Jim Page, 2007 Chapter 2: Preparation MINA Handbook

Jim Page, 2007Jim Page, 2007

Chapter 2: Preparation

MINA Handbook


The purpose of the MINA course is to train ground, weapons, and space safety personnel and other selected individuals who will be potential mishap investigators in the techniques and procedures of investigating all classes of mishaps, including high accident potential mishaps. The course emphasizes investigative techniques, technical items relative to ground, space, missile and explosives mishaps and the impact of human behavior and culture related to mishaps. The focus of the instruction shall be on the investigative process and determining root cause rather than actual report preparation.

Purpose


AFMAN 91-221, WeaponsAFMAN 91-222, SpaceAFMAN 91-223, AviationAFMAN 91-224, Ground


USAF Mishap History

• The Past – We’ve reached a plateau

• Problems?

• Quality Investigations – Sketchy

• Politics – You work for the boss

• Ethics – Your ethics, Your involvement

• Leadership?


Why Investigate?

U.S. OSHA

WORKERS Compensation

DoD Requirements

USAF Requirements

Need to Document, Trend

AFI 91-204: Find the causes of mishaps and prevent recurrence

What are your reasons to investigate?

Jim Page, 2007Jim Page, 2007 Basic Safety Concepts atWork in a Mishap Sequence

• Safety First??

– Safety or Mission

• Familiarity--“Blood Priority”

– “We haven’t had a mishap from that”

• Known Precedent

– The hazardous conditions were known before

• Accident Causation Model

– A mishap is usually the result of a failing in the management system


Basic Safety Concepts

• RANDOMNESS of DAMAGE OR INJURY

– Red Traffic Lights

• ZERO ACCIDENT RATE

– The Ultimate Goal

• RESISTANCE TO CHANGE

• THE CONCEPT OF CHANGE

– Someone has to be the

Change Agent

Jim Page, 2007Jim Page, 2007 Unsafe Acts and UnsafeConditions

• Unsafe Performance of Persons (Acts)

– Standing Under Loads

– Removal of Safeguards

– Etc.

• Mechanical or Physical Hazards

– Unguarded Gears

– Insufficient Lighting

– Etc.


Absent or Failed DefensesTeam/Individual

Actions

(Unsafe Acts)

Absent or

Failed Defenses

Incident/

Accident

Near Miss

Either a human action departing from prescribed hazard controls or job procedures or practices, or as an action causing a person unnecessary exposure to a hazard. A supervisor contributes to the cause by omission or commission when failing to have a hazard corrected.

Engineering Controls:

Source modification

Substitution

Process change

Isolation

Administrative Controls

Regulations

Instructions

Training

Quality Assurance

Scheduling

PPE

The Unwanted Event

Injury to Personnel

Equipment Damage


Heinrich’s Triangle

1MAJOR

29 MINOR

300NO-INJURY

UNSAFE UNSAFE ? 000 -- ? 000PRACTICES CONDITIONS


The Domino Theory

RO

OT

CA

US

ES

ORIGIN

S

LA

CK

OF

CO

NT

RO

L

MGM

NT

PR

OX

IMA

TE

CA

US

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SYMPTOM

AC

CID

EN

T

CONTACT

INJ

UR

Y D

AM

AG

E

LOSS


Basic Safety Concept

• Sequence of Events

– Multi-linear Events or Single Track

• Multiple Cause versus Single Cause

– Why did Titanic sink?


Accident Causation Model

CorporateGoals & Mission

EquipmentDefect

SafetyProgramDefect

ManagementError

SystemDefect

SupervisorError

Operator Error

Incident(No damage or Injury

Accident(or Incident)

Latent Failures Active Failures

The OrganizationEvent

Mishap Prevention Damage Limitation

Personal Characteristics

Jim Page, 2007Jim Page, 2007 Investigative Authorities/Jurisdictions

• Safety and Legal Investigations– Who Investigates IAW 91-204– The Accident Investigation AFI 51-503

• Safety Investigation Chain of Authority– You don’t work for the

• OSI, OSHA, and other Investigative Agencies– May work concurrently

• Other Air Force Investigations– Commander Directed AFI 90-301– Report of Survey AFMAN 23-220– Line of Duty Determination AFI 36-2910, 3212


Safety Privilege


What Reports are Privileged?

• ALL USAF Safety Investigations (Part II of Formal and all messages except 8 hour).

• Class C & HAP messages for the above categories.

• For Ground and Explosives this includes the board (investigator) deliberations, analysis, findings, causes, and recommendations.


