Lt Col Kevin J. Bohnsack

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Aircraft Mishap Response and Investigation
Lt Col Kevin J. Bohnsack DSN 580.3565, Comm
269.969.3565 kevin.bohnsack_at_ang.af.mil 110 MDG/SGP
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You get the call

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so now what do you do?

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

4
Source Documents

• AFI 91-202
• AIR NATIONAL GUARD Supplement to AFI 91-202
• AFI 91-204 Safety Investigations and Reports
• AFI 51-503 Aerospace Accident Investigation
• AFI 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 SystemBuilding
  115, Purple Heart DriveDover AFB, DE 19902
• DSN 366-8724   Phone [phone]
• Col William Pond, Indiana ANG SAS
• Recommend Ponds Pearls
• Lt Col David Hardy, RAM 09 Bravo
• Lt Col Fred Black, North Dakota ANG
• MSgt Michelle Saatoff, North Dakota ANG

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Notification

• WHO
• Aircrew, souls on board, first responders (fire,
  security, medical, safety, and BEEs)
• 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)

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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

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Site Hazards

• Scene Safe
• Follow direction of OSC (usually Fire Chief)
• PPE
• Follow direction of OSC BEEs
• 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
• Dont put your hands where you cant see! (sts)

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Site Hazards

• Environmental Hazards
• Hot, cold, sun, wind, rain, snow, critters
• Biological Hazards
• Blood borne Pathogens
• Fire Hazards
• Fuel
• Other fluids

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Site Hazards

• Radioactive Hazards
• Control Surface Counterweights depleted uranium
• Material Hazards
• Composites
• Explosives (ammo, pyrotechnics, etc)
• Pressure Vessels (tires, O2 cylinders, etc)
• Sharp Edges

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Composites

• F-15
• F-16
• F-117
• B-2
• Atlas V

• U-2
• F-22
• F-14
• B-1B
• Delta IV

• Defer to Fire Department regarding materials
  involved.

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Site Hazards/PPE
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Site Hazards
 
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Site Hazards/PPE
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Site Hazards
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Site Hazards
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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)

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Identification

• Obtain accurate flight manifest/SSNs
• Allows DNA cards to be pulled quickly
• Identifies all flight crew passengers
• Survivability assessment
• Closure 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 manifest
• Visual (tattoos)
• Anthropomorphic
• Personnel data
• Personal effects

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Positive Identification

• Dental
• Fingerprints
• Palm prints
• Foot prints
• DNA
• Radiographic ID

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Positive ID timeframe

• Dental 1 - 2 hours
• Fingerprints 24 - 48 hours
• DNA 48 hours

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Records

• Gather all Names/SSNs
• Obtain status nationality
• Sequester 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 1323
• Medication History and Mishap Details
• Use 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/tracki
  ng

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Postmortem Examination

• X-ray
• Autopsy
• Toxicology
• Lab
• Ancillary studies
• (Fatalities checklist is useful from the Flight
  Surgeons Handbook)

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X-rays

• Full body clothed
• Hands/feet/head/neck
• Permanent evidence of injuries
• All parts/pieces of all bodies must be x-rayed
• Survivors need x-rays in some cases
• ejection
• Demonstrates 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 MOUs, 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 Affairs
• With large complex mishap -- may take days

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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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Mishaps with Fatalities

• Psychological Support
• Life Skills Chaplain
• Activated by Wing/CC
• CISM (Critical Incident Stress Management) is no
  longer a standard approach
• Individual comfort

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Agenda

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

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Interim Safety Board (ISB)

• Performs initial walk-through secures site
• Gathers evidence
• Mirrors 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

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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

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ISB Flight Surgeon Timeline

• 8 hour message
• 24-48 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 AFSAS
• Transfer all information/evidence to SIB FS
• Remain available for questions

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Agenda

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

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Evidence Collection

• Observe
• Do not disturb
• Document people involved (aircrew witnesses),
  weather
• Record
• Photography
• Sketches Notes
• Collect
• Preserve

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Observe

• Dont 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

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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

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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.

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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.

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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

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Moving Wreckage

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

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Initial Walk Through
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Initial Walk Through
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Initial Walk Through
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Evidence Collection

• Observe
• Do not disturb
• Document people involved (aircrew witnesses),
  weather
• Record
• Photography
• Sketches Notes
• Collect
• Preserve

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Photography

• Purpose
• Documents the mishap
• Educates people who could not observe the site
  firsthand
• Rules of Thumb
• Over shoot and under print
• Document each photograph!!!
• Aerial Photos
• CAP, Coast Guard, SAR, wing assets, alert A/C

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Photography

• Digital
• 8 Megapixel
• Save all memory cards for future reference
• Do not delete bad pictures
• Generic Time-Sensitive Facts
• Potentially significant evidenceGround scars,
  etc.
• Medical evidence Human remains
• Wreckage
• Damage to private property (for legal purposes)
• Witness Point-of-View

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Photography

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

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Photography
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PhotographyWhat is it?
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Photography
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Photography
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Photography
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Photography
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Evidence Collection

• Observe
• Do not disturb
• Document people involved (aircrew witnesses),
  weather
• Record
• Photography
• Sketches Notes
• Collect
• Preserve

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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

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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
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Evidence Collection

• Observe
• Do not disturb
• Document people involved (aircrew witnesses),
  weather
• Record
• Photography
• Sketches Notes
• Collect
• Preserve

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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

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Evidence Collection

• Observe
• Do not disturb
• Document people involved (aircrew witnesses),
  weather
• Record
• Photography
• Sketches Notes
• Collect
• Preserve

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Preservation

• Initial Interviews
• Direct Involvement Participants, Eyewitnesses,
  Wingmen, etc.
• Indirect Schedulers, Crew Chiefs, SOF,
  maintenance
• Fluid Samples (One Pint Minimum)
• From mishap aircraft
• AGE and Servicing Equipment
• Originating and enroute locations
• Air Refueling?

