Pond Mishap Investigation - Alliance of Air National Guard Flight

Report
Accidents Happen
22 June 2013
AANGFS RSV—2013 ANGRC, Joint Base Andrews
Col William W. Pond, MD, SFS, MC, INANG
Mishap Investigation
Col William W. Pond, MD, SFS, MC
Indiana State Air Surgeon
18 June 2010
AANGFS RSV Program—Minneapolis, MN
Col William W. Pond, MD, SFS, INANG
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
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
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.
Items to cover
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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
Source Information
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Air Force Safety Center Surgeon DSN 2460830
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
18 June 2010
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
4th Edition, Feb 2006
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
Do not hesitate to ask for
assistance
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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/
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AFSC Life Sciences Branch
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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)
Types of Mishaps
 Class
 Class
 Class
 Class
 Class
A
B
C
E
J
Class A Mishap
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Greater than $1 M in damages to
airframe
Fatality or permanent total disability of
crew or passengers
Destroyed aircraft
Class B Mishap
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Greater than $200k in damage
Permanent partial injury to crew or
passengers
Hospitalization of three or more people
18 June 2010
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
Class C Mishap
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Greater than $10 K damage
Lost work day or days
Class E Mishap
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Events that don’t meet A, B, or C
criteria
Trending for safety/mishap prevention
Physiologic incidents
Class J Mishap
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Engine mishaps
Foreign Object Damage, BASH
18 June 2010
AANGFS RSV—2009 Snowbird, UT
Col William W. Pond, MD, SFS, MC, INANG
Type of Mishap Related to
Intention to Damage
1.
Aircraft Flight Mishap- damage to aircraft
with intent for or during flight operations
2.
Aircraft Flight Related Mishap- damage to
property or people from aircraft with
intent for or during flight, no reportable
aircraft damage
3.
Aircraft Ground Operations Mishapdamage to aircraft without intent for flight
18 June 2010
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
Priorities after the Mishap
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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”
Site Access
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Readiness factor
Maps
Know your local jurisdiction issues
beforehand
Appropriate authorities secure mishap
site
Work with other authorities/request
access
Mishap Site Etiquette and
Safety
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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
Purpose of Investigation
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Find underlying cause/explanation
Future mishap prevention
Improve risk management/ORM
Improve safety process
Preservation of combat resources
Safety Investigations
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NOT To Fix Blame, but Fix the Cause
NOT Merely to Gather Evidence, but to
analyze
NOT Used for Disciplinary Purposes
Safety Mishap
Investigation Boards
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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
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Wing Mishap Response Plan (MRP)
– Lists ISB member duties
– Checklists available for all base agencies
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Safety Investigation Board (SIB) - AFI 91-204
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Mishap prevention
Determine cause(s)
Recommend corrective actions
Privileged report, partially
Accident Mishap
Investigation Board
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Accident Investigation Board (AIB) AFI 51-503
– Claims & litigation
– Disciplinary action
– Adverse administrative actions
– Publicly releasable report
Board Composition
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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
Board Member Selection
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ISB Chosen By WG/CC
SIB Appointed by MAJCOM/CC
– Safety Office Researches Availability
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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
Members
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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
Flight Surgeon Role
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Medical expert for board members
Liaison to Mortuary Affairs/AFIP
Team leader for all Life Sciences
Advisor for:
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Search & Rescue Team (SAR)
Human factors
Human survivability
Aircrew medical qualification
Lifestyle
Crew rest analysis
Family liaison
Flight Surgeon Liaison
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Flight surgeon job
Local coroner/ME
Local emergency medical care
Local FS/interim board
Pathology
AFIP consultant for investigation,
photography, and autopsy
22 June 2013
AANGFS RSV—2013 ANGRC, Joint Base Andrews
Col William W. Pond, MD, SFS, MC, INANG
Procedural Legal
Considerations
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Establish jurisdiction (JAG duty)
Location of death
Location of pronouncement
Jurisdictional Issues for
Fatalities
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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
AFIP/OAFME
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Over 700 cases per year
– Suicides
– Homicides
– Other
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Aircraft Accident investigations
– 10-15 cases per year on site
– 10-15 cases in consultation
