Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 [email protected] 110 MDG/SGP

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

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Lt Col Kevin J. BohnsackDSN 580.3565, Comm 269.969.3565

[email protected] MDG/SGP

Aircraft Mishap Response and

Investigation

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 2

You get the call…


…so now what do you do?

NotificationResources Immediate Response Interim Safety Board

– Evidence Collection– Aircrew & Witness Interviews

Additional Considerations– PA– Mishap Classifications

Safety/Accident Investigation BoardsHuman Factors Analysis


Source Documents

AFI 91-202 AIR NATIONAL GUARD Supplement to AFI 91-202AFI 91-204 Safety Investigations and ReportsAFI 51-503 Aerospace Accident InvestigationAFI 91-206 Participation in a Military or Civilian

Accident Safety Investigation (NTSB)AFPAM 91-211 USAF Guide to Safety Investigation

The Society of United States Air Force Flight Surgeons Aircraft Mishap Investigation Handbook (Sixth edition dated April 2010)

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Flight Surgeon Handbook and AFPAM 91-211

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Assistance

Chain of Command Wing Safety Air Force Safety Center (AFSC)– Human Factors Division:

Flight Surgeon (DSN 263-4868, Comm 505-853-4868) – Col Berg

Aerospace Physiology (DSN 246-0986) – Maj Tugliese Pilot (DSN 246-0830, Comm 505-846-0830)

– Aircraft Engineering Technical Assistance (DSN 246-5867 or comm 505-846-5867)

Armed Forces Medical Examiner System (AFMES), formerly known as the Armed Forces Institute of Pathology (AFIP)

National Guard Bureau (NGB)

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Resources / Thanks

Air Force Safety Center

Division of Forensic Toxicology Armed Forces Medical Examiner System

Building 115, Purple Heart DriveDover AFB, DE 19902

DSN: 366-8724 Phone: (302) 346-8724

Col William Pond, Indiana ANG SAS– Recommend: Pond’s Pearls

Lt Col David Hardy, RAM ‘09 BravoLt Col Fred Black, North Dakota ANGMSgt Michelle Saatoff, North Dakota ANG

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Notification

WHO – Aircrew, souls on board, first responders (fire, security,

medical, safety, and BEE’s)WHAT

– Aircraft type, materials on board (tower, manifest)WHERE

– On- or off-base, environment (woods, water, current weather)WHEN

– Anticipated duration of response (e.g. food, water)– Time constraints (e.g. safety, time of day, predicted weather)


Resources

Mishap Investigation Kit– Medical supplies– Nitrile gloves, leather gloves, Tyvek suit, dust mask– Digital camera, photographic ruler, grease pen, evidence

collection tags– Lab collection vials / needles – KEEP THEM CURRENT IF

YOU CHOOSE TO HAVE THOSE AVAILABLE!Clothing

– Cold weather or rain gear– Boots

Infrastructure– Tentage / Comm / Trans – “For want of a nail.”– Food / Water – “An army marches on its stomach.” -Napoleon


Site Hazards

Scene Safe– Follow direction of OSC (usually Fire Chief)

PPE– Follow direction of OSC & BEE’s

Know what hazards you are dealing with! – Survey the Site!– Know toxic substances unique to aircraft

Limit access to site– Brief all personnel on hazards before entry

Don’t put your hands where you can’t see! (sts)


Site Hazards

Environmental Hazards– Hot, cold, sun, wind, rain, snow, “critters”

Biological Hazards– Blood borne Pathogens

Fire Hazards– Fuel– Other fluids


Site Hazards

Radioactive Hazards– Control Surface Counterweights = depleted

uraniumMaterial Hazards

– Composites – Explosives (ammo, pyrotechnics, etc)– Pressure Vessels (tires, O2 cylinders, etc)– Sharp Edges


Composites

F-15 F-16 F-117 B-2 Atlas V

U-2F-22F-14B-1BDelta IV

Defer to Fire Department regarding materials involved.


Site Hazards/PPE


Site Hazards


Site Hazards/PPE


Site Hazards


Site Hazards


Immediate Response

Patient Care– Treat injuries– Obtain information of medical necessity (Information

re: the mishap sequence is potentially privileged information.)

