R 171825Z SEP 20
MSGID/GENADMIN/CMC WASHINGTON DC DMCS/
SUBJ/PRELIMINARY SAFETY REPORTING GUIDANCE USING THE RISK MANAGEMENT INFORMATION (RMI), STREAMLINED INCIDENT REPORTING (SIR) SYSTEM OF RECORD FOR MISHAP INVESTIGATION, REPORTING AND RECORD KEEPING//
NARR/REF A IS OPNAVINST 3750.6S, NAVAL AVIATION SAFETY MANAGEMENT SYSTEM. REF B IS MCO 5102.1B, NAVY AND MARINE CORPS MISHAP AND SAFETY INVESTIGATION REPORTING AND RECORDKEEPING MANUAL//
POC/A. LEWIS/GS15/OPS OFFICER, NAVAL SAFETY CENTER/TEL: 757-444-3520/ALAN.R.LEWIS@NAVY.MIL//
POC/RMI HELP DESK/TEL:866-210-7474/EMAIL: RMITESTTEAM@CHENEGA.ONMICROSOFT.COM//
POC/T. BEDELL/COL/DIRECTOR, CMC SAFETY DIVISION/TEL:703-604-4365/THOMAS.BEDELL@USMC.MIL//
POC/A. WARTHEN/LTCOL/GROUND BRANCH HEAD, CMC SAFETY DIVISION/TEL:703-604-4172/ALTON.WARTHEN@USMC.MIL//
Gentext/Remarks/1. This MARADMIN is a coordinated COMNAVSAFECEN and CMC SD serves to explain the processes, roles, responsibilities, and timelines to review, endorse, finalize, and close out safety investigation reports (SIREPS/SIRS) and Hazard Reports (HAZREPS) using the Risk Management Information (RMI) program of record. This process begins when the investigation is complete and the SIREP/SIR/HAZREP is released by the Safety Investigation Board (SIB) or single investigating officer and continues until the release of the final endorsement to the SIREP/SIR/HAZREP. Additionally, this MARADMIN defines some new terms used in safety reporting in RMI and provides customers with points of contact should they have policy questions about safety reporting using RMI. The endorsement process described in this chapter must be used for all SIREPS/SIRS and HAZREPS that require endorsement whether the investigation was conducted by a SIB or by a single investigating officer. The terms and definitions provided in the MARADMIN apply to all RMI users.
2. Applicability. This MARADMIN is applicable to all Marine Corps commands and activities. Effective 29 Aug 20, the Risk Management Information Streamlined Incident Reporting (RMI SIR) will replace the Web-Enabled Safety System (WESS) as the program of record for all safety reporting.
3. General information
3.a. The endorsement process described in this MARADMIN represents a major break from past methods. The previous endorsement process relied on a specifically defined endorsing chain that typically mirrored the operational chain of command, to conduct a formal and sequential review and endorsement of the SIREP/SIR, particularly when the investigation was conducted by an SIB. Each command in the endorsing chain reviewed both the SIREP/SIR, as written by the SIB or single investigating officer, and the previous endorser(s) comments and recommendations, then added their own endorsement. This previous process was extremely lengthy, often requiring more than a year from mishap occurrence to final endorsement and closeout.
3.b. The new methodology described in this chapter adopts most of the U.S. Air Force’s memorandum of final evaluation (MOFE) process when SIREPs/SIRs and HAZREPs require endorsement. The MOFE process relies on a concurrent 45 calendar day review and endorsement period (concurrent comment period) for all endorsers and interested parties, except for the final endorser. While there remains a requirement for those identified as required endorsers to critically review the SIREP/SIR or HAZREP during the concurrent comment period, there is no requirement for endorsers to add comments if they concur with the SIREP/SIR or HAZREP as written by the SIB or single investigating officer. The absence of a comment is considered tacit approval of the SIREP/SIR or HAZREP.
