OPNAV M-5102.1_/MCO
P5102.1_. Unit safety personnel shall:
a. Preserve Evidence. Assist your command in conducting safety investigations for all mishaps
requiring a SIB until the SIB arrives. (I.e. collect and preserve evidence, obtain a list of witness names, etc.)
b. Protect Safety Information. Advise your command that of protection of safety information
requirements.
NOTE 1: Members of the unit experiencing the mishap shall not be appointed to the SIB. OPNAV
M-5102.1_/MCO P5102.1_, Chapter 1, paragraph 7.q. states “Ensure no one directly involved in a
mishap, or having personal interest that might conflict with his or her objective and impartial performance
of duties, serves as a member of the SIB.”
NOTE 2: Per DoDI 6055.07 and OPNAV M-5102.1_/MCO P5102.1_, “Personnel assigned as the primary
duty safety officer, shall neither assist nor be assigned to conduct any JAGMAN investigation.”
c. Prepare and submit HAZREPs as required per SIB Senior Member. If a SIB discovers a hazard
unrelated to the mishap that warrants immediate widespread dissemination, the unit GSO/GSM will prepare
and submit the HAZREP per Chapter 4
d. Ensure command-wide dissemination of lessons learned resulting from the SIB.
NOTE: Do not post SIREPs on bulletin boards or send via email to anyone.
Reminder: “Unauthorized disclosure of Safety information by military personnel is a
criminal offence punishable under article 92 of the UCMJ.”
“Unauthorized disclosure by civilian personnel will subject them to disciplinary action
under DON Civilian Human Resources Manual, Subchapter 752.”
Chapter 7, para 7003
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APPENDICES
Appendix A – Marine Corps Mishap Investigation Process
Map
Appendix B – Navy Mishap Investigation Process Map
Appendix C – High Potential Mishaps
Appendix D – MARADMINs (Changes to 8-day brief requirements)
Appendix E – DoD HFACS integration into METT-T
Appendix F – References and Resources
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APPENDIX - A Marine Corps Mishap Investigation Process
Marine Corps Mishap Investigation Process Map
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APPENDIX - B Navy Mishap Investigation Process
Navy Mishap Investigation Process Map
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APPENDIX - C High Potential Mishaps (HIPOM)
High Potential, On-Duty Mishap (HIPOM). Unlike some reportable mishaps such as off-duty/recreational
mishaps or twisted ankle during PT, a HIPOM is an on-duty mishap which had the potential to result in a
more severe loss (e.g., fatality, permanent total disability, permanent partial disability, severe illness, loss of
asset, significantly degraded unit readiness or significantly degraded mission capability). These type of
mishaps meet the DoD and DON criteria of Class C or D injury or damage as well as first-aid injury.
The difference between a near miss or minor mishap and a catastrophic mishap might only be sheer luck
within a second in time, millimeters in distance, or the quick thinking and reaction of alert personnel.
However, the hazardous conditions surrounding the event deserve leadership’s scrutiny to ensure the
hazard(s) is/are controlled or eliminated to prevent the probability of a reoccurrence.
Units experiencing any mishap must comply with investigation and reporting requirements detailed in DoDI
6055.07 and OPNAV M-5102.1D/MCO 5102.1B. The purpose of labeling an event as a HIPOM is to ensure
that safety personnel (i.e. Unit Safety Officers and/or civilian Safety and Occupational Health Specialists)
analyze all active and latent conditions as they would during a formal Safety/Mishap Investigation Board
(SIB) to ensure all causal factors are identified. In order to reduce hazards and alert the fleet to hazardous
conditions or behaviors, the mishap investigation report must include a detailed analysis with effective
recommendations for corrective actions to the chain of command.
Chapter 6 of OPNAV M-5102.1D/MCO 5102.1B currently states the high potential mishaps of ordnance
impacting off range outside the surface danger zone, live fire training mishaps resulting in an injury, and
explosives related mishaps shall each require a formal Safety Investigation Board (SIB).