– 72 hour and 2 week history– Separate crew members if at all possible for interviews

under direction of the Interim Safety Board (ISB)(Treatment of Survivors checklist is useful from

the Handbook)


Identification

Obtain accurate flight manifest/SSNs– Allows DNA cards to be pulled quickly

Identifies all flight crew & passengersSurvivability assessmentClosure for family

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Identification

Presumptive - identifies individual to sub-group (initial)

Positive - legal identification based on forensics

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Presumptive Identification

Flight manifestVisual (tattoos)AnthropomorphicPersonnel dataPersonal effects

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Positive Identification

DentalFingerprintsPalm printsFoot printsDNARadiographic ID

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Positive ID timeframe

Dental 1 - 2 hoursFingerprints 24 - 48 hoursDNA 48 hours

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Records

Gather all Names/SSNs Obtain status & nationalitySequester all records early

– Medical– Dental– Behavioral health– Civilian– Radiology records

Do not permit changes “after the fact”Sequester all medical/dental imaging

evidence

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Forensic Toxicology Guidelines

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Toxicology

SAMPLES Two 10 ml red tops Three 7 ml gray tops Three 7 ml purple tops 50-70 ml urine (no preservative)(CLEAN SKIN WITH BETADINE OR SOAP/WATER – NO

ALCOHOL SWABS!)

Run local tests: glucose, BAT, CBC, SMA-18, and U/A

Follow direction of Forensic Toxicology handbook from AFMES for shipping.

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Toxicology (continued)

AFMES 1323Medication History and Mishap DetailsUse the AFMES 1323 / Verify a reliable address

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Toxicology (continued)

Chain of Custody – Have a plan for security/storage while awaiting shipment

Commercial vendors ideal for accountability/tracking

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Postmortem Examination

X-rayAutopsy

ToxicologyLabAncillary studies

(Fatalities checklist is useful from the Flight Surgeon’s Handbook)

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X-rays

Full body clothedHands/feet/head/neckPermanent evidence of injuriesAll parts/pieces of all bodies must be x-rayedSurvivors need x-rays in some cases

– ejectionDemonstrates fractures/morphology

– mechanism of injury

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Autopsy Jurisdiction

Local Coroner vs. Flight Surgeon– Coroner/ME usually has jurisdiction on/off base

Dictated by MOU’s, State laws, & SOFA (for OCONUS)

– FS can perform “over-the-shoulder”– Call AFMES for coordination

Initial Response: Remains should be tagged, photographed and removed from the field

Involve Flight Surgeon and Mortuary AffairsWith large complex mishap -- may take days


Autopsy

Involve AFMES (Armed Forces Medical Examiner System) early

Crew members involved, preferably all victims Photography of remains as recovered Documentation of all injuries External examination of injuries Internal examination- chest, abdomen, cranial vault Dissection of soft tissue injuries Laminectomy if needed Documenting all injuries & natural disease Forms to perform autopsy available online at

www.afmes.mil

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Psychological Support Life Skills & Chaplain

– Activated by Wing/CC– CISM (Critical Incident

Stress Management) is no longer a standard approach

– Individual comfort

Mishaps with Fatalities






Agenda


Interim Safety Board (ISB)

Performs initial walk-through & secures siteGathers evidenceMirrors SIB membership

– Board President (BP) Usually OG or DO Overseeing functions of ISB

– “Investigating” Officer (IO) Usually a Wing FSO At scene, documenting/preserving evidence


ISB (continued)

– Pilot Member (PM) Usually Sq/FSO or Wing DOV Gathering FEF folder, training records, WX, etc.

– Flight Surgeon (FS) Local Flight Doc Survivor care or helping with remains

– Maintenance Member (MM) Usually Wing/Sq Mx Officer Gathering A/C records, fluid samples, etc

Plus ... all accomplish initial interviews


ISB Flight Surgeon Timeline

8 hour message24-48 hrs

– 72 hr & 14 day histories on all involved– Review of records & images– Notifications– Collect lab specimens & results– Preservation/shipment of items to AFIP– Interview witnesses

Begin data entry into AFSASTransfer all information/evidence to SIB FSRemain available for questions

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Agenda


Evidence Collection

Observe– Do not disturb– Document people involved (aircrew & witnesses),

weatherRecord

– Photography– Sketches & Notes

CollectPreserve


Observe

Don’t be in a hurry to move wreckage– All required photographs are taken and properly

“cataloged” – Mortuary Affairs issues/photographic support as

wreckage recovered– Technical experts need to do preliminary

work/analysis prior to moving– Need a good game plan

Note who was involved in crash and who witnessed the event


Initial Walk Through

Meet and coordinate approach with OSC – Off-site if possible – Understand hazards

Strive for a “macro” look at the site– Key to determining follow-on support

ID all major parts– Do not disturb or move parts– Coordinate with ISB or SIB/BP if you do


Assume “Control”

Every Situation is Different– Site Declared “Safe” by Senior Fire Official– Site may be Underwater

With No Fatalities– EOD Safe– Security Cordon– Hazards: Biological, Materiel, Environmental, etc.


