When a Mishap Occurs
Keith A. Williams
110414

In the Air Force, mishaps occur regularly. This is unfortunate but, inevitable when you have a workforce of over 300,000 military members and 170,000 civilian personnel. Any mishap could create a crisis situation but, the severity of that mishap determines not only the response but the investigation to prevent recurrence. Categorically, mishaps are broken down by discipline, class and duty status. The disciplines are labeled as: Ground, Flight, Space and Weapons. Ground would be a mishap which occurred; you got it, on the ground. A car accident, a trip and fall at home (as military personnel are accounted for 24 hours a day) or a sprained back while lifting a box at work would all be considered ground mishaps. Flight mishaps are those that deal with aircraft. Aircraft are defined as manned as well as unmanned, such as Remote Piloted Aircraft (RPA) or as the media calls them drones. Space mishaps deal with space flight such as rockets and satellites. Weapons mishaps are those that occur when an explosive device, such as a grenade, missile or bomb incident occurs. All of these categories are then broken down by class from A-D. A Class A being the worse, whereas there is a loss of life or property damage over $2,000,000. A Class B mishap is one where there is a loss of a limb (leg or arm) or function of an eye(s) or property damage less than $2,000,000 but more than $500,000. A Class C mishap is when there are only lost workdays from work or property damage less than $500,000 but more than $200,000. A Class D mishap is when an individual has been placed on restricted duty or property damage less than $200,000. All of these categories are viewed from a status of on-duty or off-duty. Duty status mainly applies to military members as their on-duty or off-the-job mishaps are documented as well. Usually, duty status is only a factor during a ground categorized mishap. While ground mishaps occur more often than the others, flight or aircraft mishaps draw the most attention and are usually the most severe. The attention comes not only from the media but from leadership within the Air Force. For this paper, I will discuss manned aircraft because not only do you have the cost of losing an expensive asset, you also have the potential loss of life. That is the loss that an Air Force community struggles with the most.
Last year, the Air Force lost 30 aircraft in accidents (AFSAS, 12). Each time, a chain of events began to try to deal with the crisis that was in front of the particular base. Leadership has to make quick and rationale decisions that are guided by Air Force Instructions. Some get it right from the start and the process works smoothly. Others struggle due to poor guidance from individuals or poor planning. Most are probably somewhere in-between because regardless of how much guidance you have as well as how much you have prepared, when a crisis such as an aircraft crash occurs, it will have some unforeseen events that will require leadership to make an out-of-the-box decision. In my 22 years as a safety professional, I have been intimately involved in several aircraft mishaps. Each one required our safety team’s full attention for several days and some required our attention for 30 days or more. In all of them, we lost at least one individual. Some involved multiple aircraft, some involved a large loss of life and some only involved a single aircraft. Regardless of the number of people or aircraft our safety offices responded in a decisive and professional manner, even as others seem to panic or become unsure of their own responsibilities. On the next few pages, I will take you through the entire process of when an aircraft mishap occurs.
It could be at anytime during the day or night, any weekday or weekend but traditionally an aircraft mishap occurs during the day during a weekday (AFSAS, 12). This is no doubt due to the majority of Air Force flying operations occur at that time. It usually starts with an early warning from the aircrew of a problem usually termed as an In-flight Emergency (IFE). The IFE is declared from the aircrew to the air controllers. At this point, a call via the “crash net” is sent out to various agencies through-out the installation that an aircrew has declared an IFE. The agencies are; Security Forces, Fire Department, Base Operations, Civil Engineers, Hospital, Safety and Base Leadership. This crash net is managed by an agency called Base Operations who are manned 24 hours. As first responders, the Fire Department, Security Forces and Hospital go just short of the runway where the aircraft will land and wait for further instructions. On a typical Air Force installation, this scenario could occur many times in a day and the aircraft that declared the emergency land without incident. After a few cursory checks by the Fire Department, the aircraft is turned over to aircraft maintenance personnel or if able, the aircrew will taxi the aircraft to its intended location and then maintenance will take over. However, the first responders must be prepared for the unexpected and not assume anything. If the aircrew is unable to safely land the aircraft, the actions by the first responders is critical to the mishap being controlled early. If the aircraft crashes, the first thing the first responders will attempt to do is determine if the aircrew came down with the aircraft or did they eject. For this, the controllers in the tower are important. Because of the sight advantage point they have, they assist can the first responders for indications that the aircrew did or did not leave the aircraft. If the aircrew stays with the aircraft, then the fire department goes into action to eliminate any hazards i.e. fire, chemical spills, etc before extracting the aircrew. Fire Department personnel are highly trained for any scenario that could occur to include the types of hazards an aircraft may have upon crashing. Some of these hazards could be highly toxic so before they go into action, they quickly assess the situation to ensure they have the proper protective gear to handle the situation. Once the aircrew is able to be removed from the aircraft, then the fire department begins to put out the fire, contain fuel etc. At this time the medical personnel take the aircrew and begin the process of determining injuries that the aircrew may have suffered. Also, depending on the type of aircraft, the medical personnel may ask for assistance from bio-medical personnel who can monitor the air surrounding the crash-site to assist in determining what if any additional personal protective gear may be required for anyone near the site. Simultaneously, security forces personnel begin to establish a perimeter around the crash site. Most of this is done in the first 30 minutes of an aircraft mishap with the biggest factor being the hazard of a fire or fumes that could easily slow this entire process down.