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Preservation

• Other considerations
• ATC voice and RADAR tapes
• Wingmans 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)

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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 Commanders
  judgment may have been a factor
• Obtain a letter from the wing commander to
  authorize the collection/tox testing.
• Contractors
• By consent or if a provision of the contract

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Agenda

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

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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.

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ISB Witness Interview

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

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Witness Identification

• Survivors / Relatives
• Transient Witnesses
• Local Eyewitnesses
• On Duty witnesses

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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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Safety Privilege

• Promise of ConfidentialityTwo 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.

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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

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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

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Murphys 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

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ISB Lessons Learned

• Secure evidence and dont 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

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

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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 medias access to mishap Site
• Relationship with local media very important
• OSC cant restrict access on private property
• PA can explain hazards, keep media at distance
• Deflect publishing photos of remains

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Media Relations

• Refer all questions to Public Affairs
• Only the board president is authorized to release
  info
• Use extreme courtesy
• Dont speculate on mishap cause
• Politely ask civilians media not to photograph
  fatalities or classified items
• Contact security forces if necessary
• Refer potential claimants to JA
• Avoid media let SIB/AIB do its job

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Release of Information What Not
To Say !!

• Mishap responsibility
• Failure of equipment or facilities
• Legal liability of the government
• Classified information
• Causes, factors or recommendations
• Factors not causal in the mishap
• Statements, quotations or opinions from witnesses
  or other privileged sources
• Bottomline Please refer to PA.

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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
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Class A Mishap

• Destroyed aircraft
• Greater than 1 M in damages to airframe
• Fatality or permanent total disability of crew or
  passengers

AFI 91-104 1.10
88
Class B Mishap

• Greater than 200k in damage
• Permanent partial injury to crew or passengers
• Hospitalization of three or more people

AFI 91-104 1.10
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Class C Mishap

• Greater than 20 K damage
• Lost work day or days

AFI 91-104 1.10
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Class D Mishap

• Restricted work day or days

AFI 91-104 1.10
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Class J Mishap

• Engine mishaps
• Foreign Object Damage, BASH

AFI 91-104 1.10
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Class E Mishap

• Events that dont meet A, B, or C criteria
• Trending for safety/mishap prevention
• Physiologic incidents

AFI 91-104 1.10
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Agenda

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis

102
Purpose of Investigation

• Find underlying cause/explanation
• Future mishap prevention
• Improve risk management/ORM
• Improve safety process
• Preservation of combat resources

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Safety Investigations

• NOT To Fix Blame
• NOT Merely to Gather Evidence
• NOT 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

105
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

107
Board Member Selection

• ISB Chosen By WG/CC
• SIB 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

108
Members

• Board President (Rated Colonel or O-7 for
  Fatality)
• Investigating Officer
• Maintenance Member
• Medical Officer
• Pilot Member
• AFSC Representative
• Recorder
• Technical Assistance Members As Required

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Flight Surgeon Role

• Medical expert for board members
• Liaison to Mortuary Affairs/AFIP
• Team leader for all Life Sciences
• Advisor for
• Search Rescue Team (SAR)
• Human factors
• Human survivability
• Aircrew medical qualification
• Lifestyle
• Crew rest analysis
• Family liaison

110
Flight Surgeon Liaison

• Flight surgeon job
• Local coroner/ME
• Local emergency medical care
• Local FS/interim board
• Pathology
• AFIP consultant for investigation, photography,
  and autopsy

111
Medical Analysis/Pathology

• Autopsy
• Forensic identification
• Dental evaluation
• DNA analysis
• Photography
• Examination of flight/life support gear
• Evaluates medical history/evidence
• Determines circumstances of death

112
Flight Surgeon Role

• 4-6 week commitment PLUS presentations later on
• Interview or history-taking expert on board
• Assist Line board members in understanding human
  issues/factors involved in mishap
• Consultations (aerospace physiology, aviation
  psychology, life support)
• Assist survivors, direct/indirect
• Victims
• Families
• Board
• Team support
• Data entry into AFSAS
• Tab Y

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Swiss Cheese Model
Organizational Influences
Supervision
Preconditions
Acts
114
DoD Human Factors (HFACS)
Organizational Influences Resource/Acquisition
Management Organizational Climate Organizational
Processes
Supervision Inadequate Supervision Planned
Inappropriate Operations Failure to Correct Known
Problems Supervisory Violations
Preconditions Environmental Factors Condition of
Individuals Personnel Factors
Acts Errors Violations
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Fly Awake / FAST Program
116
Simulations
117
Schweatys 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 MOUs in place with respective AD bases
  for ANG/AFR and local community/host nation if
  needed

118
Review

• Notification
• Resources
• Immediate Response
• Interim Safety Board
• Evidence Collection
• Aircrew Witness Interviews
• Additional Considerations
• PA
• Mishap Classifications
• Safety/Accident Investigation Boards
• Human Factors Analysis