Ways to Secure the Mishap Site

If a major accident occurs on property under civil jurisdiction, the involvement of military resources in the accident gives the AF no specific rights or jurisdiction

Have PA / OSC explain to Media, Local Law Enforcement, Property Owner, etc., why we need to control site– Evidence preservation can be “weak” argument– Better approach is to explain wreckage is hazardous

and that it is for the “Protection of the public”SIB/BP or Wing/CC has authority to impound.


Ways to Secure the Mishap Site

National Defense Area (NDA)– Sometimes a last resort

Implemented by OSC on behalf of CC– NDA temporarily places non-federal lands under effective

control of DoD– Used to protect priority resources

Mandatory for nuclear mishaps– May have to compensate landowners for “take-over”

Implement Overfly Restrictions– Notify Wing Commander– Establish a NOTAM– OSC & BP work with FAA through Base Ops


Moving Wreckage

An installation commander may choose to remove wreckage interfering with mission activities or causing a hazard at mishap site.






Initial “Walk Through”


Evidence Collection


weatherRecord


CollectPreserve


Photography

Purpose– Documents the mishap– Educates people who could not observe the site

firsthandRules of Thumb

– Over shoot and under print– Document each photograph!!!

Aerial Photos– CAP, Coast Guard, SAR, wing assets, alert A/C


Photography

Digital – 8 Megapixel– Save all memory cards for future reference– Do not delete “bad” pictures

Generic Time-Sensitive Facts– Potentially significant evidence…Ground scars, etc.– Medical evidence… Human remains– Wreckage– Damage to private property (for legal purposes)– Witness’ Point-of-View


Photography

“Required” Views– Overall View– Mid-Range – focus on the damage– Close-up– Extreme Close-up with Photographic Ruler


Photography


Photography…What is it?


Photography


Photography


Photography


Photography


Evidence Collection


weatherRecord


CollectPreserve


Sketches

Diagram of crash site– Work with CE– GPS for exact impact coordinates– Not necessary to plot all pieces, just critical

evidence and major pieces to get an idea of the pattern

– Should complement photographs– Use legend if it will avoid clutter– Include statements: “not to scale” and “applied

North” if applicable


Mishap Site Diagram


Mishap Site Diagram


Mishap Site Diagram


Mishap Site Diagram

I n t e g r i t y - S e r v i c e - E x c e l l e n c eAs of: 66

Evidence Collection


weatherRecord


CollectPreserve


Collect

Methods– Grid– Zone

Evidence Tag (AF Form 52)– WHO collected specimen– WHAT condition the specimen was in when

found– WHERE specimen was collected (GPS, map

coordinates, etc.)– WHEN date and time


Evidence Collection


weatherRecord


CollectPreserve


Preservation

Initial Interviews– Direct Involvement: Participants, Eyewitnesses,

Wingmen, etc.– Indirect: Schedulers, Crew Chiefs, SOF,

maintenanceFluid Samples (One Pint Minimum)

– From mishap aircraft– AGE and Servicing Equipment– Originating and enroute locations– Air Refueling?


Preservation

Other considerations:– ATC voice and RADAR tapes– Wingman’s aircraft for FDR, HUD tape, etc.– Other airborne aircraft (AWACS, Tanker, etc. )

Data Recorders– One item ISB can “work” now– AFSC will provide guidance on locating and

preserving other sources of data Engine memory, structural recorders, avionics, etc.

– Before shipping recorders for downloading…

Contact AFSC/SEFE (246-5867)


Preservation

Accomplish TOX Testing– For Class A & B flight mishaps test aircrews– For Class A, B, or C mishaps test individuals

whose actions or inactions, in the Commander’s judgment may have been a factor

– Obtain a letter from the wing commander to authorize the collection/tox testing.