3.c. Once the concurrent comment period ends, a second 45 calendar day review and endorsement period (deliberation and adjudication period) begins for the final endorser. During this period, the final endorser will review and adjudicate all comments and recommendations that have been made by the endorsers, then complete and release the final endorsement. With the release of the final endorsement, the investigation is officially considered closed. The new endorsement process will dramatically shorten the timeline from the release of SIREP/SIR/HAZREP to the final endorsement and closeout.
3.d. The endorsement process does not minimize the importance of endorsers and is a critical final step to finalize the SIREP/SIR/HAZREP. For mishap investigations, endorsers must still carefully review and evaluate the SIREP/SIR and ensure that the SIB or single investigating officer completed a sufficiently rigorous investigation that uncovered all of the root causes of the mishap. The same applies for hazard investigations requiring endorsement, except the endorsers focus on the sufficiency of the investigation to describe the characteristics of the hazard and its underlying causes. Endorsers must also verify that the controls recommended by the SIB or single investigating officer are sufficiently strong enough to mitigate the identified risks, and are sufficiently practical and feasible to implement. Note: the terms review and endorsement process, endorsement process, and MOFE process may be used interchangeably to describe the process explained in this chapter. The acronym MOFE and the term final endorsement may also be used interchangeably to describe the product released by the final endorser that finalizes the SIREP/HAZREP and officially closes the investigation.
4. Determination of the requirement for endorsement. All SIREPs/SIRs and HAZREPs that contain recommendations/corrective actions must be endorsed.
5. SIREP endorsement process steps and timeline. This section describes each step in the endorsement (MOFE) process.
5.a. Step one. Report submission. The SIB or single investigating officer completes the investigation and submits the SIREP/SIR or HAZREP into the RMI SIR program of record.
5.b. Step two. Convening authority review. The convening authority safety officer/safety staff conducts an administrative review of the entire SIREP/SIR/HAZREP submitted by the SIB/single investigative officer. This review must be completed within 10 business days. This review will:
5.b.1. Ensure the investigative guidance and documentation standards established in this instruction have been met.
5.b.2. Ensure adequate evidence and analysis is presented and sufficient to support the investigation’s findings, conclusions, and accepted causal factors.
5.b.3. Ensure Department of Defense (DOD) human factors analysis and classification system (HFACS) codes are assigned and sufficient.
5.b.4. Ensure recommendations and action agents are assigned for each accepted causal factor.
5.b.5. Determine if the SIREP/SIR/HAZREP requires endorsement (requires entry into the MOFE process).
5.b.6. When endorsement is required, identify the specific commands/activities that are required endorsers and enter the endorser information in RMI.
Note: During step two, the convening authority identifies the specific commands/activities that are required endorsers and informally lists the commands/activities in the RMI “comments box.” Once the Naval Safety Center quality control review (step three) has been completed, the convening authority must formally enter endorser information at the beginning of the MOFE process (step four).
5.c. Step three. Naval Safety Center quality control review. Naval Safety Center conducts a quality control review of the SIREP/SIR/HAZREP. Omissions or deficiencies identified during this review are addressed with the SIB/single investigating officer through the convening authority safety officer/safety staff. This review must be completed within 14 business days. Once this review is complete, the SIREP/SIR/HAZREP enters the concurrent comment period. The unendorsed SIREP/SIR/HAZREP is also available for viewing in the RMI database.
5.d. Step four. Concurrent comment period. The 45 calendar day concurrent comment period begins when the Naval Safety Center quality controls checks are completed. During this period, all required endorsers must, and other authorized individuals may, review the SIREP/SIR/HAZREP in concurrent order. Endorsers must assess the overall rigor and thoroughness of the safety investigation, evaluating the findings, causal factors, recommendations, and DOD HFACS codes that were assigned by the SIB or single investigating officer. Endorsers who have substantive comments must enter those comments into the RMI program of record database within 45 calendar days. Comments should follow the template provided in “Pubs & Refs” section of the RMI program of record database. Required endorsers who concur with the findings, causal factors, recommendations, and DOD HFACS codes in the SIREP/SIR/HAZREP, and have no comments after completing their review, have no further required actions, except for the convening authority. The convening authority must provide comments even if "concur as written" is the only applicable comment made.
