Chapter 2: Preparation

1. MINA Handbook Chapter 2: Preparation

2. Purpose 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.

3. THE RULES AFI 91-204 AFMAN 91-221, Weapons AFMAN 91-222, Space AFMAN 91-223, Aviation AFMAN 91-224, Ground

4. 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. 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. 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

7. 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. 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.

9. Absent or Failed Defenses

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

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

12. Basic Safety Concept • Sequence of Events • Multi-linear Events or Single Track • Multiple Cause versus Single Cause • Why did Titanic sink?

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

14. 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. Safety Privilege

16. 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. 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. 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. 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. 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. 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. 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)

23. 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. 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. 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. 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. 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

28. Penalties for Unauthorized Useor Disclosure • DoD Civilian • Reprimand, Suspension, Termination • Contract Employee • Affect Future Contracts • Foreign National • Nation Government Rule

29. The Economics of Safety • The Cost of Risk • Direct and Indirect Costs • Intangible Costs • Control of Cost Estimating mishap Costs: AFI 91-204

30. Fundamentals of Investigation

31. 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. 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. Personal Investigation Kit