– ContractorsBy consent or if a provision of the contract






Agenda


Aircrew Interview

Documentation of medical facts should be on an SF600 and/or AHLTA. Histories may be obtained via a questionnaire developed locally.– 72 hour history (sleep/previous sorties/food)– 2 week history (stressors/circadian rhythm)

Remote Piloted Aircraft (RPA) – specific directives on collecting information on crews operating the aircraft during and preceding the event for Class A and B as well as the most recent maintenance crew. Two separate boards may be stood up at the duty station and in the area of operation as applicable.


ISB Witness Interview

Promise of Confidentiality?“Tell me what happened”“Tell me what you saw”Few follow-on questions


Witness Identification

Survivors / RelativesTransient WitnessesLocal EyewitnessesOn Duty witnesses


Safety Privilege

Encourages frank & open communication with witnesses/contractors

Allows commander to quickly obtain accurate mishap information

Helps ensure appropriate corrective action

Ultimately, enhances national security and aviation safety

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Promise of Confidentiality…Two Part Promise– AFI 91-204, Chapter 3 - overview– AFI 91-204 Figure A3.3 1c.

“…my confidential statement(s) … will not be made public and it will only be used by authorized officials solely for mishap prevention purposes. … I understand, however, that my statement can be released pursuant to a valid court order on behalf of the defendant in a criminal trial. I further understand that if my statement contains an intentional misrepresentation, then my statement will no longer be considered confidential and can be used to support disciplinary and/or administrative actions against myself and/or others.”

Safety Privilege


Who is Authorized to Make Promise of Confidentiality– Primary duty safety personnel – ISB and SIB members

Who may Receive Promise of Confidentiality– Any witness– Includes contractors who designed, built, or

maintained equipment

Safety Privilege


When is Promise Given?– Investigator discretion to encourage witness or

contractor cooperation– Not on blanket basis to every witness

Document the Promise– Use draft templates, AFI 91-204, Chapter 2, to

document promise and to document when promise is not given

Safety Privilege


Murphy’s Laws of Witnesses

Regardless of the physical evidence to the contrary, at least one credible witness will come forward stating the aircraft was on fire prior to ground impact

For every witness statement there will be an equal and opposite witness statement


ISB Lessons Learned

Secure evidence and don’t tamper with it!Conduct recorded interviews with mishap

aircrew immediately– but not to the detriment of medical care!

Methodical turnover to SIB– ISB should stick around for a few days– Keep tabs on ISB members… future questions

Ensure privilege statement on initial interviews

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Agenda


PA Support

Provides initial news release to media – Within one hour of mishap– Coord on all news releases and pictures– Solicits & monitors media support & interest

Guides news media’s access to mishap Site– Relationship with local media very important– OSC can’t restrict access on private property– PA can explain hazards, keep media at distance

Deflect publishing photos of remains


Media Relations

Refer all questions to Public Affairs– Only the board president is authorized to release info

Use extreme courtesyDon’t speculate on mishap causePolitely ask civilians & media not to photograph

fatalities or classified items– Contact security forces if necessary

Refer potential claimants to JAAvoid media; let SIB/AIB do its job

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Release of Information “What Not To Say !!”

Mishap responsibilityFailure of equipment or facilitiesLegal liability of the governmentClassified informationCauses, factors or recommendationsFactors not causal in the mishapStatements, quotations or opinions from witnesses

or other privileged sources

Bottomline: “Please refer to PA.”


Mishap Classification

Classify mishaps by– Direct Cost– Fatality, severity of Injury or degree of illness

Class of Mishap– A, B, or C as well as Class E physiologicals

If mishap class in doubt– AF Safety Center can (and will!) assist

Access to experts to determine “best guess” dollar estimate

AFI 91-104 1.10


Class A Mishap

Destroyed aircraftGreater than $1 M in damages to airframeFatality or permanent total disability of crew

or passengers

AFI 91-104 1.10 87


Class B Mishap

Greater than $200k in damagePermanent partial injury to crew or

passengersHospitalization of three or more people

AFI 91-104 1.10 88


Class C Mishap

Greater than $20 K damageLost work day or days

AFI 91-104 1.10 89


Class D Mishap

Restricted work day or days

AFI 91-104 1.10 90


Class J Mishap

Engine mishapsForeign Object Damage, BASH

AFI 91-104 1.10 91


Class E Mishap

Events that don’t meet A, B, or C criteriaTrending for safety/mishap prevention

Physiologic incidents

AFI 91-104 1.10 92


Scenario Discussion


Scenario Discussion


Scenario Discussion


Scenario Discussion


Scenario Discussion


Scenario Discussion


Scenario Discussion


Scenario Discussion






Agenda


Purpose of Investigation

Find underlying cause/explanation Future mishap preventionImprove risk management/ORMImprove safety processPreservation of combat resources

