18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Accidents HappenAccidents Happen
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
18 June 201018 June 2010 AANGFS RSV Program—Minneapolis, MNAANGFS RSV Program—Minneapolis, MNCol William W. Pond, MD, SFS, INANGCol William W. Pond, MD, SFS, INANG
Mishap InvestigationMishap Investigation
Col William W. Pond, MD, SFS, Col William W. Pond, MD, SFS, MCMC
Indiana State Air SurgeonIndiana State Air Surgeon
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Thanks and a tip ‘o the Thanks and a tip ‘o the hat to the following:hat to the following:
Leah W Brockway, Col, USAFR, MC, FS446 ASTS, McChord AFB, WAMaj Leslie Picht, Pilot, 92 ARW Safety CenterLt Col Rick Gist, USAFR, MC, SFSAircraft Mishap Investigation HandbookCol (ret) Rob Allen, USAF, MC, CFSCol Hadley Reed, USAF, MC, SFS
Identifying data has been removed; Identifying data has been removed; sanitized presentation information sanitized presentation information is for educational and is for educational and demonstrative purposes.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.
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Items to coverItems to cover
Mishap ClassesMishap Classes Early actionsEarly actions ISB, SIB, AIB BoardsISB, SIB, AIB Boards PurposePurpose SIB CompositionSIB Composition SIB Witness InterviewsSIB Witness Interviews Safety PrivilegeSafety Privilege Site Safety Site Safety Dos & Don’tsDos & Don’ts MediaMedia
18 June 201018 June 2010
Source InformationSource Information
Air Force Safety Center Surgeon DSN Air Force Safety Center Surgeon DSN 246-0830246-0830
Life Sciences Equipment Lab, Brooks Life Sciences Equipment Lab, Brooks AFB AFB
DSN 240-4722DSN 240-4722 AFI 91-204 Safety Investigations and AFI 91-204 Safety Investigations and
ReportsReports AFJI 91-206 Participation in a Military or AFJI 91-206 Participation in a Military or
Civilian Accident Safety InvestigationCivilian Accident Safety Investigation AFPAM 91-211 USAF Guide to Safety AFPAM 91-211 USAF Guide to Safety
InvestigationInvestigationAANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
44thth Edition, Feb 2006 Edition, Feb 2006
Do not hesitate to ask Do not hesitate to ask for assistancefor assistance LtCol Lisa SnyderLtCol Lisa Snyder Col William Pond, 260-602-5167Col William Pond, 260-602-5167 Chain of CommandChain of Command Wing SafetyWing Safety Air Force Safety Center (AFSC) Air Force Safety Center (AFSC)
– DSN 246-0830, 246-0880DSN 246-0830, 246-0880– http://afsafety.af.mil/
AFSC Life Sciences BranchAFSC Life Sciences Branch– Flight Surgeon DSN 246-0871Flight Surgeon DSN 246-0871– Life Support DSN 246-0853Life Support DSN 246-0853– Aerospace Physiology DSN 246-0880Aerospace Physiology DSN 246-0880– Aviation Psychology DSN 246-3763Aviation Psychology DSN 246-3763
Air Force Institute of Pathology (AFIP)Air Force Institute of Pathology (AFIP)
Types of MishapsTypes of Mishaps
Class AClass A Class BClass B Class CClass C Class EClass E Class JClass J
Class A MishapClass A Mishap
Greater than $1 M in damages to Greater than $1 M in damages to airframeairframe
Fatality or permanent total Fatality or permanent total disability of crew or passengersdisability of crew or passengers
Destroyed aircraftDestroyed aircraft
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Class B MishapClass B Mishap
Greater than $200k in damageGreater than $200k in damage Permanent partial injury to crew Permanent partial injury to crew
or passengersor passengers Hospitalization of three or more Hospitalization of three or more
peoplepeople
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Class C MishapClass C Mishap
Greater than $10 K damageGreater than $10 K damage Lost work day or daysLost work day or days
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Class E MishapClass E Mishap
Events that don’t meet A, B, or C Events that don’t meet A, B, or C criteriacriteria
Trending for safety/mishap Trending for safety/mishap preventionprevention
Physiologic incidentsPhysiologic incidents
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Class J MishapClass J Mishap
Engine mishapsEngine mishaps Foreign Object Damage, BASHForeign Object Damage, BASH
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Type of Mishap Type of Mishap Related to Intention to Related to Intention to DamageDamage1.1. Aircraft Flight Mishap- damage to Aircraft Flight Mishap- damage to
