introduction to mishap reviews introduction to mishap reviews getting below the surface to correct...

77
Introduction to Introduction to Mishap Mishap Reviews Reviews Getting below the surface Getting below the surface to correct breakdowns to correct breakdowns Presented by Presented by CAP National Safety Team and NHQ CAP National Safety Team and NHQ Safety Safety

Upload: anis-glenn

Post on 24-Dec-2015

230 views

Category:

Documents


4 download

TRANSCRIPT

Page 1: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Introduction to Introduction to

MishapMishap ReviewsReviewsGetting below the surface to Getting below the surface to

correct breakdownscorrect breakdowns

Presented byPresented byCAP National Safety Team and NHQ SafetyCAP National Safety Team and NHQ Safety

Page 2: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Alaskan GrownAlaskan Grown

Page 3: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Helicopter PilotHelicopter Pilot

Page 4: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and
Page 5: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Alaska Flying – UH60L ESSSAlaska Flying – UH60L ESSS

Page 6: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

This course requires focus, This course requires focus, concentration, and a willingness to concentration, and a willingness to think different.think different.

This course will challenge us to This course will challenge us to change and set an example of change.change and set an example of change.

This course will emphasize what you This course will emphasize what you already will recognize as valuable. already will recognize as valuable.

Ready to focus?Ready to focus?

Page 7: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Focus and ConcentrationFocus and Concentration

Page 8: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Intro to Mishap Review: Training Intro to Mishap Review: Training ObjectivesObjectives

Why we review mishaps and the barriers to mishap reviewsWhy we review mishaps and the barriers to mishap reviews What causes injuries and damagesWhat causes injuries and damages How the process works and your roleHow the process works and your role How to begin a mishap reviewHow to begin a mishap review Identifying causal factorsIdentifying causal factors Writing the factual narrativeWriting the factual narrative Guiding the Commander on corrective actionGuiding the Commander on corrective action Implementing and tracking the corrective actionImplementing and tracking the corrective action

Page 9: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Part I: TheoryPart I: TheoryIn this part of the session we will cover:In this part of the session we will cover: traditional reviews (investigations) and traditional reviews (investigations) and

normsnorms definition review of CAPR 62-1definition review of CAPR 62-1 why and what we should explore in a mishap why and what we should explore in a mishap

review?review? barriers that may prevent us from doing a barriers that may prevent us from doing a

reviewreview the mishap analysis processthe mishap analysis process roles and responsibilitiesroles and responsibilities

Page 10: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Traditional Reviews or Traditional Reviews or NormsNorms

Reviews only serious injuriesReviews only serious injuries Blaming it on something that someone Blaming it on something that someone

diddid Concluding the mishap review too soonConcluding the mishap review too soon Makes assumptionsMakes assumptions Under reportingUnder reporting Fault-findingFault-finding Punitive Punitive

Page 11: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Remember, do not make Remember, do not make assumptions!assumptions!

Page 12: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Panel InvestigationPanel Investigation

Page 13: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Definitions (CAPR Definitions (CAPR 62-2)62-2)

Mishap (New definition): Mishap (New definition): Any unplanned or Any unplanned or unsought event, or series of events, that unsought event, or series of events, that result, in or has the potential to cause result, in or has the potential to cause death, injury, or damage to equipment or death, injury, or damage to equipment or property. property.

Accident: Serious, not so good, total loss, Accident: Serious, not so good, total loss, deathdeath

Incident: Not as serious, more than first aidIncident: Not as serious, more than first aid Minor Mishap: Minor scratches, flat tire – Minor Mishap: Minor scratches, flat tire –

no rim damage, small cut, blistersno rim damage, small cut, blisters

Page 14: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

DefinitionsDefinitions Mechanical: Mechanical: Related to mechanical Related to mechanical

malfunction only; however are not a result malfunction only; however are not a result of failure to perform routine maintenance.of failure to perform routine maintenance.

