Fatality Briefing 1 of 3

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Fatality Briefing 1 of 3
OVERALL BRIEFING CLASSIFICATION
UNCLASSIFIED Sanitized
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Executive Summary

• Three airmen were hiking on an unmarked
  mountainous path that quickly narrowed with a
  ravine on one side
• One airman (leader of the group) went ahead to
  scout area and was fatally injured after falling
  approximately 101 feet into the ravine Poor
  Risk Assessment
• Airmen had not received any formal training or
  high risk activities briefings
• Airmen were unfamiliar with this particular area
  and had no safety equipment
• The fatal airman proceeded forward in an area not
  marked for hiking

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Take-Away Points

• Conduct a thorough risk assessment to
• Identify all the hazards (step-by-step)
• Plan preventative measures to counter identified
  hazards
• Obtain training for high-risk activities
• Obtain proper PPE for activity at hand
• Become familiar with surroundings/stay on marked
  paths
• Be aware of personal limitations and never exceed
  them
• Never become overconfident in personal abilities

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Deceased Member

• Male, A1C, 21 years old
• Single, no children
• Alcohol not a factor
• Member suffered severe head/neck trauma sustained
  in mishap
• Line of Duty Determination was initiated by
  medical authority
• LOD completed Determined to be In-Line of Duty
  Willful Neglect (Approx Cause)

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72 Hour History

• 18 April
• Spent day painting and cleaning dorm room for
  dorm out- processing inspection
• 19 April
• Completed squadron out-processing actions, mailed
  packages and reserved a rental car for the
  weekend
• 20 April
• Completed last minute out-processing actions and
  picked up rental vehicle
• 2200 hrs -
• Went to base theater with friends to watch a
  movie. After movie, they made plans to go hiking
  the next day (21 Apr). Deceased member returned
  to his room and went to bed at approx 0100 hrs

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Sequence of Events

• 21 April
• 1030 hrs Deceased member and friends met and
  ate breakfast
• 1200 hrs - All three Airmen proceeded to
  destination to begin hike
• 1300 hrs - Airmen walked around the hiking area
  for about five minutes before deciding to follow
  / explore path accident occurred on
• 1305 hrs - Approx 5 minutes into hike, friends
  lose sight of deceased member he had made his
  way around a corner

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Sequence of Events

• 21 April (contd)
• 1310 hrs Friends heard rocks falling and tree
  branches breaking they called out to deceased
  member and he responds that he was safe
• Moments later, friends again hear rocks falling
  and tree branches breaking they called out
  again and did not receive a reply
• Friends made their way back to the starting point
  and used a cell phone to call for emergency
  assistance
• Other friend attempted to search for the deceased
  member by swimming up a small stream with no
  success
• Friends discontinued their active search and
  returned to their starting point to await
  emergency personnel
• 1530 hrs - local search and rescue personnel
  arrive and recovered deceased members body

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Mishap Causes

• Airmen were unfamiliar with this particular area
  and had no safety equipment
• Airmen had not received any formal training or
  high risk activities briefings
• The deceased member proceeded forward in an area
  not marked for hiking

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Factors Ruled Out

• Alcohol
• Suicide

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Contributing Factors

• Team did not conduct an adequate risk assessment

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Risk Factors

• 21 yr old male Airman overconfidence

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Conclusions

• Why did this mishap occur?
• Poor operational risk management
• The deceased member was not fully cognizant of
  the risk associated with his actions

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Fatality Briefing 2 of 3
OVERALL BRIEFING CLASSIFICATION
UNCLASSIFIED Sanitized
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Executive Summary

• Deceased member purchased motorcycle without
  prior training
• Because he was not trained, deceased member was
  unable to register motorcycle
• Deceased members friend removed license plates
  from one of his motorcycles and put them on
  deceased members motorcycle
• Friend drove deceased members motorcycle to his
  house and intended to store it in his garage
  until deceased member received training
• For reasons unknown, deceased member elected to
  remove motorcycle from friends garage and
  operate it prior to obtaining training
• Deceased member lost control of motorcycle in a
  curve, sideswiped a vehicle in the on-coming lane
  and was ejected into the windshield of another
  on-coming vehicle

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Take-Away Points

• Receive proper training prior to operating
  motorcycles
• Be aware of personal limitations and never exceed
  them
• Never become overconfident in personal abilities
• Wingmen never allow a friend to place license
  plates on an unregistered vehicle

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Deceased Member

• Male, SSgt, 25 years old
• Married, 3-year old son
• Alcohol not a factor
• Member died of severe trauma sustained in
  accident
• Line of Duty Determination was initiated by
  medical authority
• LOD is in work, currently in Legal Review

