Risk Management Information system to 

seamlessly link multiple sources of data

PAGE 6

Motorcycle Training Update I HFACS and Data Analysis I AED in the Workplace I Top 5 Explosives Concerns

THE POWER OF ONE
DECISIONS

Commander, Naval Safety Center RDML Christopher J. Murray

Deputy Commander Col. Glen Butler, USMC

Command Master Chief CMDCM(AW/SW) Paul Kingsbury

Department Head, Media and Public Affairs Margret Menzies

EDITORIAL STAFF

Head, Media Division Derek Nelson

Editor Evelyn Odango 

Art Director Allan Amen 

Graphics and Design John W. Williams

WEB CONTENT

Webmaster Darlene Savage 

Social Media Manager Christopher Jones

EDITORIAL OFFICE

Commander, Naval Safety Center 

Attn: Decisions

375 A Street 

Norfolk, VA 23511-4399

Telephone: 757-444-3520, ext. 7220 (DSN 564-3520) / Fax: 757-444-6791

General e-mail: safe-decisions@navy.mil

Editor’s e-mail: evelyn.odango@navy.mil 

Shore Mishap Line: 444-3520, ext. 7840/7145

Shore safety e-mail (USN): safe-code40@navy.mil 

Shore safety e-mail (USMC): safe-ground@navy.mil 

OSH safety e-mail: safe-oshfdbk@navy.mil

SUBMISSIONS 

Submit your stories or news items to: safe-decisions@navy.mil. E-mail letters 

to: evelyn.odango@navy.mil or write to: Commander, Naval Safety Center, 

Attn: Decisions, 375 A Street, Norfolk, VA 23511-4399. Contents and opinions 

expressed are not necessarily the official views of, or endorsed by, the U.S. Navy, 

the Department of Defense, or the U.S. Government. Photos and artwork are 

for illustrative purposes only, unless otherwise noted. Reference to commercial 

products or links to non-DoD resources do not imply Department of the Navy 

endorsement. Unless otherwise stated, material in this publication may be 

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the right to edit all submissions for clarity and applicability.

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fill out a form at http://www.public.navy.mil/comnavsafecen/pages/media/

subscription.aspx. Decisions magazine (ISSN: 2167-2431 / ISSN: 2167-244X) is 

published twice a year: Spring/Summer and Fall/Winter, and distributed to safety 

managers located at shore-based commands, deployed with aircraft squadrons and 

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Norfolk, Va. Postmaster: Send address changes to Commander, Naval Safety 

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DECISIONS MAGAZINE ON THE WEB

Keep up with every issue of Decisions magazine online. Read 

the current issue or browse archived articles at http://www.

public.navy.mil/comnavsafecen/pages/media/decisions/

index.aspx. You can also visit the Decisions home page by 

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rates may apply). You must have the PDF reader app (go to 

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MAGAZINE ADVISORY BOARD

OCCUPATIONAL HEALTH AND INDUSTRIAL SAFETY PROGRAMS DIRECTORATE

Jonathan Wilson jonathan.d.wilson2@navy.mil 

Director

CAPT Daizo Kobayashi, USN daizo.kobayashi@navy.mil 

Deputy

SHORE/GROUND SAFETY PROGRAMS DIRECTORATE 

CDR Roger Brouillet, USN roger.brouillet@navy.mil 

Director

Don Ciesielski donald.ciesielski@navy.mil

Deputy

SAFETY ANALYSTS

OCC. HEALTH AND INDUSTRIAL SAFETY Ext. 7820

Steven Geiger, MS, CSP steven.geiger@navy.mil

Safety and Occupational Health Manager

Stanley Willingham stanley.willingham@navy.mil 

Safety Programs/CNSC Safety Officer

TRAINING Ext. 7841

LT Shawn Bristle shawn.bristle@navy.mil 

Training Safety Division Head

SOC(SEAL/PJ) Dallas Cranmore, USN dallas.cranmore@navy.mil 

Training Safety Analyst (Diving/SEAL)

George Arici george.arici@navy.mil

High-Risk Training 

GMCS Jason Stout jason.stout@navy.mil 

Training Safety Analyst

TRAFFIC AND RECREATION, OFF-DUTY SAFETY (RODS) Ext. 7842

Dave Kerrick david.kerrick@navy.mil 

Traffic and RODS Division Head

Bonnie Revell bonnie.revell@navy.mil 

Traffic and RODS Specialist (PMV)

Michael Borkowski michael.borkowski@navy.mil 

Traffic and RODS Specialist (AAA/EVOC) 

Stanley Jones stanley.w.jones1@navy.mil 

Traffic and RODS Data Analyst (Motorcycle)

WEAPONS SYSTEMS Ext. 7843

LCDR Stephen Folsom, USN stephen.folsom@navy.mil 

Weapons Systems Safety Division Head

AOCS Dawn Hannon dawn.hannon@navy.mil

Weapons Analyst (Aviation)

Boyzie Hayes boyzie.hayes@navy.mil

Weapons Analyst (Shore)

GySgt Robert Taylor, USMC robert.c.taylor2@navy.mil 

Ground Explosives Safety Analyst

GySgt Daniel Devine, USMC daniel.d.devine1@navy.mil 

Weapons Analyst (Aviation)

TACTICAL SYSTEMS/INVESTIGATIONS Ext. 7844 

DJRS/Jump Ext. 7744

Jon Natividad jonas.natividad@navy.mil 

Tactical Safety Division Head/ 

CMC (SD) Liaison Officer

Capt Ryan Carlson, USMC ryan.carlson@navy.mil

Mishap Investigator, Artillery, Explosives

Capt Andrew Gay, USMC andrew.j.gay@navy.mil

Mishap Investigator, Artillery, Explosives

Capt Timothy Coots, USMC timothy.j.coots@navy.mil 

Mishap Investigator/High-Risk Training Analyst

Capt Trevor Jones, USMC trevor.a.jones@navy.mil 

Mishap Investigator, Tactical Operations

MSgt Christopher Whitley, USMC christopher.whitley2@navy.mil 

Tactical Ops, Parachute Analyst

MSgt Sherman Jilton, USMC sherman.jilton@navy.mil 

High-Risk Training Assistant (Marine Corps)

GySgt Brandon Ellis, USMC brandon.l.ellis@navy.mil 

Motor Transport Vehicle Operations Analyst

PRCS(EXW/AW/FPJ) Scott Rodberg scott.rodberg@navy.mil 

Tactical Ops/Parachute Analyst (Navy)

To contact a safety analyst by phone, call the main number, (757) 444-3520 

and dial the extension at any time during the greeting. Vol. 4., No. 1 • Resources and Information for the Safety Manager

Spring-Summer 2015

http://www.public.navy.mil/comnavsafecen

NAVAL SAFETY CENTER WEBSITE

The Anymouse program provides an outlet for safety concerns 

that have been submitted to the chain of command but remain 

unresolved. You can find the Anymouse icon on the main page 

of the Naval Safety Center web site.

ANYMOUSE PROGRAM

Join us on the web or your mobile device:

SOCIAL NETWORK
FEATURES

MOTORCYCLE SAFETY

20 12 Days of Riding

From preparation to limitations, motorcycle rider shares tips 

for enjoying a catastrophe-free journey. By CDR Jason Bragg

HOME SAFETY 

23 One Step Down to Injury

Failed self-supervision and inattention land a home-do-ityourselfer in pain. By Armando “Mondo” DeGuzman

HEALTH AND FITNESS 

24 On Death’s Doorstep

Intense workout routine nearly kills this otherwise healthy pilot 

while deployed. By LT Rob O’Donnell

HOME IMPROVEMENT 

27 ORM and DIY Tree Cutting

Knowing the risks and making thorough calculations keep 

consequences way low for this homeowner. 

By LTJG Jim Webb

RECREATION 

28 Could Have Been Worse

Self-assessment and PPE buffer a Sailor from serious harm in 

a bike-ride-gone-bad incident. 

By LT Tabitha Kingensmith and AEAN Adam Ballard

29 A Lifejacket Buys You Time

Cold-water drowning can happen in the summertime. Not 

wearing a flotation gear narrows your survival time. 

By Paul Newman

LIFE MATTERS 

31 Will You Get Skin Cancer?

Melanoma is a disease afflicting not just the elderly. If you’re 

out in the sun often, know the risks. By Wayne Rudolph

2 EDITOR’S NOTE

4 LEADERSHIP PERSPECTIVE

Factors That Influence Risk Acceptance

As a leader and safety professional, you can positively influence 

the risk decision making of your Sailors. 

By CMDCM (AW/SW) Paul Kingsbury

IN THIS ISSUE

3 NEWS BRIEFS

Mishap Reporting Module Facelift

Special-Issue “Funnies” Magazine

Rider Down

COVER STORY

6 RMI Consolidates Disjointed Reporting Systems

The fleet will transition to a single point of entry for managing 

data and sharing lessons learned by spring 2016. 

By Evelyn Odango

DEPARTMENTS

MOTORCYCLE

8 Notable Changes to Rider Training

New contract affects potential motorcycle riders, California 

requirements and installation-level courses. By Alicia Harkins

10 MSR and Mentorship Boost Awareness

Programs help riders improve risk-management skills and 

prevent mishaps. By Stanley Jones

TACTICAL AND GROUND

12 Not Enough Use of HFACS

Expanding scope of data analysis training beyond classroom 

sessions could improve risk-mitigation strategies. 

By Capt. Andrew Gay, USMC

14 Getting Schooled

Investigation course focusing on root-cause analysis plays a 

big role in improving mishap rates. 

By Capt. Ryan Carlson, USMC

WEAPONS

16 Top 5 Explosives Mishap Concerns

Training and awareness are crucial to preventing ordnancerelated injuries and property damage. By Boyzie Hayes

ORM PLAYBOOK

18 AED: Is It Part of Your Survival Kit?

The AED has become an important factor in the chain of survival. Do you know how to get to this life-saving device when 

needed? By CAPT Bob Frick, MC, USN (FS)

DECISIONS CONTENTS Spring-Summer 2015

COVER PHOTO ILLUSTRATION: 4-designer.com

THIS PAGE: Choose a sunscreen with a sun protection factor (SPF) of at least 15. Remember, clouds do not 

block UV rays, so make sure you use sunscreen even if it is cloudy outside. Photo: safety.lovetoknow.com

Spring-Summer 2015 DECISIONS 1
This spring, I discovered that 

I am allergic to just about 

anything that contains synthetic scents. Well, that is everything I 

encounter everyday!

One of the major reactions I have 

when exposed to excessive fragrance 

and strong cleaning agents is a 

massive migraine headache. Before 

my neurologist and I worked on 

establishing the pattern of culprits, I 

suffered.

In examining my symptoms, I 

almost felt like the character in the 

comedy, “Bubble Boy.” The story was 

about a boy named Jimmy Livingston 

who was born without an immune 

system. I laughed so hard when I 

saw that movie and thought “poor 

Jimmy.”

Well, my condition is not as bad 

as Jimmy’s but I sometimes feel I 

need to be protected from the world. 

Of course, I can’t do this quest for 

protection by myself so I constantly 

enlist the help of doctors, family, 

friends, and supervisors.

Short of becoming the “Bubble 

Girl,” I implement some controls on a 

daily basis to make my day bearable. 

Yep, I “ORM it.” I know ... you must 

be thinking ORM and a headache? 

You must have heard about the 

five steps of ORM by now. I’ll abbreviate them as identify, assess, decide, 

implement, and supervise. 

I know that if I don’t manage my 

exposure to risks, several things can 

happen: I will get sick to my stomach when in a room next to someone 

wearing strong cologne or perfume. I 

will start feeling the early symptoms 

of a migraine headache (sensitivity to 

food, light, noise and ... drum roll ... 

scents!). My head will feel like it’s going to explode and I won’t be able to 

concentrate (sometimes I get cranky, 

too). Then I will need to take a few 

EDITOR’S NOTE

WEB UPDATES AND NOTICES

NOW ON

public.navy.mil/comnavsafecen

Managing a Headache

Decisions magazine invites letters from readers. Send your letters via e-mail to evelyn.

odango@navy.mil; fax to (757) 444-4791; or mail to ATTN: Decisions Editor, 375 A St., Norfolk, VA 23511. Please include your contact information. We reserve the right to edit letters.

FY14 Annual Mishap Overview

The Naval Safety Center has published 

its analysis of Navy and Marine Corps 

mishaps. This report focuses on areas 

of elevated risk that require increased 

or renewed prevention efforts. The 60-

page report is available as a downloadable PDF.

 /Documents/media/FY14_Annual_Report.pdf

Sleep/Fatigue Videos

This latest series of videos demonstrates how lack of sleep and fatigue 

reduce performance and increase the 

risk of mishaps. Collaborators include 

OPNAV, COMNAVSURFLANT, Naval 

Personnel Command, the Naval Postgraduate School.