Near Miss: Near Miss: Any circumstance where the Any circumstance where the in-flight separation between aircraft in-flight separation between aircraft constitutes a hazardous situation constitutes a hazardous situation involving potential risk of collision. involving potential risk of collision.

Weather: Weather: Related to unforeseen weather Related to unforeseen weather events, ex. Hail, high wind, flooding, etc. events, ex. Hail, high wind, flooding, etc.

Page 15: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

DefinitionsDefinitions Vandalism: Vandalism: Acts of malice towards CAP Acts of malice towards CAP

property where a police report is filed.property where a police report is filed. Pre-existing conditions: Pre-existing conditions: Medical conditions Medical conditions

of a member that are undisclosed resulting of a member that are undisclosed resulting in a mishap or failure of a member to in a mishap or failure of a member to follow the limitations set due to a pre-follow the limitations set due to a pre-existing medical condition. existing medical condition.

Non-CAP: Non-CAP: Mishaps that are not the Mishaps that are not the responsibility of CAP, ex. A mishap responsibility of CAP, ex. A mishap occurring before or after a CAP activity occurring before or after a CAP activity where the Home to Work rule would apply. where the Home to Work rule would apply.

Page 16: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

DefinitionsDefinitions Other: Other: Miscellaneous one-time Miscellaneous one-time

occurrences that are not the result of occurrences that are not the result of human factors and do not fall into one human factors and do not fall into one of the other categories listed above. of the other categories listed above.

Page 17: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

DefinitionsDefinitions Safety Deviation: Safety Deviation: Any event that is perceived as Any event that is perceived as

an unsought safety act, most commonly defined an unsought safety act, most commonly defined as any act that is non-compliant with CAP rules, as any act that is non-compliant with CAP rules, regulations, or other defined policies, as well as regulations, or other defined policies, as well as local, state, or national laws or regulations that local, state, or national laws or regulations that could result in injury or damage to CAP could result in injury or damage to CAP members or equipment. These are “at risk” members or equipment. These are “at risk” behaviors that occur in motion that involve CAP behaviors that occur in motion that involve CAP members, not to be confused with static risks, members, not to be confused with static risks, defined as hazards, that are identified in CAP’s defined as hazards, that are identified in CAP’s Hazard reporting system, formerly known as a Hazard reporting system, formerly known as a Form 26. The exception to this is aircraft in-air Form 26. The exception to this is aircraft in-air related which is defined as “near- miss.”related which is defined as “near- miss.”

Page 18: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Common Sense isn’t Common Sense isn’t CommonCommon

Page 19: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Why Review Why Review Mishaps?Mishaps?

Determine;Determine;what happenedwhat happened

how it happenedhow it happened

why it happenedwhy it happened Establish corrective actions to Establish corrective actions to

prevent it from happening prevent it from happening againagain

It’s part of a safety cultureIt’s part of a safety culture

Page 20: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

The The GoalGoal

The goal of no-fault mishap reviews The goal of no-fault mishap reviews is mishap prevention!is mishap prevention!

To prevent injuries we must analyze To prevent injuries we must analyze to determine facts, conditions and to determine facts, conditions and circumstances of an incident.circumstances of an incident.

We use this information to identify We use this information to identify contributing factors and develop contributing factors and develop corrective action.corrective action.

Page 21: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

What Does it Mean in What Does it Mean in Operational Terms?Operational Terms?

REDUCTIONREDUCTION IN MEMBER INJURY IN MEMBER INJURY RATES, RATES,

FEWERFEWER MEMBERS AWAY FROM CAP MEMBERS AWAY FROM CAP ACTIVITIES, ACTIVITIES,

IMPROVEDIMPROVED MEMBER RELATIONSHIPS, MEMBER RELATIONSHIPS,

IMPROVEDIMPROVED PRODUCTIVITY AND PRODUCTIVITY AND

HIGHERHIGHER READINESS RATE. READINESS RATE.