5.d.1. There is no RMI digital protection to ensure convening authorities have endorsed the report prior to closing the comment period after 45 days.
5.d.2. The RMI program of record offers a free text box to enter comments during the concurrent comment period. Endorsers must first identify a reference point from the SIREP/SIR before entering comments. Typically, the reference point will be a finding, causal factor, DOD HFACS code, or recommendation.
5.e. Step five. Deliberation and adjudication period. Once the 45 calendar day concurrent comment period ends, the final endorser will review and adjudicate all comments and complete the final endorsement during a 45 calendar day deliberation and adjudication period. When complete, the final endorsement (MOFE) is released by entering it into the RMI database. The final endorsement (MOFE) represents the independent final evaluation and position on the causes, findings, recommendations, and DOD human factors analysis and classification system codes of a mishap or hazard investigation. Release of the final endorsement (MOFE) officially closes the investigation.
6. Determining SIREP/SIR/HAZREP endorsers. The commands, activities, and individuals listed here are either required or optional reviewers, as indicated, during the concurrent comment period for all SIREPs/SIRs and HAZREPs that require endorsement.
6.a. Required endorsers:
6.a.1. Convening authority.
6.a.2. Designated action command(s) or agency(ies) assigned one or more corrective actions in the SIREP/SIR or HAZREP.
6.a.3. Type commander, for Class A and B mishaps that involved one of their assets or personnel.
6.a.4. Commanding Officer(s) of the unit(s) involved in the mishap.
6.a.5. Masters for military sealift command vessels involved in the mishap.
6.a.6. Commanding Officer(s) and Commander(s) in the operational chain of command of the unit(s) involved in the mishap for Class A and B mishaps.
6.a.7. Systems Commanders, for Class A and B mishaps that required their expertise during the investigation (e.g., engineering investigation).
6.a.8. Lead research and development agency for a weapons system (e.g., a naval surface warfare center), when that weapons system was involved in a mishap for Class A and B mishaps
6.a.9. Commanders of combatant commands for Class A and Class B mishaps occurring in their commands.
6.a.10. A vessel’s Commanding Officer or Master for military sealift command vessels, and superiors in the chain of command, if a mishap involved a fatality, injury, or property damage to embarked Marine units.
6.a.11. Naval Ordnance Safety and Security Activity or Marine Corps Systems Command if involving a Marine Corps unit or activity.
6.b. Optional endorsers:
6.b.1. Fleet and Marine Force Commanders, for a mishap occurring in their respective area of responsibility.
6.b.2. Component Commanders of unified commands when the mishap occurred during contingency operations.
6.b.3. Individual(s) found causal in the formal SIREP/SIR.
6.b.4. Department of the Navy agencies outside the investigating command, if their functions were involved in the mishap or hazard (optional). Note: Unsolicited comments by other agencies and organizations reviewing the formal SIREP/SIR may comment on the findings, human factors, and recommendations even though they are neither in the chain of command, nor a designated action command or agency.
7. Endorsement prohibitions
7.b. Endorsements or extracts from endorsements must not be appended to, or included in, JAGMAN investigation reports, nor any other reports.
7.b. Endorsements must not include any reference to disciplinary action or any other administrative action in connection with the mishap being endorsed.
8. Extension of the concurrent comment period
8.a. Required endorsers may request an extension of the concurrent comment period. Requests must provide sufficient justification.
8.b. Only CNO N09F (Navy Investigations) and CMC SD (Marine Corps investigations) are authorized to grant extensions.
9. Reopening an investigation
9.a. The authority to reopen an investigation rests only with the convening authority and CNO N09F (Navy investigations) or CMC SD (Marine Corps investigations).
9.b. If any endorser concludes that an investigation is incomplete, or a SIREP/SIR or HAZREP is inadequate, they must recommend the reopening of the investigation by plainly stating this recommendation with specific justification when providing comments during the concurrent comment period.
9.c. When an investigation is reopened, the convening authority or higher authority who has directed the reopening, must clearly specify the areas of concern/deficiencies to the SIB or single investigating officer.