 /Pages/video/sleep-fatigue.aspx

Safe Tips for Work and Off Duty

Download quick and easy summaries 

with topics ranging from automotive, 

driving/riding/traffic, electrical, fire, 

health and personal safety, summer and 

water activities, and much more. Share 

these PDFs as printed or digital training 

resource for your next safety standdown. 

 /Pages/media/index-safetips.aspx

Seasonal Resouces

To help you prepare for your next safety 

briefing or standdown, we have stocked 

the spring/summer safety resource page 

with downloadable PDFs and presentations. 

 /Pages/media/seasonal/summer.aspx

LETTERS TO THE EDITOR

days off from work because I won’t 

be able to tolerate anything or anyone. If I don’t implement stringent 

controls over this condition, it would 

eventually have a domino effect on 

my work and performance. 

Since applying the five-step process, my headaches have not been as 

frequent, and when I have a spell, it’s 

not as bad as in the past. Since I get 

these headaches mostly when I’m at 

work, here’s a breakdown of what I 

do to minimize the risk:

Identify the areas of worst exposure: restrooms (yes, we have air 

fresheners in there) and small-space 

meeting rooms.

Assess the probability and severity of exposure and consider the 

consequences. Notifying supervisors 

about the need to leave the room or 

work in isolation if necessary.

Make risk decisions based on 

controls that are present and acceptable (oscillating fan, windows, 

exit access). Do I proceed and suffer 

through the day or excuse myself?

Implement controls by using a 

mask (disposable kind), telling supervisor of affliction, avoiding sources of 

exposure when possible.

Supervise condition and review 

effectiveness of controls with continued monitoring, exploring need for 

further assessment, and capturing 

lessons learned and best practices 

from previous episodes.

It’s not a perfect science, but having a risk-management plan helps me 

get through a day without pain. Like 

myself and our featured writers in 

this issue, I hope that when you encounter risk, using ORM will literally 

save the day. 

Have a good summer!

2 DECISIONS Spring-Summer 2015
Let us help you spread the word about your safetyrelated events and tidbits of information. Deadline for 

the 2015 fall-winter issue of Decisions is July 31.

GOT NEWS? SHARE IT!

Special-Issue 

'Funnies' Magazine

This first-ever compilation features 

highlights from the usual range of 

risk-mismanagement opportunities, 

involving drunks, balconies, snakes, 

lawn mowers, cars becoming alarm 

clocks, and the popular “Rocket Scientist of the Week.” 

Since December 2014, the 

Naval Safety Center’s shore safety 

team has been sharing actual 

mishap information with the 

motorcycle safety representatives 

(MSRs) listed in ESAMS. In an 

effort to stimulate discussion and 

bring awareness to motorcycle 

accidents and the frequency that 

two-wheeled mishaps occur, the 

MSRs receive a weekly e-mail 

report every Friday.

With a subject line, “Rider 

Down,” the e-mail contains factual information pulled from the 

weekly accident reports the Naval 

Safety Center receives through 

naval message and WESS. Individual PII and command information are redacted but the details of 

each accident – type of bike and 

injuries – are shared. By sharing 

some of these details, riders can 

identify how the situations went 

from safe to unsafe and how they 

might have been prevented. 

Rider Down is intended to get 

the riding community to openly 

talk about accidents. It promotes 

discussions on how each rider 

would have handled the situation 

and about the unnecessary risks 

riders take every day. The shore 

safety team also provides general 

information, and guidance for 

MSRs and their riders to consider 

for future safety discussions and 

presentations.

The Naval Safety Center 

(NAVSAFECEN) has revised the 

module used for reporting shore 

ground mishaps. In its effort to 

update all mishap modules and 

phase out legacy WESS entirely, 

NAVSAFECEN began implementing 

these changes in 2014. 

The change also supports the 

ensuing transition to Risk Management Information (RMI) system, 

which is now in progress. Personnel 

who use the revised module will 

notice significant improvements. 

When filling out reports, users will 

experience faster navigation between 

pages. Reports are also easier to fill 

out with separate areas for event 

description, causal factor narratives, 

and recommendations. 

The DoD human factors and 

analysis classification system, or 

HFACS, has been incorporated into 

the analysis of causal factors. This 

will provide more insight for analyzing, tracking and trending causality. 

Mishap Reporting Module Facelift 'R ider Down'

NEWS BRIEFS

If reporting material damage, a property equipment identification code 

will provide a consistent and reliable 

method of tracking specific property 

involved in a mishap.

WESS applications that are 

currently being used for reporting other mishaps remain as they 

are. The motor vehicle reporting 

system (MVRS) is used for reporting government and private motor 

vehicle mishaps. The WESS aviation 

mishap and hazard reporting system 

(WAMHRS) is used for aviation 

mishaps. All other mishaps, including dive mishaps, are reported using 

legacy WESS. Dive mishaps will be 

added to the shore ground module in 

the future.

For more information, contact the 

NAVSAFECEN WESS help desk at 

(757) 444-3520, ext. 7048 (DSN 564), 

Monday – Friday, 8 a.m. to 4:30 p.m. 

(EST). Email for support to nrfk_safe_

wesshelp@navy.mil.

Contact safe-mediafdbk@navy.mil to 

request a copy. 

Spring-Summer 2015 DECISIONS 3
LEADERSHIP PERSPECTIVE

By CMDCM (AW/SW) Paul Kingsbury

Command Master Chief, Naval Safety Center

F

ar too often safety gets a bad rap. The “products” 

of safety are narrowly seen in terms of policies 

that slow down work or require unwieldy or 

unattractive PPE. Who really digs wearing that 

glow-belt during PT or wearing a hard hat and safety 

glasses in the shipyard? These perceptions can distract us 

from truly thinking about risk-taking behaviors that we 

should understand and strive to influence. 

Consider that in the course of a typical workday, our 

people literally make millions of risk decisions. From 

the time we wake up, we are engaged in activities that 

involve hazards and risks. The risk-decision-making 

process involved only takes a matter of seconds but 

can result in outcomes that have significant financial, 

operational, and emotional cost for the individual and 

organization. Safety leaders can positively shape the decisions their people make. Leaders must understand that 

although their people may identify hazards and understand the outcomes, a variety of factors can influence 

them to take more risk than they should. 

Before we explore the factors that influence risk acceptance, we have to understand the fundamental process 

of making risk decisions. Figure 1 outlines the process 

that occurs and how the outcome of each step can lead to 

a safe or unsafe behavior. 

We’ve done a good job at identifying hazards, labeling them and training on them. However, we must also 

identify the new hazards presented by new missions and 

evolving technologies. We’re OK at ensuring our people 

understand the outcomes that can result from failure to 

implement hazard controls, but we must continue to educate in order to pass on the corporate memory of mishaps. 

The area we fail to effectively understand and influence is 

how individuals make the decision to acceptance or reject 

risk once the hazards are known and understood. 

What the model does not capture are the factors that 

can skew the decision-making process from the start, 

including stress, fatigue, and alcohol use. These can all 

affect our ability to identify hazards and understand outcomes; they influence how much risk we accept. We’ve 

constructed an entire risk-management model around 

this decision-making process. Supervision is the important last step of our five-step deliberate risk management 

process for a reason: it’s the element that is key to identifying weaknesses in the individual decision-making process and provides the opportunity to stop at-risk behavior 

before it occurs. 

We often hear the mantra of “management by walking around,” but do we consider it in the context of shaping the risk decision-making process? For example, we 

supervise maintenance evolutions to identify where our 

people are taking too much risk by not following procedures, not using PPE or falling victim to a lack of experience. We also supervise lower level leaders to ensure they 

are not modeling poor behaviors and are helping look for 

these 10 factors as well. (See next page.)

Understanding these 10 factors reinforces the value 

of knowing our people so we can identify behavioral 

changes that occur when they are distracted, tired or inebriated. In turn, we make better management decisions 

and don’t put them in situations where they are unable to 

make effective risk decisions. 

Sometimes the most important concepts to understand about leadership are the ones we take for granted. 

Taking time to understand how our people think about 

risk and the ways that you can influence that decisionmaking process will go a long way to making you a more 

effective leader while improving organizational performance.

Factors that Influence Risk Acceptance

Fig. 1: The risk-decision-making process

4 DECISIONS Spring-Summer 2015
Overestimating capability 

(younger people) and experience (role models). Reflect 

on your role as a mentor, admit 

that despite your experience the 

exposure is still there. Acknowledge skill but reinforce policies 

and procedures.

Confidence in equipment.

Overconfidence in technology 

increases risk tolerance. Ensure 

technical training captures 

the limits of equipment and 

engineering. Promote the ABCD

process and on-the-spot risk 

assessment. Make sure Sailors 

know how to gauge risk. Teach 

them to ask, “What if it fails?”

Familiarity resulting in complacency. Encourage Sailors to 

focus on the task like it’s the 

first time they have done it. How 

would I teach this to a new person? Stop and think. Draw from 

knowledge, skill and techniques.

Confidence in PPE and 

rescue. Relying solely on PPE 

and rescue efforts increases 

risk tolerance. Emphasize the 

limits of protection and rescue measures. Ensure Sailors 

understand these as “last line 

of defense” or “not to be relied 

upon” controls. Provide appropriate ORM and TCRM training.

Personal experience with an 

outcome. If you’ve seen a mishap or a near-miss that ended 

badly, you will be less tolerant 

of the risk. However, as incident 

rates improve, fewer leaders 

will have had these experiences 

resulting in scepticism. Know 

what incidents have occurred 

and point out the consequences. Tell sea stories.

Underestimating seriousness 

of the outcome. A hazard could 

involve a “pinch point” but the 

outcome actually results in 

amputation or crushing. Hazard 

identification should better 

define the outcome. Get people 

to ask, “How bad could it really 

be?” Apply the ABCD process. 

Teach Sailors worst-case 

scenarios.

Cost of non-compliance. Identify the cost of non-compliance 

and increase where necessary. 

As the actual or perceived cost 

increases, the risk tolerance 

decreases. Remove barriers and 

reward those who gauge risks 

and mitigate the factors that 

increase the potential for error.

Voluntary actions and being in 

control. Key factor in off-duty 

risk (people are 28 times more 

likely to be hurt off the job). 

Overconfidence and false sense 

of control may lead to underestimating risks. Integrate “stop and 

think” moments into personal 

activities. Use checklists to 

improve situational awareness.

Role models accepting risk.

Leaders’ actions influence the 

mindset, behavior and decisionmaking abilities of their workers. 

Identify and address risk-taking 

leadership (in the appropriate 

situations). Recognize perceived 

pressure that could lead to erosion of standards and address 

immediately. 

Potential profit or gain.

Perceived or actual (fiscal, emotional, physical) gains increase 

or decrease risk tolerance. 

Remove rewards for risk taking. 

Eliminate barriers to doing it the 

right way. Bring these concepts 

into leadership discussions to 

increase awareness. 

As a safety professional, you can positively shape the risk decision making 

of your Sailors. Although they may 

identify hazards and understand the 

outcome, a variety of factors may still 

influence them to accept more risk than 

they should. Let’s take a look at what can 

influence risk tolerance and what safety 

leaders can do to shape those behaviors.

Adapted from “Strategies for Understanding and Addressing Risk 

Tolerance,” Exxon Mobil, 2011. U.S. Navy photos

The 10 Factors of Risk Tolerance 

Spring-Summer 2015 DECISIONS 5
The Navy enterprise’s 

newest mishap-prevention 

strategy, risk management 

information (RMI), is 

paving the way for an integrated 

capability of reporting, accessing, and 

sharing mishap data. RMI will help 

Navy and Marine Corps command 

leaders focus on preventing injuries, 

fatalities, illnesses, and property loss.

All Department of the Navy 

personnel (military and civilians) are 

required by policy to report injury 

and mishaps through the webenabled safety system, or WESS, the 

DON’s incident-reporting system. 

This process is complicated by the 

fact that a number of other incidentreporting systems have emerged over 

the years. Nonetheless, there is still 

inadequate reporting of incidents, 

resulting in a significant number of 

preventable repeat occurrences across 

the enterprise.

These multiple systems result in 

data entries (for multiple systems) 

that differ in functionality and design. 

Information overlaps, becomes 

RMI Consolidates

Reporting Systems

Disjointed

redundant and proves ineffective for 

analyzing mishap trends.

To improve the quality and 

accessibility of risk management 

information, the Assistant Secretary 

of the Navy (Energy, Installations 

and Environment) has endorsed 

the RMI initiative to integrate the 

functionality of the existing legacy 

systems into a single program. 

Governed by the DON’s executive 

level, the RMI Decision Board is 

chaired by the Naval Safety Center. 

Rear Admiral Christopher J. 

Murray, Commander, Naval Safety 

Center, believes RMI will remove 

barriers to reporting and will 

dramatically improve safety across 

the enterprise. 