With the first responders in place, the safety office has an individual arrive at the crash site and monitor the activities closely. While this individual does not interfere with any of the first responder operations, they are crucial in making sure that the crash site is left intact as much as possible for the safety investigation team. As all of this orderly chaos is occurring, the same agencies that received the initial notification are notified again through the crash net that the aircraft has crashed. A few minutes later they may be notified to report to the Emergency Operations Center (EOC). When they are notified is determined by the fire chief, who is the On-Scene Commander and is in communication with base leadership via mobile phone in determining if any hazards exist for personnel to safely respond to the EOC. Representatives who respond to the EOC are: Aircraft Maintenance, Civil Engineer, Contracting, Force Support, Safety, Medical, Logistics, Security Forces, Legal, Chaplain, Public Affairs, Alert Photographer and Flying Operations. Along with representatives from these agencies, base leadership (Wing Commander and Group Commanders) are there. There are usually 4 Group Commanders; Aircraft Maintenance (MX), Medical (MDG), Mission (MSG) and Operations (OG). The MSG commander is usually in charge of the EOC. Once representatives and leadership arrive, in which they have 30 minutes, an initial briefing is given with the latest information. When a serious mishap happens on-base, the temptation is for leadership to go to the crash site to see the damage first-hand, however, this hinders the first responders because now the fire chief who is in charge of the crash site is now having to deal with additional individuals in the area and all of those individuals are above him or her. Of course that means they have to focus less on the task at hand because they are coddling leadership. While that should not be the case, unfortunately it is. If everyone follows protocol and reports to the EOC, after the initial briefing, every representative begins to use their respective checklist for the crisis that has been briefed. These checklists are from the base mishap response plan which every installation must have. With very few exceptions, every possible scenario has been vetted through exercises, training and subject matter experts to ensure every crisis can be handled in an appropriate and manner. The checklists are identified according to the event and for some agencies the event may dictate that their checklist is very short while another agencies checklist being lengthy and vice-versa. Ordinarily an update is given every 15 minutes on the status of the events that are taking place at the crash site and at that same time, each agency representative gives the status of their ongoing activities. The first 60 minutes are critical for the EOC as everyone has a major role in an aircraft mishap and if one representative is late in reporting, there could be a domino effect throughout. The EOC is the brain-trust of the crisis and as events move along, each EOC representative role and responsibilities increase exponentially.
Each EOC representative has an important role. Aircraft Maintenance gathers the maintenance documents for the mishap aircraft as well as makes available anyone who performed work on the aircraft in the last 24 hours available for drug testing. Aircraft Maintenance will also be responsible for gathering the mishap aircraft and placing it in a hangar for the safety investigation board. Civil Engineer assist with providing portable lighting, fencing for security purposes at the crash site as well portable facilities for investigators, team members etc. Contracting provides funding for any contract work that may need to take place to facilitate the mishap. While on the installation, the role of the contracting representative could be small, if the crash occurred off-base, their role could be critical. Force Support would provide food for the EOC as well as on-base lodging for members who may not be able to go home due to the crisis becoming an around-the-clock operation. Force Support’s most crucial role would be if there is a casualty. They are responsible for notifying next of kin as well as dealing with pay, benefits, life insurance pay-outs etc. They also are the lead on assembling the team to recover any human remains. Safety’s role is two-fold. First they ensure all EOC members are aware of any possible hazards at the site so they can relay this to their respective work-centers who may eventually be involved in recovery operations. Second they prepare for the Interim Safety Investigation Board (ISIB). The Safety EOC representative is in contact with the safety representative at the crash site. Medical handles any updates to the health status of the aircrew. The EOC representative is in constant communication with the medical personnel at the crash site. Logistics will assist with providing transportation once the wreckage is ready to be moved as well as provide vehicles for safety board members. Security Forces keeps EOC members aware of any potential security issues at the crash site and is in constant contact with personnel that are securing the site. They also keep an update on the safe route to the crash site. Legal is there as an advisor to leadership for any potential claims that could be processed against the Air Force. Their role would be greater if the mishap occurred outside the installation, however, there is still potential with an on-base mishap for claims if a part fell off the aircraft before it crashed and struck someone’s vehicle or if the aircraft dumped fuel prior to crashing and that fuel landed in a farmer’s field. The Chaplain Representative is there as a spiritual advisor. Their role is increased if there is a casualty. They not only would assist the family or families affected but also would be there to assist personnel who recover human remains. Public Affairs will prepare any statements that need to be released to the public. Also, they would handle all media request. Base leadership (usually the Wing Commander) usually will be the only individual outside of the Public Affairs Representative to speak to the local media and only after receiving guidance from Public Affairs. The Alert Photographer’s role is to capture the mishap site for the ISIB. Their expertise is critical to ensure the ISB has a visual scene because the crash site will eventually be cleaned up. The Flying Operations representative is there to advise on any flying operations that have been impacted by the mishap such as if other aircraft were diverted because the airfield is closed. All of these representatives have alternate EOC members in case they happen to not be available the day or time the mishap occurs. Also, each representative has personnel back at their respective work-centers that assist them in gathering any information that they need. Until the mishap site is deemed safe by the Fire Chief, EOC personnel stay at the EOC. Depending on the severity and complexity of the crash, this could be several hours. All of this is magnified if the crash site is off the installation; however each Air Force installation has a mutual agreement with the surrounding communities that they are in charge of any military aircraft crash site.