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Consultants to NTSB
AFIP/OAFME
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Autopsy
Forensic identification
Dental evaluation
DNA analysis
Photography
Examination of flight/life support gear
Evaluates medical history/evidence
Determines circumstances of death
Site Documentation
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Document everything in situ
Do not disturb remains or wreckage
Document photographically,
temporally, and in writing
Document scene and remains
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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
Photography
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Digital/film
Aerial
Scene
Remains
Static displays
Video
Marking Locations
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Grids (squares, circles)
GPS
Sifting/gravel operations
Water recovery
Identification
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Obtain accurate flight manifest/SSNs
– Allows DNA cards to be pulled quickly
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Identifies all flight crew & passengers
Flight surgeon- survivability
assessment
Closure for family
AANGFS
Col William W. Pond, MD, SFS, MC, INANG
Identification
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Presumptive- identifies individual to
sub-group (initial)
Positive- legal identification based on
forensics
Presumptive
Identification
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Flight manifest
Visual (tattoos)
Anthropomorphic
Personnel data
Medical history
Personal effects
Positive Identification
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Dental
Fingerprints
Palm prints
Foot prints
DNA
Radiographic ID
How long does it take to
identify positively
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Dental 1-2 hrs
Fingerprints 24-48 hrs
DNA 48 hrs
Records
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Gather all Names/SSNs
Obtain status & nationality
Sequester all records early
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Medical
Dental
Behavioral health
Civilian
Do not permit changes “after the fact”
Sequester all medical/dental imaging
evidence
Sequester Records
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Physical-remains
All equipment
All examinations and studies- unaltered
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Medical records (military & civilian)
Dental records
Behavioral health records
Radiology films & data
Photographs/video- at scene & autopsy
Witness information & statements
– Privileged
– Non-privileged
Postmortem Examination
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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
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Autopsy
Toxicology
Lab
Ancillary studies
X-rays
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Full body clothed
Hands/feet/head/neck
Permanent evidence of injuries
Demonstrates fractures/morphology
– mechanism of injury
Autopsy
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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
Interim Safety Board
Flight Surgeon Timeline
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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
Safety Board Flight
Surgeon
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4-6 wks
Continue data accumulation
Consultations
Team support
Data entry into AFSAS
Tab Y
SIB Witness Interviews
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Promise Of Confidentiality Available
(Aircraft, Space, Missile, Nuclear Only)
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Not Under Oath
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No Article 31 Rights
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Note Any Medications
Safety Privilege
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Encourage frank & open
communication with witnesses/contractors
Allow commander to quickly obtain accurate
mishap information
Helps ensure appropriate
corrective action
Ultimately, enhances national
security
Do’s and Don’ts
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Do talk to witnesses as soon as possible
Do ensure part locations are marked
Do preserve the evidence
Don’t
Don’t
Don’t
Don’t
Don’t
Don’t
rely on memory – take notes or use recorder
put two fractured parts together
dismantle parts without reassemble marks
release wreckage until it’s no longer needed
jump to conclusions as to mishap cause
discuss the mishap outside the board
Media Relations
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Refer all questions to Public Affairs
– Only the board president is authorized to release info
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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
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Refer potential claimants to JA
Avoid media; let AIB do its job
Flight Surgeon Role
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Assist with all life science & human factors issues
Interview or history-taking expert on board
Assist Line board members in understanding human
issues/factors involved in mishap
Assist survivors, direct/indirect
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Victims
Families
SAR
Board
Process improvement role
August 7, 2009
AANGFS RSV—2009 Snowbird, UT
Col William W. Pond, MD, SFS, MC, INANG
Help the other members to understand
the human factors component
Pond’s Pearls
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As soon as selected for the AIB, make telephone contact with
Board President and exchange contact information—the AIB
President is a sharp, knowledgeable senior pilot whose
assistance is invaluable.
Prior to arriving, read AFI 91-204, AFI 51-503, AFPAM 91-211
and the Aircraft Mishap Investigation Manual published by the
Society of United States Air Force Flight Surgeons
For and AIB, read the SIB report in its entirety and make
notes to summarize findings along with tab and page number.
This will save time when trying to recall the information.
When writing, include the document citation and location at
the time of composition—this will save a lot of time trying to
find it later.
