G3, INVESTIGATIONS, REPORTING AND TRACKING
U.S. Army Combat Readiness Center
Fort Rucker, Alabama
If you ever belonged to a unit that experienced a fatal Class A mishap, then you may have seen a team from the U.S. Army Combat Readiness Center (USACRC) arrive to investigate. The USACRC has conducted mishap investigations since 1975, dispatching teams to about 40 fatal Class A incidents annually. The organization does not investigate every Class A mishap. Factors such as complexity of the mishap, public interest and potential for Army-level recommendations help shape whether the USACRC will conduct the investigation. When the decision to investigate is made, the USACRC assembles a board of subject matter experts and follows a deliberate process to determine what happened, why it happened and how to prevent it from happening again.
The majority — 83 percent — of all major accidents involve human error. When human factors are present, we invariably see common indicators that set the conditions for a catastrophic mishap. The deliberate mishap investigation process includes documenting evidence, taking photographs and analyzing data. However, the best source of information for determining what went wrong usually comes from witnesses.
After decades of witness interviews, the USACRC continues to uncover the same mishap causal factors. Five questions we always ask up front often begins to unravel the mystery surrounding the mishap and helps lead the board to findings and recommendations. Most Army mishaps involving human error have at least one of these five issues in common:
- Was the Soldier trained properly?
- Was the Soldier supervised?
- Was the Soldier undisciplined?
- Was the Soldier overconfident?
- Was the Soldier complacent?
If you step back and review the timeline leading up to and through the mishap sequence, you will more than likely find that if the leader or Soldier had taken the time to address one or more of these questions, the outcome would have been different. When units get these five questions wrong, the results consistently produce damaged property, loss of equipment and Soldier deaths.
The applicability of these five questions are broad, and the corrective actions are not black and white. How you approach these questions prior to a mishap will always be a challenge for leaders and commanders. It starts with knowing your Soldiers and their behaviors through communication and observation. Planning, executing and documenting training events and qualifications is a step in the right direction. But it’s communication up and down the chain of command and a deliberate face-to-face risk assessment process that truly informs the leader of what questions to ask and what corrective actions need to be taken.
There are no routine missions or repetitive tasks. Treat each task and mission as if it were your first. Follow and enforce the standards and recognize when your capabilities are less than what is being asked of your unit. Failure to take the time to address these five questions during planning and preparation will undoubtedly lead to them being addressed during a USACRC mishap investigation.