Mishap Investigation &

Reporting
 Mishap Investigation &
Reporting
 An accident that appears to have any of the
consequences listed below shall be immediately
reported to the GDA:
 Fatal injury;
 Permanent totally or partial disabling injury;
 Three or more persons admitted to a hospital; or
 Property damage in excess of $200K.
 Arc Flash Incident/Accident

Contractor are responsible for notifying OSHA

when one or more employees are seriously injured.
01.D.02
Why Investigate Accidents?
 Prevent a recurrence with corrective action
 Determine the cause
 Document contractor’s version of
the incident
 Satisfy reporting requirements
Who Investigates?
 Minor Mishaps
 Contractor Investigation:
 Contractor Supervisor

 Site Safety & Health Manager

 GDA:
 ET/CME (confirm)

 Serious Mishaps
 Contractors Investigation:
 Contractor Supervisor

 Safety manager

 Production manager

 GDA:
 FEC Safety Manager

 Ech III Safety

Investigator’s Qualifications
 Accident investigation training
 Good understanding the importance
of investigation
 Ability to communicate details
 When to Investigate?
 Immediately after mishap
— Witnessmemories fade
— Equipment and clues
are moved

 Finish investigation quickly

Investigation Kit
 Camera and film
 Report forms, clipboard, pens
 Barricade tape
 Flashlight
 Tape measure
 Tape recorder
 Work gloves
When Mishap Occurs
 Employee immediately reports the
accident to a supervisor
 Supervisor treats the injury or assesses need
for outside medical treatment
 Leave the accident scene intact
 Contact the accident investigation team
 Contractor to notify GDA:
 Immediately, if serious
 Within 24 hrs, if non-serious
 Beginning the Investigation
 Gather investigation
team and kit
 Report to the scene
 Look at the big
picture
 Record initial
observations
 Take pictures
 What’s Involved?
 Who was injured?
 Medication, drugs,
or alcohol?
 Was employee ill?
 Double shift or
rotating shifts?
Witnesses
 Who witnessed the
incident?
 Was a supervisor or
lead person nearby?
 Where were other
employees?
 Why didn’t anyone
witness the incident?
Interviewing Tips
 Discuss what happened leading
up to and after the accident
 Encourage witnesses to describe
the accident in their own words
 Don’t be defensive or judgmental
 Use open-ended questions
What Was Involved?

 Machine, tool,
or equipment
 Chemicals
 Environmental
conditions
 Production schedule
Time of Incident
 Date and time?
 Normal shift?
 Employee coming
off a vacation?
 Incident Location
 Work area
 On, under, in, near
 Off-site address
 Doing normal job duties
Incident Activities

 Motion conducted at
time of incident
 Repetitive motions?
 Type of material
being handled
Incident Description
 Details so reader
can clearly picture
the incident
 Specific body
parts affected
 Specific motions
of injured employee
just before, during, and after incident
Causal Factors
 Try not to accept single cause theory
 Identify underlying causes
 Primary cause
 Secondary causes
Corrective Actions
 Immediate corrective actions
 Recommended corrective actions
— Employee training
— Preventive maintenance activities
— Better job procedures
— Hazard recognition
 Reporting
 CSIR-1 completed and
signed by
investigation
members
 Forward CSIR-1 to GDA
 GDA to notify NAVFAC
FECs of mishap using
BMS processes
 GDA to schedule Mishap
Review Board, if
required
 Mishap Reporting
 For contracts involving construction, demolition,
alteration, maintenance, repair and services
(including CLEAN, BOS, JOC, SOC, TOC, BRAC, FSCC,
ERN, etc.), where QA and/or project
management services are provided by NAVFAC
personnel, the contractor shall be required to
provide to the Contracting Officer a Contractor
Significant Incident Report (CSIR).

(NAVFACINST 5100.11.0306)
 Mishap Reporting
 Serious Mishap
 Any contractor mishap involving a fatality, regardless of
the time between the injury and death, or the length
of the illness; permanent totally disabling injury;
permanent partial disabling injury; the hospitalization
of three or more workers; or property damage in
excess of $200,000.
 Will be investigated by FEC Safety Office
 With Ech III presence

 Contractors will perform their own investigation.

 Mishap Reporting
 Recordable Mishaps
 Lost Workday Case
 Injuries other than fatalities, that result
in a lost workday. Loss of workday from
work beyond the day or shift on which it
occurred.
 Mishap Reporting
 Recordable Mishaps
 Non-fatal Case
 Mishap case without lost workdays which
results in transfer to another job or
termination of employment, or requires
medical treatment (other than first aid) or
involves property damage in excess of
$20,000 but less than $200,000 or involves:
loss of consciousness or restriction of work
or motion. This category also includes any
diagnosed occupational illnesses, which are
reported to the employer but are not classified
as fatalities or lost workday cases.
 Mishap Reporting
 Recordable Mishaps
 TheContracting Officer through the FEC
Safety Office shall ensure that an
appropriate NAVFAC investigation is
completed and the information is
entered into the FAIR database via the
ESAMS.
 Mishap Reporting
 Recordable Mishaps
 The FEC Safety Manager shall review
the report and determine if further
investigation is warranted. In addition,
the FEC SM shall complete appropriate
sections of the CSIR.
 Mishap Reporting
 Weight Handling Equipment Mishaps
 Investigatedand Reported to the Navy
Crane Center per P-307
 Need not be reported to Navy Safety
Center
 Mishap Investigation &
Reporting
 Judge Advocate General (JAGMAN)
 Any Mishap onboard Naval Installations
that result in personal injury or damage
to property requires a preliminary
inquiry to determine if a JAGMAN is
required in addition to the mishap
investigation
 Mishap Reporting &
Recordkeeping
Employees are responsible to report all
injuries or occupational related illnesses
as soon as possible to their immediate
supervisors.

 Employers and immediate supervisors

are responsible to report all injuries to
the GDA within 24 Hours

01.D.01.b
 Mishap Reporting &
Recordkeeping
 Maintain Records of all exposure and
accident experience
 Prime & Subs
 Document employee exposure to toxic
material
 Submittal of Monthly Man-hour Reports
 OSHA Form 300

01.D.05
 Summary
 Investigate accidents immediately
 Determine who was involved and
who witnessed it
 Ascertain what items or equipment
were involved
 Record detailed description
 Determine causal factors
 Conduct corrective actions
 Submit all required reports