aircraft aircraft withwith intent for or during flight intent for or during flight operationsoperations
2.2. Aircraft Flight Related Mishap- damage Aircraft Flight Related Mishap- damage to property or people from aircraft to property or people from aircraft withwith intent for or during flight, no reportable intent for or during flight, no reportable aircraft damageaircraft damage
3.3. Aircraft Ground Operations Mishap- Aircraft Ground Operations Mishap- damage to aircraft damage to aircraft withoutwithout intent for intent for flightflight
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Priorities after the Priorities after the MishapMishap SafetySafety: Do not be a victim at scene: Do not be a victim at scene Clearance from on-scene Clearance from on-scene
commander/Fire Chiefcommander/Fire Chief Treat SurvivorsTreat Survivors Preserve Life & FunctionPreserve Life & Function Run “Care of Survivors Checklist”Run “Care of Survivors Checklist” If necessary, run “Care of Fatalities If necessary, run “Care of Fatalities
Checklist”Checklist” Be attentive to psychological needs of Be attentive to psychological needs of
teamteam Refer media to PA, “no comment”Refer media to PA, “no comment”
Site AccessSite Access
Readiness factorReadiness factor MapsMaps Know your local jurisdiction issues Know your local jurisdiction issues
beforehandbeforehand Appropriate authorities secure Appropriate authorities secure
mishap sitemishap site Work with other Work with other
authorities/request accessauthorities/request access
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Mishap Site Etiquette Mishap Site Etiquette and Safetyand Safety Stay Clear Of The Mishap Scene Until Its Declared Safe Stay Clear Of The Mishap Scene Until Its Declared Safe
By The On-scene CommanderBy The On-scene Commander Walk Cautiously – Tripping & Evidence PreservationWalk Cautiously – Tripping & Evidence Preservation BewareBeware of of
– Hazardous Materials – Carbon Fibers, Etc.Hazardous Materials – Carbon Fibers, Etc.– Unexploded Ordinance – Squibs, Flares, Etc.Unexploded Ordinance – Squibs, Flares, Etc.– Pressurized Containers – O2 Bottles, Etc.Pressurized Containers – O2 Bottles, Etc.– Wild Animals, Serpents And InsectsWild Animals, Serpents And Insects– Biological Hazards – Blood, Etc.Biological Hazards – Blood, Etc.– Sharp ObjectsSharp Objects
Purpose of Purpose of InvestigationInvestigation Find underlying Find underlying
cause/explanation cause/explanation Future mishap preventionFuture mishap prevention Improve risk management/ORMImprove risk management/ORM Improve safety processImprove safety process Preservation of combat resourcesPreservation of combat resources
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Safety InvestigationsSafety Investigations
NOT To Fix BlameNOT To Fix Blame NOT Merely to Gather EvidenceNOT Merely to Gather Evidence NOT Used for Disciplinary NOT Used for Disciplinary
PurposesPurposes
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Safety Mishap Safety Mishap Investigation BoardsInvestigation Boards Interim Safety Board (ISB)Interim Safety Board (ISB)
– Preserve evidence until permanent safety board Preserve evidence until permanent safety board arrivesarrives
– Gather pertinent data that may be lost over timeGather pertinent data that may be lost over time– Accomplish initial actions for permanent boardAccomplish initial actions for permanent board
Wing Mishap Response Plan (MRP)Wing Mishap Response Plan (MRP)– Lists ISB member dutiesLists ISB member duties– Checklists available for all base agenciesChecklists available for all base agencies
Safety Investigation Board (SIB) - AFI 91-204Safety Investigation Board (SIB) - AFI 91-204– Mishap preventionMishap prevention– Determine cause(s)Determine cause(s)– Recommend corrective actionsRecommend corrective actions– Privileged report, partiallyPrivileged report, partially
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Accident Mishap Accident Mishap Investigation BoardInvestigation Board Accident Investigation Board (AIB) Accident Investigation Board (AIB)
- AFI 51-503- AFI 51-503– Claims & litigationClaims & litigation– Disciplinary actionDisciplinary action– Adverse administrative actionsAdverse administrative actions– Publicly releasable reportPublicly releasable report