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72 Hour History

• 3 Jul
• Worked normal duty day from 1500-2300
• 1500 hrs- Received flight Holiday Safety Briefing
• Uneventful night
• 4 Jul
• 1200 hrs- Deceased member received a call from
  friend planning days activities
• 1300 hrs- Deceased member and friend drove to a
  motorcycle dealership to pick up deceased
  members new motorcycle
• Friend drove motorcycle back to his house with
  the intent to leave it in his garage until
  deceased member was trained
• 2300 0200 hrs- Deceased member and friend went
  to night club deceased member was Designated
  Driver and did not drink

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Sequence of Events

• 5 Jul
• 0200 hrs- arrived at friends house Deceased
  member remained there until his departure at an
  unknown time
• 1200 hrs- Friend awoke and noticed deceased
  member and his motorcycle were gone
• 1320 hrs- Deceased member attempted to traverse a
  slight curve on motorcycle
• - Unknown reason, crossed center line into
  on-coming traffic
• - Sideswiped first vehicle then collided with
  second vehicle

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Mishap Cause

• Member had NO motorcycle training
• Member operated a bike that exceeded his
  capability

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Factors Ruled Out

• Bad Debts
• Lack of Supervision
• Work Stressors
• Weather
• Alcohol

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Contributing Factors

• New, powerful motorcycle (Aprilla 1000)
• Human Performance Factors
• Separation from family
• Returned from recent deployment
• Spouses Pregnancy
• Identified pregnancy after arrival in the states
• Medical advise was to NOT return to home station
  until after delivery

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Risk Factors

• Deceased member was not prone to unsafe acts
• Volunteered for AADD, frequent DD for flt and sq
  events
• He had no issues on his driving record at current
  duty location
• Counseled twice for expired insurance
• He was known as a safety conscious individual and
  supervisor

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Conclusions

• Deceased member died because he decided to ride a
  motorcycle he was not qualified on
• This was not characteristic behavior for him

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Fatality Briefing 3 of 3
OVERALL BRIEFING CLASSIFICATION
UNCLASSIFIED Sanitized
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Executive Summary

• Deceased member consumed alcohol between 2230 and
  0215
• For unknown reasons, the deceased member decided
  to operate his privately owned vehicle while
  under the influence of alcohol
• While negotiating a left-hand curve, the deceased
  member lost control of his vehicle, crossed the
  centerline and slide sideways into a tree

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Take-Away Points

• Never operate a vehicle while under the influence
  of alcohol
• Ensure Wingmen are tuned into possible
  uncharacteristic behaviors of their friends
• Take appropriate action to head-off any negative
  consequences of such behavior

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Deceased Member

• Male, SSgt, 25 years old
• Married with no children
• Alcohol was a factor
• Member died of blunt force trauma sustained in
  the accident
• Line of Duty Determination Pending
• Drug tests negative
• Toxicology identified positive alcohol in
  members system
• Based on tox test, SQ/CC requested formal
  investigation

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72 Hour History

• 22 Jun
• Completed full duty shift, 0700 to 1600
• Received safety briefing by flight Chief at 1230
  roll call
• Rest of day was uneventful
• 23 Jun
• Day was uneventful
• 2100 Went to Enlisted Club with spouse
• Drank 3 4 beers
• Spouse drove home

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Sequence of Events

• 24 Jun
• Day was uneventful
• 2230 Went to bed with spouse
• 2306 Post made on internet webpage
• Consumed alcohol sometime between 2230 and 0215
• 25 Jun
• 0200 Checked balance at ATM
• 0220 The deceased member traveled around a
  curve at approximately 70 kph (20 kph over posted
  speed limit)
• Deceased member lost control, slid sideways into
  the on-coming lane and struck a tree on the
  drivers side

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Mishap Cause

• Excessive speed
• 70 kph in a 50 kph zone
• Road conditions were wet and fog was in area
• Alcohol
• Blood alcohol .24 and .29 at 0500
• Confirmed levels by American toxicology

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Factors Ruled Out

• Work History
• Driving History
• Attitude/Behavior
• Vehicle Conditions
• Personal Stressors

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Contributing Factors

• Road surface
• Weather
• Time
• Fatigue
• Lack of a wingman

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Risk Factors

• None identified

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Conclusions

• Most significant contributing factors
• Alcohol
• Excessive Speed
• Supervisors were not aware of any current at-risk
  behaviors

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Safety Starts with You!BE SAFE