Unfortunately, our current resource for investigating aviation mishaps, the squadron-level aviation mishap board (AMB), has failed to eradicate hazards. Over the past ten years the naval aviation community has averaged more than 25 class-A mishaps and suffered an average of 23 fatalities per year. The mishap investigative process would be significantly improved if the Naval Safety Center (NSC) created a class-A mishap response/investigation team (or A-Team), augmented by the mishap squadron aviation safety officer (ASO), to investigate all aviation class-A mishaps. The A-Team would replace the current squadron-level AMB for investigating and preventing further such mishaps by limiting manpower drain on the mishap squadron, better identifying causes, integrating community trends, and providing concrete, actionable recommendations.
The Status Quo
After a naval aviation mishap occurs, according to the current process, the mishap squadron must convene an AMB. The board is charged with determining why the mishap occurred and recommending preventive measures. The board must include a senior member (O-5, generally another squadron's XO), a flight surgeon, the mishap squadron ASO, and representatives familiar with operations and maintenance. One NSC investigator is to be available if aircraft wreckage has been recovered.
AMB members may be experts in their respective fields but have limited experience with mishap investigation. Other than the NSC investigator and the flight surgeon, many will likely be conducting their first such inquiry. Squadron ASOs attend an excellent four-week course at the School of Aviation Safety but many have only the classroom investigation under their belts. The 3750 instruction requires quarterly mishap training, however, this usually covers initial response rather than the details of mishap investigation. Additionally, the constant turnover of squadron personnel limits the corporate knowledge within the squadron's standing AMB. The AMB members are equipped with passing knowledge of known mishap trends within their airframe and community but have a narrow understanding of the limitations of the human body and mind.
A mishap squadron loses three or more of its most important personnel to the convening of the AMB. The 3750 states that the investigation takes priority over all other responsibilities, but AMB members are chosen for their technical knowledge and are often the squadron's cornerstones. The loss of three experts to the board puts the already bruised squadron (which has most likely lost an aircraft and possibly aircrew) in a more hazardous position for continued operations. Members of the AMB will work double shifts: first as board members, second in fulfilling their jobs as pilots and naval flight officers.
AMB members spend as much time learning how to investigate and report as they do actually investigating and reporting. The steep learning curve increases the time required to communicate findings to the Fleet. More important, the use of amateur AMBs makes it more difficult to compare the causal factors with other community trends. The final safety investigation report and associated recommendations may fail to identify and eradicate the hazard.
According to the opening statement in the 3750, the ultimate measure of a board's success is whether it prevents mishaps from recurring. Unfortunately, it is well-documented that a short list of hazards-controlled flight into terrain, midair collision, G-induced loss of consciousness, and hypoxia-continue to account for the majority of aviation mishaps. Squadron-level AMBs have investigated, reported on, and recommended changes to prevent these mishaps. Yet the same short list of hazards dominates naval aviation's loss of property and life.
The 3750 instruction provides an official justification for using squadron-level AMBs. In fact, it dedicates two full pages (6-2 to 6-4) to this purpose, including philosophical reasons:
1) This system of squadron-level AMBs is consistent with one of the basic tenets of the Naval Aviation Safety Program that an individual or command detecting a hazard is obliged to others in this profession to report that hazard as soon as it is detected.
2) The system supports and encourages mutual trust and confidence common among naval aviators and avoids both the specter of adversarial investigations of one command by another and the implication that safety is the business only of higher authority.
3) Mishap investigations also demonstrate an organization's commitment to its safety program.
The 3750 also provides practical reasons:
4) The system of squadron-level AMBs provides for close coordination with other mishap-related responsibilities of the reporting custodian, which include:
Operational Reporting (OPREP, SITREP)
Telephone and message MDRs
Notification of next of kin
Reports of loss of classified material
Aircraft custody and status change (x-ray) reports.
These reasons seem plausible, however, they don't explain naval aviation's loyalty to an investigative system that continues to fail to reduce mishaps.
Solving the Problem
Our current AMB process suffers from investigative inexperience and reporting inconsistency that mar its credibility and effectiveness. The credibility problem is best demonstrated by the Safety Investigation Report (SIR) endorsement process. Endorsers show a lack of faith in AMBs' conclusions and are routinely forced to write lengthy endorsements to adjust causal factors and change or remove recommendations. Thus, the same hazards resurface all too soon in similar mishaps.
To return credibility to our AMBs, their level of investigative experience and reporting consistency must be improved. The obvious way to achieve this higher level of standardization would be by "going pro"-by switching from our current method of using laymen and one professional, to using primarily professionals with mishap squadron ASO support. Specifically, the NSC should form a cadre of professional investigators to function as an A-Team mishap response and investigation unit that would travel to sites of class-A mishaps, join with the local ASO and flight surgeon support, and investigate and report. The local ASO would serve as on-scene commander and provide the benefits associated with squadron involvement noted in paragraph 4, while the professional investigators would consider the human and environmental factors that contributed to the mishap.
The following steps should be taken to implement this plan:
- For NSC, provide one A-Team mishap response team consisting of three investigators (one each specialized in safety, maintenance, and operations) ready for "alert" worldwide alert detachment for investigation of class-A mishaps. One of the NSC investigators would serve as the AMB's senior member.
- Increase the number of investigators on NSC staff to include safety, maintenance, and operations professionals to ensure training and staffing is provided for at least five response teams. When not actively investigating mishaps, the teams could serve as instructors for the School of Aviation Safety and as individual command mishap drill and AMB training. (Note: The number of A-Teams was determined from an average of 23 class-A mishaps over the past ten years and the assumption that each team would handle five investigations per year [two months per investigation]. Further analysis of the appropriate number of A Teams would be required.)
- Rewrite paragraphs 206.a and 206.b of 3750.6R as follows: For all class-A mishaps, the AMB will consist of three NSC investigators (one each well-qualified in aircraft operations, aircraft maintenance, aircraft safety), one command ASO, and a flight surgeon.
Adding a group of A-Teams at NSC would not violate the desired goal of paragraph 1; squadrons would still be responsible for class-B and class-C mishap investigations and all other hazard identification responsibilities and privileges, such as Naval Air Training and Operating Procedures Standardization (NATOPS) changes and hazard reports.
The requirements cited in 3750 paragraph 2 would be met by a more credible, reliable, and replicable investigative process conducted by experts.
By creating an A-Team, the naval aviation community could more effectively and efficiently fulfill its responsibility, cited in 3750 paragraph 3, in investigating the class-A mishaps that cost the nation precious resources.
All responsibilities covered in paragraph 4 would still remain with the mishap squadron, and the ASO would be perfectly positioned to integrate the squadron and AMB efforts. Additionally, the current SIR endorsing process should remain in place, regardless of the class of mishap, allowing specific commanders' input.
The ASO school provides an excellent introduction to mishap investigation. The ASO education and position should be maintained to assist with the preventative portion of the squadron safety program and ensure that squadron training is conducted for initial mishap response.
Continued mishaps seem to indicate a chronic failure to detect and eradicate these risks. We are not losing our highly trained people and war fighting machines to the enemy or to new, unidentified threats; we're losing them to the same hazards that have been investigated many times before. The current plan for investigating mishaps falls short of the ultimate goal of preventing them.
A Secretary of Defense mandate exists to reduce mishaps. A short list of hazards seems to cause the majority of mishaps in the tactical aviation community. Everyone in this community agrees that we want fewer errors and higher operational readiness. We must restructure the expertise level in the investigative process. It's time to bring in trained and experienced NSC investigators, with squadron ASO support, and give the AMB process the teeth it lacks.