Introduction to Reviews Mishap Getting below the surface to correct breakdowns Presented by CAP National Safety Team and NHQ Safety Alaskan Grown Helicopter Pilot Alaska Flying – UH60L ESSS This course requires focus, concentration, and a willingness to think different. This course will challenge us to change and set an example of change. This course will emphasize what you already will recognize as valuable. Ready to focus? Focus and Concentration Intro to Mishap Review: Training Objectives Why we review mishaps and the barriers to mishap reviews What causes injuries and damages How the process works and your role How to begin a mishap review Identifying causal factors Writing the factual narrative Guiding the Commander on corrective action Implementing and tracking the corrective action Part I: Theory In this part of the session we will cover: traditional reviews (investigations) and norms definition review of CAPR 62-1 why and what we should explore in a mishap review? barriers that may prevent us from doing a review the mishap analysis process roles and responsibilities Traditional Reviews or Norms Reviews only serious injuries Blaming it on something that someone did Concluding the mishap review too soon Makes assumptions Under reporting Fault-finding Punitive Remember, do not make assumptions! Panel Investigation Definitions (CAPR 62-2) Mishap (New definition): Any unplanned or unsought event, or series of events, that result, in or has the potential to cause death, injury, or damage to equipment or property. Accident: Serious, not so good, total loss, death Incident: Not as serious, more than first aid Minor Mishap: Minor scratches, flat tire – no rim damage, small cut, blisters Definitions Mechanical: Related to mechanical malfunction only; however are not a result of failure to perform routine maintenance. Near Miss: Any circumstance where the in-flight separation between aircraft constitutes a hazardous situation involving potential risk of collision. Weather: Related to unforeseen weather events, ex. Hail, high wind, flooding, etc. Definitions Vandalism: Acts of malice towards CAP property where a police report is filed. Pre-existing conditions: Medical conditions of a member that are undisclosed resulting in a mishap or failure of a member to follow the limitations set due to a pre-existing medical condition. Non-CAP: Mishaps that are not the responsibility of CAP, ex. A mishap occurring before or after a CAP activity where the Home to Work rule would apply. Definitions Other: Miscellaneous one-time occurrences that are not the result of human factors and do not fall into one of the other categories listed above. Definitions Safety Deviation: Any event that is perceived as an unsought safety act, most commonly defined as any act that is noncompliant with CAP rules, regulations, or other defined policies, as well as local, state, or national laws or regulations that could result in injury or damage to CAP members or equipment. These are “at risk” behaviors that occur in motion that involve CAP members, not to be confused with static risks, defined as hazards, that are identified in CAP’s Hazard reporting system, formerly known as a Form 26. The exception to this is aircraft in-air related which is defined as “near- miss.” Common Sense isn’t Common Why Review Mishaps? Determine; what happened how it happened why it happened Establish corrective actions to prevent it from happening again It’s part of a safety culture The Goal The goal of no-fault mishap reviews is mishap prevention! To prevent injuries we must analyze to determine facts, conditions and circumstances of an incident. We use this information to identify contributing factors and develop corrective action. What Does it Mean in Operational Terms? REDUCTION IN MEMBER INJURY RATES, FEWER MEMBERS AWAY FROM CAP ACTIVITIES, IMPROVED MEMBER RELATIONSHIPS, IMPROVED PRODUCTIVITY AND HIGHER READINESS RATE. Mishap Investigations and Mishap Analysis is a part of a solid Safety Management System Training RM Mishap Procedures Analysis Inspection Accountability PPE Logistics Trending MX Safety Database Behavior Observations Based Safety Education Motivation Goals At-Risk Behavior Triangle We always investigate these 1 Accident 20-50 Incidents To prevent these, we must investigate these Decision Making Data 600 Minor Mishaps 15,000 At-Risk Behaviors •For every major injury there are many more minor ones (e.g. Heinrich 1950) •Investigating and preventing minor mishaps will prevent more serious ones At Risk Behavior? Barriers to Your Mishap Review Takes too much time Members don’t understand the need to report Can’t be bothered with the administrative work May result in punishment Reporting may cause the injury rate to go up Reporting may result in lost award Overcoming the barriers Tell all members why full reporting is important Don’t blame people for injuries Show concern about mishap Recognize those who report mishaps, nearmisses, or safety deviations Do not use incentives which ONLY reward lack of injuries or damages The Mishap Analysis Process Mishap • secure the area • identify witnesses • take measurements and photos • report serious injuries to OCC Collect Preliminary Data • conduct interviews • use Causal Factors Guideline • review injury or damage history • conduct risk assessment • tell the story • document key findings • document corrective action plan Causal Factors Final Report Implement Plan Provide Feedback Analyze • identify owner • develop time line • follow up with agents • trends • validate plan • update corr actions Roles and Responsibilities Who has a role in the Mishap Analysis process? Commander Safety Officer Region Safety Officers National Safety Team and NHQ Safety Commander Responsibilities Arrange for emergency medical services Contact CAP National Operations Center (NOC) if applicable Collect preliminary information Appoint a mishap review officer Develop corrective action plan after the mishap review is completed Record causal factors and corrective actions Forward the mishap review report to the Region Commander for review and approval. Implement corrective action plan Safety Officer Responsibilities Subject Matter Expert Quality Control Conduct Operational Risk Assessment Validate Corrective Action Plan Analyze for local trends Region Safety Officer Responsibilities Your Region Safety Officers Name Here Ensure mishap reports are filed within 48 hours Provide coverage and consultation as needed during the mishap review. Review mishap review reports provided Part of mishap review team Maintain accurate records of equipment and bodily injury mishaps Ensure mishap review training is conducted Etc. Etc. Etc. National Safety Team and NHQ Safety Responsibilities Review all mishaps and high risk reports and provide additional resources as required Lead or assist in mishap analysis process Trend for system wide implications Track progress on corrective action plans and approve all final mishap reviews Maintain injury/damage database, post review classifications Notify and respond to applicable outside agencies Maintain regulations Review Part I Fault-finding is an example of current investigation norms. Name at least 3 others. What is a mishap? Why do we review mishaps? What is the goal of a no-fault mishap review? What do we need to review? Who is the lead mishap review officer? BREAK 15 minutes Next: Part II: The Nuts and Bolts Part II: The Nuts & Bolts In this part of the session we will cover: Collecting the facts Completing the Preliminary Report Interview techniques Identifying fact patterns Completing the Summary Report Mishap Review Tool Kit Camera w/extra film or discs, photo log Paper (note pad and graph), pencil, ruler Tape measure Chalk or high visibility tape Flashlight Investigation forms and regulations List of phone numbers First Step Collect and Call Preliminary Report Decision: if hospitalization, etc. then contact NOC and provide info on the Preliminary Report Conduct interviews Take photographs and measurements Draw diagrams Collecting Facts Photographs Take photographs before moving anything Photograph from several different angles Take more than you think you’ll need Panoramic and close up views Use a tape measure in photo Photograph from the operator’s point of view Collecting Facts Diagrams Should accompany photographs Include locations of all equipment and personnel Include distances and compass direction Completing the Preliminary Report Becomes part of the Mishap Review package Copy for Safety Database input Preparing for the Interview Select a location for the interview Goal: hear and write down all info given Pencil and paper for you AND interviewee Keep witnesses separated until all interviews are completed Obtain a witness statement to review prior to the interview Interview Do’s One-on-one only in a quiet room, no interruptions Ask permission to ask questions and explain the purpose of the mishap review Ask open-ended questions and speak slowly and deliberately Take notes and repeat, be an active listener Ask witness to diagram event Eliminate physical barriers Interview on site if necessary Interview Do’s ALWAYS Stress that you want the facts Stress that you want to prevent the next mishap Take the extra time to get understanding Interview Techniques Ask: Who was injured? What happened? Where were you? When did it happen? (not simply time) How did it happen? Why did it happen? Interview Techniques Open-ended questions first •describe in your own words what happened. •what did you see? •where were you standing? Directed questions to clarify •who gave you instructions? •what are the procedures? Interview Do’s Be prepared with questions, references, procedures Ask for their opinion or suggestions Have paper available for notes Make your interview like a conversation, comfortable Thank them for their help Example of an interview? Who Should be Interviewed? Those present when the mishap took place The member involved in the mishap Personnel who set up area Members with technical expertise The activity leader and/or unit commander Interview DON’Ts Don’t ask leading questions or express opinions Don’t arrive at premature