Pocket Reference to Aircraft Mishap Investigation
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The Naval Flight Surgeon's Pocket Reference to Aircraft Mishap Investigation The Naval Safety Center, Aeromedical Division In conjunction with Dedicated Aerospace Medicine Professionals Fifth Edition 2001 INTRODUCTION Aircraft mishap investigation can be extremely difficult, time consuming, stressful, but also rewarding when we recognize that the contributions we make will improve aviation safety. A thorough mishap investigation is absolutely necessary to determine the cascading events causal to a mishap and recommending corrective actions to prevent recurrence. This edition of the Pocket Reference introduces a new tool in accident investigation, the Human Factors Analysis and Classification System (HFACS). HFACS provides the accident investigator with a proven template that aids in organizing the investigation while providing a detailed analysis of human error for post-hoc mishap data analysis, revealing previously unidentified trends and hazards. Historical data has shown that human error, by itself or in combination with other factors, is present in about 80% of aircraft mishaps, and is therefore the single greatest aviation hazard. As a member of an Aircraft Mishap Board (AMB), the Flight Surgeon is responsible for doing an exhaustive investigation in an area most likely to yield results: the medical and human-factors portion. Past investigations have shown that human factors are not limited to just pilot error. Human factors extend to aircraft maintainers, air-traffic controllers, the Squadron chain of command, Airwing, TYCOM, and can continue to CNO. The role of an investigating Flight Surgeon is not limited solely to an in-depth analysis of the individuals directly involved in the mishap, it must include all of the individuals and events that, through careful analysis, reveal the entire mishap chain. How the Flight Surgeon meets the duties and responsibilities of a mishap investigation will affect his appraisal by his peers and seniors in the Navy as an officer, a Flight Surgeon, and a physician, perhaps to a larger extent than anything else he may do while on active duty. During an investigation, he should demonstrate the same respect for objectivity and confidentiality that is expected of the Flight Surgeon in his role as a personal physician. If, by his efforts as a physician and mishap investigator, a Flight Surgeon prevents one aviation mishap in a 20-year Naval career, he will have saved the Navy more than his entire career pay. While a Flight Surgeon may never have absolute proof that he prevented a mishap, he must always do his best to prevent damage, injury, or death. Developing and maintaining sharp mishap-investigation skills is difficult, since most Flight Surgeons investigate mishaps infrequently. Consequently, it is easy to commit errors due to lack of experience and the rapid pace of the mishap investigation. And, as most mishaps occur at inconvenient times, to say the least, preparedness is ii paramount. This reference was compiled to help the Flight Surgeon avoid some of the common pitfalls encountered in these infrequently, but chaotic situations. The Flight Surgeon is both the Human Factors and Medical expert for the AMB. It is incumbent on the Flight Surgeon to prepare for this role and be able to provide on scene guidance to protect the team from biological, chemical, physical and environmental hazards. We have included a number of sections discussing biological and material hazards encountered during an investigation. Some hazards are not covered in this text. We advise that you work with your local fire/rescue teams and industrial hygiene professionals to better identify and prepare for the specific/unique hazards that your squadron’s aircraft will present at the mishap site. This reference is an adjunct to formal instructions that govern mishap investigation and is not meant to supplant the other references that address aeromedical aspects of mishap investigation. Use this guide as a ready reference in the field to make sure that your data retrieval is complete and that you preserve perishable evidence. It also may serve as a source for obtaining additional assistance. Acknowledgments This is the fifth edition of the mishap investigation pocket reference. This edition is a result of a collaborative effort between contributors throughout Naval Aerospace Medicine. The goal of this edition is to provide both a print and electronic version of vital Aeromedical Mishap Investigation information to all members of Aircraft Mishap Investigation Teams. The electronic version is available on line at the Naval Safety Center's Home Page: http://safetycenter.navy.mil. The Fifth Edition