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 disabling injury;
Permanent partial disabling injury;
Three or more persons admitted to a hospital; or
Property damage in excess of $200K.
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
