1. November 2011
Preventability
What’s the issue? hap rate was one-tenth of that, thanks to standard-
If you don’t think a particular kind of mishap is ized procedures (such as NATOPS and the NAMP),
preventable, you probably aren’t going to try to keep improved training and better equipment.
it from happening. But is there such a thing as an
unpreventable mishap? Today
OK, so there were a lot more preventable mis-
Background haps back then—both a greater number of potential
We’ve come a long way from the days when mil- mishaps that could have been avoided, and ones that
itary personnel accepted bloody, expensive mishaps were much easier to prevent. Where are we now?
as the cost of doing business. “Our job is inherently Let’s start with a definition: A preventable mis-
dangerous,” went the line of reasoning. “People are hap is one in which the risks were known in advance
going to get hurt and killed.” but weren’t controlled.
Given extremely high mishap rates more than 50 For example: If the victim in an auto crash had
years ago, you can’t blame people during that time been wearing his seatbelt, he wouldn’t have got-
for feeling that way. In the early 1950s, more than ten ejected through the windshield. It may still
700 Navy aircraft per year were ending up in smok- have been a mishap because of an injury, but the
ing holes, killing more than 300 pilots and aircrew driver would have almost certainly survived. Or,
members. There were so many mishaps in the if the victim hadn’t been going 60 miles per hour
training command that there was a standing memo- into a 35-mile-per-hour curve on his motorcycle, he
rial service every Friday at the base chapel, because wouldn’t have lost control and crashed into the guard
there was always one or more fatal wrecks that rail.
week. In FY11, there were nine Navy aviation Class In the five years from FY06 through FY10, there
A mishaps and two fatalities. were 429 Navy mishap fatalities overall. PMV account-
It is ironic to look back at the 1956 rate of 33.3 ed for 266 of these. How many of these were prevent-
accidents per 100,000 flight hours and to read of- able? Anyone who has read a substantial number of
ficial descriptions of that rate as “outstanding” and a mishap reports would agree that, theoretically, most of
“gratifying achievement.” Thirty years later, the mis- them were. The mishaps weren’t brand-new, unheard-

2. of or totally unexpected (not that anyone “expects” to able,” one report said. About another mishap, in
get in a mishap, but that is a whole other problem). which a civilian mariner who was moving a ton of
Furthermore, you could make the case that most palletized cargo with a piece of equipment ran over a
of the preventable mishaps seem easily preventable, at co-worker’s foot, the report said, “This was a pre-
least in terms of the difficulty of the action that would ventable mishap.” The same comment appeared in
have been necessary. It isn’t hard to call a cab when a report about a Sailor who was driving after drink-
you’ve been out drinking and have to get back home ing. He crossed a median and two lanes of opposing
or to the ship. It isn’t hard to stop for a cup of coffee or traffic, then went up and down an embankment. The
a soda and a chance to stretch your legs when you get vehicle flipped. The Sailor, who wasn’t buckled up,
drowsy. It isn’t hard to ease off the accelerator. The was pronounced dead on the scene.
problem is a host of familiar (and potent) human fac- However, sometimes the people who report a mis-
tors, including deeply ingrained bad habits, misplaced hap feel that it was inevitable. For example, one mishap
optimism, complacency, and artificial, self-imposed involved a Sailor who was changing a starter (that had a
deadlines when we need to get somewhere. short) on a light. She “took all proper precautions,” the
Maybe part of the process is changing our mind- report said, but still got a 5-second shock. “This shock
set about a new plateau or threshold. What does it was not preventable.” Really? What exactly do they
take to ratchet it down a level? In FY11, there were mean by “all” precautions? Was a qualified electrician
only nine Navy 4-wheel PMV fatalities, half that of involved? Was the circuit tagged out?
the previous year. In the words of one of our statisti- Another service member was break dancing on a
cians, that is “an amazingly low record.” basketball court. He stepped in a pothole and twisted
A search of the Naval Safety Center mishap his ankle. “This sort of incident is not completely
report database for the word “preventable” turned preventable,” the report said, but “the likelihood of
up some pertinent examples. “This injury was from such an injury can be reduced with some common
being complacent and therefore completely prevent- sense.” Common sense—there’s another topic.
DISCUSSION ITEMS AND OPEN QUESTIONS
1. What was the last mishap you witnessed?
2. Could it have been prevented? How?
3. Why didn’t someone prevent it?
4. Can you think of an activity you engage where you take the expected precautions, but
have a gut feeling you’re still taking too much risk? You can be “right” and still end up
with some awfully negative results. Based on conditions, minimum precautions might
not be enough—you can still choose to modify your original plan.
BY DEREK NELSON, HEAD MEDIA DIVISION
Supervisors: Use this page to guide safety discussions with your personnel
Send your feedback to: safe-mediafdbk@navy.mil
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