CHIEF WARRANT OFFICER 4 MARK LEUNG
G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama

“Everybody has a plan until they get punched in the mouth.” — Mike Tyson

As aviation safety officers, we like to believe we are prepared to handle a catastrophic situation such as a Class A mishap with one or more fatalities. In reality, most units are unprepared for such an event. The alarming factor is they don’t fully understand what they need to do to prepare until it is too late.

A unit’s first task is to prepare/review/update its pre-accident plan (PAP), which is required in accordance with Army Regulation 385-10, The Army Safety Program. The PAP needs to be nested with the higher headquarters and installation plan and must be updated when the unit departs home station for deployments, combat training centers and off-post training events. Units are required to test their PAP quarterly, as well as conduct a full rehearsal with all responding agencies annually. During the course of mishap investigations, the U.S. Army Combat Readiness Center (USACRC) often discovers the unit’s PAP had not been fully rehearsed in a long time. Consequently, many of the individuals with responsibilities within the PAP were unaware of their roles.

Unit battle drills for downed aircraft should also follow the PAP. I have seen battle drills that were developed in a vacuum from the PAP, and the unit’s operations section was confused about which plan to follow in a time of need. When a mishap occurs, emotions often run high and it’s not uncommon for steps to be skipped or key components forgotten. Therefore, the PAP should be easy to follow. All key personnel should have a copy of the plan on their smartphones — or at least their responsibilities and key phone numbers — because accidents do occur when you are away from your desk/workspace. The Soldiers in the flight operations cell are the quarterbacks of the PAP and must know it inside and out.

Unfortunately, catastrophic mishaps do occur. Initial notification to the USACRC can be made via telephone 24 hours a day and the Department of the Army Form 7305 or 7306 as appropriate. When reporting a mishap, be sure to include as much factual information as possible so the USACRC can better develop a plan for an investigation team. (In the near future, part of the initial notification will come through the USACRC’s new accident reporting tool — the Army Safety Management Information System 2.0, or ASMIS 2.0.)

Once a USACRC safety investigation board (SIB) is en route to your installation, what should the unit expect and what can it do to assist? Someone from the SIB, usually the board recorder, will e-mail the unit point of contact with a list of data that will be needed immediately upon arrival as well as any required follow-on information. The email will also include instructions about the mishap scene. Nothing should be removed from the scene without the board president’s direct consent. Should a unit be directed to remove a component for analysis, such as a flight data recorder, step-by-step instructions regarding how to send it to the USACRC for exploitation will be included.

The mishap site must be secured to preserve the location. This perimeter should encompass not just all wreckage, but also any ground scaring. The unit safety officer should document the area as much as possible before it is further contaminated by recovery efforts. Photographs and measurements will be immensely valuable to the SIB, especially if there is an extended travel time (e.g., the mishap happens in a combat theater and the investigation team has to move through Kuwait first).

The SIB email will also include a list of documents and supplies that will be needed as soon as possible. Physical copies of documents and publications are good, but digital versions will make the SIB’s job easier. Some examples of these documents include standing operating procedures (SOPs), PAPs, digital photos, a witness list, initial statements (not sworn statements), risk assessments, crewmembers’ Centralized Aviation Flight Records System (CAFRS), aircraft historical files, and weather data.

Another thing the SIB will need immediately is a boardroom workspace. Ideally, this would be a lockable room that only SIB members have access to. The room must be large enough to hold the entire SIB and allow them to work uninterrupted. An SIB is typically comprised of a board president and board recorder, both from the USACRC; a standardization pilot, typically from the Directorate of Evaluations and Standardization (DES); a maintenance test pilot/examiner, technical inspector and flight surgeon, who normally come from within the mishap brigade; and a Department of the Army civilian from the Corpus Christi Army Depot (CCAD) Analytical Investigative Branch as a materiel adviser. The board president may require other experts to join the SIB as necessary. Examples include weather officers, a host-nation liaison and aviation engineers.

Once the team arrives, the first order of business is usually to visit the mishap scene as soon as possible for an initial investigation and to take more photographs and measurements. This may be the first of several visits to the mishap location before the aircraft can be recovered. When it does come time for recovery operations to begin, SIB members will be present for every step to ensure the chain of custody is maintained as well as to further document the aircraft. This will assist with identifying damage from the actual mishap versus any damage that occurred during the recovery process.

The SIB will be as unobtrusive as practical during the investigation and, as much as possible, accommodate the mishap organization’s work schedules, locations and security concerns. The SIB must consider the mission operations tempo and available resources of the subject organization during conduct of the investigation. The intent is to effectively execute the investigation in a timely manner while the organization successfully prosecutes its mission.

The SIB’s overall goal is to answer three questions: What happened? Why it happened? What to do about it? The investigation is broken down into four distinct phases: organization, data collection, analysis/deliberations and completing the field report. The organization phase is relatively short, with key events such as the site visit, boardroom setup, briefing SIB members on their roles and any command inbriefs.

During the data collection phase, the SIB focuses on answering the first question: What happened? The team will review the documents the unit safety officer collected, request further supporting documents, conduct both formal and informal interviews, conduct an analysis of the aircraft and other physical evidence, and send off parts for further examination at CCAD or by the manufacturer.

During the data analysis/deliberation phase, the SIB will come together to answer the second question: Why it happened? The team will use a variety of methods to find the root cause of the mishap, whether environmental, materiel or human error. If human error is identified, the SIB will further analyze the roles of support, standards, training, leadership and individual failures (SSTLI).

The final phase, completing the field report, focuses on the final question: What to do about it? By this point, the SIB will have compiled an enormous amount of information, filled out dozens of forms, reviewed any audio/video files hundreds of times and poured over huge data spreadsheets. Next, it must show the findings and make recommendations that can prevent similar mishaps from occurring again.

The SIB model is built around a 21-day investigation, though this is simply just an initial plan. We have had investigations that were slightly shorter and some that lasted several months. The SIB will outbrief the board convening authority on what it found during the course of the investigation, including issues that led up to the mishap, the mishap phase and the post-mishap timeline.

The outbrief culminates with the presentation of the findings and recommendations. Some of these issues will be able to be addressed by the battalion, brigade and division leadership immediately. There might also be recommendations that go all the way to the Department of the Army level. The USACRC has a team that ensures these recommendations reach the appropriate offices and receives official responses on what that entity is doing to address the SIB’s recommendations.

Any unit can suffer a catastrophic accident. When it happens, it will be devastating to morale, and the leadership will have the tough task of refocusing the unit. While it can be difficult to have your unit’s deficiencies pointed out, take these learning points and make your unit better. The SIB is not evaluating the unit; it’s there to “hold up a mirror” to provide insight into what is happening internally. Great units will learn from these incidents and make the internal corrections to ensure they don’t happen again. Readiness Through Safety!

FYI

For more information on pre-accident plans, see Chief Warrant Officer 4 Robert Moran’s article in Risk Management magazine at https://safety.army.mil/MEDIA/Risk-Management-Magazine/ArtMID/7428/ArticleID/6367/Practice-Makes-Perfect.