Lt Col Kevin J. Bohnsack DSN 580.3565, Comm 269.969.3565 kevin.bohnsack@ang.af.mil 110 MDG/SGP

1. 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

2. You get the call…

3. …so now what do you do? • Notification • Resources • Immediate Response • Interim Safety Board • Evidence Collection • Aircrew & Witness Interviews • Additional Considerations • PA • Mishap Classifications • Safety/Accident Investigation Boards • Human Factors Analysis

4. Source Documents • 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)

5. Flight Surgeon Handbook and AFPAM 91-211

6. 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)

7. Resources / Thanks • Air Force Safety Center • Division of Forensic Toxicology Armed Forces Medical Examiner SystemBuilding 115, Purple Heart DriveDover 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

8. 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)

9. Resources • 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

10. 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)

11. Site Hazards • Environmental Hazards • Hot, cold, sun, wind, rain, snow, “critters” • Biological Hazards • Blood borne Pathogens • Fire Hazards • Fuel • Other fluids

12. Site Hazards • Radioactive Hazards • Control Surface Counterweights = depleted uranium • Material Hazards • Composites • Explosives (ammo, pyrotechnics, etc) • Pressure Vessels (tires, O2 cylinders, etc) • Sharp Edges

13. F-15 F-16 F-117 B-2 Atlas V U-2 F-22 F-14 B-1B Delta IV Composites • Defer to Fire Department regarding materials involved.

14. Site Hazards/PPE

15. Site Hazards

16. Site Hazards/PPE

17. Site Hazards

18. Site Hazards

19. 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)

20. Identification • Obtain accurate flight manifest/SSNs • Allows DNA cards to be pulled quickly • Identifies all flight crew & passengers • Survivability assessment • Closure for family

21. Identification • Presumptive - identifies individual to sub-group (initial) • Positive - legal identification based on forensics

22. Presumptive Identification • Flight manifest • Visual (tattoos) • Anthropomorphic • Personnel data • Personal effects

23. Positive Identification • Dental • Fingerprints • Palm prints • Foot prints • DNA • Radiographic ID

24. Positive ID timeframe • Dental 1 - 2 hours • Fingerprints 24 - 48 hours • DNA 48 hours

25. 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

26. Forensic Toxicology Guidelines

27. 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.

28. Toxicology (continued) AFMES 1323 • Medication History and Mishap Details • Use the AFMES 1323 / Verify a reliable address

29. Toxicology (continued) • Chain of Custody – Have a plan for security/storage while awaiting shipment • Commercial vendors ideal for accountability/tracking

30. Postmortem Examination • X-ray • Autopsy • Toxicology • Lab • Ancillary studies (Fatalities checklist is useful from the Flight Surgeon’s Handbook)

31. 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

32. 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

33. 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

34. 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

35. 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

36. Interim Safety Board (ISB) • 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

37. 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

38. ISB Flight Surgeon Timeline • 8 hour message • 24-48 hrs • 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

39. 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

40. Evidence Collection • Observe • Do not disturb • Document people involved (aircrew & witnesses), weather • Record • Photography • Sketches & Notes • Collect • Preserve

41. 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

42. 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

43. 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.

44. 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.

45. 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

46. Moving Wreckage • An installation commander may choose to remove wreckage interfering with mission activities or causing a hazard at mishap site.

47. Initial Walk Through

48. Initial Walk Through

49. Initial “Walk Through”

50. Evidence Collection • Observe • Do not disturb • Document people involved (aircrew & witnesses), weather • Record • Photography • Sketches & Notes • Collect • Preserve