10. Introduction of new information. If, during the deliberation and adjudication period, the convening authority, or CNO N09F (Navy investigations) or CMC SD (Marine Corps investigations), learns facts that were not available to safety investigators, or that shed new light on the published findings, causes, and recommendations, they must take one of the following actions:
10.a. Reopen the investigation.
10.b. Include the new facts as a “comments for MOFE” by selecting the "provide comments for MOFE" link.
11. Submission of comments after the concurrent comment period. Once the stated concurrent comment period has closed, late entries or new information cannot be entered into RMI. Commands desiring to provide other information must do so through official correspondence, i.e., naval message or naval letter. While additional comments may be transmitted to the Naval Safety Center and Safety Division via organizational email, emailed comments are unofficial and are not guaranteed to be considered during MOFE deliberations.
12. Final endorsement. The final endorsement (MOFE) will address findings, recommendations, other findings of significance, other recommendations of significance, designated action command or agency responsibilities, and DOD HFACS coding. The final endorsement is used to:
12.a. Provide comments about findings to address procedural errors, changes to causal or not causal, additions or deletions, or to add information not available to the SIB. Provide specific information to support the requested changes.
12.b. Provide comments about recommendations to address procedural errors, changes to designated action agencies, or to make additions and or deletions.
12.b.1. If changes to designated action commands or agencies are required, provide contact information for the newly designated action command or agency, to include the name, rank or civilian grade, office symbol, DSN or commercial phone number, and government e-mail address. Additionally, comments may address the recommendation narrative to clarify intent or correct errors.
12.b.2. If a recommendation has already been completed and the action agency has provided sufficient documentation of actions taken, the final endorser may close the recommendation in the final endorsement (MOFE).
12.c. CNO N09F (Navy investigations) or CMC SD (Marine Corps investigations) are the final endorsers for all SIREPs/SIRs and HAZREPs that require endorsement. Note: this is a procedural change from previous practice as described in reference (b) . Previously, MARFOR, Fleet and other higher-level commands were able to provide close-out endorsement of Class C mishaps and less significant HAZREPSs via the Web Enabled Safety System. RMI does not provide this functionality.
13. Significant changes to findings. If the final endorser adds a person to a causal finding, or significantly changes an individual's role in the findings, the final endorser will notify the individual through his/her command safety representative and afford the individual an opportunity to submit comments. Comments are not required.
13.a. The individual will be provided with pertinent sections of the draft final endorsement to review.
13.b. No others may provide further comment (i.e., the individual’s command).
13.c. The individual has 15 calendar days to provide comments.
13.d. The individual may request an extension with justification to the final endorser who may grant an extension.
13.e. The final endorsement (MOFE) must not be released until after the individual has had an opportunity to respond.
14. Definitions. There are new or modified definitions used in RMI as follows.
14.a. Mishap. A mishap is any unplanned or unexpected event or seriesof events that results in damage to DOD property; occupational illness to DOD personnel; injury to on- or off-duty DOD military personnel; injury to on-duty DOD civilian personnel; or damage to public or private property, or injury or illness to non-DOD personnel, caused by DOD activities.
14.a.1. Class A mishap. The resulting total cost of damages to government and other property is $2.5 million or more, a DOD aircraft is destroyed (excluding UAS groups 1, 2, or 3), or an injury or occupational illness results in a fatality or permanent total disability.
14.a.2. Class B mishap. The resulting total cost of damages to government and other property is $600,000 or more, but less than $2.5 million. An injury or occupational illness results in permanent partial disability, or when three or more personnel are hospitalized for inpatient care (which, for mishap reporting purposes only, does not include just observation or diagnostic care) as a result of a single mishap.
14.a.3. Class C mishap. The resulting total cost of property damages to government and other property is $60,000 or more, but less than $600,000; or a nonfatal injury or illness that results in 1 or more days away from work, not including the day of the injury.
14.a.4. Class D mishap. Recordable injury or illness not otherwise classified as a Class A, B, or C mishap (e.g., work-related illness or injury that involves medical treatment beyond first aid, loss of consciousness, light or limited duty for military personnel, or restricted work or job transfer for on-duty Navy and Marine Corps civilian employees); or, a total cost of damages for public or private property of $25,000 or more, but less than $60,000.