Chapter 3, Chapter 4 ,and Glossary 1 of OPNAV M-5102.1D/MCO 5102.1B outlines all mishaps, nearmishaps and hazards which require reporting to the Naval Safety Command via the authoritative web-based
mishap data collection system. Although some lower level classifications of injuries, damage or nearmishaps do not deserve detailed scrutiny, the following mishap types are considered HIPOMs and demand
a more thorough investigation by Unit Safety Officers and/or civilian Safety and Occupational Health
Specialists:
Mishap Type
Minimum
Injury Classification
Minimum
Property Damage
Classification
Mishap
Investigation
Type
Explosives related
1st aid and above
Class D or above
SIB / SIB
Live Fire training with injury
1st aid and above
N/A
SIB / SIB
Ordnance impacting off range (outside the
established SDZ)
1st aid and above
(Does not need to
meet a minimum
cost threshold)
SIB / SIB
GMV or GVO rollover or crash
1st aid, Class D or C
$5,000 or greater
Unit/Command
N/A
Unit/Command
N/A
Unit/Command
Any
Water borne training or operations
(I.e. survival training, screenings, diving, etc.)
Confined Space operations
Decompression illness,
Loss of consciousness,
1st aid, Class D or C
Loss of consciousness,
1st aid, Class D or C
Fall from height of four (4) feet or greater while
working on an aircraft, a ground vehicle, a
ladder, scaffold, aloft, etc.
1st aid, Class D or C
N/A
Unit/Command
Parachuting where there is suspected
malfunction of equipment or human error
1st aid, Class D or C
Any
Unit/Command
1st aid, Class D or C
(Does not need to
meet a minimum
cost threshold)
Any Helicopter Rope Suspension Technique
(I.e. Special Patrol Insertion/Extraction, Jacob's
Ladder operations, rappelling, fast rope, etc.)
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APPENDIX - C High Potential Mishaps (HIPOM)
Minimum
Property Damage
Classification
Any
Mishap
Investigation
Type
1st aid, Class D or C
(Does not need to
meet a minimum cost
threshold)
Unit/Command
Operations involving transportation of personnel or
equipment by LCAC, AAV, boat, aircraft,
submersible, etc.
1st aid, Class D or C
Class D or C
Unit/Command
Command sanctioned physical training event
where multiple personnel receive medical
treatment above first-aid (i.e. conditioning hikes,
unit PT with multiple heat casualties, etc.)
1st aid, Class D or C
N/A
Unit/Command
Struck by moving GMV or GVO during field training
events, shipboard operations, waterborne
1st aid, Class D or C
operations, or garrison ground operations.
N/A
Unit/Command
Mishap Type
Minimum
Injury Classification
Any Helicopter Rope Suspension Technique (I.e.
Special Patrol Insertion/Extraction, Jacob's Ladder
operations, rappelling, fast rope, etc.)
Pinched by moving GMV or GVO during field
training events, shipboard operations, waterborne
operations, garrison ground operations.
1st aid, Class D or C
N/A
Unit/Command
Struck by equipment during maintenance activities
or normal work activities.
1st aid, Class D or C
N/A
Unit/Command
Pinched by equipment during maintenance or
normal work activities.
1st aid, Class D or C
N/A
Unit/Command
Exposure to inadvertent release of toxic
substances (E.g. chemicals, biologicals, fire
suppression agents, etc.)
Near-miss,
1st aid, Class D or C
N/A
Unit/Command
Electrical related injuries during work.
(E.g. Arc flash, shock, etc.)
Near-miss,
1st aid, Class D or C
N/A
Unit/Command
N/A
Unit/Command
Electrical related injuries to guests, family
Near-miss,
members, visitors, etc., resulting from DON
1st aid, Class D or C
equipment or inside a DON facility.
Electrical related damage or fire to DON equipment
or inside a DON facility.
N/A
(E.g. melting or burning of electrical components
such as wires, cords, outlets, etc.)
Fire on or in: a Naval vessel, a DON facility, range,
1st aid, Class D or C
tactical equipment, non-tactical equipment, etc.
