October 16, 2014 -- Installations, Environmental and Safety Division, Marine Corps Logistics Command, hosted the Ground Mishap Investigation Course recently aboard Marine Corps Logistics Base Albany.
The 19 attendees included LOGCOM staff from IE&S, Marine Depot Maintenance Command and MCLB Albany staff from the Risk Management Office.
The Marine Corps Ground Mishap Investigation course was developed in 2011 by Commandant Marine Corps Safety Division’s “Team Rucker.” This team from Fort Rucker, Alabama, aids in closing a skills gap of ground safety officers and civilian safety personnel. Additionally, this course fulfills the requirements set forth in the Marine Corps Safety Program.
The course’s primary focus is on root cause analysis with extensive study and direct application of the Department of Defense Human Factors Analysis and Classification System and Safety Investigation Report writing.
With facilitator guidance, students worked in teams to analyze and determine root causes and recommend corrective actions.
The Ground Mishap Investigation course provided 40 hours of advanced mishap investigation instructions beyond the introductory classes offered in the Ground Safety for Marines course.
Upon completion of this course, each team member took away the basic knowledge and skills to investigate any mishap ranging from a near miss to a major mishap. This course also provided a certification which authorizes personnel to participate as a member of a formal Marine Corps Safety Investigation Board.
Ken Sator, director, IE&S, LOGCOM, hosted the course for the LOGCOM staff and invited MCLB Albany safety personnel to take advantage of this opportunity as well.
Sator stated this was a great partnership between LOGCOM, CMC/SD, and the instructors from Fort Rucker to provide this excellent training right here in Albany. The Mishap Investigation course provided a much higher level of knowledge and expertise that enabled the attendees to immediately use their new skills if the need arose. Understanding the analytical methods used to determine the actual cause of a mishap is critical to implementing changes in the workplace and/or behaviors to prevent future occurrences.
“One of the key messages we communicate in this course is that things do not ‘just happen,’ instructor Chris Acord said. “It takes a series of omissions, errors and oversights to cause an unwanted, unplanned and unintended event we call a mishap. And when we look back through those events leading up to the mishap, we usually find many points where ‘it only takes a second’ to make a change and stop the mishap from occurring.”
As the organization strives for a mishap-free environment, it also recognizes that as long as humans are involved mishaps will occur. Most mishaps are minor and should serve as a “wake up call.” Unfortunately those “near mishaps” or “minor mishaps” often get discussed and the unsafe conditions or unsafe acts remain uncorrected until they lead to a catastrophic event.
When a mishap occurs, more than the immediate surroundings of the event must be examined. Safety personnel, supervisors, leaders must consider systemic deficiencies, oversights, errors, omissions or unanticipated changes at all levels, which may be the precursor to “operator error.”
If safety personnel, supervisors and leaders give each minor mishap or near mishap the same vigor as given to a catastrophic event, the organization can significantly reduce the probability of the minor mishap from becoming a tragedy.