HQ AFFSA: Ms. Diana Malone

1. Safety Programs & Impact on Airfield Ops HQ AFFSA: Ms. Diana Malone Global Access for America

2. INTRO Our Business was Built on the Mishaps of Others

3. Overview • Aircraft Mishap Review Process • HATRs and CMA Violations • MACA/BASH Program

4. Aircraft Mishap Review Process • Safety Investigation Board (SIB) • Accident Investigation Board (AIB) • Memorandum of Final Evaluation (MOFE) • NTSB It’s not the “Who”/It’s the “What, Why, and How” that’s Important

5. Aircraft Mishap Review ProcessSafety Investigation Board • Governing Directives • AFI 91-204, Safety Investigations and Reports • AFMAN 91-223, Aviation Safety Investigations and Reports • AFI 13-204, Functional Management of Airfield Operations, Chapter 4

6. Aircraft Mishap Review ProcessSafety Investigation Board • The Primary Purpose of a Safety Investigation is to find the cause of an accident in order to take preventative actions.

7. Aircraft Mishap Review ProcessSafety Investigation Board • Interim Board Convened, Mishap Scene Secured and Relevant Data Collected • Convening Authority Appoints SIB Members • Investigation Completed Within 30 Days • SIB Produces 2-Part Final Report • Part I -- Non-Privileged, Factual Info • Part II -- Witness/Contractor Statements & Docs -- SIB Deliberations/Findings/Recs • Part II is Privileged Information • Primary Members May Publish Minority Opinion

8. Aircraft Mishap Review ProcessSafety Investigation Board • Airfield Ops Expert Serves as Primary “Conditional” Member • “Conditional” = If ATC/AM Involved • 13MX, 1C1X1 or 1C7X1 May be Requested at SIB President’s Discretion • If Resource not Available w/in Command, AFFSA/XA Assists in Selection • Completion of AMIC not Required • May Convert to Secondary Member Status if ATC/AM Determined not a Factor

9. Aircraft Mishap Review ProcessAccident Investigation Board • Governing Directives • AFI 51-503, Aerospace Accident Investigations • AFI 13-204, Functional Management of Airfield Operations, Chapter 4 • Commander who Convenes the SIB • Determines if AIB is Required • Convenes Corresponding AIB

10. Aircraft Mishap Review ProcessAccident Investigation Board The Purpose of an Accident Investigation: • To Provide a Publicly Releasable Report of Facts and Circumstances Surrounding the Accident • Includes a Statement of Opinion on the Cause (s) of the Accident        • To Gather and Preserve Evidence for: • Claims • Litigation • Disciplinary/Adverse Administrative Actions • For All Other Purposes

11. Aircraft Mishap Review ProcessAccident Investigation Board • Investigation Separate/Independent of SIB • AIB not Authorized Access to Privileged Safety Documents (Part II of SIB Report) • AIB Produces Single Non-Privileged Report Based on Board President’s Assessment • Minority Option is not a Factor on the AIB

12. Aircraft Mishap Review ProcessMemorandum of Final Eval • Final SIB Report is Not so Final… • AFSC Calls for Command Indorsement/ Comments for All Class A & B SIB Reports • Normally 30 Days to Provide Comments • Memorandum of Final Evaluation (MOFE) Produced by AFSC After Comments are Received • Historically, 6-12 months to Publish MOFE • MOFE Process for Class C & E Mishaps Determined by the MAJCOM

13. Aircraft Mishap Review ProcessSummary • SIB Takes Priority Over the AIB • AOF Personnel may Serve as: • Primary/Secondary SIB Member • AIB Technical Expert • Goal of SIB is to Identify What Caused the Mishap and Take Preventive Action • MOFE - Real Final SIB Report • Punitive Action May Result from AIB • Could Result from SIB, if Witness Gives False Testimony

14. NTSB Investigations • May Occur Concurrent with or Instead of SIB/AIB • May Take 12-18 Months to Produce Final Report • USAF May be Party to the NTSB • 50% of NTSB Investigations Occur Outside U.S. • Led by State (country) where Accident Occurs • Accredited Representatives from State of Registry, Operator, Design and Manufacture • Investigation Under Control of Investigator-in-Charge (IC) with Core Team of Investigators and Party Participation • Family Members/News Media not part of the Investigation, but May be Present at the Site – not in Team Deliberations

15. NTSB Reference Publications • ICAO, ANNEX 13 to the Convention on International Civil Aviation • TITLE 49 – Aircraft Accident Reporting • 49 CFR, PART 831 – Investigation Procedures • Manual of Aircraft Accident and Incident Investigation • TITLE 49 – Accident Hearings and Reports • ICAO Human Factors Training Manual

16. Manual of Aircraft Accident and Incident Investigation • The Sole Objective of an NTSB Aircraft Accident or Incident Investigation (Defined in Annex 13) is the Prevention of Future Accidents and Incidents • It is Not the Purpose of an Investigation to Apportion Blame or Liability • Any Judicial or Administrative Proceedings to Apportion Blame or Liability Should be Separate from Any Investigation Conducted Under the Provisions of Annex 13 • The Emphasis of an Aircraft Accident or Incident Investigation is on Remedial Actions

17. 49 CFR PART 831 – Accident/Injury Investigation Procedures • 831.7 Right to Representation. Any person interviewed by an authorized representative of the Board during the investigation, regardless of the form of the interview (sworn, unsworn, transcribed, not transcribed, etc.) has the right to be accompanied, represented, or advised by an attorney or non-attorney representative.

18. NTSB Summary • Purpose of an NTSB investigation is the same as for a SIB – prevention of future accidents or incidents • Protection of the NTSB report is equivalent to AIB • public hearings; news releases; press interviews • posted on NTSB web site http://www.ntsb.gov/default.htm • Any person interviewed has the Right to Representation • One person of your choosing may accompany – Choose wisely

19. HATR/CMAV PROGRAM • Sole Purpose of the Program is Mishap Prevention • Reports are Not Privileged Information and May Be Released Outside USAF Channels • Anyone Aware of a Reportable Incident May File a HATR or CMAV • Guidance in AFMAN 91-223

20. Class E Events • HATRs and CMA Violations - Both Class E Events • If the Violation Resulted in the Endangerment of an Aircraft, Report as a Class E HATR Event • Both Now Reportable to Flight Safety • Report All HATR Events Using the AF Form 651 • Report CMA Violations Using the AF Form 457 • AOF/CC Comments Are Required on All HATRs Involving ATC/AM Services • Minimum: Concur or Non-Concur • If Non-Concur, State Why

21. MACA/BASH Programs • MACA/BASH Programs Established in AFI 91-202, USAF Mishap Prevention Program • Wing Flight Safety Owns Program Management • AOF Supports MACA via Pilot/Controller Liaison Program per AFI 13-204 • BASH – AFPAM 91-212, Bash Management Techniques • BHWG • Wing BASH Plan BASH Management is a Team Event

22. Airfield Operations Safety Web Page • Published off of AFFSA/XA Web Site • Comments Regarding MOFE Status/Corrections • Crossfeed for HATRs and Associated Training • History of OIF HATRs with Links to Text • History of CMA Violations AFFSA XA XA AIRFIELD CONTACT HOME DIVISIONS MAIN MENU OPERATIONS SAFETY Aviation MishapsHATRsContingency HATRsCMA ViolationsAMIC Grads https://private.andrews.amc.af.mil/AFFSA/xa/affsaxa_dir.htm

23. 1 second to near miss In the blink of an eye... What’s your role in preventing mishaps?

24. Final Thoughts… “I don’t care Who made this mess…How do we keep it from happening again?”