Integrity - Service - Excellence
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
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You get the call…
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…so now what do you do?



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Notification
Resources
Immediate Response
Interim Safety Board
– Evidence Collection
– Aircrew & Witness Interviews

Additional Considerations
– PA
– Mishap Classifications


Safety/Accident Investigation Boards
Human Factors Analysis
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Source Documents
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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)
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Flight Surgeon Handbook
and AFPAM 91-211
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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)
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Resources / Thanks

Air Force Safety Center

Division of Forensic Toxicology
Armed Forces Medical Examiner System
Building 115, Purple Heart Drive
Dover 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
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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)
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Resources
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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
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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)
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Site Hazards
 Environmental
Hazards
– Hot, cold, sun, wind, rain, snow, “critters”
 Biological
Hazards
– Blood borne Pathogens
 Fire
Hazards
– Fuel
– Other fluids
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Site Hazards
 Radioactive
Hazards
– Control Surface Counterweights = depleted
uranium
 Material
–
–
–
–
Hazards
Composites
Explosives (ammo, pyrotechnics, etc)
Pressure Vessels (tires, O2 cylinders, etc)
Sharp Edges
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Composites
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F-15
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U-2
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F-16
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F-22
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F-117
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F-14
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B-2
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B-1B
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Atlas V
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Delta IV
Defer to Fire Department regarding materials involved.
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Site Hazards/PPE
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Site Hazards
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Site Hazards/PPE
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Site Hazards
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Site Hazards
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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)
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Identification
 Obtain
accurate flight manifest/SSNs
– Allows DNA cards to be pulled quickly
 Identifies
all flight crew & passengers
 Survivability assessment
 Closure for family
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Identification
 Presumptive
- identifies individual to subgroup (initial)
 Positive
- legal identification based on
forensics
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Presumptive Identification
 Flight
manifest
 Visual (tattoos)
 Anthropomorphic
 Personnel data
 Personal effects
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Positive Identification
 Dental
 Fingerprints
 Palm
prints
 Foot prints
 DNA
 Radiographic ID
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Positive ID timeframe
 Dental
 Fingerprints
 DNA
1 - 2 hours
24 - 48 hours
48 hours
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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
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Forensic Toxicology Guidelines
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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.
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Toxicology (continued)
AFMES 1323
 Medication History and Mishap Details
 Use the AFMES 1323 / Verify a reliable address
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Toxicology (continued)


Chain of Custody – Have a plan for security/storage
while awaiting shipment
Commercial vendors ideal for accountability/tracking
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Postmortem Examination
 X-ray
 Autopsy
 Toxicology
 Lab
 Ancillary
studies
(Fatalities checklist is useful from the Flight
Surgeon’s Handbook)
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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
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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
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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
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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
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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
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Interim Safety Board (ISB)
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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
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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
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ISB Flight Surgeon Timeline


8 hour message
24-48 hrs
–
–
–
–
–
–
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
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
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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
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Evidence Collection
 Observe
– Do not disturb
– Document people involved (aircrew & witnesses),
weather
 Record
– Photography
– Sketches & Notes
 Collect
 Preserve
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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
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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
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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.
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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.
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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
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Moving Wreckage

An installation commander may choose to remove
wreckage interfering with mission activities or
causing a hazard at mishap site.
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Initial Walk Through
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Initial Walk Through
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Initial “Walk Through”
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Evidence Collection
 Observe
– Do not disturb
– Document people involved (aircrew & witnesses),
weather
 Record
– Photography
– Sketches & Notes
 Collect
 Preserve
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Photography
 Purpose
– Documents the mishap
– Educates people who could not observe the site
firsthand
 Rules
of Thumb
– Over shoot and under print
– Document each photograph!!!
 Aerial
Photos
– CAP, Coast Guard, SAR, wing assets, alert A/C
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Photography
 Digital
– 8 Megapixel
– Save all memory cards for future reference
– Do not delete “bad” pictures
 Generic
Time-Sensitive Facts
– Potentially significant evidence…Ground scars,
etc.
– Medical evidence… Human remains
– Wreckage
– Damage to private property (for legal purposes)
– Witness’ Point-of-View
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Photography
 “Required”
–
–
–
–
Views
Overall View
Mid-Range – focus on the damage
Close-up
Extreme Close-up with Photographic Ruler
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Photography
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Photography…What is it?
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Photography
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Photography
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Photography
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Photography
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Evidence Collection
 Observe
– Do not disturb
– Document people involved (aircrew & witnesses),
weather
 Record
– Photography
– Sketches & Notes
 Collect
 Preserve
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Sketches
 Diagram
of crash site
– Work with CE
– GPS for exact impact coordinates
– Not necessary to plot all pieces, just critical
evidence and major pieces to get an idea of the
pattern
– Should complement photographs
– Use legend if it will avoid clutter
– Include statements: “not to scale” and “applied
North” if applicable
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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
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Mishap Site Diagram
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Evidence Collection
 Observe
– Do not disturb
– Document people involved (aircrew & witnesses),
weather
 Record
– Photography
– Sketches & Notes
 Collect
 Preserve
As of:
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Collect
 Methods
– Grid
– Zone
 Evidence
Tag (AF Form 52)
– WHO collected specimen
– WHAT condition the specimen was in when
found
– WHERE specimen was collected (GPS, map
coordinates, etc.)
– WHEN date and time
As of:
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Evidence Collection
 Observe
– Do not disturb
– Document people involved (aircrew & witnesses),
weather
 Record
– Photography
– Sketches & Notes
 Collect
 Preserve
As of:
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Preservation
 Initial
Interviews
– Direct Involvement: Participants, Eyewitnesses,
Wingmen, etc.
– Indirect: Schedulers, Crew Chiefs, SOF,
maintenance
 Fluid
–
–
–
–
Samples (One Pint Minimum)
From mishap aircraft
AGE and Servicing Equipment
Originating and enroute locations
Air Refueling?
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Preservation
 Other
considerations:
– ATC voice and RADAR tapes
– Wingman’s aircraft for FDR, HUD tape, etc.
– Other airborne aircraft (AWACS, Tanker, etc. )
 Data
Recorders
– One item ISB can “work” now
– AFSC will provide guidance on locating and
preserving other sources of data