What is Privileged Information?• Privileged Information Includes SIB Conclusions, Findings,

Causes, Recommendations & Deliberative Process (This includes notes and other papers)– Photographs, films & videotapes, diagrams or any exhibits

which depict the Board’s analysis or conclusions– Computer/Simulator reenactments

• If they contain SIB analysis or input– Life Sciences Materials– IF Confidentiality is promised (Does usually not apply to

Ground/Explosives Investigations:• Witness Statements• Contractors who designed, built, maintained Equipment


What is NOT Privileged?• All Part I Materials (Factual)

– Summary of Facts– Flight & Personnel Records (Tab G)– Maintenance Records (Tab H)– Technical Evaluations (Tab J)– Damage & Repair Costs (Tab M)– Transcripts of Ground & Air-Air Communications (Tab N)– Additional Facts (Tab O)– Damage to Private Property (Tab P)– Orders Appointing SIB (Tab Q)– Diagrams (Tab R)– Photographs (Tab S){Non-staged}– List of Witnesses


Promise of Confidentiality

• “Promise of Confidentiality” can only be given by:

– Designated Interim and permanent SIB members or SIO

• Access is limited to mishap prevention needs

Jim Page, 2007Jim Page, 2007 Who Can Get A Promise of Confidentiality?

• Witnesses. (Normally in Ground/Explosives Investigations witnesses are NOT offered confidentiality. Requires approval of USAF/SE).

• Gov’t contractors who built, designed, or maintained equipment and participate in the investigation. (if requested).

• Investigators.


Witness Confidentiality

• Statements cannot be used.– EXCEPT:

• IF YOU LIE• JENCKS ACT

Statements May be released to Defense

Judge Orders

Government Releases or Drops Specifications

Part of Witness Advisement


Compelling Testimony

Privileged Investigation

• Depends on Status of Witness

– Military Members: Yes

– DoD Civilians: Yes

– Contract Employees: Terms of Contract

– Civilians: Persuasion Only

General-Use Investigation

• Protected Under Constitution (5th Amendment or Article 31, UCMJ)


Toxicology Testing

• Flight Crews if involved in Mishap.

• Military who may have been factors in mishap sequence.

• DoD Civilians if evidence indicates that they may have caused the mishap.

• Contract employees if they may have been a factor in the mishap sequence AND if in contract or by consent.


Limited Use• Privileged safety investigation information is to be used

for MISHAP PREVENTION ONLY.

• It is provided only to persons and agencies with relevant mishap prevention duties.

– CAN NOT be used for any punitive, disciplinary or adverse administrative actions, or determining misconduct, line-of-duty, FEB, or liability claims.


Release of Privileged Information

• Only AFSC can release outside USAF

• SIB does not provide any public disclosure (Press, next of kin, etc.) period!!

• “Do Not Discuss” limitations:

– Mishap Responsibility

– Statements, quotations, opinions

– Failure of equipment, facilities, support services

– Indications of liability, Classified Information

– Cause factors or recommended corrective action

– Factors NOT Causal

Jim Page, 2007Jim Page, 2007 Release of Non-Privileged Information

• Release authorized outside USAF once Privacy Act Information is removed.

• Installation Chief of Safety in release authority inside USAF.

• HQ AFSC/JA is release authority outside USAF.

Jim Page, 2007Jim Page, 2007 Penalties for Unauthorized Useor Disclosure

Military

– Confinement for Two Years

– Dismissal or Dishonorable Discharge

– Forfeiture of Pay and Allowances

– Reduction to Lowest Grade

Article 92 UCMJ and 91-204, 1.13.1.5

Jim Page, 2007Jim Page, 2007 Penalties for Unauthorized Useor Disclosure

• DoD Civilian

– Reprimand, Suspension, Termination

• Contract Employee

– Affect Future Contracts

• Foreign National– Nation Government Rule


The Economics of Safety

• The Cost of Risk

– Direct and Indirect Costs

– Intangible Costs

– Control of Cost

Estimating mishap Costs: AFI 91-204


Fundamentals of Investigation


Organize to Investigate

• Make a plan and a schedule– Determine support requirements– Get those assisting you to help– Assign Duties– Work with “designated” representatives– Establish time line events

• Organize your information– Promote exchange of information and ideas

• Plan your daily activities– Establish priorities

• Be aware of the critical incident stress syndrome• Use principles of basic investigation management


Pre-Mishap Response Planning

• Any potential mishap on- or off-base• Notification of all pertinent agencies & safety• Ensure all investigators are familiar with publications required

for investigation• Plan for investigative organization• Prearrange transportation• Pre-identify heavy equipment available• Prepare an investigative kit• Photography• Security

Test and exercise the plan


Personal Investigation Kit

•Notebook/pens/pencils

•Lined Paper

•Witness Statement Forms

•High visibility marking tape

•Camera, film, photo log, memory cards

•Sample bottles/bags/tags

•Models

•Flashlight w/batteries

•Small whiteboard w/markers

•Warning signs

•Ruler and 50’ tape measure

•Cassette recorder w/tape or digital recorder

•Reporting forms

•Investigation guidelines

•Gloves

•Cellular Phone/Radio

Documents

Jim Page, 2007 Chapter 2: Preparation MINA Handbook