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Board CompositionBoard Composition
Full Board- Class A, full Full Board- Class A, full compliment of memberscompliment of members
Tailored Board- only the required Tailored Board- only the required board members (determined by board members (determined by convening authority)convening authority)
Single investigator- when formal Single investigator- when formal board not requiredboard not required
18 June 201018 June 2010
Board Member Board Member SelectionSelection ISB Chosen By WG/CCISB Chosen By WG/CC SIB Appointed by MAJCOM/CCSIB Appointed by MAJCOM/CC
– Safety Office Researches AvailabilitySafety Office Researches Availability Annotates Adverse Impact To Individual And / Or Annotates Adverse Impact To Individual And / Or
Wing Wing Seeks Members With Desire To Be ChosenSeeks Members With Desire To Be Chosen AlwaysAlways A Short Notice Suspense A Short Notice Suspense
– Wing CC Approves Local List Submitted To Wing CC Approves Local List Submitted To MAJCOMMAJCOM
– MAJCOM/CC AppointsMAJCOM/CC Appoints
18 June 201018 June 2010
MembersMembers
Board President (Rated Colonel or O-7 for Board President (Rated Colonel or O-7 for Fatality)Fatality)
Investigating OfficerInvestigating Officer Maintenance MemberMaintenance Member Medical OfficerMedical Officer Pilot MemberPilot Member AFSC RepresentativeAFSC Representative RecorderRecorder Technical Assistance Members As RequiredTechnical Assistance Members As Required
18 June 201018 June 2010
Flight Surgeon RoleFlight Surgeon Role
Medical expert for board members Medical expert for board members Liaison to Mortuary Affairs/AFIPLiaison to Mortuary Affairs/AFIP Team leader for all Life SciencesTeam leader for all Life Sciences Advisor for:Advisor for:
– Search & Rescue Team (SAR)Search & Rescue Team (SAR)– Human factorsHuman factors– Human survivabilityHuman survivability– Aircrew medical qualificationAircrew medical qualification– LifestyleLifestyle– Crew rest analysisCrew rest analysis
Family liaisonFamily liaison
Flight Surgeon Liaison Flight Surgeon Liaison
Flight surgeon jobFlight surgeon job Local coroner/MELocal coroner/ME Local emergency medical careLocal emergency medical care Local FS/interim boardLocal FS/interim board PathologyPathology AFIP consultant for investigation, AFIP consultant for investigation,
photography, and autopsyphotography, and autopsy
18 June 201018 June 2010 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Procedural Legal Procedural Legal ConsiderationsConsiderations Establish jurisdiction (JAG duty)Establish jurisdiction (JAG duty) Location of deathLocation of death Location of pronouncementLocation of pronouncement
Jurisdictional Issues Jurisdictional Issues for Fatalitiesfor Fatalities Local Mortuary Affairs OfficerLocal Mortuary Affairs Officer Local Laws- coroner may have to Local Laws- coroner may have to
give permission before remains give permission before remains are movedare moved
Fed Jurisdiction- Office of Armed Fed Jurisdiction- Office of Armed Forces Medical Examiner (OAFME) Forces Medical Examiner (OAFME) must be notifiedmust be notified
International issues- JAG to contact International issues- JAG to contact appropriate liaisonappropriate liaison
AFIP/OAFMEAFIP/OAFME
Over 700 cases per yearOver 700 cases per year– Suicides Suicides – HomicidesHomicides– OtherOther
Aircraft Accident investigationsAircraft Accident investigations– 10-15 cases per year on site10-15 cases per year on site– 10-15 cases in consultation10-15 cases in consultation
Consultants to NTSBConsultants to NTSB
AFIP/OAFMEAFIP/OAFME
AutopsyAutopsy Forensic identificationForensic identification Dental evaluationDental evaluation DNA analysisDNA analysis PhotographyPhotography Examination of flight/life support gearExamination of flight/life support gear Evaluates medical history/evidenceEvaluates medical history/evidence Determines circumstances of deathDetermines circumstances of death
Site DocumentationSite Documentation
Document everything in situDocument everything in situ Do not disturb remains or Do not disturb remains or
wreckagewreckage Document photographically, Document photographically,
temporally, and in writingtemporally, and in writing Document scene and remains Document scene and remains