Engine memory, structural recorders, avionics, etc.
– Before shipping recorders for downloading…
Contact AFSC/SEFE (246-5867)
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Preservation
 Accomplish
TOX Testing
– For Class A & B flight mishaps test aircrews
– For Class A, B, or C mishaps test individuals
whose actions or inactions, in the Commander’s
judgment may have been a factor
– Obtain a letter from the wing commander to
authorize the collection/tox testing.
– Contractors
 By consent or if a provision of the contract
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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
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Aircrew Interview

Documentation of medical facts should be on an
SF600 and/or AHLTA. Histories may be obtained via
a questionnaire developed locally.
– 72 hour history (sleep/previous sorties/food)
– 2 week history (stressors/circadian rhythm)

Remote Piloted Aircraft (RPA) – specific directives
on collecting information on crews operating the
aircraft during and preceding the event for Class A
and B as well as the most recent maintenance crew.
Two separate boards may be stood up at the duty
station and in the area of operation as applicable.
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ISB Witness Interview
 Promise
of Confidentiality?
 “Tell me what happened”
 “Tell me what you saw”
 Few follow-on questions
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Witness Identification
 Survivors
/ Relatives
 Transient Witnesses
 Local Eyewitnesses
 On Duty witnesses
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Safety Privilege
 Encourages
frank & open
communication with
witnesses/contractors
 Allows
commander to quickly
obtain accurate mishap
information
 Helps
ensure appropriate
corrective action
 Ultimately,
enhances national
security and aviation safety
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Safety Privilege

Promise of Confidentiality…Two Part Promise
– AFI 91-204, Chapter 3 - overview
– AFI 91-204 Figure A3.3 1c.
“…my confidential statement(s) … will not be made public and
it will only be used by authorized officials solely for mishap
prevention purposes. … I understand, however, that my
statement can be released pursuant to a valid court order
on behalf of the defendant in a criminal trial. I further
understand that if my statement contains an intentional
misrepresentation, then my statement will no longer be
considered confidential and can be used to support
disciplinary and/or administrative actions against myself
and/or others.”
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Safety Privilege
 Who
is Authorized to Make Promise of
Confidentiality
– Primary duty safety personnel
– ISB and SIB members
 Who
may Receive Promise of
Confidentiality
– Any witness
– Includes contractors who designed, built, or
maintained equipment
As of:
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Safety Privilege
 When
is Promise Given?
– Investigator discretion to encourage witness or
contractor cooperation
– Not on blanket basis to every witness
 Document
the Promise
– Use draft templates, AFI 91-204, Chapter 2, to
document promise and to document when
promise is not given
As of:
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Murphy’s Laws of Witnesses
 Regardless
of the physical evidence to the
contrary, at least one credible witness will
come forward stating the aircraft was on fire
prior to ground impact
 For
every witness statement there will be an
equal and opposite witness statement
As of:
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ISB Lessons Learned
 Secure
evidence and don’t tamper with it!
 Conduct recorded interviews with mishap
aircrew immediately
– but not to the detriment of medical care!
 Methodical
turnover to SIB
– ISB should stick around for a few days
– Keep tabs on ISB members… future questions
 Ensure
privilege statement on initial
interviews
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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
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PA Support
 Provides
initial news release to media
– Within one hour of mishap
– Coord on all news releases and pictures
– Solicits & monitors media support & interest
 Guides
news media’s access to mishap Site
– Relationship with local media very important
– OSC can’t restrict access on private property
– PA can explain hazards, keep media at distance
 Deflect
publishing photos of remains
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Media Relations

Refer all questions to Public Affairs
– Only the board president is authorized to release info

Use extreme courtesy
 Don’t speculate on mishap cause
 Politely ask civilians & media not to photograph
fatalities or classified items
– Contact security forces if necessary


Refer potential claimants to JA
Avoid media; let SIB/AIB do its job
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Release of Information
“What Not To Say !!”