14.a.5. Class E mishap. An injury or damage not otherwise classified as a class A, B, C, or D mishaps. Use of the class E mishap category will differ by community. For aviation, if there is cost ($1 to $24,999) or any injury (including first aid), it is a Class E. Class E’s will not be privileged, so essentially class E’s are HAZREPs with cost/first aid injury.
14.b. Incident. A planned or unplanned occurrence or series of occurrences resulting in injury or damage that does not meet mishap reporting criteria. Used to capture events that are exempt from the provisions of the DODI 6055.07 (table 8) or 5102.1d/3750.6s. These may be rare, but some are still mandatory reports (e.g., intentional acts, workplace violence, direct enemy action). These will not require a safety investigation and other than the basic information and a narrative, they do not require factors, recommendations, or endorsement. Note: component wear and tear exceptions or any other incident which poses a hazard to naval operations will be reported under hazards for tracking and mitigation. In doing so, units can align recommendations in order to better mitigate these hazards.
14.c. Hazard. Any real or potential condition that can cause injury, illness, or death to personnel or damage to or loss of equipment or property, mission degradation. These are broken into two areas:
14.c.1. An act or event (i.e., near miss) that may have resulted in a mishap where the fatality, injury, illness, property damage, or loss of asset was avoided merely by chance, the actions of a single person, a small measure of distance, or a few moments in time.
14.c.2. A work place condition that might result in injury, health impairment, illness, disease, or fatality to any worker who is exposed to the condition, or which might result in damage to or loss of property or equipment.
14.d. Convening authority (CA). RMI merges the authorities and responsibilities of the appointing authority, the CA, the controlling custodian (non-aviation communities), and some of the authority of the aircraft controlling custodian (ACC) into the RMI CA role. In RMI, the CA approves the release of the preliminary message (comparable to the current initial notification) and the SIREP/SIR, sets the endorsing chain, and is a mandatory endorser in the first 45 day concurrent comment period. Of note, the second 45 day window is for the final endorser only (CNO N09F (Navy)/CMC SD (Marine Corps). The CA also has responsibility for mishap report recommendation management. When CA responsibilities are delegated to a lower level, these authorities are delegated as well. The CA role will take significant bandwidth. CMC SD recommends each CA establish a standardized “delegation” matrix to better manage recommendations. Commands establishing a standardized delegation memo / matrix for subordinate units will inform Naval Safety Center, Mishap Investigations Directorate (Code 90). Example: Class A, B, C mishaps: CA: Echelon II command, MARFOR level command, TYCOM or ACC (aviation), TYCOM (surface/submarine), MARFOR (USMC) Class D: O-6 level command, Hazards: O-5 level command. Note: If the Class D mishap/HAZREP recommendations are external to the unit, the CA must be equal to or a greater echelon level than any action agency assigned. If the recommendations are for a SYSCOM or external to the unit’s chain of command, then Echelon II, MARFOR level command or TYCOM must be the CA.
14.e. Accounting organization. Also known as a reporting custodian: reporting custodians are Commanding Officers and, in some cases, Officers-in-Charge (OICs) of detachment operations of Navy and Marine Corps organizations who are responsible to account for, or otherwise provide information about, assigned assets. It is the organization that experienced the loss of an owned asset, regardless of any determination as to the responsibility for the event. If more than one reporting custodian is involved in a mishap, the senior command (senior commander) does the reporting unless relieved by higher authority.
14.f. Factors. A factor is any deviation, out-of-the-ordinary, or deficient action or condition discovered in the course of a mishap investigation that in opinion of the SIB (or single investigating officer) contributed to the eventual outcome. Determining mishap factors (and eliminating non-factors) enables the investigators to focus the investigation to those specific areas that are significant in the mishap. RMI has three options in the drop down menus; causal factors, factors (non-causal but contributing), and non-factors worthy of discussion. There is a fourth type of factor, the non-factor, but the non-factor is not available in the drop down and instead would be listed in the narrative.
