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Accidents Happen

Accidents Happen. Mishap Investigation. Col William W. Pond, MD, SFS, MC Indiana State Air Surgeon. Thanks and a tip ‘o the hat to the following:. Leah W Brockway, Col, USAFR, MC, FS 446 ASTS, McChord AFB, WA Maj Leslie Picht, Pilot, 92 ARW Safety Center Lt Col Rick Gist, USAFR, MC, SFS

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Accidents Happen

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  1. AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  2. Accidents Happen AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  3. Mishap Investigation Col William W. Pond, MD, SFS, MC Indiana State Air Surgeon AANGFS RSV Program—Minneapolis, MN Col William W. Pond, MD, SFS, INANG

  4. AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  5. Thanks and a tip ‘o the hat to the following: Leah W Brockway, Col, USAFR, MC, FS 446 ASTS, McChord AFB, WA Maj Leslie Picht, Pilot, 92 ARW Safety Center Lt Col Rick Gist, USAFR, MC, SFS Aircraft Mishap Investigation Handbook Col (ret) Rob Allen, USAF, MC, CFS Col Hadley Reed, USAF, MC, SFS

  6. Identifying data has been removed; sanitized presentation information is for educational and demonstrative purposes. • INFORMATION IN THIS BRIEFING IS FOR SAFETY PURPOSES ONLY. THE BRIEFING CONTAINS PRIVILEGED, LIMITED-USE SAFETY INFORMATION. UNAUTHORIZED USE OR DISCLOSURE CAN SUBJECT YOU TO CRIMINAL PROSECUTION, TERMINATION OF EMPLOYMENT, CIVIL LIABILITY, OR OTHER ADVERSE ACTIONS. RESTRICTIONS IN AFI 91-204 APPLY.

  7. Items to cover • Mishap Classes • Early actions • ISB, SIB, AIB Boards • Purpose • SIB Composition • SIB Witness Interviews • Safety Privilege • Site Safety • Dos & Don’ts • Media AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  8. Source Information • Air Force Safety Center Surgeon DSN 246-0830 • Life Sciences Equipment Lab, Brooks AFB DSN 240-4722 • AFI 91-204 Safety Investigations and Reports • AFJI 91-206 Participation in a Military or Civilian Accident Safety Investigation • AFPAM 91-211 USAF Guide to Safety Investigation AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  9. 4th Edition, Feb 2006 AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  10. Do not hesitate to ask for assistance • LtCol Lisa Snyder • Col William Pond, 260-602-5167 • Chain of Command • Wing Safety • Air Force Safety Center (AFSC) • DSN 246-0830, 246-0880 • http://afsafety.af.mil/ • AFSC Life Sciences Branch • Flight Surgeon DSN 246-0871 • Life Support DSN 246-0853 • Aerospace Physiology DSN 246-0880 • Aviation Psychology DSN 246-3763 • Air Force Institute of Pathology (AFIP)

  11. Types of Mishaps • Class A • Class B • Class C • Class E • Class J

  12. Class A Mishap • Greater than $1 M in damages to airframe • Fatality or permanent total disability of crew or passengers • Destroyed aircraft

  13. Class B Mishap • Greater than $200k in damage • Permanent partial injury to crew or passengers • Hospitalization of three or more people AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  14. Class C Mishap • Greater than $10 K damage • Lost work day or days AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  15. Class E Mishap • Events that don’t meet A, B, or C criteria • Trending for safety/mishap prevention • Physiologic incidents AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  16. Class J Mishap • Engine mishaps • Foreign Object Damage, BASH AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  17. Type of Mishap Related to Intention to Damage • Aircraft Flight Mishap- damage to aircraft with intent for or during flight operations • Aircraft Flight Related Mishap- damage to property or people from aircraft with intent for or during flight, no reportable aircraft damage • Aircraft Ground Operations Mishap- damage to aircraft without intent for flight AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  18. Priorities after the Mishap • Safety: Do not be a victim at scene • Clearance from on-scene commander/Fire Chief • Treat Survivors • Preserve Life & Function • Run “Care of Survivors Checklist” • If necessary, run “Care of Fatalities Checklist” • Be attentive to psychological needs of team • Refer media to PA, “no comment” AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  19. Site Access • Readiness factor • Maps • Know your local jurisdiction issues beforehand • Appropriate authorities secure mishap site • Work with other authorities/request access