Accident sceneAccident scene Mark & photograph all remains in Mark & photograph all remains in
situsitu Crew spacesCrew spaces EquipmentEquipment Impact pointsImpact points
– May be distant from main debris fieldMay be distant from main debris field– Avoid area disturbance until search Avoid area disturbance until search
completecomplete
AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
PhotographyPhotography
Digital/filmDigital/film AerialAerial SceneScene RemainsRemains Static displaysStatic displays VideoVideo
Marking LocationsMarking Locations
Grids (squares, circles)Grids (squares, circles) GPSGPS Sifting/gravel operationsSifting/gravel operations Water recoveryWater recovery
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
IdentificationIdentification
Obtain accurate flight manifest/SSNsObtain accurate flight manifest/SSNs– Allows DNA cards to be pulled quicklyAllows DNA cards to be pulled quickly
Identifies all flight crew & Identifies all flight crew & passengerspassengers
Flight surgeon- survivability Flight surgeon- survivability assessmentassessment
Closure for familyClosure for family
IdentificationIdentification
Presumptive- identifies individual Presumptive- identifies individual to sub-group (initial)to sub-group (initial)
Positive- legal identification based Positive- legal identification based on forensicson forensics
Presumptive Presumptive IdentificationIdentification Flight manifestFlight manifest Visual (tattoos)Visual (tattoos) AnthropomorphicAnthropomorphic Personnel dataPersonnel data Medical historyMedical history Personal effectsPersonal effects
Positive IdentificationPositive Identification
DentalDental FingerprintsFingerprints Palm printsPalm prints Foot printsFoot prints DNADNA Radiographic IDRadiographic ID
How long does it take How long does it take to identify positivelyto identify positively Dental 1-2 hrsDental 1-2 hrs Fingerprints 24-48 hrsFingerprints 24-48 hrs DNA 48 hrsDNA 48 hrs
RecordsRecords
Gather all Names/SSNs Gather all Names/SSNs Obtain status & nationalityObtain status & nationality Sequester all records early Sequester all records early
– MedicalMedical– DentalDental– Behavioral healthBehavioral health– CivilianCivilian
Do not permit changes “after the fact”Do not permit changes “after the fact” Sequester all medical/dental imaging Sequester all medical/dental imaging
evidenceevidence
Sequester RecordsSequester Records
Physical-remainsPhysical-remains All equipmentAll equipment All examinations and studies- unalteredAll examinations and studies- unaltered
– Medical records (military & civilian)Medical records (military & civilian)– Dental recordsDental records– Behavioral health recordsBehavioral health records– Radiology films & dataRadiology films & data
Photographs/video- at scene & autopsyPhotographs/video- at scene & autopsy Witness information & statementsWitness information & statements
– PrivilegedPrivileged– Non-privilegedNon-privileged
Postmortem Postmortem ExaminationExamination X-rayX-ray All parts/pieces of all bodies must be x-rayedAll parts/pieces of all bodies must be x-rayed Intact bodies need specified series of filmsIntact bodies need specified series of films Survivors need x-rays in some casesSurvivors need x-rays in some cases
– ejectionejection AutopsyAutopsy ToxicologyToxicology LabLab Ancillary studiesAncillary studies
AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
X-raysX-rays
Full body clothedFull body clothed Hands/feet/head/neckHands/feet/head/neck Permanent evidence of injuriesPermanent evidence of injuries Demonstrates Demonstrates
fractures/morphologyfractures/morphology– mechanism of injurymechanism of injury
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
AutopsyAutopsy
Involve AFIP earlyInvolve AFIP early Crew members involved, preferably all victimsCrew members involved, preferably all victims Photography of remains as recoveredPhotography of remains as recovered Documentation of all injuriesDocumentation of all injuries External examination of injuriesExternal examination of injuries Internal examination- chest, abdomen, cranial Internal examination- chest, abdomen, cranial
vaultvault Dissection of soft tissue injuriesDissection of soft tissue injuries Laminectomy if neededLaminectomy if needed Documenting all injuries & natural diseaseDocumenting all injuries & natural disease