While all of this is going on, safety has gathered names to be on the ISB. These names are given to leadership for approval. Before given to leadership the names have already been vetted for qualifications such as experience with safety investigation training, knowledge of the mishap aircraft, possible alibis such as upcoming personal leave, medical issues etc. The safety office is required to maintain a list of anyone base-wide that has had safety training and update it monthly for this reason. At a minimum, the ISIB will consist of; Board President, Investigating Officer (must be someone who is qualified to fly the mishap aircraft), Maintenance Officer, Medical Officer, Life Support Officer, Airfield Officer (air controller qualified) and Recorder (AFI 91-204, 12). Once the list is approved, the ISB members are told to report to the Wing Safety office. The Wing Safety office is also where the mishap aircraft maintenance records and the mishap aircrew medical records are delivered. Once the ISIB members arrive at the safety office, they are given the latest information on what has occurred. They are also given a refresher briefing on the do’s and don’ts of the investigation process. Both of these briefings are given by the Safety EOC representative. After the briefings, the ISIB is given their respective investigation kits (which are maintained by the safety office) shown the pre-determined location where they will be performing the investigation and issued vehicles. An ISIB is replaced by an outside Safety Investigation Board (SIB) within 3-5 days but their work is critical because the gathering of witness statements and other data is best done in the early stages of an investigation for accuracy purposes. The SIB initially has 30 days to complete their investigation (AFI 91-204, 12). Some members from the ISIB may stay on the SIB but at a minimum the board president will be replaced.
Once the mishap scene is deemed safe, the fire chief turns everything over to the EOC. As stated earlier, depending upon the size of the aircraft, the number of victims involved and any collateral damage from the wreckage, the fire chief may be in control of the scene for a few hours. The EOC commander will come out to the scene with other base leadership to survey the sight first-hand. At this point, the scene is turned over to the ISIB. Regardless of the time-frame when this all occurs, the Wing Commander releases an electronic message to other Air Force bases world-wide within 2 hours stating that an aircraft has crashed. The message gives only a few details (type of aircraft, time of day, weather conditions, the number of aircrew on board) and states that further information will come through safety channels. Within 8 hours, the ISIB releases their preliminary message. Concerning the local media, the Wing Commander will address them within 4 hours of the mishap taking place. Of course, the probability of phones ringing across the base is high with folks outside the base wanting to know information but, with the scene controlled, there really isn’t much information that can be gathered by those outside the EOC and ISIB. The individuals in the EOC and ISIB know that they do not discuss any details of the mishap with the media or with anyone else. Once the scene is turned over to the ISIB, the alert photographer goes out with them and begins to capture the scene. The scene has only been disturbed for fire-fighting purposes so if there are casualties, they are left in place (likely still in their cockpit seats). Once the scene has been captured with measurements, photos etc and remains if any are removed the wreckage is moved to a hangar for further investigation purposes. In the perfect scenario, this whole process takes less than 8 hours.
A perfect scenario is usually wishful thinking as my experience has shown that this initial process takes 12-16 hours. After the initial process, the safety investigation is vital to prevent recurrence of this type of mishap again. The safety report along with feasible recommendations is compiled and then presented to a 4-Star General for approval. The report is disseminated to every Air Force base with an aircraft like the mishap aircraft. All recommendations must have action taken before they are closed. Once all recommendations have been closed, the report is officially closed by the Air Force Safety Center and the report is archived.
I believe the Air force has a first-class response plan for any crisis. The key is preparation and because we exercise every scenario in our plans annually, we are ready if and when a mishap occurs.

Bibliography
Air Force Safety Automated System, https://afsas.kirtland.af.mil//
Air Force Instruction 11-202, Flight Operations General Flight Rules, June 2006
Air Force Instruction 91-204, Safety Investigations and Reports, June 2012
Barton L., Crisis Leadership Now, October 2008
Joint Base San Antonio Mishap Response Plan, 2012