Near-miss,
Fire during refueling operations
1st aid, Class D or C
Near-miss,
Fire during maintenance operations
1st aid, Class D or C
Any
(Does not need to
meet a minimum cost
threshold)
Unit/Command
Class D or C
Unit/Command
Class D or C
Unit/Command
Class D or C
Unit/Command
Note: Some HIPOMs may have a causal factor related to an unsafe equipment design or function. If the
safety / mishap investigation determines a hazard with any component of military owned equipment, a
HAZREP must be submitted IMMEDIATELY in accordance with Chapters 3 and 4 of OPNAV M-5102.1D/
MCO 5102.1B.
Additionally, Marine Corps Commanders shall submit any tactical related equipment hazards to Marine Corps
Systems Command (MCSC) in a manner described by MCO 5100.34A.
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APPENDIX - D
Date Signed: 12/21/2016
Marine Corps Eight (8) Day Brief Requirements
R 201952Z DEC 16
MARADMIN 672/16
MSGID/MARADMIN/CMC WASHINGTON DC DMCS//
SUBJ/CHANGE TO MARADMIN 558/16 EIGHT DAY BRIEF REQUIREMENTS//
REF/A/MSG DTG 201913Z OCT 16//
NARR/REF (A) IS MARADMIN 558/16 EIGHT DAY BRIEF REQUIREMENTS/POC/LTCOL ADAM
PASTOR/CMC SAFETY DIVISION/TEL: (703)604-4362(DSN 664)/E-MAIL:
ADAM.PASTOR(AT)USMC.MIL//
GENTEXT RMKS/1. Effective immediately, delete paragraph 4 (recipients) from ref (A).
2. Distribution of all eight day briefs shall be by encrypted email from the first general officer in the chain of
command to the Assistant Commandant of the Marine Corps (ACMC) and approved courtesy copy recipients
via the following distribution lists:
2.a. All Aviation Mishap eight day briefs shall be sent to the “8 Day Aviation Mishap” distribution list in the
Global Address List (GAL).
2.b. All Suicide or Attempted Suicide eight day briefs shall be sent to the “8 Day Suicide/Attempt” distribution
list in the GAL.
2.c. All other eight day briefs shall be sent to the “8 Day Ground/Off-Duty” distribution list in the GAL.
3. Membership of the distribution lists is by billet as directed by MCO 5100.29 and the ACMC. Requests to
add/remove billets from the distribution list must be approved by the ACMC.
4. The distribution lists shall be administered by CMC Safety Division. Incumbents shall coordinate with
POC for changes to the distribution list due to personnel changes within approved billets.
5. Questions regarding this message may be submitted to the CMC (SD) POC listed above.
6. Release authorized by James B. Lassater
R 051950Z SEP 18
MARADMIN 490/18
MSGID/MARADMIN/CMC WASHINGTON DC DMCS//
SUBJ/CHANGE TO EIGHT DAY BRIEFS ROUTING AND DISTRIBUTION//
REF/A/MCO 5100.29/20110728//
REF/B/MSG DTG R201952Z DEC 16//
NARR/REF (A) IS MCO 5100.29B MARINE CORPS SAFETY PROGRAM, REF (B) IS MARADMIN 672/16
CHANGE TO 8 DAY BRIEF REQUIREMENTS.//
POC/LTCOL CHRISTOPHER HORTON/CMC SAFETY DIVISION/TEL: (703) 604-4362 (DSN 664)/E-MAIL:
CHRISTOPHER.R.HORTON@USMC.MIL//
GENTEXT REMARKS/1. Per reference (a), all serious mishaps (Class A and B) and non-combat deaths not
stemming from disease or illness, including suicides and deaths attributed to criminal activity, require an 8day brief. Ref (b) added suicide attempts, when verified by medical authority, as another required 8-day brief
event. This MARADMIN does not change the 8-day reporting requirement, but it does change how this
report is routed within the USMC chain-of-command.
a. All Aviation Mishap 8-day briefs shall be sent to the “8 Day Aviation Mishap” distribution list in the Global
Address List (GAL).