Page 22: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Mishap Investigations and Mishap Investigations and Mishap Analysis is a part Mishap Analysis is a part

of a solid of a solid SSafety afety MManagement anagement

SSystemystemTraining

Procedures

Inspection

RM

MishapAnalysis

PPE

Logistics

MX

Observations

Trending

Safety Database

Behavior Based Safety

AccountabilityAccountability EducationEducation MotivationMotivation GoalsGoals

Page 23: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

At-Risk Behavior At-Risk Behavior TriangleTriangle

We always

investigate these

1Accident

20-50Incidents

600Minor Mishaps

15,000At-Risk Behaviors

To prevent these,

we mustinvestigate these

•For every major injury there are many more minor ones (e.g. Heinrich 1950)

•Investigating and preventing minor mishaps will prevent more serious ones

Decision MakingData

Page 24: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

At Risk Behavior?At Risk Behavior?

Page 25: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Barriers to Your Barriers to Your Mishap ReviewMishap Review

Takes too much timeTakes too much time Members don’t understand the need to Members don’t understand the need to

reportreport Can’t be bothered with the administrative Can’t be bothered with the administrative

workwork May result in punishmentMay result in punishment Reporting may cause the injury rate to go upReporting may cause the injury rate to go up Reporting may result in lost awardReporting may result in lost award

Page 26: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Overcoming the Overcoming the barriersbarriers

Tell all members why full reporting is Tell all members why full reporting is importantimportant

Don’t blame people for injuriesDon’t blame people for injuries Show concern about mishapShow concern about mishap Recognize those who report mishaps, Recognize those who report mishaps,

near-misses, or safety deviationsnear-misses, or safety deviations Do not use incentives which ONLY Do not use incentives which ONLY

reward lack of injuries or damagesreward lack of injuries or damages

Page 27: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

The Mishap Analysis ProcessThe Mishap Analysis Process

Collect Preliminary Data

Causal Factors

Final Report

Analyze

Implement Plan

• secure the area

• identify witnesses• take measurements and photos• report serious injuries to OCC

Mishap

• conduct interviews• use Causal Factors Guideline• review injury or damage history• conduct risk assessment

• tell the story• document key findings• document corrective action plan

Provide Feedback

• identify owner• develop time line

• follow up with agents

• trends• validate plan• update corr actions

Page 28: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Roles and Roles and ResponsibilitiesResponsibilities

CommanderCommander Safety OfficerSafety Officer Region Safety OfficersRegion Safety Officers National Safety Team and NHQ National Safety Team and NHQ

SafetySafety

Who has a role in the Mishap Analysis process?Who has a role in the Mishap Analysis process?

Page 29: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Commander Commander ResponsibilitiesResponsibilities

Arrange for emergency medical Arrange for emergency medical servicesservices

Contact CAP National Operations Contact CAP National Operations Center (NOC) if applicableCenter (NOC) if applicable

Collect preliminary information Collect preliminary information Appoint a mishap review officerAppoint a mishap review officer Develop corrective action plan Develop corrective action plan

after the mishap review is after the mishap review is completedcompleted

Record causal factors and Record causal factors and corrective actionscorrective actions

Forward the mishap review report Forward the mishap review report to the Region Commander for to the Region Commander for review and approval.review and approval.

Implement corrective action planImplement corrective action plan

Page 30: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Safety Officer Safety Officer ResponsibilitiesResponsibilities

Subject Matter ExpertSubject Matter Expert Quality ControlQuality Control Conduct Operational Risk Conduct Operational Risk

AssessmentAssessment Validate Corrective Action PlanValidate Corrective Action Plan Analyze for local trendsAnalyze for local trends

Page 31: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Region Safety Officer Region Safety Officer ResponsibilitiesResponsibilities

Ensure mishap reports are filed within Ensure mishap reports are filed within 48 hours48 hours

Provide coverage and consultation as Provide coverage and consultation as needed during the mishap review.needed during the mishap review.

