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ALMAR 037/04
 | | | |
| Date signed: | 07/14/2004 | MARADMIN Number: | 037/04 |
| Subject: | JUNE 2004 SAFETY SUMMARY | ||
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R 142008Z JUL 04 FM CMC WASHINGTON DC(uc) TO AL ALMAR(uc) ALMAR BT UNCLASSIFIED ALMAR 037/04 MSGID/GENADMIN/CMC WASHINGTON DC SD// SUBJ/JUNE 2004 SAFETY SUMMARY// GENTEXT/REMARKS/1. DURING JUNE, ONE MARINE DIED IN AN OPERATIONAL GROUND MISHAP, ONE MARINE AND ONE CANADIAN EXCHANGE PILOT DIED IN AVIATION MISHAPS, AND TWO MARINES DIED IN NON-OPERATIONAL MISHAPS. A. OPERATIONAL GROUND (1) A MARINE WAS FATALLY WOUNDED WHEN A FELLOW MARINE'S WEAPON DISCHARGED WHILE HE WAS CLEANING THE WEAPON. B. AVIATION (1) AIRCRAFT LOST AT SEA DURING NIGHT CV OPS. ONE FATALITY. (2) AIRCRAFT DEPARTED RUNWAY DURING LANDING ROLL OUT. ONE FATALITY (CANADIAN EXCHANGE PILOT). C. NON-OPERATIONAL (1) A CPL DROWNED IN A RECREATIONAL SCUBA DIVING CLASS WHILE ON ANNUAL LEAVE. (2) WHILE TRYING TO GIVE AID TO OTHERS INVOLVED IN AN ACCIDENT, A MARINE WARRANT OFFICER WAS KILLED WHEN ANOTHER VEHICLE HIT THE FIRST VEHICLE. 2. OBSERVATIONS/TRENDS A. OPERATIONAL RISK MANAGEMENT (ORM) DEFINES RISK ASSESSMENT CODES BASED ON FREQUENCY AND SEVERITY OF A HAZARD. HOWEVER, MOST CLASS A MISHAPS AND FATALITIES RARELY INVOLVE ONLY ONE CAUSAL FACTOR - ESPECIALLY THE MOST PREVENTABLE ONES. THERE IS TYPICALLY A CHAIN OF EVENTS THAT INVOLVES NUMEROUS HAZARDS THAT WERE OVERLOOKED OR IGNORED. (1) MAKING GOOD RISK DECISIONS IS A PART OF MATURITY. EXPERIENCE AND TRAINING CONTRIBUTE TO THIS LEARNING PROCESS AND SOME INDIVIDUALS ACHIEVE A HIGHER LEVEL OF COMPETENCE AT MAKING RISK DECISIONS THAN OTHERS. (2) WITHIN MOST PEOPLE IS A BASIC INSTINCT THAT DETECTS DANGER; HOWEVER, THERE ARE TIMES WHEN PEER PRESSURE, INCONVENIENCE, OR THE NEED TO ACCOMPLISH A MISSION TELL US TO IGNORE THAT INSTINCT. (3) WE NEED TO DEVELOP OUR CAPABILITY TO RECOGNIZE RISK, AND LEARN TO TRUST OUR INSTINCTS WHEN SOMETHING TELLS US THAT WHAT WE ARE ABOUT TO DO IS UNSAFE. SERIOUS HAZARDS CAN BE THOUGHT OF AS FLASHING RED LIGHTS. IF THERE ARE MULTIPLE FLASHING RED LIGHTS, THE OVERALL RISK IS INCREASED DRAMATICALLY. WHEN DEALING WITH MULTIPLE HAZARDS, BREAK THE CHAIN OF EVENTS BEFORE THEY MULTIPLY. B. THE PURPOSE OF ORM IS NOT TO TELL US WE CAN'T DO SOMETHING. IN CONTRAST, ORM ALLOWS US TO COMPLETE OUR TASK WITH THE LOWEST POSSIBILITY OF MISHAPS. THIS IS EQUALLY CRITICAL ON DUTY AND AFTER HOURS. 3. SEMPER FIDELIS, M. W. HAGEE, GENERAL, U.S. MARINE CORPS, COMMANDANT OF THE MARINE CORPS.// | |||
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