  20. Mishap Site Etiquette and Safety • Stay Clear Of The Mishap Scene Until Its Declared Safe By The On-scene Commander • Walk Cautiously – Tripping & Evidence Preservation • Beware of • Hazardous Materials – Carbon Fibers, Etc. • Unexploded Ordinance – Squibs, Flares, Etc. • Pressurized Containers – O2 Bottles, Etc. • Wild Animals, Serpents And Insects • Biological Hazards – Blood, Etc. • Sharp Objects AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  21. Purpose of Investigation • Find underlying cause/explanation • Future mishap prevention • Improve risk management/ORM • Improve safety process • Preservation of combat resources

  22. Safety Investigations • NOT To Fix Blame • NOT Merely to Gather Evidence • NOT Used for Disciplinary Purposes AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  23. 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 AANGFS RSV—2010 Minneapolis, MN Col William W. Pond, MD, SFS, MC, INANG

  24. Accident Mishap Investigation Board • Accident Investigation Board (AIB) - AFI 51-503 • Claims & litigation • Disciplinary action • Adverse administrative actions • Publicly releasable report AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  25. 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 AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  26. 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

  27. 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

  28. 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

  29. 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

  30. AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  31. Procedural Legal Considerations • Establish jurisdiction (JAG duty) • Location of death • Location of pronouncement AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  32. Jurisdictional Issues for Fatalities • Local Mortuary Affairs Officer • Local Laws- coroner may have to give permission before remains are moved • Fed Jurisdiction- Office of Armed Forces Medical Examiner (OAFME) must be notified • International issues- JAG to contact appropriate liaison

  33. AFIP/OAFME • Over 700 cases per year • Suicides • Homicides • Other • Aircraft Accident investigations • 10-15 cases per year on site • 10-15 cases in consultation • Consultants to NTSB

  34. AFIP/OAFME • Autopsy • Forensic identification • Dental evaluation • DNA analysis • Photography • Examination of flight/life support gear • Evaluates medical history/evidence • Determines circumstances of death

  35. Site Documentation • Document everything in situ • Do not disturb remains or wreckage • Document photographically, temporally, and in writing • Document scene and remains

  36. Accident scene • Mark & photograph all remains in situ • Crew spaces • Equipment • Impact points • May be distant from main debris field • Avoid area disturbance until search complete

  37. Photography • Digital/film • Aerial • Scene • Remains • Static displays • Video AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  38. Marking Locations • Grids (squares, circles) • GPS • Sifting/gravel operations • Water recovery

  39. Identification • Obtain accurate flight manifest/SSNs • Allows DNA cards to be pulled quickly • Identifies all flight crew & passengers • Flight surgeon- survivability assessment • Closure for family AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

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

  41. Presumptive Identification • Flight manifest • Visual (tattoos) • Anthropomorphic • Personnel data • Medical history • Personal effects

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

  43. How long does it take to identify positively • Dental 1-2 hrs • Fingerprints 24-48 hrs • DNA 48 hrs

  44. Records • Gather all Names/SSNs • Obtain status & nationality • Sequester all records early • Medical • Dental • Behavioral health • Civilian • Do not permit changes “after the fact” • Sequester all medical/dental imaging evidence

  45. Sequester Records • Physical-remains • All equipment • All examinations and studies- unaltered • Medical records (military & civilian) • Dental records • Behavioral health records • Radiology films & data • Photographs/video- at scene & autopsy • Witness information & statements • Privileged • Non-privileged

  46. Postmortem Examination • X-ray • All parts/pieces of all bodies must be x-rayed • Intact bodies need specified series of films • Survivors need x-rays in some cases • ejection • Autopsy • Toxicology • Lab • Ancillary studies

  47. X-rays • Full body clothed • Hands/feet/head/neck • Permanent evidence of injuries • Demonstrates fractures/morphology • mechanism of injury AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  48. Autopsy • Involve AFIP 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 AANGFS RSV—2009 Snowbird, UT Col William W. Pond, MD, SFS, MC, INANG

  49. Interim Safety Board 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

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