conclusion Don’t argue, accuse or imply blame Don’t discuss things with other interviewers Don’t interrupt the interviewee Interview - Verify Information gathered in interviews must be verified The witness may be mistaken Erroneous information can adversely affect the investigation Additional Sources of Supporting Documentation LG MX records, manufacturer Pre-operations checklist Manual references, codes Inspection results Training records Injury or damage history and action plans Blue prints Police reports Other miscellaneous documentation Contributing Factors Guidelines It is a guideline designed to point you in the right direction by identifying contributing factors that allow you to develop meaningful corrective action. It will not cover every situation. It is a worksheet. Identifying Contributing Factors Equipment Work Environment People and Procedures Personal Protective Equipment (PPE) Ergonomics Industrial Hygiene Management System Preliminary Report Description of Mishap Tell the story with available info Use only known facts Include a description of the activity Include extent of injury or damage Was the member sent to the hospital Contributing Factors Equipment “Was the failure of the equipment a contributing factor?” Ground equipment or tools involved If yes, or unsure...answer the questions Resources: local mechanics, logistics, manufacturer representatives Examples Contributing Factors Work Environment “Was the work environment a contributing factor?” A condition, something tangible Location of equipment or facilities Size or layout of facilities Slippery substances, trip hazards Housekeeping Contributing Factors People and Job Procedures “Was the job procedure a contributing factor?” Identify substandard performance Identify weakness in standards or procedures Did the right people know and understand the procedures? Ask why did the person or procedure fail? Contributing Factors Personal Protective Equipment Was the lack of, or misuse of PPE a contributing factor?” Hearing protection Safety vests Protective eyewear Contributing Factors Industrial Hygiene Noise Chemicals Exhaust Contributing Factors Ergonomics Design of equipment Muscular skeletal disorders Repetitive motion Contributing Factors Management System Did we anticipate the hazard? Did we communicate the hazard? or did we accept the risk? Summary Report Records contributing factors states the fact patterns associated to a mishap. Becomes part of the mishap review package Entered into the mishap management database Review Part II What is the first step in the Mishap Review process? The Contributing Factors Guideline is a process to help you identify causes of the mishap. The mishap management database is used to record your findings as a factual narrative. Part II Review - Interview Techniques Opening: Explain your purpose Ask open-ended questions Repeat for clarification Ask for suggestions Thank You! BREAK 15 minutes Next: Part III: Closing the Loop Part III: Closing the Loop In this part of the session we will cover: Assisting with the development of corrective action Writing the report Implementing and tracking corrective action Tool kit Developing Corrective Actions Factors that influence corrective actions include: Effectiveness Feasibility Impact on operation Time required to implement Extent of remedial training required Acceptance by the member Development and acceptance by the commander Corrective Action Smarts Specific Measurable Achievable Realistic Timed Sustainable Corrective Action Plan All corrective action plans must have: Owner Estimated completion date Writing the Report “just the facts ma’am” History Mishap Review Tell the story using only facts Who was interviewed What was photographed or diagrammed Procedures and training reviewed Findings Corrective Action Based on findings Owner Timeline Provide Feedback To all affected members Get input on corrective action plan Distribute a preliminary report when necessary Update members on progress Tracking Corrective Action Use CAP’s mishap management database (Future Upgrades coming in 2012) Wing CC inputs corrective action plan Wing SE validates implementation and completion Revise plan if necessary Review Part III Assessing the potential for severity helps to ensure the right priority is given to high risk mishaps Corrective actions must be S.M.A.R.T. All corrective actions must have an owner Provide feedback to all members Update safety database with corrective action info The Result, Safety Recommendations Chinese leader Deng Xiaoping said it this way: “Try to gather all the facts so that you can discover the truth.” Win-Win Partnerships, p.153 Where is the next mishap, incident, accident going to occur? Please feel free to send your questions and comments directly to the National Safety Team and NHQ Safety @ safety@capnhq.gov QUESTIONS? Contact Information Col Bob Diduch Frank Jirik National Safety Officer P.O. Box 3036 Trenton, NJ 08619 609-731-5600 cell Safety, CAP NHQ 105 S. Hansell St. Maxwell AFB, AL 36112 800-227-9142 ext. 232 907-350-7559 cell safety@capnhq.gov