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Accidents Happen

Accidents Happen. Mishap Investigation. Col William W. Pond, MD, SFS, MC Indiana State Air Surgeon. Course for Flight Surgeon - B3OZY48G3 003 Nominated by MAJCOM SGP/SGPA For additional information, contact: usafsamregistrar@wpafb.af.mil. Thanks and a tip ‘o the hat to the following:.

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Accidents Happen

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  1. Accidents Happen AANGFS RSV—2016 JB Andrews Col William W. Pond, MD, SFS, MC, INANG

  2. Mishap Investigation Col William W. Pond, MD, SFS, MC Indiana State Air Surgeon AANGFS RSV JB Andrews Col William W. Pond, MD, SFS, INANG

  3. Course for Flight Surgeon - B3OZY48G3 003 • Nominated by MAJCOM SGP/SGPA • For additional information, contact: usafsamregistrar@wpafb.af.mil AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  4. Thanks and a tip ‘o the hat to the following: Col Kevin Bohnsack, ANG Leah W Brockway, Col, USAFR, MC, FS 446 ASTS, McChord AFB, WA Maj Leslie Picht, Pilot, 92 ARW Safety Center Lt Col Rick Gist, USAFR, MC, SFS Aircraft Mishap Investigation Handbook Col (ret) Rob Allen, USAF, MC, CFS Col Hadley Reed, USAF, MC, SFS

  5. Identifying data has been removed; sanitized presentation information is for educational and demonstrative purposes. • INFORMATION IN THIS BRIEFING IS FOR SAFETY PURPOSES ONLY. THE BRIEFING CONTAINS PRIVILEGED, LIMITED-USE SAFETY INFORMATION. UNAUTHORIZED USE OR DISCLOSURE CAN SUBJECT YOU TO CRIMINAL PROSECUTION, TERMINATION OF EMPLOYMENT, CIVIL LIABILITY, OR OTHER ADVERSE ACTIONS. RESTRICTIONS IN AFI 91-204 APPLY.

  6. Items to cover • Mishap Classes • Early actions • ISB, SIB, AIB Boards • Purpose • SIB Composition • SIB Witness Interviews • Safety Privilege • Site Safety • Dos & Don’ts • Media AANGFS RSV—2016 Joint Base Andrews Col William W. Pond, MD, SFS, MC, INANG

  7. Source Information • Air Force Safety Center Surgeon DSN 246-0830 • Life Sciences Equipment Lab, Brooks AFB DSN 240-4722 • AFI 91-204 Safety Investigations and Reports • AFJI 91-206 Participation in a Military or Civilian Accident Safety Investigation • AFPAM 91-211 USAF Guide to Safety Investigation—revised 8 June 2016

  8. 8 June 2016

  9. Do not hesitate to ask for assistance • Col Lisa Snyder • Col William Pond, 260-602-5167 • Chain of Command • Wing Safety • Air Force Safety Center (AFSC) • DSN 246-0830, 246-0880 • http://afsafety.af.mil/ • AFSC Life Sciences Branch • Flight Surgeon DSN 246-0871 • Life Support DSN 246-0853 • Aerospace Physiology DSN 246-0880 • Aviation Psychology DSN 246-3763 • Air Force Institute of Pathology (AFIP)

  10. Types of Mishaps • Class A • Class B • Class C • Class E • Class J

  11. Class A Mishap • Greater than $2 M in damages to airframe • Fatality or permanent total disability of crew or passengers • Destroyed aircraft

  12. Class B Mishap • Greater than $500k in damage • Permanent partial injury to crew or passengers • Hospitalization of three or more people AANGFS RSV—2016 JB Andrews Col William W. Pond, MD, SFS, MC, INANG

  13. Class C Mishap • Greater than $50 K damage • Lost work day or days AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  14. Class E Mishap • Events that don’t meet A, B, or C criteria • Trending for safety/mishap prevention • Physiologic incidents

  15. Class J Mishap • Engine mishaps • Foreign Object Damage, BASH

  16. Type of Mishap Related to Intention to Damage • Aircraft Flight Mishap- damage to aircraft with intent for or during flight operations • Aircraft Flight Related Mishap- damage to property or people from aircraft with intent for or during flight, no reportable aircraft damage • Aircraft Ground Operations Mishap- damage to aircraft without intent for flight

  17. Priorities after the Mishap • Safety: Do not be a victim at scene • Clearance from on-scene commander/Fire Chief • Treat Survivors • Preserve Life & Function • Run “Care of Survivors Checklist” • If necessary, run “Care of Fatalities Checklist” • Be attentive to psychological needs of team • Refer media to PA, “no comment”