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Safety Investigations

NOT To Fix BlameNOT Merely to Gather EvidenceNOT Used for Disciplinary Purposes

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Safety Mishap Investigation Boards

Interim Safety Board (ISB)– Preserve evidence until permanent safety board arrives– Gather pertinent data that may be lost over time– Accomplish initial actions for permanent board

Wing Mishap Response Plan (MRP)– Lists ISB member duties– Checklists available for all base agencies

Safety Investigation Board (SIB) - AFI 91-204– Mishap prevention– Determine cause(s)– Recommend corrective actions– Privileged report, partially

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Accident Mishap Investigation Board

Accident Investigation Board (AIB) - AFI 51-503– Claims & litigation– Disciplinary action– Adverse administrative actions– Publicly releasable report

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Board Composition

Full Board - Class A, full compliment of members

Tailored Board- only the required board members (determined by convening authority)

Single investigator- when formal board not required

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Board Member Selection

ISB Chosen By WG/CCSIB Appointed by MAJCOM/CC

– Safety Office Researches Availability Annotates Adverse Impact To Individual And / Or Wing Seeks Members With Desire To Be Chosen Always A Short Notice Suspense

– Wing CC Approves Local List Submitted To MAJCOM

– MAJCOM/CC Appoints

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Members

Board President (Rated Colonel or O-7 for Fatality) Investigating OfficerMaintenance MemberMedical OfficerPilot MemberAFSC RepresentativeRecorderTechnical Assistance Members As Required

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Flight Surgeon Role

Medical expert for board members Liaison to Mortuary Affairs/AFIPTeam leader for all Life SciencesAdvisor for:

– Search & Rescue Team (SAR)– Human factors– Human survivability– Aircrew medical qualification– Lifestyle– Crew rest analysis

Family liaison

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Flight Surgeon Liaison

Flight surgeon jobLocal coroner/MELocal emergency medical careLocal FS/interim boardPathologyAFIP consultant for investigation,

photography, and autopsy

110


Medical Analysis/Pathology

AutopsyForensic identificationDental evaluationDNA analysisPhotographyExamination of flight/life support gearEvaluates medical history/evidenceDetermines circumstances of death

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Flight Surgeon Role4-6 week commitment PLUS presentations later on Interview or history-taking expert on boardAssist Line board members in understanding human

issues/factors involved in mishapConsultations (aerospace physiology, aviation psychology,

life support)Assist survivors, direct/indirect

– Victims– Families– Board

Team supportData entry into AFSASTab Y

112


Accident & InjuryAccident & Injury

Latent Conditions

Latent Conditions

Latent Conditions

Active Conditions

Failed orAbsent Defenses

After Reason (1990)

HAZARDHAZARD

Swiss Cheese Model

OrganizationalInfluences

Supervision

Preconditions

Acts

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DoD Human Factors (HFACS)

ActsErrorsViolations

SupervisionInadequate SupervisionPlanned Inappropriate OperationsFailure to Correct Known ProblemsSupervisory Violations

PreconditionsEnvironmental FactorsCondition of IndividualsPersonnel Factors

Organizational InfluencesResource/Acquisition ManagementOrganizational ClimateOrganizational Processes

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Fly Awake / FAST Program

As of: 115


Simulations

116


Schweaty’s Bullets

Gain operational SA– Your assigned airframe– Other assigned airframes

Check your AFSAS– Sign up for notifications on airframes of interest.– Gain familiarity with the interface.

Get involved with Safety office– The first time you meet your wing or flight safety officer should not

be in the field!– Participate in monthly or quarterly flight safety meetings.

Clarify and Exercise your capabilities.– Involve MDG and other wing players.– Ensure MOU’s in place with respective AD bases for ANG/AFR and

local community/host nation if needed

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Review