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APPENDIX - D
Marine Corps Eight (8) Day Brief Requirements
b. All Suicide or Attempted Suicide 8-day briefs shall be sent to the “8 Day Suicide/Attempt” distribution list in
the GAL.
c. All other 8-day briefs shall be sent to the “8 Day Ground/Off-Duty” distribution list in the GAL.
d. Membership of the distribution lists is by billet as directed by MCO 5100.29 and the DMCS. Requests to
add/remove billets from the distribution list must be approved by the DMCS.
e. The distribution lists shall be administered by CMC Safety Division. Incumbents shall coordinate with
POC for changes to the distribution list due to personnel changes within approved billets.
2. The 8-day brief was originally devised and intended as a SPOTREP to provide the Assistant
Commandant of the Marine Corps (ACMC) early insight into the circumstances of each loss and to prevent
the re-occurrence of similar events. Since the inception of the 8-day brief more than 10-years ago, the
Marine Corps has increased visibility on the facts, circumstances, and causal factors underpinning our most
egregious losses of life and materiel. Based on these developments and a desire to empower the chain-ofcommand, the following change to the 8-day reporting process is in effect. General Officers originating 8-day
briefs will no longer provide these briefs directly to the Assistant Commandant of the Marine Corps (ACMC).
3. Commanders suffering losses requiring an 8-day brief will route the briefs to the first Lieutenant General
in the reporting unit's chain of command and to HQMC staff offices as detailed in the references. For those
commanders and staff sections that do not have a three star in their chain of command or who report directly
to CMC or ACMC, those reports will be sent to the Director of the Marine Corps Staff. The 8-day formats
and suspense timelines remain unchanged, (i.e., via encrypted email and not later than the 8th day following
the event). HQMC Safety Division will publish a reporting tree to ensure all commands and staff sections in
the Marine Corps know who they will be submitting their 8-day reports to in the chain-of-command.
4. Each Lieutenant General in receipt of an 8-day brief will provide ACMC and CMC a monthly executive
summary of the 8-day briefs and other relevant information gleaned from final investigative reports, (e.g.,
Safety Investigation Reports, JAG Manual/Command Investigations, etc.). The content, format, and length of
this summary will not be prescribed and instead will be left to the discretion of the first three star in the chainof-command. Additionally, CMC, SMMC, all other Lieutenant Generals, TMO, DC M&RA/MF Division,
Director CMC (Safety Division) and Executive Director HQMC (Force Preservation Directorate) will be copied
on the monthly 8-day summary correspondence.
5. Commands are reminded that 8-day briefs are designated for official use only and contain both Personal
Identifiable Information (PII) and Protected Health Information (PHI) and shall be safeguarded accordingly.
Moreover, the 8-day brief constitutes general officer pre-decisional communications and shall not be
released or included in any other reports without coordination with and approval from originating or receiving
general officer. All Freedom of Information Act (FOIA) requests for 8-day briefs will be forwarded to HQMC
FOIA office for review and concurrence prior to release by the local FOIA office.
6. Lastly, by 1 Nov 2018 request those receiving 8-day reports provide feedback to DMCS on ways to
improve the 8-day report. Our goal is to evolve and mature the 8-day report into a tool that continues to help
us reduce the number of Marines who are killed and injured due to accident and self-injury. Your feedback is
critical to achieving this important objective.
7. Questions regarding this message may be directed to the CMC (SD) POC listed above.
8. Release authorized by Michael G. Dana, Lieutenant General, Director, Marine Corps Staff
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APPENDIX - E
DoD HFACS Integration into METT-TC
DEPARTMENT OF DEFENSE HUMAN FACTORS ANALYSIS & CLASSIFICATION SYSTEM (DOD
HFACS). Another hazard identification tool is the Department of Defense Human Factors Analysis &
Classification System. This tool was designed to aid safety investigators during mishap investigation and
supports the DoDI 6055.07 however, when effectively trained in its application, safety personnel and
military leadership will find it extremely valuable during the METT-TC (aka; step 1 of RM) process in
determining potential human performance vulnerabilities and human-environment or human-equipment
interface.
Example of DoD HFACS Integration into METT-TC (Identify Hazards):
•
MISSION:
•
ENEMY: Overall threats to mission
•
TERRAIN / WEATHER: (What are the hazards of terrain, meteorological conditions, other environmental
conditions/hazards) (Use DoD HFACS Preconditions codes from “Physical Environment”)
•
–
Are there conditions effecting vision (fog, airborne particulates, rain, darkness, etc.) that impede safe
operations?