While the number one goal is to 

reduce the number of preventable 

mishaps, injuries and illnesses 

through rapid sharing of lessons 

learned, RDML Murray is confident 

that RMI will accommodate ease of 

reporting. 

“With RMI replacing WESS, 

ESAMS and other fragmented 

systems, ease of reporting is key 

to getting people on the computer. 

Collecting data is an IT-driven 

environment and we must leverage 

technology, best practices, new data, 

as well as old data. This improvement 

in reporting will make us better 

predictors of trends.”

Studies conducted by the DoD 

Inspector General and the Naval 

Audit Service concluded that some 

units report less than 20 percent of 

mishaps below the level of Class B. 

Class C and D mishaps occur far 

more frequently than Class A and B 

mishaps with similar causal factors. 

This under-reporting has prevented 

the Navy from accurately collecting 

and analyzing mishap trends.

During the initial phase of 

transition, RDML Murray wants to 

demonstrate the improvements RMI 

will bring: information sharing, better 

data collection, streamlined reporting 

processes, and advanced analysis 

capability. This advancement in 

safety management will deliver key 

information necessary to focus on 

total loss prevention, control and 

data analysis. 

Incident reporting 

solution coming to 

the fleet spring 2016

By Evelyn Odango

Naval Safety Center

The largest-of-its-kind 

effort within the DoD, 

the RMI implementation 

phase has already 

begun. Technical experts 

are now designing 

the user interfaces for 

Navy and Marine Corps 

communities to ensure 

a smooth transition to 

streamlined incident 

reporting.

COVER STORY

6 DECISIONS Spring-Summer 2015
“This is certainly a good 

transition to any good safety 

management system,” said RDML 

Murray. “But we are just scratching 

the surface. If we can show early on 

how easy it is to input and retrieve 

data, people will see that RMI has a 

lot more work equity than WESS or 

ESAMS.”

The evolution to RMI will 

not only save costs but will also 

increase employee productivity and 

warfighter readiness. RDML Murray 

stresses the long-term value of keying 

in hazard reports and Class C and D 

mishaps, as they will help examine 

possible leading indicators to more 

severe mishaps.

RDML Murray expects that 

when RMI rolls out, people will ask 

more questions. Dialogue across 

communities will be extremely 

important. “It’s powerful when 

people feel more tied to their 

community, like they’re in the 

system,” RDML Murray added.

[Naval Safety Center] Command 

Information Officer Joe McMahon is 

the lead for the implementation plan. 

McMahon, who has been working 

very closely with key players 

within DON, cites several reasons 

for the change: data consistency, 

process improvement, and cost 

savings. Perhaps the most significant 

motivation for embracing RMI is the 

ability to rapidly identify issues and 

conduct trend analyses. 

McMahon believes that RMI 

will provide a critical business 

service to warfighters and the 

safety community. “RMI will 

enable command leaders to quickly 

influence habits, processes and 

procedures vital to preventing 

injuries, illnesses, and property loss,” 

he said.

In the months ahead, affected 

organizations will start seeing 

changes in terms of training and 

requirements.

“The application itself should 

provide intuitive user interfaces,” 

said McMahon. “Safety managers 

will quickly learn and adapt to 

managing command information 

and identifying trends and causal 

factors.” 

By the third quarter of FY16, 

commands will begin the transition 

process. Echelon II organizations 

are assisting in the priority order for 

migrating to RMI. Once streamlined 

incident reporting is established, RMI 

will continue to deliver capability 

improvements for analysis and 

dissemination as well as safetyprogram management.

“By FY18, RMI will serve as the 

single point of entry for all DON 

safety management,” said McMahon.

By consolidating the capabilities 

of current disjointed safety databases 

and systems, RMI is expected to 

significantly reduce the number of 

fatalities and save the Navy hundreds 

of millions of dollars lost each year 

because of mishaps. 

Will you be affected by the 

change? If you’re one of the 

thousands of Navy, Marine Corps 

and civilian stakeholders in the 

following organizations, expect a 

significant impact: 

U.S. Fleet Forces and Pacific 

Fleet Commands, TYCOMs, Naval 

Air Systems Command, Naval 

Sea Systems Command, Navy 

Installations Command; and all Navy, 

Marine Corps and OSH communities 

that report incidents, injuries and 

occupational illnesses. The Naval 

Safety Center will continue to 

provide updates and information via 

the web and magazines. 

Ms. Odango is the editor of Decisions and 

Sea Compass magazines.

Spring-Summer 2015 DECISIONS

7
Notable Changes to Rider Training

By Alicia Harkins

Navy Installations Command

Class-Attendance Minimums 

and Cancellations

1. Six-student class minimum.

Previously, motorcycle class offerings had a maximum of 12 students 

for the Basic Rider Course (BRC) and 

six students for the other classes. The 

new class-size maximum is now six 

students for all classes. Two BRC 

classes can be run simultaneously, 

since most of the motorcycle ranges 

can accommodate 12 riders. 

When potential students read the 

class schedule posted online or on 

ESAMS, they might see two classes 

listed for the same day, time and 

location to get the maximum of 12. 

Students are to register for only one 

of the classes. At a minimum, one of 

the two classes will be held. 

2. No cancellation due to “no 

shows.” Students who arrive for class 

will receive the training regardless of 

the number of students enrolled in 

that class. 

3. Class-cancellation procedure.

If less than four students are enrolled 

in a class scheduled for that week, 

the class instructor will cancel and 

reschedule that class. Cancelling 

the class ahead of time will prevent 

unnecessary travel and lost work 

time for Sailors.

The Navy traffic safety contractor, Information Sciences Consulting, Inc. (ISCI), will provide training 

motorcycles as required for the BRC. 

The contractor may use contractorowned motorcycles or use a thirdparty vendor to provide motorcycles. 

At some smaller or remote locations, 

ISCI may subcontract all motorcycle 

training to a third-party vendor, such 

as a community college or a Total 

Control school. The government 

will no longer provide governmentowned motorcycles (these are being 

transferred to the Defense Reutilization and Marketing Office).

California’s Motorcycle Rider 

Requirements

California changed its state 

motorcycle-license training requirement from the Motorcycle Safety 

If you’re a rider or a trainer, 

you may already have 

heard of changes to the 

Navy motorcycle rider safety 

training and the American 

Automobile Association Driver 

Improvement Program (AAA/

DIP). Commander, Navy 

Installations Command (CNIC) 

has implemented a new 

training contract that affects 

potential riders, California state 

requirements, and installationlevel training and driver 

improvement courses. 

8 DECISIONS Spring-Summer 2015
the Navy (DON) civilian personnel. These services are specifically 

directed for government motor 

vehicle operators, drivers operating private motor vehicles on a 

Navy installation, and operators 

who have been determined to be at 

fault in a traffic mishap while on a 

Navy installation. OPNAV policy 

does not specify that CNIC provide 

non-motorcycle training as part 

of the Navy motorcycle contract. 

OPNAV policy also does not specify 

that CNIC provide individual training as a result of a moving violation 

received off base. Individuals who 

receive a ticket or are in an accident 

off base are responsible for correcting 

any violation themselves. 

The Navy does have a resource 

for DIP training through the Naval 

Safety Center. Mike Borkowski, a 

traffic safety specialist, is a certified 

master trainer for AAA/DIP and can 

train employees to become AAA/DIP 

instructors.

Installation commanding officers 

can use this resource by designating 

at least one person to be the AAA/

DIP instructor for the installation. The 

designated person can be a member 

of the command training team, force 

protection, fleet and family readiness, 

or from any department within the 

organization.

Ms. Harkins works for CNIC as a safety and 

occupational health program manager. She 

is also the traffic safety program contracting 

officer representative.

Foundation (MSF) courses to the 

Total Control motorcycle training 

courses. As of Jan. 1, 2015, a motorcycle rider in California who wants 

to get his or her first motorcycle 

rider license (or a new license) must 

take classes from Total Control; MSF 

classes are no longer accepted by the 

California Department of Motor Vehicles. ISCI is providing MSF classes 

only nationwide except in California 

where Total Control classes will be 

offered. 

Navy policy currently requires 

MSF courses, but allows Total Control courses as an equivalent option 

when approved by the Naval Safety 

Center. 

The Navy is required to provide 

motorcycle rider training to Sailors 

per the Navy Traffic Safety Program 

instruction (OPNAVINST 5100.12J). 

The Navy is not required to provide motorcycle rider licenses or to 

provide motorcycle rider training to 

meet state requirements. This means 

that in California, and possibly other 

states, Sailors might have to fulfill 

two sets of requirements (Navy and 

state) to get a new/first motorcycle 

license. Sailors will have to take additional state-mandated training on 

their own and at their own cost.

Motorcycle riders who already 

have their motorcycle licenses are not 

affected by the change in the California law (unless California has a recertification requirement) because they 

only have to meet the Navy’s training 

requirement. 

Clarification of Traffic and 

Motorcycle Rider Safety 

Training Management

CNIC’s responsibility to provide traffic safety training is shared 

throughout the chain of command. 

Specific responsibilities are stated 

in paragraph six of OPNAVINST 

5100.12J. CNIC region and host installation commanders are also resourced 

to provide traffic safety program services to tenant commands and other 

Navy commands within the region at 

the installation level. 

Currently, CNIC HQ provides 

motorcycle training via a centrally 

managed Navy contract. The current contract targets motorcycle 

safety training and not AAA/DIP 

training. A few Alive @ 25 driverimprovement classes were included 

in the Navy contract, but they are 

not the primary focus of the contract. 

The Alive @ 25 class provides driver 

improvement information pertinent 

to Sailors 25 years old and under. 

If the Alive @ 25 training does not 

meet the needs of the individual 

Sailor, then it is up to the Sailor’s host 

installation command to provide the 

resources for the Sailor to obtain the 

eight-hour AAA/DIP training. 

As stated in the Navy Traffic 

Safety Program instruction, CNIC 

regional and host installation commanders shall coordinate, manage, 

and provide resources for an effective overall traffic safety program. 

Where CNIC resources are limited 

at the installation command level, 

then region commanders can submit 

a resource allocation management 

issue to request additional funding 

from CNIC headquarters.

CNIC provides general traffic 

safety services Navy-wide for all 

Navy military and Department of 

RESOURCES

OPNAVINST 5100.12J: “Navy Traffic Safety Program”

Navy Motorcycle Rider: www.navymotorcyclerider.com

ESAMS: https://esams.cnic.navy.mil/esams_gen_2/loginesams.aspx

Photo by MC2 (SW) Justin A. Johndro

MOTORCYCLE

Spring-Summer 2015 DECISIONS 9
MSR and Mentorship Boost Awareness

MOTORCYCLE

I

n 2009, the Navy saw a drop in 

motorcycle fatality rates, but the 

rates have been steadily climbing 

since. From fiscal years 2012 through 

2014, the Navy lost 57 Sailors. Naval 

Safety Center data show that the 

average experience of these riders 

was less than three years. Inexperience, lack of training, poor situational 

awareness, and inaccurate decisions 

contributed to these fatalities. These 

deaths have had significant impact on 

Navy and Marine Corps readiness. 

The Navy Traffic Safety Program 

(OPNAVINST 5100.12J) requires 

a command to have an MSR and a 

motorcycle mentorship program. 

Although designated as a collateral 

duty, the MSR position is critical to 

the success of a command’s motorcycle safety program.

The MSR’s Role

The MSR has a wide range of 

responsibilities, including administrator, record keeper, liaison, and 

program manager. Using the motorcycle module in the Enterprise Safety 

Applications Management System 

(ESAMS), the MSR maintains the 

training records and list of command 

riders. The MSR works very closely 

with the commanding officer and the 

safety officer to ensure that all riders 

acquire and maintain the required 

training for the type of motorcycle 

they ride. 

Managing the command motorcycle mentorship program is the 

MSR’s biggest responsibility. In 

addition to scheduling mentorship 

meetings and non-formal motorcycle 

training, the MSR also identifies 

motorcycle riders and assigns mentors as needed. 

Motorcycle Mentorship Program

The program helps riders maintain hazard awareness and avoid 

mishaps through continuing education and skills development. This 

program provides a means for riders 

to enhance their knowledge and 

skills through formal and informal 

instruction, mentorship and practical application exercises, and events. 

Each motorcycle rider is required to 

actively participate and support the 

objectives of the Navy’s motorcycle 

safety program. Command involvement has great influence on the success of this program. The CO, safety 

officer, and MSR must ensure that all 

personnel can get the assistance and 

training they need to be successful 

and safe as riders. 

Get your experienced riders 

with your junior riders, whether it’s 

during group outings or one-on-one 

rides. If you don’t have enough riders 

in your command — or even if you 

do — partner with other commands 

so that you can provide the most 

experienced riders as mentors. 

