1. Jim Page, 2007 Chapter 2: Preparation MINA Handbook

2. Jim 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

3. Jim Page, 2007 AFMAN 91-221, Weapons AFMAN 91-222, Space AFMAN 91-223, Aviation AFMAN 91-224, Ground

4. Jim 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?

5. Jim 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?

6. Jim Page, 2007 Basic Safety Concepts at Work 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

7. Jim 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

8. Jim Page, 2007 Unsafe Acts and Unsafe Conditions Unsafe Performance of Persons (Acts) –Standing Under Loads –Removal of Safeguards –Etc. Mechanical or Physical Hazards –Unguarded Gears –Insufficient Lighting –Etc.

9. Jim Page, 2007 Absent or Failed Defenses Team/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

10. Jim Page, 2007 Heinrich’s Triangle 1 MAJOR 29 MINOR 300 NO-INJURY UNSAFE ? 000 -- ? 000 PRACTICES CONDITIONS

11. Jim Page, 2007 The Domino Theory ROOT CAUSES ORIGINS LACK OF CONTROL MGMNT PROXIMATE CAUSES SYMPTOM ACCIDENT CONTACT INJURY DAMAGE LOSS

12. Jim Page, 2007 Basic Safety Concept Sequence of Events –Multi-linear Events or Single Track Multiple Cause versus Single Cause –Why did Titanic sink?

13. Jim Page, 2007 Accident Causation Model Corporate Goals & Mission Equipment Defect Safety Program Defect Management Error System Defect Supervisor Error Operator Error Incident (No damage or Injury Accident (or Incident) Latent FailuresActive Failures The Organization Event Mishap Prevention Damage Limitation Personal Characteristics

14. Jim 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

15. Jim Page, 2007 Safety Privilege

16. Jim 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.

17. Jim 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

18. Jim 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

19. Jim Page, 2007 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

20. Jim 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.

21. Jim 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

22. Jim 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 (5 th Amendment or Article 31, UCMJ)

23. Jim Page, 2007 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.

24. Jim 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.

25. Jim 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

26. Jim 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.

27. Jim Page, 2007 Penalties for Unauthorized Use or 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

28. Jim Page, 2007 Penalties for Unauthorized Use or Disclosure DoD Civilian –Reprimand, Suspension, Termination Contract Employee –Affect Future Contracts Foreign National –Nation Government Rule

29. Jim 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

30. Jim Page, 2007 Fundamentals of Investigation

31. Jim 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

32. Jim 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

33. Jim Page, 2007 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