–
Is there a temperature situation that can cause a Heat or Cold Stress injury for those exposed?
–
Are there visibility restrictions other than fog or airborne particulates (e.g. glare from sun) that may
result in a hazardous condition?
–
Is the workspace compatible to personnel to complete the mission or does the working are pose
hazards? (I.e. terrain features that effect safe movement of personnel or equipment or that
negatively impact ability to get to the objective in a timely manner/safe manner or move equipment?)
–
Are there Inclement weather conditions (Lightning, High Winds, Heavy Rain/Flash flooding that
impedes safe operations)
TROOPS & EQUIPMENT: (Use of DoD HFACS Preconditions, Supervision, and Organizational
Influences)
–
“What physical conditions (i.e. fatigue, body size, physical strength, substance effects) of individual
team members could lead to an unsafe act and cause a mishap”?
–
“Are all personnel of a clear state of mind to ensure each will not commit an unsafe act and cause a
mishap”?
–
“Are all team members trained to constantly assess for changes in the environment and either make
real-time risk decisions or report the changes effectively?
–
“Are all personnel effectively trained, competent, and proficient in the tasks they are assigned.”
–
“Are all team members competent in the skills required to operate equipment, complete tasks, etc.”?
–
“Are all team members fully aware of each other’s capabilities and limitations and have the
empowerment to effectively communicate al known and new hazards?
–
“What can supervisors on our team do, or fail to do, that may cause a mishap”?
–
“Is the team composition, size, and experience appropriate to meet all task demands?
–
“What are the equipment hazards that may contribute to a mishap”?
–
“What resource vulnerabilities exist that may contribute to a mishap”?
•
TIME: What are the time constraints / limitations that may contribute to a mishap? (Use of DoD HFACS
Organizational Influences of “OPTEMPO”)
•
CIVILIAN: What are the human hazards (Local Civilians)?
–
Is there potential to cause a mishap while interacting in the same space as civilians?
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APPENDIX - F
References and Resources
a. DoDI 6055.07, Mishap Notification, Investigation, Reporting, and Record Keeping, 06 June, 2011.
b. DoD HFACS 7.0, Department of Defense Human Factors Analysis and Classification System, a Mishap
Investigation and Data Analysis Tool. 2014.
c.
SECNAVINST 5100.10K, Department of the Navy Safety Program, 12 May 2015
d. OPNAVINST 3500.39D, Operational Risk Management 29 Mar 2018
e. OPNAVINST 5100.23G, CH-1, Navy Safety & Occupational Health Manual, 21 July, 2011
f.
OPNAVISNT 1500.75D, Policy and Guidance for Conducting High Risk Training, 10 Aug 2017
g. OPNAVINST 5102.1D / MCO P5102.1B, Navy and Marine Corps Mishap and Safety Investigation,
Reporting, and Recordkeeping Manual, 07 January 2005 –Should be updated Summer 2021
h. MCO 5100.8, Marine Corps Occupational Safety & Health Policy Order, 15 May 2006
i.
MCO 5100.29C, Marine Corps Safety Program, 15 Oct 2020
j.
MCO 5100.34A, Deadline Safety of Use Message Instructions to Suspend Operations of Marine Corps
Ground Equipment and Weapons Systems, Safety of Use Message and Maintenance Advisory
Messages, 19 June 2017
k.
NAVMC Directive 5100.8, Marine Corps OSH Program Manual, 15 May 2006
l.
NAVMC 1553.2, Marine Corps Formal School Management Policy Guidance, 21 Sep 2015
m. Human Error, 1990, James Reason, published by Cambridge University Press, Cambridge, UK,
ISBN: 0 521 31419 4.
n. A Human Error Approach to Aviation Mishap Analysis, 2005, Douglas A. Wiegmann and Scott A
Shappell, published by Ashgate Publishing Limited, Burlington, VT 05401, ISBN:0 7546 1873 0.
o. Memory-Enhancing Techniques for Investigation Interviewing, The Cognitive Interview, 1992, Ronald P.