An example of a command 

directive delineating the process and 

responsibilities of the above may be 

found on the Naval Safety Center’s 

website motorcycle page. Browse an 

extensive collection of downloadable tools and guidelines, such as an 

11-chapter mentorship guide and 

mentorship program examples. For 

more information you can contact the 

Naval Safety Center Traffic Division 

at SAFE_Code42@navy.mil.

Mr. Jones is a traffic program analyst with the 

shore safety team.

By Stanley Jones

Naval Safety Center

Chief Culinary Specialist Luis 

Siguenza, assigned to the Los 

Angeles-class attack submarine 

USS San Francisco (SSN-711), 

participates in a cornering 

exercise during the Military Sport 

Bike Rider Course at Naval Air 

Station North Island. The oneday course provides specialized 

training tailored to military sport 

bike riders and focuses on the 

critical skill sets and decision 

making incumbent with riding 

high-powered sport motorcycles. 

Photo by MC3 Bradley J. Gee

Motorcycle safety representatives (MSRs) and mentorship programs help 

commands improve hazard awareness and increase command commitment, 

thus helping riders boost confidence, improve skills, and prevent mishaps.

10 DECISIONS Spring-Summer 2015
WHAT YOU NEED FOR A MOTORCYCLE MENTORSHIP PROGRAM

 Complete list of riders and their experience level.

 Exercises for the mentor to work with riders that target their particular needs.

 Risk-assessment worksheet to provide information and feedback for the rider and the mentor on unnecessary risks that 

a rider may be assuming.

 A formalized checklist for group rides approved by the commanding officer that provides information on who’s going, 

what’s required, where rides will take place, timeline, safety brief, mentors (a.k.a., ride captains), and route.

 Get your “plan-to-own” riders involved early. Have them attend the motorcycle meetings where you discuss techniques 

for turns, riding in traffic, what to do at intersections, and other safe practices. Involving new riders will help them 

adopt the safe mindset early. This will also allow for discussing the type and size of motorcycle they will purchase. 

Many new riders are not ready for the motorcycles they buy (for example, a Ninja 259 vice a 1000RR sport bike). 

Ensure there are no artificial barriers to a member who wants to train and ride (for example, not allowed training until 

qualifications are completed). Far too many times this can drive a new rider “underground,” and the command will not 

know about them until something happens.

 Ensure operational risk management is incorporated into the program. Make ORM part of the overall command picture.

Naval Safety Center

RESOURCES

Military Safety Resources

 Motorycle – http://www.public.navy.mil/comnavsafecen/pages/ashore/motor_vehicle/motorcycle.aspx

 YouTube Videos – www.youtube.com/navalsafetycenter 

 National Highway Transportation Safety Administration – http://www.nhtsa.dot.gov

 U.S. Department of Transportation (Distracted Driving) – http://www.distraction.gov/

 National Institute on Alcohol Abuse and Alcoholism – http://www.niaaa.nih.gov/

 Base/Installation Safety Office (Contacts for regional base safety) – http://www.cnic.navy.mil/

 Marine Corps – http://www.marines.mil/

 US Army Combat Readiness Center – https://safety.army.mil/

 USAF Safety Center – http://www.afsc.af.mil/

 US Coast Guard – http://www.uscg.mil/

 Navy & Marine Corps Public Health Center – http://www.med.navy.mil/sites/nmcphc/health-promotion/Pages/

health-promotion-toolbox.aspx

 Navy Knowledge Online “Drive for Life” (Driver Improvement Course) – https://www.nko.navy.mil/portal/home/

 Keep What You’ve Earned – http://www.public.navy.mil/bupers-npc/support/21st_Century_Sailor/nadap/campaign_

events/drinkresponsibly/Pages/default.aspx

 NADAP E-Grams – http://www.public.navy.mil/bupers-npc/support/21st_Century_Sailor/nadap/policy/Pages/

NADAPE-Gram.aspx

The Department of Motor Vehicles and state and local police are good resources to provide speakers for standdowns 

and safety fairs. Contact them for information related to that area (e.g., high-mishap areas, dangerous areas). Below 

is a list of training and information resources including presentations, statistics, campaigns, planners, programs, and 

much more. 

GET MORE RESOURCES ONLINE

http://www.public.navy.mil/comnavsafecen/pages/media/magazines/decisions/index.aspx

National Safety Agencies

Spring-Summer 2015 DECISIONS 11
TACTICAL & GROUND

DATA ANALYSIS TOOL

Not Enough Use of HFACS

We’re improving our abilities 

to analyze mishaps, but we 

can do better. Our safety 

experts have been analyzing mishaps 

for years and have concluded that 

human error is the largest single 

hazard in both civilian and military 

environments, acknowledged as a 

causal factor in 80 to 90 percent of all 

mishaps.

To mitigate this risk, you must 

understand what causes human 

errors and how to detect trends 

across an organization. If you have 

a piece of machinery that has a 

systematic failure, you will have 

quantifiable data with which to 

isolate the cause of the failure and 

By Capt. Andrew Gay, USMC

Naval Safety Center

Image courtesy of QuickSeries Publishing

fix the problem. Before 2005, no such 

system existed for conducting trend 

analysis on human components. 

In 2005, the Department of 

Defense Human Factors Analysis and 

Classification System (DoD HFACS) 

became a required process for all 

mishap investigations. The system 

has helped safety professionals 

analyze trends and produce data with 

which to identify trends. However, 

the system is still significantly 

underused within the Navy and 

Marine Corps.

Training for DoD HFACS is not 

widely implemented in the DON 

and is currently limited to safety and 

aviation personnel. Understanding 

Through a series of studies published from 1997 to 2003, 

Dr. Scott Shappell and Dr. Douglas Wiegmann developed the 

Human Factors Analysis and Classification System, which 

created the process to quantify elements of human errors. The 

HFACS organization that they developed is built heavily upon 

the 1990 “Swiss cheese” model of human error proposed by 

James Reason.

Reason specified four levels of human error that resemble 

four slices of Swiss cheese: 

Unsafe acts of operators

Preconditions for unsafe acts

Unsafe supervision

Organizational influences

Each of these levels has either active or latent failures that 

allow for holes in the defenses. When holes on all four levels 

align, mishaps result. Reason’s explanation revolutionized 

accident causation theories by taking the focus off of the user 

and forcing the observer to analyze and fix the failures on 

multiple levels. 

Shappell and Wiegmann retained Reason’s four tiers 

and titles for each slice of cheese, but provided a much more 

in-depth description of what constitutes a failure at each level. 

Within the first tier (unsafe acts), Shappell and Wiegmann break 

it down by errors and violations and then further subdivide those 

categories until you are left with single elements of failure such 

as “omitted checklist item” or “violated training rules.” These 

single elements are associated with a nanocode that can be easily 

used to detect trends across a series a mishaps. Trending errors 

identify where focus needs to be placed in order to prevent future 

mishaps or plug up the holes.

When DoD adopted their own variant of the HFACS in 2005, 

they also organized a human-factors working group, which meets 

on a semiannual basis to discuss revisions to the organization 

of the DoD HFACS. In the spring of 2014, the group published 

version 7.0 of the DoD HFACS. This most recent version contains 

109 nanocodes that cover possible failures in all four tiers of the 

system.

Read more about the study: https://www.nifc.gov/fireInfo/

fireInfo_documents/humanfactors_classAnly.pdf

DoD HFACS: A Mishap Investigation and Data Analysis Tool

12 DECISIONS Spring-Summer 2015
human factors is not a skill set that 

can be effectively learned through 

computer-based training. Without 

consistent training and proper 

immersion, safety professionals are 

missing out on the full potential of 

the system. There are a number of 

reasons why DoD HFACS should be 

taught to a wider audience, but its 

most instrumental element is that the 

system forces you to go through the 

analytical process, which can be used 

in any number of environments. 

As an assistant instructor for 

the Marine Corps ground mishap 

investigation course, I’ve seen 

first-hand that the students who 

gain the most understanding of this 

system are the ones who engage 

in the classroom discussions and 

debates. I also serve as an advisor to 

several safety investigation boards. 

Oftentimes, board members who get 

a dose of DoD HFACS training come 

away with an appreciation of the 

process after recognizing the value 

of how it forces you to look beyond 

“user error.” 

During a session of the mishap 

investigation course, a gunnery 

sergeant was adamant that the cause 

of every mishap scenario was user 

error by the mishap victim. As the 

course continued to the section 

on HFACS, this student began to 

be less vocal about his opinions. 

In the end, he shared that better 

understanding of the system had 

changed his outlook on mentorship 

and counseling. 

HFACS had helped him look at 

the latent failures beyond the unsafe 

act and made him question his 

instincts to find the Marine or Sailor 

at fault. He began thinking about 

the effectiveness of supervision, 

publications, and other potential 

areas. The most effective time to use 

the DoD HFACS in a preventive 

manner is during deliberate 

operational risk management (ORM). 

Deliberate ORM helps identify 

all potential hazards during an 

operation and develop measures of 

control to mitigate the hazard down 

to an acceptable risk level.

Combining HFACS with ORM 

ensures that you are considering 

all potential hazards. Some ORM 

worksheets are templated products 

from previous operations, so they 

have been vetted and cover most 

environmental factors. However, I 

have rarely seen one that discusses 

human factors other than fatigue or 

lack of nutrition contributing to a 

heat or cold injury. 

An HFACS-based ORM would 

include potential hazards such as 

“negative habit transfer” if the ORM 

is for a training exercise with a newer 

version of equipment, or “pressing” 

to mitigate potential hazards arising 

from a high op-tempo.

The applicability of HFACS to 

multiple communities is one of its 

major strengths, but also is the most 

underused aspect of the system. 

While the use of DoD HFACS has 

improved the safety community’s 

ability to conduct thorough analyses 

and identify trends among the human 

element of mishaps, there are other 

processes that could be improved 

upon by adapting the same system.

Broadening the scope of training 

beyond the occasional safety class 

and the five members of a safety 

investigation board is a manpowerintensive prospect. Yet, the return on 

investment could potentially give the 

safety community a wider range of 

options for risk-mitigation strategies.

Capt. Gay, an artillery explosives analyst, 

serves as a mishap investigator.

Combining HFACS 

with ORM ensures that 

you are considering all 

potential hazards.

James Reason Swiss Cheese Model

Spring-Summer 2015 DECISIONS 13
By Capt. Ryan Carlson, USMC

Naval Safety Center

TACTICAL & GROUND

Getting Schooled

MISHAP INVESTIGATION

I

n FY14 the Navy and 

Marine Corps lost 

$1.28 billion and 112 

lives to mishaps. Although overall trends are 

decreasing, we still need 

to improve mishap rates 

and eliminate the potential for another spike.

Identifying and analyzing root 

and contributing causes play a big 

role in achieving this goal. However, 

many safety professionals don’t 

understand root-cause analysis.

In 2008 II MEF (Marine 

Expeditionary Force) hired retired 

Navy Corpsman Chief Christopher 

Acord as a civilian tactical safety 

specialist to manage the command’s 

mishap investigation and prevention 

program. He instantly identified 

a significant problem: the quality 

of safety investigation reports 

lacked detailed root-cause analysis 

and failed to identify long-lasting 

corrective actions. 

In 2010, while serving as a 

Marine Corps Safety Division 

[CMC(SD)] instructor at a joint 

services safety and occupational 

health training program, Acord 

developed the ground mishap 

investigation course to address these 

issues and improve the quality of 

analysis. Students learn to go beyond 

the previous requirement of merely 

collecting evidence for the purpose of 

submitting a report. 

Students learn how to use 

multiple tools to understand all of 

the elements involved in a mishap. 

These methods consist of barrier and 

change analyses, cause and effect (or 

fishbone) analysis, and event and 

causal factor analysis (commonly 

referred to as “cause-mapping”).

As the event is analyzed, the 

entire situation is examined as a 

process eliminating blame from 

individual people and, instead, 

looking at how circumstances and 

regulations influenced their behavior. 

This analysis is known as the Human 

Factors Classification and Analysis 

System or HFACs. (Read the article, 

“Not Enough Use of HFACS” on 

page 12.)

With these changes in effect, 

there has been a significant increase 

in the quality of mishap reporting 

and analysis. These changes enable 

mishap investigators and unit safety 

officers to identify the best possible 

control for the causal factors and 

recommend salient changes to the 

organization in order to prevent 

mishaps. 

As the curriculum advanced 

to focus on the identification and 

analysis of causal factors, the course 

grew rapidly. Instructors and courses 

weren’t available to meet demand. 

Tactical-mishap investigators from 

CMC(SD) joined the instructor 

pool, helping expand the technical 

knowledge provided to the students 

(military safety officers, civilian 

safety and occupational health 

technicians and practitioners, systems 

safety engineers, and other subjectmatter experts within the naval safety 

community). The new investigators 

improved the quality of classroom 

discussion as they brought firsthand lessons learned from recent 

investigations.