Pond’s Pearls -- 2
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Read all interviews and data from the SIB and review HUD
tapes as soon as practicable.
For the first several days, be a sponge soaking up information
and making notes, but not conclusions.
Formulate possible scenarios, and let the data guide the
formulation of hypotheses.
Remember, medical members are expert at the scientific
method and analytical thought process which they use in daily
practice—this thought process is key to the AIB process.
Realize that some key data may never be available due to the
nature of the mishap—a 300 knot impact and flaming JP8 are
very effective at destroying evidence.
Pond’s Pearls -- 3
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Review news clippings and tapes early.
Hope that Safety Privilege was granted by SIB only to those
needing it; otherwise it may be necessary to again ask the
wife and others the same questions.
Limit testimony to facts and observations and avoid
speculations.
Place date/time on footer of documents such as timelines that
may be updated frequently, so that the prior versions are not
confused with the most current one.
Take videos of flight simulator scenarios.
Pond’s Pearls -- 4
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Fly path of mishap and get video.
Personally listen to the tapes while reviewing the transcript. (E.g.
the tape said, “Give me an oral airway and BVM,” but the
transcribed version said, “Give me an oral airway and beam me
up.”)
Formulate a timeline to incorporate the data from all sources and to
coordinate several time measures such as Zulu, HUD and ACMI.
Utilize DoD Human Factors guide that lists all 140+ human factors
with explanations to examine each person and action. This will
assure completeness and uniformity with other investigations.
Enlist the assistance of an aerospace physiologist or Guard
physician specialists.
Pond’s Pearls -- 5
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“Murder Board” is the process whereby board members read and
critique the report as it is displayed on the screen. This is valuable
because it gives a thorough insight into others’ information and
thought processes. Comments from the group on the individual’s
section are important because sometimes the author gets so
involved in his/her own section that he/she assumes that certain
items are known or clear.
The AIB document is released to the public, so one must be sensitive
to the feelings of the next of kin and privacy. The graphic details of
the autopsy reports are not public, so the Flight Surgeon should
compose a summary of the medical findings for Tab X with details
only to the extent necessary to support the conclusions and answer
the questions of the family.
Get 2 monitor screens and functional scanner.
Remember that medical records are protected medical information
and cannot be released.
Pond’s Pearls -- 6
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Make sure the orders include a rental car.
Assure that orders allow travel time before the convening of
Board.
Flight surgeon is eligible for incentive pays if service is greater
than 30 days, continuous, not aggregate.
Guard days and funding must “flow,” a complex process that
may require expediting.
Get good computer support and email access early.
Do not plan on free time—
– 14 hours per day,
– 6 ½ days per week
Pond’s Pearls -- 7
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To enhance possibility of selection for a Board,
– Be prepared to give an immediate answered, yes or no—“I
will check” means no.
– Have all training issues completed.
– Document all items in mobility folder; have it checked by
Unit Deployment Manager.
– Arrange windows of availability with associates for
coverage.
– Assemble SIB Information and keep it packed or on disk.
Bring personal camera and get CDs to transfer to military
computer.
Oh yes,
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Learn to use Table of Contents on MS Word.
Back up early and frequently.
Bring personal laptop.
Bring Flying Forms.
Bring Aerospace Physiology reference book or write
me.
Cell phone and international data plan for PDA.
Scan documents early and file by person and type.
Have Adobe distiller on computer.
AANGFS RSV—2009 Snowbird, UT
Col William W. Pond, MD, SFS, MC, INANG
Oh, I just remembered
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Assist the Board President in preparing thank you letters on
your behalf by supplying addresses and template
AANGFS RSV—2013 ANGRC, Joint Base Andrews
Col William W. Pond, MD, SFS, MC, INANG
Don’t expect luxury
accommodations
18 June 2010
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
Realize that the process is all consuming; you will think
about it before you sleep and when you awaken, when
you eat, shower and walk—but it is that
conscientiousness and attention to detail that assures
you have left no stone unturned and no question
unanswered. We owe that level of dedication to our
comrades, their families and the Air Force.
18 June 2010
AANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANG
Do expect to make a true
impact on the future
22 June 2013
AANGFS RSV—2013 ANGRC, Joint Base Andrews
Col William W. Pond, MD, SFS, MC, INANG

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