of this reference is available in an Adobe Acrobat ® format and can be downloaded and printed by any interested party. The Mishap Investigation Guide has traditionally been issued to all Naval Flight Surgeons as part of their basic training in Mishap Investigation at the Naval Aerospace Medical Institute in Pensacola, Florida. Recognizing the need for the continued publication of this reference, The Society of United States Naval Flight Surgeons (SUSNFS) underwrites the printing costs of this text as a service to its members. A printed version of this guide may be obtained by contacting the Society at http://www.aerospacemed.org . iii Chief Editor CDR Nicholas Webster MC, USN Assistant Command Surgeon Aerospace Medicine Naval Safety Center [email protected] Contributing Editors CDR Rick Erickson Aeromedical Safety Officer (AMSO) MSC, USN Aeromedical Physiology Naval Safety Center [email protected] CDR Doug Knittel Survivor Laboratory Specimen Collection MC, USN The Autopsy Director Pathology Handling Fatalities without AFIP Assistance Forensic Pathology Injury Analysis NRMC Portsmouth Carbon Monoxide Level Interpretation [email protected] Ethanol Concentration Interpretation Search and Recovery of Remains CAPT James Fraser Aeromedical Analysis MC, USN Aeromedical Analysis Sample Command Surgeon Aerospace Medicine Naval Safety Center [email protected] Mr. Bob Vallaster Fire Investigation Senior Investigator Diagrams of Wreckage Naval Safety Center Wreckage Evaluation, Recovery and [email protected] Preservation Fire Temperature Estimations LCDR Nancy Jones Privileged Information JAG, USN Naval Safety Center [email protected] Mr. Bruce Trenholm Aviation Life Support Systems Investigation MIST Team coordinator Assistance NAVAIRSYSCOM NAWC-WD [email protected] CDR Andy Bellenkes Human Factors Engineering Investigation MSC, USN Aerospace Experimental Psychologist, NPS Monterey [email protected] iv CAPT Nick Davenport Crash Survivability MC, USN Factors Affecting Crash Survivability Associate Residency Director Human Crash Tolerances Aerospace Medicine NAMI, Pensacola [email protected] CAPT Mike McCarten Crash Survivability MC, USN Factors Affecting Crash Survivability Chief Resident Human Crash Tolerances Aerospace Medicine NAMI, Pensacola LCDR Dave DeLonga Crash Survivability MC, USNR Factors Affecting Crash Survivability Resident Human Crash Tolerances Aerospace Medicine NAMI, Pensacola [email protected] CDR Scott Shappell Human Factors Analysis And Classification MSC, USNR System Human Factors CAMI, FAA [email protected] Reviewers Special thanks to the aeromedical professionals who dedicated their time to insure the accuracy of this guide: CDR John Umlauf, CDR Michael Francis, LCDR Michael Reddix, Mr. Robert Veasey, Dr. Alex Wolbrink, CAPT Glenn Merchant, CAPT Dean Bailey, LtCol Tom Luna, LCDR David Service, CDR Edmond Feeks, CAPT Fanancy Anzalone, CAPT Mary Anderson, LCDR Tomas Faulkner, LT Patrick Young, CDR Jay Dudley, LCDR David Kleinberg Feedback The Naval Safety Center enthusiastically encourages suggestions to improve this reference. Please send them to: Commander, Naval Safety Center Aeromedical Division (Code 14) 375 A Street Norfolk, VA 23511-4399 Email: [email protected] Or call the Aeromedical Division at: Commercial (757) 444-3520, Ext-7268 DSN 564-3520, Ext-7268 FAX (757) 444-7049 v TABLE OF CONTENTS INTRODUCTION _______________________________________ii Acknowledgments ___________________________________ iii Chief Editor ________________________________________ iv Contributing Editors__________________________________ iv Reviewers___________________________________________ v Feedback ___________________________________________ v TABLE OF CONTENTS ________________________________ vi BACKGROUND INFORMATION AND DEFINITIONS________ 1 OPNAVINST 3750.6R Instructions to the Medical Department _ 1 Basic Definitions _____________________________________ 3 Mishap Classification__________________________________ 9 Privileged Information ________________________________ 11 Hazard Reporting ____________________________________ 14 Human Factor HAZREP ______________________________ 16 Physiological Episode HAZREP ________________________ 17 PREMISHAP PLANNING _______________________________ 18 Aircraft Mishap Board ________________________________ 18 Aeromedical Safety Officer (AMSO)_____________________ 21 Premishap Plans _____________________________________ 22 Bloodborne Pathogens ________________________________ 25 Composite-Fiber Material _____________________________ 28 Aeromedical Mishap Investigation Kit____________________ 32 POST MISHAP DUTIES ________________________________ 34 Immediate Post-Mishap Duties of the Flight Surgeon ________ 34 Post Mishap Physical Examination ______________________