Identifying the strengths of 

the course and the need for further 

expansion of this training, CMC(SD) 

has partnered with the Naval Safety 

and Environmental Training Center 

to bring this course to the Navy 

fleet. Augmentation and instructor 

preparation are underway. The new 

curriculum’s first course is scheduled 

for October 2015.

Capt. Carlson, an artillery explosives analyst, 

serves as a mishap investigator. 

14 DECISIONS Spring-Summer 2015
The Course

Section 1: Defines a mishap and gives a brief 

history of the necessity of mishap investigation.

Section 2: Describes the mishap classification 

process based on specific cost and humanimpact metrics, reporting requirements and 

requirements for a formal safety investigation 

board. This section is critical for fleet safety 

officers as it outlines the investigation and 

reporting requirements associated with each 

mishap classification. 

Section 3: Breaks down the process of mishap 

investigation into six phases: preparation, site 

management, evidence gathering, reconstruction, 

analysis of evidence, and conclusions and 

recommendations. While each of these phases 

is important, the primary emphasis is placed on 

analysis of evidence. 

Mishap Reporting Matrix

Naval Safety Center illustration

DOWNLOAD THE REPORTING MATRIX 

http://www.public.navy.mil/comnavsafecen/pages/media/magazines/decisions/index.aspx

Spring-Summer 2015 DECISIONS 15
WEAPONS

Top 5 Explosives Mishap Concerns

By Boyzie Hayes

Naval Safety Center

Mishap-reporting systems 

are the core of risk management, and every ordnance program is subject to mishapreporting requirements. 

Two different instructions govern 

reporting requirements for explosives 

mishaps and deficiencies. Sometimes 

reporting is required by both instructions for the same incident. This 

results in duplicating and/or underreporting when usually only one system receives the report. This affects 

both the attempt to mitigate risks and 

correct equipment deficiencies. 

To improve reporting, the Naval 

Safety Center (NAVSAFECEN) and 

Naval Air Systems Command have 

collaborated to use the new Risk 

Management Information (RMI) 

system, which is coming to the fleet 

this fall. Using RMI will eliminate 

user-input duplication and will seamlessly share information between the 

two systems. (Read the article “RMI 

Consolidates Disjointed Reporting 

System” on page 6.) 

Naval Safety Center mishap data 

from this five-year period shows that 

although ordnance programs demand the use of instructions, trends 

demonstrate the need for better 

risk-management efforts. These are 

the top-five explosives and ordnance 

safety concerns, along with the actions necessary to prevent injuries 

and property damage.

SMALL ARMS

Small-arms negligent discharges, 

both on- and off-duty, remain a serious problem. Training for preventing on-duty mishaps is focused on 

specific requirements, ensuring that 

all military weapons are covered during the training of personnel involved 

with the mission. 

Off-duty weapons-handling involves many types of weapons. Training should cover basic weapon-safety 

rules and recommend all personnel 

review the weapon manufacturer’s 

owner’s guide. Ensure personnel are 

familiar with their personal weapon 

prior to loading or firing. Mishap 

data shows that personnel who handle a shipmate’s weapon often don’t 

understand the functions or safety 

features of that weapon. Personnel 

under the age of 25 who drink and 

clean their personal firearms are most 

likely to have a negligent discharge. 

GRENADES

NAVSAFECEN sends ALSAFE 

messages about suspected or potential defective or misused ordnance 

items, or when analysis indicates 

such issues. Incidents involving grenades have increased in the past five 

years; the most common occur during 

training. Most grenade incidents have 

involved the use of tape to hold the 

safety pin and/or hold the “spoon” 

in place. Ensure personnel receive 

adequate briefings on safety and operations for grenades. It is critical that 

only the authorized and approved 

standard operating procedures are 

used.

QUALIFICATION/CERTIFICATION

Mishap trends reveal the involvement of personnel who are either 

working outside their task area or not 

proficient in the task area. Remember 

that the use of live ordnance to obtain 

certification is prohibited for a teammember level certification. Ensure 

personnel obtain proper qualification and certification as directed by 

the “Navy Personnel Conventional 

Ammunition and Explosives Handling Qualification and Certification 

Program” (OPNAVINST 8023.24C or 

MCO 8023.3B).

MISHAP REPORTING

Some of the problems we’ve 

found include: incomplete reports, 

under-reported or unreported 

mishaps, duplication, and noncomHuman factors have caused most of the explosives-related mishaps during the 

past five years. Although mishap-reporting instructions are clear, there still 

seems to be a problem with under-reporting, coupled with confusion of when and 

where to report explosives mishaps.

16 DECISIONS Spring-Summer 2015
REFERENCES:

The “Navy and Marine Corps Mishap 

and Safety Investigation, Reporting, 

and Recordkeeping Manual”

(OPNAVINST 5102.1 series) requires 

that all explosives mishaps, hazards 

and near-misses be reported in the 

Web-Enabled Safety System (WESS) 

database. 

The “Naval Ordnance Management 

Policy Manual” (OPNAVINST 8000.16 

series) requires all explosives events 

and ordnance deficiencies be reported 

into the All-Weapons Information System 

(AWIS) deficiency reporting system 

database.

DID YOU KNOW?

A safety investigation board, 

or SIB, is required for any 

Class A, B or C incident 

involving explosives; a reportable 

injury (fatality, disability, lost 

work time); and all ordnance 

landing off-range (whether 

there is an injury or not). A 

unit investigation must 

be conducted for all 

other explosive mishaps.

pliance with instructions. Deficiencies in reporting directly affect the 

trending and analysis of explosives 

incidents. NAVSAFECEN analysts 

rely on the data to improve programs 

that could mitigate mishaps, share 

lessons learned and improve mission readiness. In addition to refining 

explosives mishap/deficiency reporting, there are efforts to establish data 

sharing between reporting systems 

(WESS/AWIS/RMI). 

FATALITIES

Thanks to all of the qualifications and certifications required for 

personnel to be involved in ordnance 

evolutions, there are few fatalities. 

However, lapses in judgment and 

failure to pay close attention to details 

still result in fatal mishaps. In the 

past five years, there have been 19 

ordnance-related fatalities. Seven of 

the fatalities occurred during a single 

incident.

Identifying areas for improvement is an all-hands effort. Risk 

management increases awareness to 

potential risk in a routine task. Follow your SOPs, checklists, weapons 

assembly and loading manuals to the 

letter. They are the only approved 

instructions for ordnance handling. 

Ninety-nine percent of the time, the 

weapon(s) involved in a mishap 

worked as advertised from the manufacturer.

Mr. Hayes is a weapons analyst in the shore/

ground safety programs directorate.

This photo: GM2 Andrew Thomasy and FC1 Waylon 

Clement, assigned to Surface Warfare Detachment 

3, load high-explosive incendiary tracer rounds into 

the ammunition feeder-can of a 30mm weapons 

system. Photo by MC2 Antonio Turretto

Top: Ship Weapons Department Sailors transport 

ordnance in a hangar bay. Photo by MC2 Scott Fenaroli

Right: Line coach GM2 Brittany Payne directs AT1 

Jacob Stephens to fire three to five shot bursts on 

an M240 machine gun at a firing range. 

Photo by MC3 Patrick Enright

Spring-Summer 2015 DECISIONS 17
By CAPT Bob Frick, MC, USN (FS) 

Naval Safety Center

Source: Journal of the American College of Cardiology

MANAGE RISK. ENSURE SUCCESS. COMPLETE THE MISSION.

AED: Is It Part of Your Survival Kit?

S

udden, non-traumatic death 

is relatively rare in our activeduty population. It has been 

attributed primarily to cardiacrelated events. Data show that one 

of the most significant risk factors is 

age. 

A 10-year review (1998-2008) of 

all non-traumatic sudden deaths of 

service members age 18 years and 

older was conducted by the San 

Antonio, Texas-based Brooke Army 

Medical Center’s Cardiovascular 

Division in 2011. 

The study found that sudden 

death was attributed to a cardiac 

condition in 715 (79.3 percent) 

and was unexplained in 187 (20.7 

percent). The overall annual 

incidence rate for sudden cardiac 

death (SCD) in males was 6.7 per 

100,000 and 1.4 per 100,000 for 

females during this 10-year period. 

The risk of SCD increased from an 

annual incidence of 2.44/100,000 in 

the 20-24 year old male age group 

to 111.45/100,000 in the 50 and over 

male age group. Some of the activities 

noted at the time of sudden death are 

listed in Table 1.

SURVIVAL

An automated external 

defibrillator (AED) has become 

an important factor in surviving 

sudden cardiac arrest. Bystander 

participation a critical factor in the 

success of its operation. However, 

individuals often ignore pre-arrest 

symptoms such as chest pain until it’s 

too late. People near the victim may 

be reluctant to intervene due to lack 

of training and experience or fear of 

legal issues. 

Training in the use of an AED 

is available and can be found 

through the education and training 

department of your local military 

treatment facility. EMS and fire and 

emergency services (F&ES) groups 

also teach classes. The AHA has 

established a website link to search 

for basic life support and AED 

training classes (“Heart Saver CPR 

AED”) by zip code. 

“Good Samaritan” laws exist in 

all 50 states and have been successful 

in shielding first responders and 

bystanders from legal problems if 

they try to save a person in cardiac 

arrest. Public access defibrillation 

is important to improving survival 

rates in out-of-hospital cardiac arrest. 

According to the AHA, the earlier 

defibrillation occurs, the higher the 

survival rate. A website sponsored 

by the University of Washington 

Specific Activities at Time of

Exertional Sudden Death in 361 Young Adults Table 1

18 DECISIONS Spring-Summer 2015
is available to assist persons with 

AEDs or those who are considering 

purchase of an AED. This site is not 

intended to replace formal training.

INSTALLATION

Public-access AEDs currently 

cost $1,300-$3,000, with a yearly 

estimated operating cost of $50-$390. 

New AEDs must be approved by 

the installation AED coordinator 

to ensure standardization and 

compatibility of AED devices for 

training, operation and maintenance 

purposes. Tenants are encouraged to 

place AEDs within their AOR on an 

installation (Table 2). 

The installation AED coordinator 

works with the tenant to select an 

AED, batteries and supply equipment 

compatible with the installation AED 

program. The tenant is responsible 

Where to Install Your AED?

The “Navy Installation Automated External Defibrillation Program” (OPNAVINST 5100.29) recommends the following priority 

placement list on Navy installations for AEDs:

Table 2

 Gymnasiums and indoor athletic facilities:

 (a) By the main desk

 (b) Consider placing additional AED courtside if location is in 

a high-occupancy facility (i.e., stadium or arena)

 By the main desk at staffed fitness centers

 Swimming pools:

 (a) In a visible location inside of a publicly accessible 

lifeguard office

 (b) If there is no lifeguard office, then in a location that is out 

of the sun and safe from the elements

 By the front checkout counters of main commissaries

 By the front checkout counters of main exchanges

 Schools:

 (a) By the gymnasium

 (b) By the main office or reception desk

 Administrative buildings having more than 250 adults over 

50 years of age present for more than 16 hours per day:

 (a) By public elevators of a central floor if the building has 

multiple stories

 (b) Outside of centralized restrooms if the building is single 

story

 High-risk training areas. Locations to be determined by 

operational risk management review (i.e., high-intensity physical 

training, high-risk training activities and areas where hazardous 

work environments exist).

Tenants and organizations not within the scope of priority 

locations listed above are encouraged to participate in the 

program. AEDs should be placed in any high-occupancy areas or 

other locations deemed appropriate and necessary by the AED 

coordinator, tenant commands, medical director and or F&ES chief.

for funding the purchase of the AED, 

batteries and supply equipment. 

F&ES will incorporate the tenant 

AED unit into the AED inventory 

tracking system.

CAPT Frick is a flight surgeon assigned to the 

aeromedical division. Read the full version 

of his article at: http://www.public.navy.mil/

comnavsafecen/pages/media/magazines/

decisions/index.aspx.

THE CHAIN OF SURVIVAL

Since its inception in the late 1980s by Mary Newman, the “chain 

of survival” concept has been used and improved by the American 

Heart Association. This concept emphasizes that a series of 

interdependent interventions enhances the chances of survival of 

individuals suffering from a cardiac arrest. 

However, the chain is only as strong as its weakest link and that 

each link is dependent on the other for the overall success of the 

interventions. A lack or weakness of any of these links will lead to 

a failure in the chain of survival. 

Illustration courtesy of the American Heart Association

ONLINE

American Heart Association “Heart Saver CPR AED” by Zip Code

http://ahainstructornetwork.americanheart.org/AHAECC/classConnector.jsp?pid=ahaecc.classconnector.home

AHA Chain of Survival

http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/ECCIntro/Chain-of-Survival_UCM_307516_Article.jsp

University of Washington Learn AED

http://www.learnaed.org

Spring-Summer 2015 DECISIONS 19
Motorcycling can be hazardous, so how is it that we 

went over 15,000 combined miles in under two weeks and 

came home unscathed? We had mostly good weather, no 

tire punctures, and not one of our lodging reservations 

got bungled, but it had to be something more. Years of 

experience and a lot of planning were mixed with countless individual risk decisions to yield a spectacular trip. 