Interim Safety Board Interim Safety Board Flight Surgeon Flight Surgeon TimelineTimeline 8 hour message8 hour message 24-48 hrs24-48 hrs
– 72 hr & 14 day histories on all involved72 hr & 14 day histories on all involved– Review of records & imagesReview of records & images– NotificationsNotifications– Collect lab specimens & resultsCollect lab specimens & results– Preservation/shipment of items to AFIPPreservation/shipment of items to AFIP– Interview witnessesInterview witnesses
Begin data entry into AFSASBegin data entry into AFSAS Transfer all information/evidence to SIB FSTransfer all information/evidence to SIB FS Remain available for questionsRemain available for questions
Safety Board Flight Safety Board Flight SurgeonSurgeon 4-6 wks4-6 wks Continue data accumulationContinue data accumulation ConsultationsConsultations Team supportTeam support Data entry into AFSASData entry into AFSAS Tab YTab Y
SIB Witness InterviewsSIB Witness Interviews
Promise Of Confidentiality Promise Of Confidentiality Available (Aircraft, Space, Missile, Available (Aircraft, Space, Missile, Nuclear Only)Nuclear Only)
Not Under OathNot Under Oath No Article 31 RightsNo Article 31 Rights Note Any MedicationsNote Any Medications
Safety PrivilegeSafety Privilege
Encourage frank & open Encourage frank & open communication with communication with witnesses/contractorswitnesses/contractors
Allow commander to quickly obtain Allow commander to quickly obtain accurate mishap informationaccurate mishap information
Helps ensure appropriate Helps ensure appropriate corrective actioncorrective action
Ultimately, enhances national Ultimately, enhances national securitysecurity
AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Do’s and Don’tsDo’s and Don’ts
DoDo talk to witnesses as soon as possible talk to witnesses as soon as possible DoDo ensure part locations are marked ensure part locations are marked DoDo preserve the evidence preserve the evidence
Don’tDon’t rely on memory – take notes or use recorder rely on memory – take notes or use recorder Don’tDon’t put two fractured parts together put two fractured parts together Don’tDon’t dismantle parts without reassemble marks dismantle parts without reassemble marks Don’tDon’t release wreckage until it’s no longer needed release wreckage until it’s no longer needed Don’tDon’t jump to conclusions as to mishap cause jump to conclusions as to mishap cause Don’tDon’t discuss the mishap outside the board discuss the mishap outside the board
Media RelationsMedia Relations
Refer all questions to Public AffairsRefer all questions to Public Affairs– Only the board president is authorized to release Only the board president is authorized to release
info info Use extreme courtesyUse extreme courtesy Don’t speculate on mishap causeDon’t speculate on mishap cause Politely ask civilians & media not to Politely ask civilians & media not to
photograph fatalities or classified itemsphotograph fatalities or classified items– Contact security forces if necessaryContact security forces if necessary
Refer potential claimants to JARefer potential claimants to JA Avoid media; let AIB do its jobAvoid media; let AIB do its job
Flight Surgeon RoleFlight Surgeon Role
Assist with all life science & human factors Assist with all life science & human factors issues issues
Interview or history-taking expert on boardInterview or history-taking expert on board Assist Line board members in understanding Assist Line board members in understanding
human issues/factors involved in mishaphuman issues/factors involved in mishap Assist survivors, direct/indirectAssist survivors, direct/indirect
– VictimsVictims– FamiliesFamilies– SARSAR– BoardBoard
Process improvement roleProcess improvement role
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Help the other members to Help the other members to understand the human factors understand the human factors componentcomponent
AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Pond’s PearlsPond’s Pearls
As soon as selected for the AIB, make telephone contact with As soon as selected for the AIB, make telephone contact with Board President and exchange contact information—the AIB Board President and exchange contact information—the AIB President is a sharp, knowledgeable senior pilot whose President is a sharp, knowledgeable senior pilot whose assistance is invaluable.assistance is invaluable.