Review mishap review reports providedReview mishap review reports provided Part of mishap review teamPart of mishap review team Maintain accurate records of equipment Maintain accurate records of equipment

and bodily injury mishapsand bodily injury mishaps Ensure mishap review training is Ensure mishap review training is

conductedconducted Etc.Etc. Etc.Etc. Etc.Etc.

Your Region Safety OfficersName Here

Page 32: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

National Safety Team National Safety Team and NHQ Safety and NHQ Safety ResponsibilitiesResponsibilities

Review all mishaps and high risk reports and Review all mishaps and high risk reports and provide additional resources as requiredprovide additional resources as required

Lead or assist in mishap analysis processLead or assist in mishap analysis process Trend for system wide implicationsTrend for system wide implications Track progress on corrective action plans and Track progress on corrective action plans and

approve all final mishap reviewsapprove all final mishap reviews Maintain injury/damage database, post review Maintain injury/damage database, post review

classificationsclassifications Notify and respond to applicable outside Notify and respond to applicable outside

agenciesagencies Maintain regulationsMaintain regulations

Page 33: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Review Review Part IPart I

Fault-finding is an example of current Fault-finding is an example of current investigation norms. Name at least 3 investigation norms. Name at least 3 others.others.

What is a mishap?What is a mishap? Why do we review mishaps?Why do we review mishaps? What is the goal of a no-fault mishap What is the goal of a no-fault mishap

review?review? What do we need to review?What do we need to review? Who is the lead mishap review officer?Who is the lead mishap review officer?

Page 34: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

BREAKBREAK

15 minutes15 minutes

Next:Next:

Part II: The Nuts and BoltsPart II: The Nuts and Bolts

Page 35: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Part II: The Nuts & Part II: The Nuts & BoltsBolts

In this part of the session we will cover:In this part of the session we will cover:

Collecting the factsCollecting the facts Completing the Preliminary Completing the Preliminary

ReportReport Interview techniquesInterview techniques Identifying fact patternsIdentifying fact patterns Completing the Summary ReportCompleting the Summary Report

Page 36: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Mishap Review Tool Mishap Review Tool KitKit

Camera w/extra film or discs, photo logCamera w/extra film or discs, photo log Paper (note pad and graph), pencil, Paper (note pad and graph), pencil,

rulerruler Tape measureTape measure Chalk or high visibility tapeChalk or high visibility tape FlashlightFlashlight Investigation forms and regulationsInvestigation forms and regulations List of phone numbers List of phone numbers

Page 37: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

First Step - First Step - Collect and CallCollect and Call

Preliminary ReportPreliminary Report Decision: if hospitalization, etc. Decision: if hospitalization, etc.

then contact NOC and provide info then contact NOC and provide info on the Preliminary Reporton the Preliminary Report

Conduct interviewsConduct interviews Take photographs and Take photographs and

measurementsmeasurements Draw diagramsDraw diagrams

Page 38: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Collecting Facts - Collecting Facts - PhotographsPhotographs

Take photographs before moving Take photographs before moving anythinganything

Photograph from several different anglesPhotograph from several different angles Take more than you think you’ll needTake more than you think you’ll need Panoramic and close up viewsPanoramic and close up views Use a tape measure in photoUse a tape measure in photo Photograph from the operator’s point of Photograph from the operator’s point of

viewview

Page 39: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Collecting Facts - Collecting Facts - DiagramsDiagrams

Should accompany photographsShould accompany photographs Include locations of all equipment Include locations of all equipment

and personneland personnel Include distances and compass Include distances and compass

directiondirection

Page 40: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Completing the Completing the Preliminary ReportPreliminary Report

Becomes part of the Mishap Becomes part of the Mishap Review packageReview package

Copy for Safety Database inputCopy for Safety Database input

Page 41: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Preparing for the Preparing for the InterviewInterview

Select a location for the interviewSelect a location for the interview Goal: hear and write down all info Goal: hear and write down all info

givengiven Pencil and paper for you AND Pencil and paper for you AND

intervieweeinterviewee Keep witnesses separated until all Keep witnesses separated until all

interviews are completedinterviews are completed Obtain a witness statement to review Obtain a witness statement to review

prior to the interviewprior to the interview

Page 42: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Interview Interview Do’sDo’s

