of improving safety. Never try to obtain written
statements or record the information verbatim.
INDIVIDUALS INTERVIEWED DURING
INVESTIGATIONS CONDUCTED PUR-
SUANT TO OPNAVINST 5102.1C SHALL
NOT TESTIFY UNDER OATH AND
SHALL BE ADVISED THAT THEIR
STATEMENTS ARE FOR ONE PUR-
POSE ONLYTHE PREVENTION OF
FURTHER MISHAPS. INFORMATION
OBTAINED DURING ANY INVESTIGA-
TION PURSUANT TO OPNAVINST
5102.1C SHALL NOT BE USED AS THE
BASIS FOR ANY ADMINISTRATIVE,
REGULATORY, DISCIPLINARY, OR
CRIMINAL PROCEEDING WITHIN
THE DEPARTMENT OF THE NAVY.
Handbook for the Conduct
of Forces Afloat Safety
Investigations
The following are some basic guidelines you
should observe during your investigation:
Never delay medical treatment to interview
a person.
Let the witness tell you what happened.
Interview witnesses separately.
Ask only one question at a time.
If a witness refers to they, determine
exactly who they are. If nothing else,
get a description and send an investigation
team out to locate they.
Sometimes you will find that reconstructing
the mishap will help you get a clear picture of how
the mishap occurred. Have those who take part
in recreating the mishap proceed up to the point
of the mishap. Beyond the point of the mishap,
talk about the action taken and walk through the
steps. Many times you will discover the cause of
the mishap through the reconstruction.
CAUSE FACTORS
Your investigative procedures should have
answered the what, when, and where questions.
Next you must investigate the how and why.
Review the evidence gathered in an analytical
fashion to determine if you can answer how and
why the mishap occurred. DON'T OVERLOOK
THE OBVIOUS. Since most mishaps are caused
by people, look to see if the personnel involved
were affected by any of the following conditions:
Physical condition: drunk, hangover, drug
affected (prescribed or unauthorized),
tired, ill, or hungry
Mental attitude: worried, frightened,
bored, depressed, distracted, day dream-
ing, confused, or complacent
Attitude toward shipmates: distrustful,
overtrusting, or contemptuous
State of training for the task: formally
trained, trained on-the-job, team trained,
overtrained, or insufficient mental ability
for needed training
Next, look to see if any of the following
environmental conditions could have contributed
Environment: hot, cold, humid, dusty,
too bright, too dark, too noisy, smokey,
windy, or cramped
Equipment being operated: controls poorly
located, instruments unreadable, design
non-standard, operating procedure inade-
quate, maintenance manual incomplete, or
access difficult
Clothing and outfits: adequate, burden-
some, or clumsy
TYPES OF MISHAP REPORTS
Mishap Investigation and Reporting, OP-
NAVINST 5102.1C, prescribes the format to be
used in reporting most mishaps. It defines the
various categories of reportable circumstances, the
format used for specific categories, and the
entries required in each section of the report.
The formats discussed in this instruction are
designed to assist the investigator in determining
all the factors previously mentioned, with
particular emphasis on the question why. A brief
description of these reports and their uses follows:
1. Personnel Injury/Death/Occupational
Illness Report, OPNAV 5102-1Used to report
mishap injury, death, or occupational illness of
all military personnel attached to Navy units or
8-3
to the mishap: