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

A2.B.12. THE MISHAP/INCIDENT INVESTIGATION
A2.B.12.1. FORMAL NAME. The mishap/incident investigation
A2.B.12.2. ALTERNATIVE NAMES. The incident tool
A2.B.12.3. PURPOSE. The traditional mishap investigation has the objective of determining the causes of
a mishap so that these causes can be eliminated or mitigated. The ORM approach adds a new dimension to
the traditional concept. ORM stresses the determination of the inadequacies in the risk management
process that allowed the mishap cause factors to impact the organization. A mishap investigation therefore
becomes primarily an investigation of the risk management process itself to determine if it can be
strengthened to control the risk factors that led to the mishap. The question now is not only what is the
cause, but also how could the cause exist in the context of the risk management process.
A2.B.12.4. APPLICATION. Ideally all mishaps and incidents should be thoroughly investigated.
Unfortunately, mishap investigations are expensive. Ideally the organization should have a process to
select mishaps and incidents against which to allocate limited investigative resources. Severity is a relevant
factor in this decision, but it should not be the dominate factor that it is in most investigation systems
today. Simply because a mishap was serious does not mean that it is worth in-depth investigation. On the
other hand, what appears on the surface to be a minor incident may be a gold mine of data regarding the
risk management process. An effective risk manager will be able to sort out the opportunities and direct
the investigative effort where it will produce the best return on investment.
A2.B.12.5. METHOD. Both the technical and management processes involved in a mishap/incident
investigation are complex beyond the scope of this publication. Detailed guidance is provided in Air Force
publications. From a risk management perspective the key is to investigate the risk management issues that
are the cause of the direct mishap causes. Only by correcting these root risk management cause factors
will the mishap investigation process be fully effective.
A2.B.12.6. RESOURCES. Most safety offices have personnel trained in detail in mishap investigation
processes. They can serve as consultants in this critical process. Policy and procedures to follow in the
process of investigating and reporting mishaps is contained in AFI 91-204, Safety Investigations and
Reports, and applicable supplements.
A2.B.12.7. COMMENTS. Mishap and incident investigations have a long track record of success in
preventing future mishaps.
A2.B.12.8. EXAMPLES. Base safety offices can provide guidance on the investigation and reporting
process and on the use of the data for hazard identification.
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