One-on-one only in a quiet room, no One-on-one only in a quiet room, no interruptionsinterruptions

Ask permission to ask questions and Ask permission to ask questions and explain the purpose of the mishap explain the purpose of the mishap reviewreview

Ask open-ended questions and speak Ask open-ended questions and speak slowly and deliberatelyslowly and deliberately

Take notes and repeat, be an active Take notes and repeat, be an active listenerlistener

Ask witness to diagram eventAsk witness to diagram event Eliminate physical barriersEliminate physical barriers Interview on site if necessaryInterview on site if necessary

Page 43: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

IntervieInterview Do’sw Do’s

ALWAYSALWAYS Stress that you want Stress that you want

the factsthe facts Stress that you want Stress that you want

to prevent the next to prevent the next mishapmishap

Take the extra time Take the extra time to get understandingto get understanding

Page 44: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Interview Interview TechniquesTechniques

Ask:Ask: WhoWho was injured? was injured? WhatWhat happened? happened? WhereWhere were you? were you? WhenWhen did it happen? did it happen?

(not simply time)(not simply time) HowHow did it happen? did it happen? WhyWhy did it happen? did it happen?

Page 45: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Interview TechniquesInterview Techniques

•describe in your own words what happened.•what did you see?•where were you standing?

•who gave you instructions?•what are the procedures?

Open-ended questions first

Directed questions to clarify

Page 46: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

IntervieInterview Do’sw Do’s

Be prepared with Be prepared with questions, references, questions, references, proceduresprocedures

Ask for their opinion or Ask for their opinion or suggestionssuggestions

Have paper available Have paper available for notesfor notes

Make your interview Make your interview like a conversation, like a conversation, comfortablecomfortable

Thank them for their Thank them for their helphelp

Page 47: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Example of an interview?Example of an interview?

Page 48: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Who Should be Who Should be Interviewed?Interviewed?

Those present when the Those present when the mishap took placemishap took place

The member involved in The member involved in the mishapthe mishap

Personnel who set up Personnel who set up areaarea

Members with technical Members with technical expertiseexpertise

The activity leader The activity leader and/or unit commanderand/or unit commander

Page 49: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Interview Interview DON’TsDON’Ts

Don’t ask leading questions Don’t ask leading questions or express opinionsor express opinions

Don’t arrive at premature Don’t arrive at premature conclusionconclusion

Don’t argue, accuse or Don’t argue, accuse or imply blameimply blame

Don’t discuss things with Don’t discuss things with other interviewersother interviewers

Don’t interrupt the Don’t interrupt the intervieweeinterviewee

Page 50: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Interview - Verify Interview - Verify

Information gathered in interviews Information gathered in interviews must be verifiedmust be verified The witness may be mistakenThe witness may be mistaken Erroneous information can adversely Erroneous information can adversely

affect the investigationaffect the investigation

Page 51: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Additional Sources of Additional Sources of Supporting Supporting

DocumentationDocumentation LG MX records, manufacturerLG MX records, manufacturer Pre-operations checklistPre-operations checklist Manual references, codesManual references, codes Inspection resultsInspection results Training recordsTraining records Injury or damage history and action plansInjury or damage history and action plans Blue printsBlue prints Police reports Police reports Other miscellaneous documentationOther miscellaneous documentation

Page 52: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors GuidelinesFactors Guidelines

It is a guideline designed to point It is a guideline designed to point you in the right direction by you in the right direction by identifying contributing factors identifying contributing factors that allow you to develop that allow you to develop meaningful corrective action.meaningful corrective action.

It will not cover every situation.It will not cover every situation. It is a worksheet.It is a worksheet.

