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CAP Safety Tip of the Week Archive
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Risk Management |
Mishap Reporting |
Mishap Reviews |
Risk Management: Involve Members in Safety Planning
Involving members in the safety planning process creates ownership, enhances risk assessment and mitigation, and improves real-time risk awareness.
Why this is important
When members are involved in the risk assessment process, they are more likely to feel a sense of pride or ownership in protecting people and resources. Awareness of hazards and how they can be mitigated benefits from a diverse range of perspectives, and improves the quality of the planning and execution of a mission or activity.
Do this
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Do ask for members' inputs on the hazards, risks, and mitigation
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Do talk to them about their role and responsibility for safety -- for themselves and each other
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Do always encourage members to speak up immediately when they notice an unmitigated hazard
Not this
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Don't complete risk management in a vacuum: involve others and invite their advice and feedback
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Don't treat risk management as a "paperwork exercise."
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Don't ignore important safety information when raised by members
Mishap Reviews: The 5 Ms
More than a "checklist," the 5 M's Worksheet is a means of keeping track of contributing factors to a mishap. When used well, the worksheet can help Review Officers ask critical question about what led to the events that resulted in the mishap.
Why this is important:
Once you identify all the events that led to a mishap, the 5 M's focuses your review questions on the factors that may have contributed. By asking the question, "What led to this event in the chain?" as many times as needed, you get specific information about human and non-human factors. It's also important to think beyond just the individual(s) involved in a mishap. For example, ask yourself, "What could lead others involved in the mission or activity to have a similar event?" That question can lead to systemic factors that we need to address across the organization to mitigate risk.
Do this:
- Do use the 5 M's Worksheet to guide you to answer questions about what might have led to an event in the event chain
- Do focus on documenting the contributing factors that can be corroborated with information you gain from the review
- Do go beyond the individuals involved in a mishap and ask if something that led to the mishap that may need a systemic level mitigation
Not this:
- Don't document uncorroborated speculation on the 5 M's worksheet - note when you don't know what led to an outcome, but have a supported opinion
- Don't get caught up in trying to make the 5 M's "fit" - not every "M" is going to be a contributing factor - note when something isn't likely a factor and move to the next on
- Don't start with speculation and then go validate it - this will result in a biased review and missed opportunities for continuous improvement
Risk Management: Getting Proactive
A commitment to proactively identifying and managing risk, to relentless responsibility for assuring the safest outcomes possible, is one of the key features of our ideal safety culture and one of the most important ways that we demonstrate our integrity.
Why this is important:
One of the goals of the CAP SMS is to become an organization that proactively identifies and manages risk. When we acknowledge and accept responsibility and cooperate to manage safety risk, to act in ways that are consistent with the ideals of our safety culture, we seek out opportunities for vigilance and early intervention before something goes wrong.
Do this:
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Do work to cultivate awareness for the potential for failure across all activities
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Do resist simplifying explanations for why things succeed or fail
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Do consider every operation as possessing its own unique hazards and risks
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Do learn from the people closest to the activity - they are the most knowledgeable
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Do assume the system is always at risk for failure and operate to quickly assess situations when new information emerges
Not this:
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Don't assume that some things are inevitable and, therefore, unpreventable
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Don't default to thinking that something can't be prevented because it's frequent or "minor"
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Don't assume everyone participating in an activity of mission knows the hazards and risks
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Don't succumb to thinking the only way to prevent negative safety outcomes is to not do the activity or mission
Risk Management: Hazards in the CAP Meeting Place
Contributed by Col Bob Castle - SWR Director of Safety, National Senior Safety Program Advisor
When was the last time you inspected the area where you hold your CAP meetings?
Why is this important?
- Hazards in the meeting place can exist for years or they can develop quickly
- Members can see the hazard and not recognize the danger
- Slips, trips and falls are contributing factors in many bodily injury mishaps reported by CAP members
- The potential for serious injury can be reduced by a few proactive steps
Do this:
- Conduct regular area inspections to look for hazards
- Keep meeting areas neat and uncluttered
- Inspect electrical cords and ensure they are in good condition and do not present a trip hazard
- Have a new member help with the inspection – they may identify hazards that have been overlooked on previous looks
- Correct discrepancies on the spot or at the earliest possible time
- Contact the facility manager for borrowed CAP meeting spaces to correct hazards related to the facility
Not this:
- Don't ignore hazards or take them for granted. Just because one member is aware of a hazard doesn’t mean everyone else does!
- Don't bypass safety processes that are put in place to mitigate hazards.
Risk Management: Take Time for Safety
Don't be tempted to take shortcuts when it comes to safety processes and practices
Why is this important?
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One of the ways safety is eroded is when time is involved. When we're short on time, we think it's ok to skip a safety check "just this once."
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Safety processes and practices are designed to create effective barriers between actions (or inactions) and negative safety outcomes - skipping these even once can lead to damage or injury
Do this:
- Take the time to prepare yourself mentally to complete all safety processes and practices
- It's OK to be late - it's better to arrive safe and sound than to rush and leave out an important safety step
Not this:
- Avoid complacency - just because nothing happened this time doesn't mean it won't happen in the future!!!
- Don't skip the checklist or other safety check, even if you're pressed for time!!!