14.f.1. Causal factors. Factors which caused the mishap. If the factor was corrected, eliminated, or avoided, the mishap/hazard/or incident would not have happened.
14.f.2. Factors (non-causal but contributing). Factors which were present but not necessarily causal. Factors formerly termed as “other damage or injury” would now be a factor.
14.f.3. Non-factors worthy of discussion (NFWOD). NFWODs typically fall into one of three categories; areas uncovered during the investigation that did not cause the mishap or influence the outcome but should be fixed due to the potential to be a factor in a future mishap (e.g., incorrect information in a maintenance publication), areas that were thoroughly investigated and subsequently ruled out as factors (in order to provide context to the audience on why these areas are not factors), and areas that may be considered an interest item to the ca (e.g., risk management, crew resource management, etc.). NFWODs are the source for other findings and recommendations of significance. Examples: implementation of flight data recorders, not causal or contributory, but important for the organization’s safety posture.
14.f.4. Non-factors. Non-factors are a list of those areas/items the SIB (or single investigating officer) considered, but determined not to be a factor in the mishap and not worthy of additional discussion. The non-factors will be listed at the bottom of the narrative. It is not an all-encompassing list, but rather a list of areas/items the SIB (or single investigating officer) investigated and ruled out, similar to rejected causal factors in WESS but without justification needed.
14.g. Findings. The term, “finding” is new and establishes lines of evidence. Each finding is a single event, condition, or data point which is important in the mishap / hazard, but not necessarily causal. Findings are used to establish factors. Each factor must be associated with at least one finding. There are three types of findings: causal primary finding, non-causal finding, and other finding of significance. These are important because they link to the types of recommendations.
14.g.1. Causal primary finding: associated with a causal factor.
14.g.2. Non-causal primary finding: associated with a non-causal but contributory factor.
14.g.3. Other finding of significance: associated with NFWOD.
14.h. Recommendations. Recommendations fulfill the same purpose as with WESS. Recommendations are used to address hazards identified during the investigation and describe the risk controls necessary to mitigate the risks associated with the hazard. In RMI, there are two types of recommendations, primary recommendations and other recommendations of significance.
14.h.1. Primary recommendation. This is a recommendation which fixes causal and non-causal factors.
14.h.2. Other recommendations of significance (ORS). ORS are recommendations which fixes factors / findings that the safety investigators believe could contribute to future mishaps and/or warrant command attention, but were not part of the mishap. These are generated NFWODs. Since the concept of ORS were expressly forbidden in WESS/previous safety reporting policy, this concept of applying recommendations to something that was not “causal” or “other damage or injury” is new. CAs must carefully scrutinize NFWODs and ORS to ensure they are aimed to address the risks associated with a specific hazard and that they don’t just become a laundry list of things the fleet wants.
14.i. Assigning recommendations. RMI has two options to assign recommendations. An OPR (office of primary responsibility) and an OCR (office of collateral responsibility).
14.i.1. Assignment of and OPR is required for every recommendation. The OPR is a specific action agency point of contact, by name, assigned to the recommendation. The OPR is used as the primary contact for recommendations. In some instances commands may determine their specific OPR action agency point of contact is better paired to a specific command job billet to ensure continuity of effort for SIB recommendations. These individuals have the authority to update the recommendation and recommend closure. OPRs will provide assigned individual’s contact information and the command’s organizational email for correspondence.
14.i.2. An OCR is not required for every recommendation. OCRs assist the OPR in completing the recommendations and multiple OCRs may be assigned to each recommendation.
15. RMI user guide/RMI special edition magazine. The Naval Safety Center has published two documents to assist command and unit safety personnel to better understand RMI’s use and functionality. The RMI user guide details the technical aspects of the electronic web-based application and provides a how-to manual for the unit level user. Additionally, the RMI special edition magazine provides a broader description of the RMI application and targets leaders and staff. Both documents can be downloaded at: https:(slash)(slash)safety. Navylive.DODlive.mil/files/2020/07/RMI-special-edition.pdf.
16. Released authorized by Major General Gregg P. Olson, Staff Director of the Marine Corps.//