Jim Page, 2007 Chapter 2: Preparation MINA Handbook.
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Transcript of Jim Page, 2007 Chapter 2: Preparation MINA Handbook.
Jim Page, 2007Jim Page, 2007
Chapter 2: Preparation
MINA Handbook
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
AFMAN 91-221, WeaponsAFMAN 91-222, SpaceAFMAN 91-223, AviationAFMAN 91-224, Ground
Jim Page, 2007Jim Page, 2007
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?
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
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.
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
Heinrich’s Triangle
1MAJOR
29 MINOR
300NO-INJURY
UNSAFE UNSAFE ? 000 -- ? 000PRACTICES CONDITIONS
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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
ES
SYMPTOM
AC
CID
EN
T
CONTACT
INJ
UR
Y D
AM
AG
E
LOSS
Jim Page, 2007Jim Page, 2007
Basic Safety Concept
• Sequence of Events
– Multi-linear Events or Single Track
• Multiple Cause versus Single Cause
– Why did Titanic sink?
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
Safety Privilege
Jim Page, 2007Jim Page, 2007
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.
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
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
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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.
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
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)
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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.
Jim Page, 2007Jim Page, 2007
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.
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
The Economics of Safety
• The Cost of Risk
– Direct and Indirect Costs
– Intangible Costs
– Control of Cost
Estimating mishap Costs: AFI 91-204
Jim Page, 2007Jim Page, 2007
Fundamentals of Investigation
Jim Page, 2007Jim Page, 2007
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
Jim Page, 2007Jim Page, 2007
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
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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