  18. Site Access • Readiness factor • Maps • Know your local jurisdiction issues beforehand • Appropriate authorities secure mishap site • Work with other authorities/request access

  19. Mishap Site Etiquette and Safety • Stay Clear Of The Mishap Scene Until Its Declared Safe By The On-scene Commander • Walk Cautiously – Tripping & Evidence Preservation • Beware of • Hazardous Materials – Carbon Fibers, Etc. • Unexploded Ordinance – Squibs, Flares, Etc. • Pressurized Containers – O2 Bottles, Etc. • Wild Animals, Serpents And Insects • Biological Hazards – Blood, Etc. • Sharp Objects

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

  21. Dangers of training • ”Losses during WWII ran something like this; about 1/3 to training crashes, about 1/3 to operational accidents; and about 1/3 to enemy combat. • It was twice as dangerous to learn, and get into combat, than it was to actually fly the mission! • More USAAF pilots were killed in the "graveyard spiral" than were killed in combat, more pilots and crews were lost in scud running and weather related collisions with the ground than were lost in combat. AANGFS RSV Program—JB Andrews, ANGRC Col William W. Pond, MD, SFS, MC, INANG

  22. 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) • Mishap prevention • Determine cause(s) • Recommend corrective actions • Privileged report, partially AANGFS RSV—2016 Joint Base Andrews Col William W. Pond, MD, SFS, MC, INANG

  23. Safety Investigations • NOT To Fix Blame • NOT Merely to Gather Evidence • NOT Used for Disciplinary Purposes • It is used for Quality Improvement AANGFS RSV—20106 Joint Base Andrews Col William W. Pond, MD, SFS, MC, INANG

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

  25. 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

  26. Board Member Selection • ISB Chosen By Wing/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

  27. 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

  28. 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

  29. Flight Surgeon Liaison with • Local flight surgeons • Local coroner/ME • Local emergency medical care • Local FS/interim board • Pathology • AFIP consultant for investigation, photography, and autopsy

  30. Procedural Legal Considerations • Establish jurisdiction (JAG duty) • Location of death • Location of pronouncement

  31. Jurisdictional Issues for Fatalities • Local Laws- coroner may have to give permission before remains are moved • Fed Jurisdiction- Office of Armed Forces Medical Examiner (OAFME) must be notified • International issues- JAG to contact appropriate liaison

  32. AFIP/OAFME • Over 700 cases per year • Suicides • Homicides • Other • Aircraft Accident investigations • 10-15 cases per year on site • 10-15 cases in consultation • Consultants to NTSB

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

  34. Site Documentation • Document everything in situ • Do not disturb remains or wreckage • Document photographically, temporally, and in writing • Document scene and remains

  35. Accident scene • Mark & photograph all remains in situ • Crew spaces • Equipment • Impact points • May be distant from main debris field • Avoid area disturbance until search complete

  36. Photography • Digital/film • Aerial • Scene • Remains • Static displays • Video

  37. Marking Locations • Grids (squares, circles) • GPS • Sifting/gravel operations • Water recovery

  38. Identification • Obtain accurate flight manifest/SSNs • Allows DNA cards to be pulled quickly • Identifies all flight crew & passengers • Flight surgeon- survivability assessment • Closure for family

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

  40. Presumptive Identification • Flight manifest • Visual (tattoos) • Anthropomorphic • Personnel data • Medical history • Personal effects

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

  42. How long does it take to identify positively • Dental 1-2 hrs • Fingerprints 24-48 hrs • DNA 48 hrs

  43. Records • Gather all Names/SSNs • Obtain status & nationality • Sequester all records early • Medical • Dental • Behavioral health • Civilian • Do not permit changes “after the fact” • Sequester all medical/dental imaging evidence

  44. Sequester Records • Physical-remains • All equipment • All examinations and studies- unaltered • Medical records (military & civilian) • Dental records • Behavioral health records • Radiology films & data • Photographs/video- at scene & autopsy • Witness information & statements • Privileged • Non-privileged

  45. Postmortem Examination • X-ray • All parts/pieces of all bodies must be x-rayed • Intact bodies need specified series of films • Survivors need x-rays in some cases • ejection • Autopsy • Toxicology • Lab • Ancillary studies

  46. X-rays • Full body clothed • Hands/feet/head/neck • Permanent evidence of injuries • Demonstrates fractures/morphology • mechanism of injury

  47. Autopsy • Involve AFIP 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

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