Prior to arriving, read AFI 91-204, AFI 51-503, AFPAM 91-211 Prior to arriving, read AFI 91-204, AFI 51-503, AFPAM 91-211 and the Aircraft Mishap Investigation Manual published by and the Aircraft Mishap Investigation Manual published by the Society of United States Air Force Flight Surgeonsthe Society of United States Air Force Flight Surgeons
For and AIB, read the SIB report in its entirety and make For and AIB, read the SIB report in its entirety and make notes to summarize findings along with tab and page notes to summarize findings along with tab and page number. This will save time when trying to recall the number. This will save time when trying to recall the information.information.
When writing, include the document citation and location at When writing, include the document citation and location at the time of composition—this will save a lot of time trying to the time of composition—this will save a lot of time trying to find it later.find it later.
Pond’s Pearls -- 2Pond’s Pearls -- 2
Read all interviews and data from the SIB and review Read all interviews and data from the SIB and review HUD tapes as soon as practicable.HUD tapes as soon as practicable.
For the first several days, be a sponge soaking up For the first several days, be a sponge soaking up information and making notes, but not conclusions.information and making notes, but not conclusions.
Formulate possible scenarios, and let the data guide the Formulate possible scenarios, and let the data guide the formulation of hypotheses.formulation of hypotheses.
Remember, medical members are expert at the scientific Remember, medical members are expert at the scientific method and analytical thought process which they use in method and analytical thought process which they use in daily practice—this thought process is key to the AIB daily practice—this thought process is key to the AIB process.process.
Realize that some key data may never be available due Realize that some key data may never be available due to the nature of the mishap—a 300 knot impact and to the nature of the mishap—a 300 knot impact and flaming JP8 are very effective at destroying evidence.flaming JP8 are very effective at destroying evidence.
Pond’s Pearls -- 3Pond’s Pearls -- 3
Review news clippings and tapes early.Review news clippings and tapes early. Hope that Safety Privilege was granted by SIB only to Hope that Safety Privilege was granted by SIB only to
those needing it; otherwise it may be necessary to those needing it; otherwise it may be necessary to again ask the wife and others the same questions.again ask the wife and others the same questions.
Limit testimony to facts and observations and avoid Limit testimony to facts and observations and avoid speculations.speculations.
Place date/time on footer of documents such as Place date/time on footer of documents such as timelines that may be updated frequently, so that the timelines that may be updated frequently, so that the prior versions are not confused with the most current prior versions are not confused with the most current one.one.
Take videos of flight simulator scenarios.Take videos of flight simulator scenarios.
Pond’s Pearls -- 4Pond’s Pearls -- 4
Fly path of mishap and get video.Fly path of mishap and get video. Personally listen to the tapes while reviewing the transcript. (E.g. Personally listen to the tapes while reviewing the transcript. (E.g.
the tape said, “Give me an oral airway and BVM,” but the the tape said, “Give me an oral airway and BVM,” but the transcribed version said, “Give me an oral airway and beam me transcribed version said, “Give me an oral airway and beam me up.”)up.”)
Formulate a timeline to incorporate the data from all sources and Formulate a timeline to incorporate the data from all sources and to coordinate several time measures such as Zulu, HUD and to coordinate several time measures such as Zulu, HUD and ACMI.ACMI.
Utilize DoD Human Factors guide that lists all 140+ human Utilize DoD Human Factors guide that lists all 140+ human factors with explanations to examine each person and action. factors with explanations to examine each person and action. This will assure completeness and uniformity with other This will assure completeness and uniformity with other investigations.investigations.
Enlist the assistance of an aerospace physiologist or Guard Enlist the assistance of an aerospace physiologist or Guard physician specialists.physician specialists.
Pond’s Pearls -- 5Pond’s Pearls -- 5
““Murder Board” is the process whereby board members read and Murder Board” is the process whereby board members read and critique the report as it is displayed on the screen. This is valuable critique the report as it is displayed on the screen. This is valuable because it gives a thorough insight into others’ information and because it gives a thorough insight into others’ information and thought processes. Comments from the group on the individual’s thought processes. Comments from the group on the individual’s section are important because sometimes the author gets so section are important because sometimes the author gets so involved in his/her own section that he/she assumes that certain involved in his/her own section that he/she assumes that certain items are known or clear.items are known or clear.
