Aircraft mishap investigation can be extremely difficult, timeconsuming, stressful, but also rewarding when we recognize that thecontributions we make will improve aviation safety. A thoroughmishap investigation is absolutely necessary to determine thecascading events causal to a mishap and recommending correctiveactions to prevent recurrence. This edition of the Pocket Referenceintroduces a new tool in accident investigation,the Human FactorsAnalysis and Classification System(HFACS).HFACS provides theaccident investigator with a proven template that aids in organizingthe investigation while providing a detailed analysis of human error for post-hoc mishap data analysis, revealing previously unidentifiedtrends and hazards.Historical data has shown that human error, by itself or incombination with other factors, is present in about 80% of aircraftmishaps, and is therefore the single greatest aviation hazard. As amember of an Aircraft Mishap Board (AMB), the Flight Surgeon isresponsible for doing an exhaustive investigation in an area mostlikely to yield results: the medical and human-factors portion. Pastinvestigations have shown that human factors are not limited to just pilot error. Human factors extend to aircraft maintainers, air-trafficcontrollers, the Squadron chain of command, Airwing, TYCOM, andcan continue to CNO. The role of an investigating Flight Surgeon isnot limited solely to an in-depth analysis of the individuals directlyinvolved in the mishap, it must include all of the individuals andevents that, through careful analysis, reveal the entire mishap chain.How the Flight Surgeon meets the duties and responsibilities of amishap investigation will affect his appraisal by his peers and seniorsin the Navy as an officer, a Flight Surgeon, and a physician, perhapsto 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 Surgeonin his role as a personal physician. If, by his efforts as a physicianand mishap investigator, a Flight Surgeon prevents one aviationmishap in a 20-year Naval career, he will have saved the Navy morethan his entire career pay. While a Flight Surgeon may never haveabsolute proof that he prevented a mishap, he must always do his bestto prevent damage, injury, or death.Developing and maintaining sharp mishap-investigation skills isdifficult, since most Flight Surgeons investigate mishaps infrequently.Consequently, it is easy to commit errors due to lack of experienceand the rapid pace of the mishap investigation. And, as most mishapsoccur at inconvenient times, to say the least, preparedness is
paramount. This reference was compiled to help the Flight Surgeonavoid some of the common pitfalls encountered in these infrequently, but chaotic situations.The Flight Surgeon is both the Human Factors and Medical expertfor 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 teamfrom biological, chemical, physical and environmental hazards. Wehave included a number of sections discussing biological and materialhazards encountered during an investigation. Some hazards are notcovered in this text. We advise that you work with your localfire/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 governmishap investigation and is not meant to supplant the other referencesthat address aeromedical aspects of mishap investigation. Use thisguide as a ready reference in the field to make sure that your dataretrieval is complete and that you preserve perishable evidence. Italso may serve as a source for obtaining additional assistance.
This is the fifth edition of the mishap investigation pocketreference. This edition is a result of a collaborative effort betweencontributors throughout Naval Aerospace Medicine. The goal of thisedition is to provide both a print and electronic version of vitalAeromedical Mishap Investigation information to all members of Aircraft Mishap Investigation Teams. The electronic version isavailable on line at the Naval Safety Center's Home Page:http://safetycenter.navy.mil.The Fifth Edition of this reference is available in an AdobeAcrobat
format and can be downloaded and printed by anyinterested party.The Mishap Investigation Guide has traditionally been issued toall Naval Flight Surgeons as part of their basic training in MishapInvestigation at the Naval Aerospace Medical Institute in Pensacola,Florida. Recognizing the need for the continued publication of thisreference, The Society of United States Naval Flight Surgeons(SUSNFS) underwrites the printing costs of this text as a service to itsmembers. A printed version of this guide may be obtained bycontacting the Society athttp://www.aerospacemed.org.