Risk Management Magazine

Search for Articles

Sort by Date

«August 2020»

Latest Articles

Mishap Response Deficiencies

Mishap Response Deficiencies

Mishap Response Deficiencies


G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama



Units often don’t think about what happens behind the scenes of a mishap. Normally, units — mine included — would call in a 9-line medical evacuation or transport the injured Soldier to a casualty collection or ambulance exchange point. From there, we assume the installation will assist in getting the Soldier to the appropriate level of care as fast as possible. Unfortunately, not all installations have adequate systems and processes established to ensure this occurs. Several recent safety investigation boards (SIB) uncovered significant mishap response deficiencies at multiple installations.


In the first mishap, the SIB found an installation’s unity of command for MEDEVAC procedures to be lacking. Following a mass-casualty Army vehicle accident, a military and a civilian fire chief arrived at the scene almost simultaneously. They decided to share command, which led to each having different information and prevented injured Soldiers from being triaged and categorized quickly.

To further complicate matters, the installation’s organic MEDEVAC aircraft were deployed, which required another unit to cover for them. The two units had previously conducted a left-seat, right-seat ride, but no one notified the cover MEDEVAC crew that the hospital’s FM frequency had changed. Additionally, there were no systems in place to enable either fire chief to contact the installation’s Army medical center. These deficiencies resulted in the hospital not tracking an inbound MEDEVAC aircraft. Therefore, when the aircraft landed, an ambulance was not waiting to transport the mishap victims to the medical center. As a result, the aircraft’s crew chief ran to the emergency room to get an ambulance. The lack of systems and processes at this installation caused a 17-minute delay in an injured Soldier receiving medical treatment.

The SIB also discovered that this installation expected the medics in the back of an ambulance to call the emergency room, which would have forced someone to stop treatment on an injured Soldier. This could be a major issue if a medic was engaged in lifesaving procedures. Regardless, none of the medics had the emergency room contact information, which prevented the hospital from tracking the number and types of injuries inbound.


During the investigation into another mishap, the SIB discovered issues with the installation’s Primary Crash Alarm System (PCAS), which is designed to distribute accident information to all agencies (i.e., the fire department, control tower, military police, hospital and radar control). None of those agencies activated the PCAS after an aircraft crash. This prevented the smooth flow of information to the required responding agencies. Each found out about the accident from different civilian agencies, creating a knowledge gap among all of the necessary responders.

In addition, the SIB uncovered that the radar was not incorporated into the PCAS. While flying in the local training area, aircrews flight follow with the radar. If an aircraft were to have an accident and make a mayday call, radar would not be able to activate the PCAS. The airfield manager thought radar was included inside the PCAS, but, in actuality, it wasn’t. This lack of oversight created a break in the installation’s ability to respond to mishaps.

What can units do?

One item an SIB always reviews is the post-mishap response. As the two incidents above illustrate, an SIB often finds deficiencies in an installation’s response to a mishap. Normally, the deficiencies are a result of multiple agencies having different or incorrect information. For example, a unit might call Range Control to request MEDEVAC support for an injured Soldier at Checkpoint 3 inside Training Area 5. That sounds like a normal radio transmission until Range Control looks at its map and sees there is no Training Area 5 on the installation. Unfortunately, this is a common occurrence and should make a leader’s skin crawl because it always results in a Soldier suffering.

To be successful in any mission, every unit needs common operating terms and graphics. These enable each maneuvering and non-maneuvering unit to have situational awareness of the battlefield and a common operating picture. Garrison and training units often develop their own checkpoints and graphics when they train at their home station. This is great initiative, but it can desynchronize agencies required to respond to emergencies.

At the installation level, a single agency needs to be responsible for tracking, developing and overseeing the graphics inside the training area. Known checkpoints, roads and training areas must be established and disseminated to all training units as well as to agencies required to respond to an emergency. This is not meant to constrain the training unit. Rather, it gives flexibility and predictability to agencies required to respond.

SIBs also look at how often an installation rehearses its mishap response. Was a full dress rehearsal conducted with every agency responding? Or did it involve just the fire department driving to the commissary? The task and standards for responding to an emergency do not change. The only variable that changes are the conditions. Full dress rehearsals executed during the most demanding environments will identify friction points and deficiencies. Addressing these deficiencies will reduce response times and could save lives.


While these SIBs mentioned above ultimately found the units’ responses were appropriate, they also revealed several deficiencies. Installations must have the proper systems and procedures in place before a mishap occurs. A responding agency’s failure to understand its role and responsibilities could result in a delay in a Soldier receiving lifesaving treatment. No installation wants to discover its mishap response plan is deficient at a time when a well-organized operation is needed most.



  • 1 June 2020
  • Author: USACRC Editor
  • Number of views: 362
  • Comments: 0
Categories: On-DutyAviation

Theme picker