Mishap Findings and Recommendations 101
TIMOTHY EDGETTE and MICHAEL BARKSDALE
G3, Investigations, Tracking and Reporting
U.S. Army Combat Readiness Center
Fort Rucker, Alabama
When a mishap occurs within your formation, there is the potential that you may be assigned as a safety investigation board (SIB) member. As a board member, you will have certain responsibilities based on your position, skill set and experience. In addition to gathering documentation and collecting data, the SIB will review and analyze the information. The SIB members also participate in a deliberation of the data with the end state of developing the findings and recommendations of the factors involved in the mishap. This part of the investigation is most beneficial and has the greatest impact on the Army.
Assuming the mishap was not the result of materiel or environmental factors, then the resultant causal factor is human error. Human error remains the leading cause of all Army mishaps. When you arrive at this point in the investigation, the SIB will transition to the Human Factors Analysis and Classification System (HFACS) for coding. First, the SIB determines the act(s) related to the mishap sequence. These acts answer questions such as, “Did the person make an inaccurate decision or violate a policy?” The 13 acts outlined in the HFACS explain the “what happened” paragraph, which is the first paragraph of a mishap finding and states what caused or contributed to the incident or the severity of injury or damage. There is always only one active failure per finding.
Second, the SIB determines the system inadequacies or latent failures, which will comprise the second paragraph of the finding. The system inadequacy codes fall into five distinct categories: support, standards, training, leader and individual. By following a flowchart comprised of a set of questions, the SIB can identify the system inadequacy codes. These codes answer the “why or the reason” the person did the unsafe act. Once the SIB identifies the system inadequacies, the SIB can then write the “why” paragraph, or the second paragraph of a finding. There can be, and usually is, more than one latent failure against a single unsafe act that was identified in paragraph one.
Using a two-paragraph template, you and the board will be able to write a finding that explains “what happened” and “why it happened.” The “why it happened” is where the recommendations are derived and focused. There must be a recommendation for every system inadequacy identified against the unsafe act at the appropriate level(s) to correct the system inadequacy. For example, if there is a latent failure code “PC101, Not Paying Attention” against an unsafe act, a recommendation may be to “reinforce, through training the consequences of not paying attention and staying alert, even while performing repetitive tasks.” The SIB focuses recommendations on each of the system inadequacies identified in the second paragraph of the finding. If leaders implement the recommendations, it lessens the likelihood of similar mishaps in the future.
Remember, a human error had to occur in the form of an unsafe act to answer the “what happened.” This unsafe act occurred because of the system inadequacies identified by the SIB. The mishap has already occurred, so what recommendations can you make to preclude similar mishaps in the future?
Writing a finding and making recommendations is not rocket science. Following the flow of the process and through repetition, you should be able to write an applicable finding for your investigation. Hopefully, your recommendations will be accepted and implemented at all levels, thereby precluding the likelihood of a similar mishap occurring in the future.