1 / 118

Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 kevin.bohnsack@ang.af.mil 110 MDG/SGP

Aircraft Mishap Response and Investigation. Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 kevin.bohnsack@ang.af.mil 110 MDG/SGP. You get the call…. …so now what do you do?. Notification Resources Immediate Response Interim Safety Board Evidence Collection

hilde
Télécharger la présentation

Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 kevin.bohnsack@ang.af.mil 110 MDG/SGP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Aircraft Mishap Response and Investigation Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 kevin.bohnsack@ang.af.mil 110 MDG/SGP

  2. You get the call…

  3. …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)

  5. Flight Surgeon Handbook and AFPAM 91-211

  6. 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)

  7. 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: (302) 346-8724 • Col William Pond, Indiana ANG SAS • Recommend: Pond’s Pearls • Lt Col David Hardy, RAM ‘09 Bravo • Lt Col Fred Black, North Dakota ANG • MSgt Michelle Saatoff, North Dakota ANG

  8. 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)

  9. 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

  10. 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)

  11. Site Hazards • Environmental Hazards • Hot, cold, sun, wind, rain, snow, “critters” • Biological Hazards • Blood borne Pathogens • Fire Hazards • Fuel • Other fluids

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

  13. F-15 F-16 F-117 B-2 Atlas V U-2 F-22 F-14 B-1B Delta IV Composites • Defer to Fire Department regarding materials involved.

  14. Site Hazards/PPE

  15. Site Hazards

  16. Site Hazards/PPE

  17. Site Hazards

  18. Site Hazards

  19. 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)

  20. Identification • Obtain accurate flight manifest/SSNs • Allows DNA cards to be pulled quickly • Identifies all flight crew & passengers • Survivability assessment • Closure for family

  21. Identification • Presumptive - identifies individual to sub-group (initial) • Positive - legal identification based on forensics

  22. Presumptive Identification • Flight manifest • Visual (tattoos) • Anthropomorphic • Personnel data • Personal effects

  23. Positive Identification • Dental • Fingerprints • Palm prints • Foot prints • DNA • Radiographic ID

  24. Positive ID timeframe • Dental 1 - 2 hours • Fingerprints 24 - 48 hours • DNA 48 hours

  25. 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

  26. Forensic Toxicology Guidelines

  27. 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.

  28. Toxicology (continued) AFMES 1323 • Medication History and Mishap Details • Use the AFMES 1323 / Verify a reliable address

  29. Toxicology (continued) • Chain of Custody – Have a plan for security/storage while awaiting shipment • Commercial vendors ideal for accountability/tracking

  30. Postmortem Examination • X-ray • Autopsy • Toxicology • Lab • Ancillary studies (Fatalities checklist is useful from the Flight Surgeon’s Handbook)

  31. 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

  32. 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 Affairs • With large complex mishap -- may take days

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

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

  41. 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

  42. 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

  43. 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.

  44. 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.

  45. 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

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

  47. Initial Walk Through

  48. Initial Walk Through

  49. Initial “Walk Through”

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

More Related