Fisher and R. Edward Geiselman, published by Charles C. Thomas. Springfield, IL 62794; ISBN: 0-39806121-1
p. Boundless. “Considerations for Eyewitness Testimony.” Boundless Psychology. Boundless, 20 Sep.
2016. Retrieved 21 Nov. 2016 from https://www.boundless.com/psychology/textbooks/boundlesspsychology-textbook/memory-8/memory-distortions-58/considerations-for-eyewitness-testimony-22512760/
q. Forensic Vision with Application to Highway Safety with CD-Rom 3rd Edition. Author: Marc Green Ph.D.
Co-Authors: Merrill J. Allen O.D., Ph.D., Bernard S. Abrams O.D., Leslie Weintraub O.D. Contributor: J.
Vernon Odom Ph.D. ISBN 10: 978-1-933264-54-7 ISBN 13: 978-1-933264-54-7 Copyright Date Ed:
June 1, 2008
r.
Norretranders, T., J. (1999). The User Illusion: Cutting Consciousness Down To Size, 186-87. New York:
Penguin Books.
s.
Mishap Investigation Techniques, Basic Theories-Analytical Methods-Applications, (Second Edition),
2012, Jeffery S. Oakley, published by The American Society of Safety Engineers, Des Plaines, IL; ISBN
1-885581-47-5
t.
Naval Safety Supervisor, NAVEDTRA 12971, 1993, published by Naval Education and Training Program
Management Support Activity, 0502-LP-477-0400
u. Managing the Risks of Organizational Mishaps, 2005, published by Ashgate Publishing Company,
Burlington, VT, 05401; ISBN 1 84014 105 0 (Pbk)
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APPENDIX - F
References and Resources
Web Resources
Commandant of the Marine Corps (Safety Division)
www.safety.marines.mil
Naval Safety Command
https://navalsafetycenter.navy.mil/
Marine Corps Center for Lessons Learned (MCCLS)
https://www.mccll.usmc.mil/
Center for Army Lessons Learned (CALL)
http://usacac.army.mil/cac2/call/index.asp
Joint Risk Assessment Tool (JRAT)
http://jrat.safety.army.mil
U.S. Army Public Health Command
https://phc.amedd.army.mil/Pages/default.aspx
Navy & Marine Corps Public Health Command
https://www.med.navy.mil/sites/nmcphc/Pages/Home.aspx
OSHA
http://www.osha.gov/
National Highway Traffic Safety Administration
(NHSTA)
http://www.nhtsa.gov/
Think Reliability (Problem Solving)
http://www.thinkreliability.com/
HFACS Inc.
https://www.hfacs.com/
SOLOGIC
(Causelink® - Root Cause Analysis Software)
https://www.sologic.com/en-us/rca-software/overview
RMI
https://afsas.safety.af.mil
Naval Mishap Investigation Contact Numbers
CMC (Safety Division) - Investigations Branch
(Naval Safety Command Detachment) Comm: (757) 444-3520 DSN:
564-3520
CRASH LINE: (757) 444-2929
Branch Head (GS)
x 7147
Ground Investigator / Advisor (Capt / Maj)
x 7137
Ground Investigator / Advisor (Capt / Maj)
x 7198
Ground Investigator / Advisor (Capt / Maj)
x 7261
Ground Investigator / Advisor (Capt / Maj)
x 7128
SOH Manger / Ground Investigator / Advisor (GS)
x 7160
Afloat Investigators (O5 and GS)
X 7161
Aviation Investigators (O4, O5 and GS)
X 7241
Parachute safety analyst (MSgt)
x 7245
Ammo & Explosives safety analyst (GySgt)
x 7021
Tactical MV (GVO) safety analyst (GySgt)
x 7129
SOH Specialist (RMI SIREP QA) (GS)
x 7181
SOH Specialist (RMI SIREP analyst) (GS)
x 7148
SOH Manager (Liaison to Army Safety) (GS)
(334) 255-0237
RMI Help Desk (M-F 0800-1600 EST)
(866) 210-7474
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