Page 53: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Identifying Identifying Contributing Contributing

FactorsFactors EquipmentEquipment Work EnvironmentWork Environment People and ProceduresPeople and Procedures Personal Protective Equipment (PPE)Personal Protective Equipment (PPE) ErgonomicsErgonomics Industrial HygieneIndustrial Hygiene Management SystemManagement System

Page 54: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Preliminary Report Preliminary Report - Description of - Description of

MishapMishap Tell the story with available infoTell the story with available info Use only known factsUse only known facts Include a description of the Include a description of the

activityactivity Include extent of injury or damageInclude extent of injury or damage Was the member sent to the Was the member sent to the

hospitalhospital

Page 55: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors -

EquipmentEquipment““Was the failure of the equipment a Was the failure of the equipment a

contributing factor?”contributing factor?” Ground equipment or tools involvedGround equipment or tools involved If yes, or unsure...answer the questions If yes, or unsure...answer the questions Resources: local mechanics, logistics, Resources: local mechanics, logistics,

manufacturer representativesmanufacturer representatives ExamplesExamples

Page 56: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Factors - Contributing Factors - Work EnvironmentWork Environment

““Was the work environment a Was the work environment a contributing factor?”contributing factor?”

A condition, something tangibleA condition, something tangible Location of equipment or facilitiesLocation of equipment or facilities Size or layout of facilitiesSize or layout of facilities Slippery substances, trip hazardsSlippery substances, trip hazards Housekeeping Housekeeping

Page 57: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors - People People

and Job Proceduresand Job Procedures““Was the job procedure a contributing Was the job procedure a contributing

factor?”factor?” Identify substandard performanceIdentify substandard performance Identify weakness in standards or Identify weakness in standards or

proceduresprocedures Did the right people know and Did the right people know and

understand the procedures?understand the procedures? Ask why did the person or procedure Ask why did the person or procedure

fail?fail?

Page 58: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors - Personal Personal

Protective Protective EquipmentEquipment

Was the lack of, or misuse of PPE a Was the lack of, or misuse of PPE a contributing factor?”contributing factor?”

Hearing protectionHearing protection Safety vestsSafety vests Protective eyewearProtective eyewear

Page 59: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors - Industrial Industrial

HygieneHygiene

NoiseNoise ChemicalsChemicals ExhaustExhaust

Page 60: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors -

ErgonomicsErgonomics

Design of equipmentDesign of equipment Muscular skeletal disordersMuscular skeletal disorders Repetitive motionRepetitive motion

Page 61: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contributing Contributing Factors - Factors -

Management Management SystemSystem

Did we anticipate the hazard?Did we anticipate the hazard? Did we communicate the hazard? Did we communicate the hazard?

or did we accept the risk?or did we accept the risk?

Page 62: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Summary ReportSummary Report

Records contributing factors states the Records contributing factors states the fact patterns associated to a mishap.fact patterns associated to a mishap.

Becomes part of the mishap review Becomes part of the mishap review packagepackage

Entered into the mishap management Entered into the mishap management databasedatabase

Page 63: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Review Part IIReview Part II

What is the first step in the What is the first step in the Mishap Review process?Mishap Review process?

The Contributing Factors The Contributing Factors Guideline is a process to help you Guideline is a process to help you identify causes of the mishap.identify causes of the mishap.

The mishap management database The mishap management database is used to record your findings as is used to record your findings as a factual narrative.a factual narrative.

Page 64: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Part II Review - Part II Review - Interview Interview

TechniquesTechniques

Part II Review - Part II Review - Interview Interview

TechniquesTechniques Opening: Explain your purposeOpening: Explain your purpose Ask open-ended questionsAsk open-ended questions Repeat for clarificationRepeat for clarification Ask for suggestionsAsk for suggestions Thank You!Thank You!

