BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

A2.B.9. THE MISSION MISHAP ANALYSIS
A2.B.9.1. FORMAL NAME. The mission mishap analysis
A2.B.9.2. ALTERNATIVE NAMES. The mission accident analysis
A2.B.9.3. PURPOSE. Most organizations have accumulated extensive, detailed mishap databases that are
gold mines of risk data. The purpose of the mission mishap analysis is to assure that this data is being
effectively applied to the prevention of future mishaps.
A2.B.9.4. APPLICATION. Every organization should complete a mission mishap analysis annually. The
objective is to update the understanding of current mishap trends and causal factors. Changes that occur in
less than a year are not likely to be statistically significant. Waiting more than a year may miss important
changes in trends. The analysis should be completed for each organizational component that is likely to
have unique mishap factors.
A2.B.9.5. METHOD. The art and science of mishap analysis can be approached in many ways.
Essentially it relies on Pareto’s law (the fact that in a wide variety of activities, 80% of the problems are
found in 20% of the exposure). For example, 80% of the unsafe acts in a group of employees may be
committed by only 20% of the employees. The process of mission mishap analysis is finding the 20% of
personnel, facilities, activities, etc. that are causing the bulk of the risk in the organization. If the mishap
database is computerized, the computer can do much of the initial sorting of the data. A human analyst
will have to do the final interpretation of the data. If the work must be done manually, the process involves
the determination of likely risk factors and then the examination of the data to determine if the factors in
fact exist. Typical factors to examine include the following:
A2.B.9.5.1. Activity at the time of the mishap.
A2.B.9.5.2. Distribution of mishaps among personnel.
A2.B.9.5.3. Mishap locations.
A2.B.9.5.4. Distribution of mishaps by sub-unit.
A2.B.9.5.5. Patterns of unsafe acts or conditions.
A2.B.9.6. RESOURCES. The mission mishap analysis relies on a relatively complete and accurate mishap
database. The base safety office will normally have the needed data. That office can also provide
assistance in the analysis process. Safety personnel may have already completed analyses of similar
activities or they may be able to suggest the most productive areas for initial analysis.
A2.B.9.7. COMMENTS. The data in mishap databases has been acquired the hard way - through the
painful and costly mistakes of hundreds of individuals. It is tragic when organizations fail to take full
advantage of this information and therefore doom themselves to experience the same failures over and over
again.
A2.B.9.8. EXAMPLES. Examples of mishap analyses and mishap data available can be obtained from
servicing safety offices.
70