Mishap Reporting: Non-mishap reportable events (NMREs)
Non-mishap reportable events only apply to aircraft, not to vehicles, injuries/illness, or facilities
Why is this important?
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Because of the non-mishap hazards associated with aircraft that can impact safety, CAPR 160-2 established reporting for events that did not meet the definition of a mishap (See CAPR 160-2, Section 5.5)
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CAPR 160-2, Section 5.9: "All injuries and illnesses that occur as a result of, or during, any CAP event, mission or activity will be reported as a bodily injury mishap. This includes illnesses or injuries that are believed to have pre-existed before the event or activity."
Do this:
- Report all injuries/illnesses as mishaps
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Discuss reporting of mishaps and NMREs with your Director or Safety to ensure they are categorized correctly
Not this:
- Do not label injuries, illness, vehicle, or facility issues as NMREs
- Do not label any damage to aircraft, vehicles, or facilities as an NMRE
Mishap Reviews: Key principles
Contributing factors may be previously undetected hazards, or inadequately controlled risks, that should be addressed with corrective actions.
Why is this important?
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We look for the cause; we don’t find fault. Safety mishap reviews are conducted solely to determine what went wrong and what can be improved to prevent it from going wrong again.
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The amount of energy expended in discovering the causes of mishaps has nothing to do with the amount of damage they cause. A minor injury may reveal the same hazards as a serious injury.
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Our goal is to analyze the sequence of events leading up to a mishap and determine what improvements can be made to prepare members to respond should the situation occur again.
Do this:
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Look at every element in the event chain that led to the mishap and drill down using the 5Ms and the 5 Whys to determine if there are opportunities to "break" the chain
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Share your review with your Director of Safety and be open to their feedback on improving both the review and the recommended mitigations
Not this:
- Assume that a mishap, no matter how small, is unpreventable
- Think you "know" the cause of a mishap without conducting a review
Mishap Reporting: Notify before entering
It is imperative that wing and region leadership is informed of mishaps on a timely basis.
Why is this important?
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The reporting of mishaps, observed hazards, and other hazard-revealing events is a key component of CAP’s commitment to identifying hazards which have the potential to increase risk to CAP members, CAP missions, and CAP assets.
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The commander or the leader of the activity is responsible for ensuring the mishap is reported in SIRS in eServices as soon as possible after the mishap occurs.
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A mishap is any occurrence or series of occurrences that results in damage or injury. Any damage or injury is evidence that a mishap has occurred, even if the precipitating occurrence or cause is not known. All mishaps must be reported.
Do this:
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Members at every level are responsible for reporting any mishap when they witness the mishap or see evidence that a mishap has occurred. This includes reporting to leadership as well as reporting in SIRS.
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Talk with your local Director of Safety to ensure the information gets entered in the right part of SIRS and gets entered correctly - not all safety-related events are mishaps!
Not this:
- Enter information into SIRS without notification to region and wing leadership
- Enter an observed hazard or hazard-revealing event as a mishap
Mishap Reviews: Stop or Learn More?
Sometimes the mishap event chain will reveal very little, if anything, that we can do to prevent it. An event chain with enough information about what led to the mishap will go a long way toward determining how much effort to put into a mishap review.
Why this is important:
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The risk associated with some mishaps may be low enough that a full review is more effort than benefit
Do This (example only!):
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Construct an event chain and associated conditions
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Example
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Mishap - member sprained wrist
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Event chain and conditions
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Member fell
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Did not regain balance
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Member tripped
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Rocks on trail
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Trail was dry
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Member walking
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Footwear appropriate
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Briefed on trail conditions
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Given the example, is there anything else CAP could/should have done to mitigate the risk of the injury?
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If no, discuss with your Wing Safety Officer to determine if there's more to be learned or if the review should stop here - remember, your commander is the final authority on whether to review the mishap further.
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Document the event chain and the reasoning in the mishap review
Not this:
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Member tripped over own feet and sprained wrist. Member was treated by EMS personnel and returned to activity.
Mishap Reviews: Event Chain
When assigned as a Review Officer, constructing an "Event Chain" will help uncover factors that may have contributed to the mishap
Why this is important:
- The event chain helps you look for contributing factors systematically
- Drilling down on an event chain with the "5Ms" and the "5 Whys" focuses your review and maps contributing factors to events
- Mapping contributing factors to events increases the chances that a corrective action will prevent the causes of the mishap in the future
Do This (example only!):
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Mishap - Scraped knee
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Events - 1. Tripped 2. Running 3. Ball thrown 4. Etc.
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What conditions were present around the tripping "event"? Hole in ground, sun in eyes, etc.
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What conditions were present around running? Chasing a ball, looking up and back (not down), etc.
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Etc.
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Once the events and all associated conditions are laid out, then look at where there are conditions that, if addressed, would prevent the event in the chain.
Not this:
- Cadet tripped and scraped knee. First aid administered. No further action required.
Mishap Reporting: Keep It Simple!
Avoid using proper names – including location or unit information - in the “Brief Description of Mishap” section. Use generic references only and keep the account as brief as possible.
Why this is important:
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Names of people, locations, units, etc. are entered elsewhere in the mishap report
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Simple, brief descriptions make it easier to look through a long list of mishap reports
Do This:
A senior member stumbled and fell on a patch of ice and was transported to the emergency room for treatment.