Page 65: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

BREAKBREAK

15 minutes15 minutes

Next:Next:

Part III: Closing the LoopPart III: Closing the Loop

Page 66: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Part III: Part III: Closing the Closing the

LoopLoopIn this part of the session we will In this part of the session we will

cover:cover: Assisting with the development of Assisting with the development of

corrective actioncorrective action Writing the reportWriting the report Implementing and tracking Implementing and tracking

corrective actioncorrective action Tool kitTool kit

Page 67: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Developing Developing Corrective ActionsCorrective Actions

Factors that influence corrective actions include:Factors that influence corrective actions include:

EffectivenessEffectiveness FeasibilityFeasibility Impact on operationImpact on operation Time required to implementTime required to implement Extent of remedial training requiredExtent of remedial training required Acceptance by the memberAcceptance by the member Development and acceptance by the Development and acceptance by the

commandercommander

Page 68: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Corrective ActionCorrective Action Smarts Smarts

SSpecific

MMeasurable

AAchievable

RRealistic

TTimed

SSustainable

Page 69: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Corrective Action Corrective Action PlanPlan

Corrective Action Corrective Action PlanPlan

OwnerOwner Estimated completion dateEstimated completion date

All corrective action plans must have:All corrective action plans must have:

Page 70: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Writing the Writing the ReportReport

“just the facts “just the facts ma’am”ma’am”

HistoryHistory Tell the story using only factsTell the story using only facts

Mishap ReviewMishap Review Who was interviewedWho was interviewed What was photographed or diagrammedWhat was photographed or diagrammed Procedures and training reviewedProcedures and training reviewed

FindingsFindings Corrective ActionCorrective Action

Based on findingsBased on findings OwnerOwner TimelineTimeline

Page 71: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Provide FeedbackProvide Feedback To all affected membersTo all affected members Get input on corrective action planGet input on corrective action plan Distribute a preliminary report when Distribute a preliminary report when

necessarynecessary Update members on progressUpdate members on progress

Page 72: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Tracking Tracking Corrective Action Corrective Action

Use CAP’s mishap management Use CAP’s mishap management database database (Future Upgrades coming in 2012)(Future Upgrades coming in 2012)

Wing CC inputs corrective action Wing CC inputs corrective action planplan

Wing SE validates implementation Wing SE validates implementation and completionand completion

Revise plan if necessaryRevise plan if necessary

Page 73: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Review Part IIIReview Part III

Assessing the potential for severity Assessing the potential for severity helps to ensure the right priority is helps to ensure the right priority is given to high risk mishapsgiven to high risk mishaps

Corrective actions must be S.M.A.R.T.Corrective actions must be S.M.A.R.T. All corrective actions must have an All corrective actions must have an

owner owner Provide feedback to all membersProvide feedback to all members Update safety database with Update safety database with

corrective action infocorrective action info

Page 74: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

The Result, Safety The Result, Safety RecommendationsRecommendations

Page 75: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Chinese leader Deng Xiaoping said it this way:Chinese leader Deng Xiaoping said it this way:

““Try to gather all the facts so that you can discover Try to gather all the facts so that you can discover the truth.”the truth.”

Win-Win Partnerships, p.153Win-Win Partnerships, p.153

Page 76: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Where is the next mishap, incident, accident going to Where is the next mishap, incident, accident going to occur?occur?

Please feel free to send your questions and comments Please feel free to send your questions and comments directly to directly to

the National Safety Team and NHQ Safety @the National Safety Team and NHQ Safety @

[email protected]@capnhq.gov

QUESTIONS?QUESTIONS?

Page 77: Introduction to Mishap Reviews Introduction to Mishap Reviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and

Contact InformationContact Information

Col Bob DiduchCol Bob Diduch Frank JirikFrank Jirik

National Safety OfficerNational Safety Officer Safety, CAP NHQSafety, CAP NHQ

P.O. Box 3036P.O. Box 3036 105 S. Hansell St.105 S. Hansell St.

Trenton, NJ 08619Trenton, NJ 08619 Maxwell AFB, AL 36112Maxwell AFB, AL 36112

609-731-5600 cell 609-731-5600 cell 800-227-9142 ext. 232800-227-9142 ext. 232

907-350-7559 cell907-350-7559 cell

[email protected]@capnhq.gov