Mishap responsibility
 Failure of equipment or facilities
 Legal liability of the government
 Classified information
 Causes, factors or recommendations
 Factors not causal in the mishap
 Statements, quotations or opinions from witnesses
or other privileged sources
 Bottomline:
“Please refer to PA.”
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Mishap Classification
 Classify
mishaps by
– Direct Cost
– Fatality, severity of Injury or degree of illness
 Class
of Mishap
– A, B, or C as well as Class E physiologicals
 If
mishap class in doubt
– AF Safety Center can (and will!) assist

AFI 91-104 1.10
Access to experts to determine “best guess” dollar
estimate
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Class A Mishap
 Destroyed
aircraft
 Greater than $1 M in damages to airframe
 Fatality or permanent total disability of crew
or passengers
AFI 91-104 1.10
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Class B Mishap
 Greater
than $200k in damage
 Permanent partial injury to crew or
passengers
 Hospitalization of three or more people
AFI 91-104 1.10
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Class C Mishap
 Greater
than $20 K damage
 Lost work day or days
AFI 91-104 1.10
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Class D Mishap
 Restricted
AFI 91-104 1.10
work day or days
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Class J Mishap
 Engine
mishaps
 Foreign Object Damage, BASH
AFI 91-104 1.10
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Class E Mishap
 Events
that don’t meet A, B, or C criteria
 Trending for safety/mishap prevention
 Physiologic
AFI 91-104 1.10
incidents
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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Scenario Discussion
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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
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Purpose of Investigation
 Find
underlying cause/explanation
 Future mishap prevention
 Improve risk management/ORM
 Improve safety process
 Preservation of combat resources
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Safety Investigations
 NOT
To Fix Blame
 NOT Merely to Gather Evidence
 NOT Used for Disciplinary Purposes
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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) - AFI 91-204
–
–
–
–
Mishap prevention
Determine cause(s)
Recommend corrective actions
Privileged report, partially
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Accident Mishap Investigation
Board
 Accident
Investigation Board (AIB) - AFI 51-
503
–
–
–
–
Claims & litigation
Disciplinary action
Adverse administrative actions
Publicly releasable report
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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
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Board Member Selection
 ISB
Chosen By WG/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

– Wing CC Approves Local List Submitted To
MAJCOM
– MAJCOM/CC Appoints
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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
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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
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Flight Surgeon Liaison
 Flight
surgeon job
 Local coroner/ME
 Local emergency medical care
 Local FS/interim board
 Pathology
 AFIP consultant for investigation,
photography, and autopsy
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Medical Analysis/Pathology
 Autopsy
 Forensic
identification
 Dental evaluation
 DNA analysis
 Photography
 Examination of flight/life support gear
 Evaluates medical history/evidence
 Determines circumstances of death
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Flight Surgeon Role





4-6 week commitment PLUS presentations later on
Interview or history-taking expert on board
Assist Line board members in understanding human
issues/factors involved in mishap
Consultations (aerospace physiology, aviation
psychology, life support)
Assist survivors, direct/indirect
– Victims
– Families
– Board



Team support
Data entry into AFSAS
Tab Y
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Swiss Cheese Model
HAZARD
Organizational
Influences
Latent Conditions
Supervision
Latent Conditions
Preconditions
Latent Conditions
Acts
Active Conditions
Failed or
Absent Defenses
After Reason (1990)
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DoD Human Factors (HFACS)
Organizational Influences
Resource/Acquisition
Management
Organizational Climate
Supervision
Organizational Processes Inadequate Supervision
Planned Inappropriate
Operations
Failure to Correct Known
Problems
Supervisory Violations
Preconditions
Environmental
Factors
Condition of
Individuals
Personnel Factors
Acts
Errors
Violations
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Fly Awake / FAST Program
As of:
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Simulations
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Schweaty’s Bullets

Gain operational SA
– Your assigned airframe
– Other assigned airframes

Check your AFSAS
– Sign up for notifications on airframes of interest.
– Gain familiarity with the interface.

Get involved with Safety office
– The first time you meet your wing or flight safety officer
should not be in the field!
– Participate in monthly or quarterly flight safety meetings.

Clarify and Exercise your capabilities.
– Involve MDG and other wing players.
– Ensure MOU’s in place with respective AD bases for
ANG/AFR and local community/host nation if needed
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Review




Notification
Resources
Immediate Response
Interim Safety Board
– Evidence Collection
– Aircrew & Witness Interviews

Additional Considerations
– PA
– Mishap Classifications


Safety/Accident Investigation Boards
Human Factors Analysis
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