ACCIDENT AND INJURY REPORT

Question 1

**Hazard

Answer 1

A work place condition that might result in injury, health impairment,
illness, disease, or death to any worker who is exposed to the condition, or which might result in damage to or loss of property or equipment.

Question 2

**Hazard Severity

Answer 2

An assessment of the worst potential consequence is likely to occur as a result of deficiencies.

Question 3

**Injury

Answer 3

A traumatic wound or other condition of the body caused by external force including stress or strain.

Question 4

**Mishap

Answer 4

Any unplanned or unexpected event causing death, injury, occupational illness, including days away from work, job transfer or restriction, and material loss or damage

Question 4

Mishap Probability

Answer 4

The likelihood that a hazard will result in a mishap or loss.

Question 5

** Near Mishap

Answer 5

Is an act or event which injury or damage was avoided merely by chance.

Question 6

** (WESS)

Answer 6

Web-Enabled Safety System

Question 7

** Web-Enabled Safety System (WESS)

Answer 7

A web-based safety mishap data collection and reporting system developed for the Navy and Marine Corps by COMNAVSAFECEN.

Question 8

** Mishap Notification, Investigation, Reporting and Record
Keeping

Answer 8

DODI 6055.07 (6 Jun 2011)

Question 9

**Navy & Marine Corps Mishap and Safety Investigation, Reporting and Record Keeping Manual.

Answer 9

OPNAVINST 5102.1D/MCO P5102.1B (07 Jan 2005)

Question 10

** Naval Aviation Safety Management System.

Answer 10

OPNAVINST 3750.6S (May 14)

Question 11

**Mishap Investigation and Reporting Purposes

Answer 11

(1) To identify hazards with potential to cause frequent and severe mishaps.
(2) To identify hazards that could cause future mishaps.

** (3) To identify unsafe acts and conditions and apply corrective measures.

(4) To identify mishap causal factors and develop appropriate corrective actions which, when implemented, will help prevent similar mishaps.

Question 12

Investigation and Reporting Required Conditions

Answer 12

(1) Class A, B and C government property damage mishaps.
(2) Class A, B, and C on-duty DoD civilian mishaps and military on/off-duty mishaps.

• • (3) Any other work-related illness or injury that involves medical treatment beyond first aid.
    (a) Loss of consciousness,
    * * (b) Lost work day
    (c) Light duty or limited duty for on/off-duty military personnel

(4) Other incidents of interest to the Navy and Marine Corps for mishap prevention purposes.
(5) All on-duty military fatalities or permanent total disabilities that are the result of a medical event that commenced within one hour of a command-sponsored Physical Training (PT)
(6) Mishaps occurring as the result of a DoD activity, operation, or evolution that results in the injury or death of a guest or military dependent.

(7) All on-duty military training-related fatalities, and any high or moderate risk training
mishaps that result in the:
(a) Loss of one training day
(b) Rolling back or disenrollment of the student from a course

(8) All explosive mishaps, including all ordnance impacting off range and all live fire mishaps.
(9) All on-duty diving cases

(10) All afloat cases of grounding, collision, and flooding.
(
11) All fires occurring afloat (all cases except small trash fires in which no personnel were injured and the material property damage was limited to trash.)

(12) All Government Motor Vehicle (GMV) or Government Vehicle Other (GVO) mishaps resulting in:
* * (a) $5000 or more government vehicle, government property damage, private vehicle, or private property damage.
(b) Injury/fatality of DoD-personnel, or non-DoD personnel.

(13) Any medically diagnosed work-related illness and injury, such as cumulative trauma disorder or musculoskeletal disease.

• *(14) Work-related Significant Threshold Shift (STS) in hearing.
  * *(a) Averaging 10 dB or more at 2000, 3000, and 4000 Hz in one or both ears
  (b) The person’s total hearing level is 25 decibels or more above audiometric zero in the same ears(averaged at 2000, 3000, 4000 Hz)
  (c) The shift is toward deteriorated hearing, is permanent, and is considered to be of occupational origin.

(15) Any work-related needle stick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material.
(16) Work-related tuberculosis infection, as evidenced by a positive skin test or diagnosis by a physician, after exposure to a known case of active tuberculosis.

Question 13

**Mishap Classifications

Answer 13

Class A, B, C, D

Question 14

** Class A mishap

Answer 14

**(a) The resulting total cost of damages to Government and other property is $2 million or more.

**(b) DoD aircraft is destroyed.

(c) An injury or occupational illness results in a fatality or permanent total disability.

Question 15

** Class B mishap

Answer 15

**(a) The resulting total cost of damages to Government and other property is $500,000 or more, but less than $2 million.

(b) An injury or occupational illness results in permanent partial disability.
(c) When three or more personnel are hospitalized for inpatient care as a result of a single mishap.

Question 16

** Class C mishap

Answer 16

**(a) The resulting total cost of property damages to Government and other property is $50,000 or more, but less than $500,000.

(b) Nonfatal injury or illness that results in 1 or more days away from work, not including the day of the injury.

Question 17

** Class D mishap

Answer 17

**(a) The resulting total cost of property damages is $20,000 or more, but less than $50,000.

(b) Recordable injury or illness not otherwise classified as a Class A, B, or C mishap.

Question 18

Mishap Report Types

Answer 18

1. Accident and Injury Report
2. Safety Investigation Report (SIREP)
3. Hazard Report (HAZREP)

Question 19

**Accident and Injury report

Answer 19

• Medical Department will submit*

* *a) Copy to the Safety Officer

Question 20

** Safety Investigation Report (SIREP)

Answer 20

(a) Submitted to Commander, Naval Safety Center (COMNAVSAFECEN).
(b) Using Web-Enabled Safety System (WESS).
(c) Using WESS-DS via e-mail (if internet connectivity is a problem).

Question 21

*Hazard Report (HAZREP)

Answer 21

Submitted for near-mishaps and situations where lessons learned should be shared.

Question 22

**The Safety Officer is responsible for

Answer 22

ensuring an investigation is conducted

Question 23

** The ISIC or higher authority appoints

Answer 23

mishap investigation board

Question 24

*Mishap investigation board

Answer 24

(1) Minimum of 3 Member Team
(2) If fatality was involved, a medical member may be appointed to the board.
(3) May be assisted by technical representatives or NAVSAFECEN personnel. They are not official members of the board.
(4) Encourage free and open disclosure during an investigation.
(5) Mishap Investigation Report (MIR) must be submitted within 30 days to the Naval Safety Center via chain the command.

Question 25

All occupational injuries and illnesses are recorded in the following forms

Answer 25

(a) SF 600 (Chronological Record of Medical Care)
(b) ETR SF 558 (Emergency Treatment Record)

**(c) SF 513 (Consultation)

(d) Accident Injury Report (SAMS Program or Local Form)