I hope my experience helps you plan your riding adventure.

PREPARATION. We carefully planned our locations 

for overnight stops, with a close look at mileage and how 

far we could realistically ride in a day, as well as lodging 

availability. Being on a budget, we stayed with a friend 

one night, used some hotel points for a couple free nights, 

and found a $39 room at a casino. We also went about 

six weeks prior to peak season, which simplified finding 

lodging but meant weather was less predictable. We estimated total mileage so we could budget for fuel (which 

adds up over thousands of miles even on fuel-efficient 

motorcycles). On a ride this long, we also considered 

when to get the oil changed and if the tires would last the 

whole trip. Anticipate changing weather and temperatures. Plan your luggage space for gear you are going to 

need. If planning and preparation are not your strong 

suits, either take the time to do it right or just take a car 

— at least you can sleep in the back seat at a rest stop if 

things don’t quite come together on that rainy night out 

on the plains of Kansas.

EQUIPMENT. The right riding equipment is more 

complicated than just getting a proper helmet and jacket. 

There are suits that are versatile enough to cover all conditions, but the ones that truly work for everything cost 

a fortune. I wore a $200, three-season, CE-armored jacket 

that is just big enough for extra layers underneath and 

packed an inexpensive rain suit that fits over jacket and 

riding pants. This arrangement can get stuffy if it is rainy 

and warm, but we all choose our compromises. I did ride 

in steady rain for about five hours on a 45-degree day and 

was content (except my feet got cold since I didn’t bring 

ski socks — lesson learned for next time).

Riding gear is important, but you’re probably going 

to get some equipment for your motorcycle, too. You 

probably don’t need as much stuff as you think, but it 

depends on which bike you have and your personal 

By CDR Jason Bragg

HSM-40

et me tell you about my June adventure from Florida through South 

Dakota, Wyoming, Colorado, and back. During this 12-day, 5,200-mile 

ride, two other motorcyclists and I rode through 14 states. We saw 

sun, wind, and rain, humid woodlands, arid plains, and the Rocky 

Mountains with temperatures ranging from 35 to 95 degrees. All three of us 

returned home safely, without an injury, mishap, or mechanical failure.

MOTORCYCLE SAFETY

A mishap-free motorcycle journey

20 DECISIONS Spring-Summer 2015
tolerance for discomfort. If you buy luggage, windscreen, 

seat cushions, cruise control, tie downs, pegs, grips, crash 

protection, or other equipment, don’t use your big trip as 

a trial run for any of it. If you add lights, GPS, or heated 

grips/seat, make sure the bike’s electrical system can 

power them and that you know how to use them. Whatever gear you choose, mount it all ahead of time and take 

it out for at least a few hours of riding to make sure it’s all 

functional and secure.

I bought a very large windscreen for my trip, and 

when I was trying it out I noticed that my motorcycle felt 

less stable at highway speeds, particularly in the turbulence of 18-wheelers. The wind protection was excellent 

and I felt like it was still safe so I kept the windscreen, but 

it was nice to make that decision a few weeks before the 

trip and know what to expect. You might even consider 

packing the entire bike up ahead of time to make sure 

you have enough luggage space and aren’t overloading 

the motorcycle; they can handle differently with all that 

weight.

LIMITATIONS. Six hundred miles in one day is 

about all I want to do, but that is me on my particular 

bike. I don’t recommend that for everyone, and it only 

works for me under ideal conditions. I also have personal 

limits on speed, passing, ride time between stops, hydration, caffeine intake, and many other factors throughout a 

day of riding. It is important that riding companions have 

similar limits, or at least provide an honest assessment so 

everyone knows what to expect. Anything more than 500 

miles is a long day of riding and can be exhausting even 

if conditions are good. I didn’t ride that far most days and 

definitely not on the last couple days of the trip.

I rode during daylight almost exclusively thanks to 

long summer days; the sightseeing is better. Riding in 

the dark is even more taxing and lack of sleep increases 

risk. Fatigue degrades reaction time and decision making 

in a comparable way to intoxication — don’t ride drunk, 

don’t ride tired! On long trips you should plan for a day 

completely off the bikes to rejuvenate; I didn’t do that on 

my trip, but we did have at least two days of low mileage which served us well. You will probably be riding in 

unfamiliar areas and for long periods of time, so if you 

have to change the plan to manage the risk, then you 

must change your plan.

BE FLEXIBLE. This is hard when you’ve had a plan 

developed over months and you are on track. Know 

that you will, at some point, have to deviate from that 

plan. I really wanted to ride to the top of Pike’s Peak, 

but I knew that it would depend on the weather. Snow, 

sleet, fog, and sub-freezing temperatures were common 

there in the weeks leading up to my trip. It turned out 

to be a clear and sunny day when I went, and the view 

from the 14,000-ft peak was glorious. On a different day, 

however, we were riding into some ominous looking 

thunderheads. We tried to wait them out, but as night fell 

the lightning in the distance was like a fireworks show. 

The group takes a brief pause in Custer State Park, South Dakota. Photo courtesy of the author

Spring-Summer 2015 DECISIONS 21
The highlight of the trip was riding Colorado and Rocky Mountain National 

Park. Photo courtesy of the author

Instead of continuing to our planned hotel, which was 

only 30 miles away, we doubled back to another place 

and stayed dry and safe. Riding even a short distance 

in hail, wind, and lightning was on our list of things to 

avoid, so we changed our lodging plan even though it 

was too late to get a refund on the reservation we had. 

Risk decisions should not become financial decisions. 

Budget some emergency funds for when your plan 

changes, or just break out a credit card if that’s what it 

takes to ensure you’ll be around to ride another day.

A simple way to build-in flexibility is to stay at the 

same lodging for multiple nights. Initially, we were considering travelling all the way to western Wyoming to see 

Yellowstone National Park. This would have added many 

miles more and would have meant that we were staying 

at a different place every night. It was too aggressive a 

riding schedule for our time constraints so we chose to 

skip Yellowstone. Instead, we stayed three nights in the 

Black Hills of South Dakota. The first day we were there 

was cold, wet and very foggy, so we did not get to see 

Mount Rushmore on the day we had planned, but we 

went to tour Wind Cave (since the weather doesn’t matter 

when you are underground) and still had time to visit the 

presidents the next morning. I also planned to be home 

on a Saturday, with Sunday as a flex day just in case I was 

delayed. I always like to have a day to unpack and get 

organized before work on Monday, but it also builds in 

additional flexibility in case of an unplanned delay.

JUST IN CASE. I packed a first-aid kit and a tirerepair kit, which I didn’t have to use. Space is at a premium on a motorcycle, so you have to make good choices 

on what to pack. If you are going alone, especially in 

the mountains, a personal GPS tracker/transmitter is 

something to consider since cell phone towers can be few 

and far between. I recommend paper maps for the same 

reason, or at least some written directions; it is surprisingly easy to stump a GPS and have no service for smartphone apps. One item I brought that was surprisingly 

useful was an empty backpack. It was handy for picking 

up snacks and drinks when our luggage was still packed 

full. I highly recommend a tool kit with such things as 

spare fuses, zip ties and a tire gauge. 

MAINTENANCE. Your bike needs to be in tip-top 

condition before you depart. T-CLOCS is only a start 

if you are prepping for a multi-day trip. Have your 

machine serviced at a dealer and/or review your owner’s 

manual service intervals to ensure the machine is ready 

to go. Also anticipate what normal maintenance would 

be required along the way. At a bare minimum I had to 

bring everything necessary to keep my KTM’s drive chain 

clean, lubed, and adjusted properly. We all rode modern, 

reliable machines, but I still brought a substantial tool kit. 

I replaced a fuse just once — it was for the power outlet 

I used to charge my cell phone. We brought cleaner for 

visors and windscreens, and some WD-40 came in handy 

when my luggage lock had collected enough road crud 

that the key wouldn’t turn.

My friend’s Victory has a 5,000-mile service interval. 

Part of the planning he did was to locate a Victory dealer 

in Boulder, Colorado, and make an oil-change appointment for the day we would be there. My other riding 

partner had a front tire wearing faster than expected, so 

he found a dealer in South Dakota and got a new one 

(tires aren’t cheap, but as I said earlier, risk decisions 

should not become financial decisions). 

Out of 12 days, we rode together for 10, and I spent 

the other two riding on my own. Riding in a small group 

is enjoyable, and we had helmet communicators which 

made it even better. Splitting up for a day, however, was 

also great. It was refreshing to be on my own pace, schedule, appetite, and fuel range, and there were no hard 

feelings about it — we simply had different priorities for 

the day and when we all met up in the evening we had 

something new to talk about. 

Some motorcyclists ride around town, some ride 

around the world. Some of us cruise, some commute 

and some race. Motorcycling is an individual adventure 

and no two rides or riders are identical. Stay within your 

limits and ride your own ride. 

CDR Bragg is the training officer for HSM-40.

22 DECISIONS Spring-Summer 2015
fter completing projects 

around the yard, I entered 

the front door of the 

house and noticed the sun’s rays on 

the floor shining through the windows located 20 feet above the door. 

I noted how dingy the windows were 

and decided to clean them before my 

wife and kids returned from soccer 

practice.

Given the height of the windows, I recognized the hazards of me 

climbing an extension ladder or apex 

ladder without someone to help support the ladder. I decided to use an 

extension pole with a sponge attachment, along with my two-step ladder 

that I’ve had for decades. 

Progress was going well – stepping on and off the ladder – as I 

moved it into position to reach the 

majority of the windows. The ladder 

and extension were shy of reaching 

the last window apex by about four 

feet. Since I had decided not to use 

the tall apex ladder, I thought I’d just 

buy a new four-step ladder, which 

had four steps that were 16 inches 

apart. It would take some getting 

used to. For years I’d stepped down 

One

 Step 

Down to 

 Injury

from a two-step ladder that had steps 

eight inches apart. 

As I was putting the finishing 

touches on the windows, the sun’s 

warm rays shone through the glass. I 

started thinking about playing golf. I 

stepped off the ladder as I had always 

done in the past. Unfortunately, I had 

stepped down from the top step of 

the new ladder!

I was still in the middle of my 

mental checklist for golf when I realized that my step down took seemingly longer to touch the ground. I 

realized, mid-fall, “This is not good.” 

I’m guessing my right leg hit the floor 

fully extended with a left body twist 

continuing to rotate and then hitting 

the floor on my back and the back of 

my head. 

I sat up, unable to move or bend 

my right leg. I looked at my right 

knee and noticed a void depression where my knee cap should be. 

I flexed my right quadriceps and 

noticed the knee cap up the middle of 

my thigh. The tendon that attached 

to my knee cap was severed and, to 

make things worse, the fall tore the 

left and right collateral knee ligaments. From a simple fall!

Four days later, I had a fivehour operation on my knee. The 

orthopedic surgeon drilled four 

holes (extending from the lower to 

upper part of the knee cap), threaded 

strands of the tendon through the 

knee cap holes and cross-stitched the 

tendon back to the knee cap.

I thought I had adequately 

ORM’d my original task. I’d identified the hazard of falling from a high, 

unsupported ladder. I’d assessed that 

I would not use my high-apex ladder 

and implemented some control by 

using a much smaller step ladder and 

an extension pole to clean the windows. However, I failed to supervise 

myself. I was inattentive to one of the 

tasks at hand and the steps (literally) 

I should have taken until I had both 

feet on the ground. 

Take it from me. Apply the ORM 

process, levels and principles to 

help you avoid that one step down 

to injury. It will keep you healthy, 

wealthy and wise.

Mr. DeGuzman is a safety manager and 

platform coordinator with HX-21.

By Armando “Mondo” DeGuzman

HX-21 Photo: safety.lovetoknow.com

HOME SAFETY

Spring-Summer 2015 DECISIONS 23
Photo illustration by Allan Amen

It started with what I thought 

was a simple workout. It landed me 

in a hospital, and the cause was rhabdomyolysis, commonly referred to as 

“rhabdo.” It occurs when you overwork your muscle tissue to such an 

extreme level that it basically shreds, 

explodes and dies.

During my deployment, I had 

promised myself to work out as 

much as I could and shed a couple 

of pounds. When members of the 

aviation detachment (AVDET) asked 

me to join them on the flight deck for 

By LT Rob O’Donnell

HITRON Jacksonville

I

’m a healthy person: 

I work out often, 

eat a balanced 

diet, and get plenty of 

sleep. However, on my 

latest deployment with 

the Helicopter Tactical 

Interdiction Squadron 

(HITRON) Jacksonville, 

I had the scare of my 

life, the kind that almost 

ended it, and I wasn’t 

even in the aircraft! 

HEALTH AND FITNESS

24 DECISIONS Spring-Summer 2015
a workout, I said, “Heck, yeah! Let’s 

do it!” 

It was going to be my first experience with CrossFit, a workout regimen developed by a fitness company. 

I’d always wanted to try the highrepetition, high-intensity program 

and this was the perfect opportunity.

Flights for the night were cancelled, so we met at about 1600. The 

instructor used a CrossFit app to 

create the workouts, which consisted 

of 100 burpees (full-body exercise) 

for about 15 minutes, farmer’s carry 

of about 70 pounds, 90 sit-ups, 

120 crunches, and the plank for 60 

seconds. I was told that this was an 

average workout of the day. 

I took my time, but did push 

myself with the burpees, which 

would be the culprit and would 

eventually send me to the hospital. 

Burpees are considered a positive 

and negative movement. The physical action of completing the upward 

motion of the push-up is positive 

and the dropping to your hands and 

completing the downward motion of 

the push-up is the negative motion. 

“Jumping” or “kipping” pull-ups are 

another negative movement that can 

be notorious for leading to rhabdo. 

The body is an amazing thing. It 

will let you know when it has had too 

much of a positive motion, causing 

your muscles to fail and give out. 

However, you can overrule your 

muscular system during the negative 

portion of the movement by “cheating” your way into a position and 

then making it fight to resist a movement. Even if your muscles have 

given out on you, they’ll still contract 

beyond their actual capacity through 

the negative portion of the movement 

– until they literally explode. 

After completing the workout I 

felt tired. It wasn’t the hardest workout I’d done, but I was satisfied. I was 

excited that I had done it and was 

looking forward to continuing and 

committing myself to do more. The 

next morning I woke up sore and had 

a hard time moving my arms. I didn’t 

think much of it. Maybe I just had a 

good workout and would get over 

the soreness in a day or so. I even 

went out that morning and flew on 

a three and a-half hour interdiction; 

unfortunately there were no drugs on 

board the panga. 

That night the soreness and stiffness worsened, but again, I figured 

I just had a great workout. I woke 

up to the same symptoms and was 

slightly concerned that I wasn’t feeling better. The red flag was my urine 

being the color of cola; never a good 

sign. I freaked out, and did what any 

logical person would do: I Googled 

it. I had every symptom, except one, 

for rhabdo: extreme soreness, darkened urine, but no substantial muscle 

swelling (that would come). After 

reading this information, I visited 

the cutter’s health services technician (HS). She had me complete a 

urinalysis that yielded high amounts 

of protein and an extreme amount of 

blood. 

My overstressed muscles had 

released myoglobin into my bloodstream, which was then routed to 

my kidneys. Kidneys are designed to 

be internal scrubbers. They remove 

toxins from your blood, send your 

clean blood on its way, and then will 

route the toxins into your urine so it 

can be evacuated from your body. 

Being the good scrubbers that they 

are, they went into overdrive trying 

to remove all of the myoglobin from 

my blood. When kidneys try to break 

down other compounds they emit an 

enzyme called creatine phosphokinase (CPK). 

I had every symptom, except one, for rhabdo: extreme 

soreness, darkened urine, but no substantial muscle 

swelling (that would come).

Continued next page.

Spring-Summer 2015 DECISIONS 25
The HS (to whom I am forever 

indebted for saving my life) quickly 

initiated an IV. My body absorbed 

two liters of IV fluid in about 40 minutes. I was then placed on a steady 

drip for the rest of the night, while 

the cutter altered course and made 

best speed for Panama (I was going 

to be taken off by medevac in the 

morning). 

Ashore, I was quickly swept into 

an ambulance while the other pilot 

had to fly back solo to the cutter. 

At the hospital, medical personnel immediately performed a blood 

test. I figured I would get the results 

quickly and was already making 

dinner plans for the evening that 

didn’t include a hospital. Four or five 

hours later the results arrived, and so 

did more IVs. The doctor explained 

that they had to dilute my blood 10 

times because it continuously measured off their scales. Ten times! 

Normal CPK levels are between 

80-360 u/ml. Mine was 129,000 u/ml 

and was probably around 150,000 u/

ml the night before my medevac. 

With levels that high, kidney 

failure is almost guaranteed. Having 

kidney failure on the ship would 

have been catastrophic, especially 

since there is zero chance for dialysis 

to clean out my sickened kidneys. 

What saved me was the eight bags 

of IV I had on the cutter that saturated my system and opened up my 

clogged kidneys. I was admitted to 

the ICU (where I spent three days) 

and had two IVs dripping into me 

simultaneously. I was eventually 

moved to the general ward but 

remained on IVs for another two 

days and would spend six days in the 

hospital. In total, I’m guessing I had 

upwards of 35 IVs in the hospital and 

at the time of my discharge, I was still 

at about 12,000 u/ml CPK. 

Who would think that a workout 

would nearly kill me? The scariest 

thing about this is that minus the sore 

arms and pee, I felt fine. It is still hard 

for me to believe exactly how bad of a 

place I was in.

WHERE DID IT ALL GO WRONG?

First, I should have known better. 

My goal to get some good workouts 

during the deployment changed my 

normal workout routine. I am mostly 

a runner, but I wanted to try something new and I had been curious 

about CrossFit. It was the perfect 

time, especially since members of my 

AVDET were pretty experienced (one 

being a certified CrossFit instructor 

and the other having an earlier bout 

with rhabdo). I urge anyone that has 

had a similar experience to alert your 

crew and make sure they understand 

what could happen. While operational on a deployment, I should have 

reduced the amount of risk I was 

physically being exposed to and stuck 

to the elliptical. 

Second, I should have observed 

the outside conditions. I set myself 

up nearly perfectly for contracting 

rhabdo, and the weather could have 

played a major role in it. We were on 

a Caribbean patrol, and it was about 

85 degrees with nearly 95 percent 

relative humidity. This combination 

could have made me more dehydrated than I expected. I was sucking 

down water all day, during, and post 

workout, but I underestimated how 

much water I was losing. Dehydrated 

muscles are literally like beef jerky – 

easy to shred.

THE TOUGH-GUY MINDSET

Not realizing it, perhaps my 

attitude made me more susceptible 

to rhabdo. I felt that I could do 100 

push-ups and I would have a pretty 

good cardio, so 100 burpees should 

be no problem. 

Some people, such as athletes and 

folks in the military or law enforcement, are naturally more mentally 

tough and can push through a higher 

level of discomfort than others. This, 

however, may also make them be 

more susceptible to rhabdo. Scale 

back a workout to match your experience level. In my case, 30-40 burpees 

would have sufficed to give me the 

introduction to CrossFit, while ensuring I was still getting some good 

work-in. Would you attempt to run 

15 miles without ever running a mile? 

My CPK levels have finally 

returned to normal, but my liver is 

still working hard to rid my body of 

the remaining toxins.

If you plan to start a highintensity, functional movement-type 

program, whether on deployment, 

in a gym, or at home, find a program 

that focuses on (in order): 1) form, 

2) consistency, and 3) intensity. Not 

adhering to that fundamental framework can land you in a hospital. 

Editor’s Note: Portions of this article 

were constructed by the author from his 

own research via online resources, scientific articles and blogs.

LT O’Donnell flies with the U.S. Coast Guard’s 

Helicopter Interdiction Tactical Squadron.

ONLINE RESOURCES 

Symptoms of Rhabdomyolisis – Crossfitimpulse.com/rhabdo-and-crossfit

US National Library of Medicine – Ncbi.nlm.nih.gov 

The Netherlands Journal of Medicine – Njmonline.nl

26 DECISIONS Spring-Summer 2015
ORM and

DIY Tree Cutting

By LTJG Jim Webb

VAW-125

HOME IMPROVEMENT

T

his past year, I cut down seven large pine trees 

in my backyard. Several of the trees were old 

and had begun to drop large branches on my car, 

house, and neighbor’s house.

First, I called the insurance company, which was 

unwilling to help. Second, I called a professional who 

quoted, based on the size and proximity to the house, 

$3,500 to cut all of the trees. I just didn’t have this cash 

lying around, but I needed to act. If I cut the trees myself 

and one fell on the house, it could have easily done 

$50,000 worth of damage. The chance of a tree falling on 

the house was small; but the consequences were large, 

and this risk was simply too high.

This is where ORM came into play. I realized that if I 

were to free-cut the trees, the benefit would not outweigh 

the risk. I asked myself the question, “Can I reduce the 

risk to tip the ORM scale in my favor?” I began to look at 

ways that I could reduce the risk of a tree falling on my 

house. I discovered that I might be able to cut each tree 

with an acceptable level of risk if I used straps to pull 

the tree in the direction I wanted it to fall. Testing this 

method would still introduce a lot of risk, so I needed to 

implement controls to reduce the risk during testing as 

well. The solution was to cut small low-risk trees first, 

then progressively work up to high-risk trees. 

My wife and I came up with a plan. It involved a 

lot of elements, including climbing trees, cutting with a 

chainsaw, felling trees, and coming up with contingencies 

in case things started to go wrong. 

All of the elements required planning, research, and 

training. I used lineman gear to climb, 10,000-lb straps 

and come-alongs to pull the tree down; backup straps to 

change the direction if the tree started to move sideways; 

additional crew to help; briefings; and plenty of PPE. 

I was not about to cut anything myself unless I could 

make the risk infinitely small, otherwise the $3,500 option 

would have been more attractive.

By pulling the tree with straps, we could stop at any 

point and analyze the situation to see which way the 

tree would fall. By the time we were complete with the 

last tree, we had learned all of the difficult lessons on the 

low-risk trees, and had perfected a method that would 

nearly guarantee success with a small amount of risk on 

the larger trees. After each tree cut, we would talk about 

what went wrong, and what we could do better on the 

next tree. I wasn’t happy with the tree just falling where 

I wanted it to; I had to see the strap pull the tree to a lean 

so that I could stop the process at any point.

Let’s look at the four principles of ORM: 

How would you have handled the situation 

differently? ORM is a fluid concept, and it is not always 

black and white. Assessing risk tends to be the hardest 

and most important aspect of ORM. To make it harder, 

every person places different weight on different 

hazards. What one person views as a low-risk hazard, 

another person may view as a high-risk hazard.

While most Sailors may never find themselves in a 

position to cut down 100-foot pine trees, the principles 

in this example can be applied to any off-duty activity. 

Next time you find yourself about to take on a risky 

evolution, stop yourself and think about the forces 

driving you to do what you are about to do. Think 

about what may go wrong and how it would affect 

you, then find ways to make what you are doing safer. 

Communicate what you are doing and ask for help. Ask 

yourself if the risk is worth it. Most importantly, realize 

risk is present in everything you do — the goal is to 

manage and mitigate it.

LTJG Webb is the VAW-125 ground safety officer.

Four Principles of ORM

1. Accept risk when benefits outweigh the cost. Did 

the benefits of cutting the trees myself outweigh 

the cost (risk of hitting the house)?

2. Accept no unnecessary risk. Did I need to cut the

trees down? Could I have done more to reduce

the risk or would the cost have been too high?

3. Anticipate and manage risk by planning. Did I 

plan appropriately?

4. Make risk decisions at the right level. Who is 

responsible? Who needs to know?

Spring-Summer 2015 DECISIONS 27
On a sunny 

autumn 

day in San 

Diego, a 

group of Sailors from 

one of our maintenance 

divisions took advantage 

of a Saturday afternoon 

to spend some quality time together. Their 

activity of choice was 

mountain biking; and 

unlike most of the events 

in the weekly “Friday 

Funnies,” this story 

begins and ends with 

using ORM.

The group had mixed experience 

levels and chose an easy trail with 

gradual slopes and plenty of room. 

They all wore helmets. Despite these 

precautions, one of the Sailors hit a 

small rut that launched him into the 

air. He landed face-first in the dirt. 

His friends rushed him to a local 

hospital. The emergency room docs 

diagnosed his injuries as mild concussion, black eye, lacerations requiring 

stitches, and general bruising. 

The fact that he was wearing 

appropriate PPE, assessed his experience level honestly, and rode with a 

group buffered this Sailor from much 

more serious harm. 

No matter what outdoor activity you choose, there will always be 

a potential for mishap. Using the 

principles of ORM, you should be 

able to step back and ask if you have 

Could Have Been Worse

By LT Tabitha Klingensmith and AEAN Adam Ballard

HSL-49

mitigated the probability and severity 

of a mishap. Do your best to reduce 

the occurrence of mishaps and make 

sure their severity is minimized. 

Constantly evaluate the way you 

approach your off-duty time.

LT Klingensmith (ground safety officer) and 

AEAN Ballard are with HSL-49.

A black eye was among the injuries AEAN Ballard sustained during his mountain biking accident. 

