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
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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
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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:
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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
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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)
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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
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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
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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
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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
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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?
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Determine;
what happened
how it happened
why it happened
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Establish corrective actions to prevent it
from happening again
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It’s part of a safety culture
The Goal
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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?
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REDUCTION IN MEMBER INJURY RATES,
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FEWER MEMBERS AWAY FROM CAP
ACTIVITIES,
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IMPROVED MEMBER RELATIONSHIPS,
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IMPROVED PRODUCTIVITY AND
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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
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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
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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?
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Commander
Safety Officer
Region Safety Officers
National Safety Team and NHQ Safety
Commander Responsibilities
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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
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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
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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
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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
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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:
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Collecting the facts
Completing the Preliminary Report
Interview techniques
Identifying fact patterns
Completing the Summary Report
Mishap Review Tool Kit
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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
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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
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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
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Should accompany photographs
Include locations of all equipment and
personnel
Include distances and compass direction
Completing the
Preliminary Report
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Becomes part of the Mishap Review package
Copy for Safety Database input
Preparing for the
Interview
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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
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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
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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?
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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
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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
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Information gathered in interviews must be
verified
The witness may be mistaken
 Erroneous information can adversely affect the
investigation
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Additional Sources of
Supporting Documentation
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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
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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
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Equipment
Work Environment
People and Procedures
Personal Protective Equipment (PPE)
Ergonomics
Industrial Hygiene
Management System
Preliminary Report Description of Mishap
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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?”
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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?”
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Hearing protection
Safety vests
Protective eyewear
Contributing Factors Industrial Hygiene
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Noise
Chemicals
Exhaust
Contributing Factors Ergonomics
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Design of equipment
Muscular skeletal disorders
Repetitive motion
Contributing Factors Management System
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Did we anticipate the hazard?
Did we communicate the hazard? or did we
accept the risk?
Summary Report
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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
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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
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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:
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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:
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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:
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Owner
Estimated completion date
Writing the
Report
“just the facts ma’am”
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History
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Mishap Review
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Tell the story using only facts
Who was interviewed
What was photographed or diagrammed
Procedures and training reviewed
Findings
Corrective Action
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Based on findings
Owner
Timeline
Provide Feedback
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To all affected members
Get input on corrective action plan
Distribute a preliminary report when necessary
Update members on progress
Tracking Corrective
Action
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Use CAP’s mishap management database
(Future Upgrades coming in 2012)
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Wing CC inputs corrective action plan
Wing SE validates implementation and
completion
Revise plan if necessary
Review Part III
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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