The AIB document is released to the public, so one must be sensitive 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 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 the autopsy reports are not public, so the Flight Surgeon should compose a summary of the medical findings for Tab X with details compose a summary of the medical findings for Tab X with details only to the extent necessary to support the conclusions and answer only to the extent necessary to support the conclusions and answer the questions of the family.the questions of the family.
Get 2 monitor screens and functional scanner.Get 2 monitor screens and functional scanner. Remember that medical records are protected medical information Remember that medical records are protected medical information
and cannot be released.and cannot be released.
Pond’s Pearls -- 6Pond’s Pearls -- 6
Make sure the orders include a rental car.Make sure the orders include a rental car. Assure that orders allow travel time before the Assure that orders allow travel time before the
convening of Board.convening of Board. Flight surgeon is eligible for incentive pays if service is Flight surgeon is eligible for incentive pays if service is
greater than 30 days, continuous, not aggregate.greater than 30 days, continuous, not aggregate. Guard days and funding must “flow,” a complex Guard days and funding must “flow,” a complex
process that may require expediting.process that may require expediting. Get good computer support and email access early.Get good computer support and email access early. Do not plan on free time—Do not plan on free time—
– 14 hours per day, 14 hours per day, – 6 ½ days per week6 ½ days per week
August 7, 2009August 7, 2009 AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Pond’s Pearls -- 7Pond’s Pearls -- 7
To enhance possibility of selection for a Board,To enhance possibility of selection for a Board,– Be prepared to give an immediate answered, yes Be prepared to give an immediate answered, yes
or no—“I will check” means no.or no—“I will check” means no.– Have all training issues completed.Have all training issues completed.– Document all items in mobility folder; have it Document all items in mobility folder; have it
checked by Unit Deployment Manager.checked by Unit Deployment Manager.– Arrange windows of availability with associates for Arrange windows of availability with associates for
coverage.coverage.– Assemble SIB Information and keep it packed or on Assemble SIB Information and keep it packed or on
disk.disk. Bring personal camera and get CDs to transfer to Bring personal camera and get CDs to transfer to
military computer.military computer.
AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Oh yes,Oh yes,
Learn to use Table of Contents on MS Word.Learn to use Table of Contents on MS Word. Back up early and frequently.Back up early and frequently. Bring personal laptop.Bring personal laptop. Bring Flying Forms.Bring Flying Forms. Bring Aerospace Physiology reference book or Bring Aerospace Physiology reference book or
write me.write me. Cell phone and international data plan for PDA.Cell phone and international data plan for PDA. Scan documents early and file by person and Scan documents early and file by person and
type.type. Have Adobe distiller on computer.Have Adobe distiller on computer.
AANGFS RSV—2009 Snowbird, UTAANGFS RSV—2009 Snowbird, UTCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Oh, I just rememberedOh, I just remembered
Assist the Board President in preparing thank you Assist the Board President in preparing thank you letters on your behalf by supplying addresses and letters on your behalf by supplying addresses and templatetemplate
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Don’t expect luxury Don’t expect luxury accommodationsaccommodations
Realize that the process is all consuming; you will Realize that the process is all consuming; you will think about it before you sleep and when you think about it before you sleep and when you awaken, when you eat, shower and walk—but it is awaken, when you eat, shower and walk—but it is that conscientiousness and attention to detail that that conscientiousness and attention to detail that assures you have left no stone unturned and no assures you have left no stone unturned and no question unanswered. We owe that level of question unanswered. We owe that level of dedication to our comrades, their families and the dedication to our comrades, their families and the Air Force. Air Force.
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MN
Col William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
18 June 201018 June 2010 AANGFS RSV—2010 Minneapolis, MNAANGFS RSV—2010 Minneapolis, MNCol William W. Pond, MD, SFS, MC, INANGCol William W. Pond, MD, SFS, MC, INANG
Do expect to make a Do expect to make a true impact on the true impact on the futurefuture