RECREATION

Photo courtesy of the authors

28 DECISIONS Spring-Summer 2015
How can someone drown so quickly without even 

struggling to swim on the surface? Witnesses said he 

didn’t hit his head. What he likely experienced was “cold 

shock response,” the first stage of cold water immersion. 

The sudden fall into cold water made him gasp underwater. He aspirated water and began choking. He probably 

panicked and started sinking into colder, deeper water. 

He made ineffective, frantic movements with his arms, 

which had been momentarily stunned by the cold water. 

That “gasp reflex” is one we all have experienced 

either in a cold shower or jumping into a cold pool 

(“cold” means water less than 70 degrees). According to 

By Paul Newman

11th Coast Guard District

I

t was a beautiful summer day on Lake Tahoe. The air temperature was 75 

degrees and the water about 60 degrees on the surface. It was his first time 

on a stand-up paddleboard, or SUP, and he knew he was supposed to carry a 

lifejacket. So he tied it to the top of the board with the leash that should have gone 

around his ankle. About 50 yards off the beach, he lost his balance, fell off the SUP 

and drowned, seemingly in an instant.

the U.S. Water Fitness Association, swimming pool water 

should be 80 to 90 degrees. Our body temperature is 98.6 

degrees — it’s no wonder we gasp when the water is 60 

degrees! In winter these symptoms are only made worse 

by colder water. Research has shown that this is probably 

why many boaters, fishermen, hunters, and others drown 

so quickly. 

Cold Water Boot Camp USA was a 2008 research 

project of the National Water Safety Congress, funded by 

a Coast Guard grant to understand what happens in the 

first few minutes of being exposed to cold water. They 

took eight volunteers, including a Coast Guard rescue 

Spring-Summer 2015 DECISIONS 29
swimmer, and had them jump into 45-degree water to see 

what happened. 

They all experienced the symptoms of cold shock 

response: an initial gasp, hyperventilation, and extreme 

difficulty swimming. Since they knew they were going 

in the water they were prepared, but some couldn’t even 

swim the length of a 25-foot Coast Guard boat without 

needing help. 

If they calmed themselves and stayed in the water a 

few minutes longer, they experienced the second phase: 

cold incapacitation (not to be confused with hypothermia, 

which takes much longer). After about 10 minutes, their 

fingers and arms stopped working and they couldn’t 

climb back onboard a boat or help themselves. They also 

succumbed to swim failure: their arms and legs couldn’t 

make effective swimming motions to keep them afloat. 

They would have drowned if they hadn’t had rescuers 

nearby to hold them up. 

The test involved seeing how long it took people – 

wearing lifejackets – to suffer mild hypothermia. That 

took a lot longer than most people think. It takes an hour 

or more for hypothermia to take full effect (depending on 

water temperature and body composition) and another 

hour after you lose consciousness for your heart to stop. 

Without a lifejacket or something to keep you afloat, 

you’ll drown long before you die of hypothermia. 

The Cold Water Boot Camp USA website summarized the three stages of cold water immersion with the 

1-10-1 Principle: 

This graphic shows the timeline of 

the effects cold water immersion 

has on the human body. Graphic by 

PO3 Adam Stanton, USCG

1: Cold Shock (first minute)

• Gasp reflex (inhaling or aspirating up to a quart 

of water if underwater).

• Hyperventilation (rapid, uncontrolled, ineffective breathing).

• Drowing if you can’t calm yourself

10: Cold Incapacitation (in the 10 

minutes or more, if able to survive 

cold shock)

• Loss of muscle dexterity (can’t get back in the 

boat, operate radio).

• Swim failure (can’t swim, no longer a “strong 

swimmer”).

• Possible drowning if not rescued.

1: Fatal Hypothermia (assuming you 

haven’t drowned)

Cold Shock (lifejacket buys you 

time to catch your breath

Cold Incapacitation (lifejacket 

buys you time to rescue yourself)

Hypothermia (after an hour or 

more — lifejacket buys you time 

to wait for rescue)

Three Stages of Cold Water Immersion Using the 1-10-1 Principle

Still not convinced? A week after the man on the 

SUP drowned on Lake Tahoe, a 17-year old boy drowned 

on the same lake. He was with a bunch of friends who 

all begin to panic in the cold water while swimming 

25 yards back to their boat from a small island. While 

rescuers from the boat tried to get lifejackets to the boys, 

the 17-year old drowned. He experienced swim failure 

caused by cold incapacitation. 

So let’s change the conversation about lifejackets 

using what we know about cold water immersion: “That 

water is cold and will make you gasp if you fall in. Wear 

a lifejacket because a lifejacket buys you time.” 

● Time to catch your breath 

(1 minute). 

● Time to rescue yourself (10 

minutes). 

● Time to wait for rescue (1 

hour or more). 

Editor’s Note: Original blog 

posted by LTJG Katie Braynard, 

Tuesday, Jan. 6, 2015, Coast 

Guard Compass (Official Blog 

of the U.S. Coast Guard) http://

coastguard.dodlive.mil/2015/01/

a-lifejacket-buys-you-time/

Mr. Newman is a recreational boating safety specialist with the 11th 

Coast Guard District. 

30 DECISIONS Spring-Summer 2015
Every day Sailors and Marines are out in all 

kinds of weather. They sweat, overheat, freeze, 

and get soaked. They have on protective gear, 

double hearing protection, float coats, cranials, 

flight-deck boots, and gloves. Every inch of their bodies 

is covered with gear, except ... their noses! The sun is 

constantly shining on the nose. 

The skin is the largest organ of the human body and 

has an amazing ability to repair itself. Every time someone is sunburned, the skin grows new cells to replace 

the ones that the sun has killed. Sunburn is just that, a 

first-degree burn, possibly second degree if exposure lasts 

long enough. However, if damage to the skin occurs constantly, the skin can wear out or become defective. If you 

stay out in the sun long enough without protection, the 

day may arrive when a funny spot appears on your nose. 

Maybe it is a little darker than the surrounding skin. As 

the days and weeks go by it gets bigger. The shape starts 

to appear unusual. You trot to sickbay and discover that 

you may have melanoma.

What is melanoma? 

People hear about it for years but some do not pay attention. It is something that worries old people. In a sense 

that is true: the median age for melanoma is 61. However, 

what Sailors and Marines do now can determine if they 

get a melanoma in their golden years or not. According 

to the National Cancer Institute, two percent of men and 

Will You Get

By Wayne Rudolph

Special to the Naval Safety Center

SkinCancer?

LIFE MATTERS

Photo: Microsoft

Spring-Summer 2015 DECISIONS 31
women alive today will be diagnosed with melanoma in 

their lifetime. For a typical aircraft carrier, it equates to 

90 crewmembers acquiring melanoma in their lifetime; 

an LHD with embarked troops, 70 cases; a small boy, six 

Sailors; and a submarine crew would have about three 

melanoma cases. 

Melanoma contributes to less than five percent of the 

skin cancer cases, but the vast majority of deaths. Of the 

seven most common cancers, melanoma is the only one 

whose numbers are growing. It is the most common form 

of cancer for young adults 25-29 years old and the second 

most common form of cancer for young people 15-29 

years old. The four most common sites for malignant 

melanoma are: head/neck, upper limb/shoulder, trunk, 

and lower limbs. Melanoma is the type of skin cancer 

that is most likely to spread to other tissues and possibly 

cause death. 

There are a number of risk factors for acquiring skin 

cancer. Sunlight, which is a source of the known carcinogen ultraviolet radiation (UVR), is the most important 

risk factor. Other risk factors include a blistering sunburn, lifetime sun exposure, family history of skin cancer, 

skin that burns easily, certain medications, and tanning. 

Many times the first sign of melanoma is a change in 

a pre-existing mole. The shape, color, size or feel of that 

existing mole may change. It may be a quick change; it 

may take place over a period of weeks. Melanoma may 

also appear as a new mole. Whether it is new or old, it 

is changing. The best way to keep on top of this is to 

perform a monthly head-to-toe self-assessment. Look for 

the A-B-C-D-E of melanoma (see table). Melanoma can 

vary greatly in appearance. Some may show all of the 

typical characteristics and some may just have a couple. 

No matter what the change seems to be, have it checked 

if there are any concerns.

How do you protect yourself during times when 

PPE is not a requirement and the job entails being out in 

the sun for many hours of the day? How about during 

● One person dies of melanoma every 57 minutes.

● An estimated 73,870 new cases of invasive melanoma will be diagnosed in the U.S. in 2015.

● 1 in 50 men and women will be diagnosed with melanoma during their lifetime.

● An estimated 6,640 men and 3,300 women in the U.S. will die from melanoma in 2015. 

 Skin Cancer Foundation 

the off-duty hours when you’re on the beach, swimming, 

hiking or just lazing around the backyard? Sun protection products can be confusing – there is “sunscreen” and 

“sun block” with varying sun protection factors (SPF), 

sun-protective clothing, and a host of others. 

Sunscreen or Sun Block? Sunscreen reacts with the 

ultraviolet rays and filters them to attenuate the effect of 

those UV rays. Sun block creates a physical barrier to the 

sun’s rays.

Waterproof or Water Resistant? Waterproof sunscreen must maintain the SPF protection after 80 minutes 

of exposure to the water, while “water resistant” only 

requires 40-minute protection. If you are planning on 

swimming, participating in sports or just sweat a lot, go 

for the waterproof sunscreen. Remember to reapply after 

the 80-minute contact time.

What to Wear? Clothing, including hats, can go a 

long way toward protecting the skin from UV rays. The 

tightness of the weave, the type of fiber, density of the 

cloth, and color of the cloth are all items to consider when 

planning your summer wardrobe. People typically think 

less is more when it comes to summer clothing. To protect the skin from the sun, nothing could be farther from 

the truth. Long-sleeved, tightly woven synthetic fibers 

that are dark provide the most protection. Alternatively, 

there are garments that have a UV protection factor 

assigned to them. There are also laundry supplements 

that add sunscreen to your clothing. Hats with a threeinch brim all the way around extend the most protection 

to the head, face, ears and lips. 

Cancer research and studies show that the incidence 

of melanoma is rising. Equally as concerning is the fact 

that melanoma is becoming the major cancer of young 

people. Protecting against UV radiation is the best prevention. 

Mr. Rudolph, a retired Navy chief hospital corpsman, worked as a 

researcher in the Naval Safety Center’s aeromedical division.

32 DECISIONS Spring-Summer 2015
Source: Skin Cancer Foundation

Source: Therapeutic Derma Limited

Source: Melanoma Foundation New England

THE A-B-C-D-E CHARACTERISTICS OF MELANOMA

NORMAL MOLE MELANOMA SIGN CHARACTERISTIC

A

Asymmetry

Half of the mole does 

not match the other half.

The border (edges) of 

the mole are ragged or 

irregular.

The color of the mole 

varies throughout.

The mole’s diameter is 

larger than a pencil’s 

eraser.

The mole has changed 

over the last few weeks 

or months.

B

Border

C

Color

D

Diameter

E

Evolving

SPF indicates how well that product blocks ultraviolet 

rays. There are two types of UV rays that sunscreens 

are designed to block: UVA and UVB. SPF describes the 

sunscreen’s ability to block UVB rays. The Federal Drug 

Administration does not have a UVA protection rating 

system at this time. UVA radiation penetrates deeper and 

contributes to premature aging and wrinkling.

WHAT IS AN SPF?

SPF RATING = UVB PROTECTION

SPF 100 99%

SPF 50 98%

SPF 30 97%

SPF 15 93%

SPF 2 50%

None = 0%

SPF CHART: WHICH LOTION IS FOR YOU?

Each time your skin burns in the sun, it accelerates aging. 

The SPF acts as a sunburn time meter allowing tanning 

without getting burned from UVB light.

Source: Beyond Coastal Suncare

THE DANGERS

OF TANNING

There is another risk factor related to a popular pastime: tanning in the 

sun or in a tanning bed. Understanding that tanning is bad for your skin’s 

health is one thing. How to protect the body from the effects of tanning bed 

radiation is another. Here are some facts to consider:

• People who use tanning beds once a month before the age of 35 

increase their melanoma risk by 75 percent.

• The more you tan and the younger you start tanning, the more likely it is 

that you will get melanoma.

• Using a tanning bed for 20 minutes is equivalent to spending one to 

three hours a day at the beach with no sun protection at all.

• Tanning beds put out three to six times the amount of radiation given off 

by the sun.

ONLINE RESOURCES 

National Cancer Institute 

http://www.cancer.gov 

Skin Cancer Foundation 

http://www.skincancer.org

American Cancer Society 

http://www.cancer.org 

American Melanoma Foundation

www.melanomafoundation.org

Heat Index Charts

http://www.public.navy.mil/comnavsafecen/

pages/ashore/off-duty_rec/

RODSResources.aspx

Spring-Summer 2015 DECISIONS 33