According to the DoD, an aviation mishap is an unplanned event or series of events involving DoD aircraft or military flight operations that result in damage to DoD or public property on illness or injury to military, civilian, or non-DoD personnel caused by DoD activities. During the review, the GAO audited mishap data collected by the Army Combat Readiness Center, the Naval Safety Center – which manages Marine Corps aviation safety, and the Air Force Safety Center (safety centers) and shared with the Office of the Secretary of Defense (OSD). The GAO also learned during the review that the DoD is considering reorganizing certain policy and oversight functions related to aviation mishaps.
Non-standardized mishap dataIn conflict with current DoD instruction, the GAO specifically found that the safety centers did not collect standardized data as part of their mishap investigations and, depending on the service branch, the safety centers only collected 10 to 17 of the 35 data elements required by the OSD, with those missing data elements either unaccounted for or collected in a non-standard format.
(Image source: GAO)
According to officials, the safety centers utilize separate, service-specific data systems that evolved independently over time to collect data to meet the unique requirements for each military service and developed and upgrade their data systems over time based on individual service branch needs. Some safety centers pointed to upgrade delays affecting their compliance.
No consensus on reporting causal factorsThis same lack of consensus led the safety centers to not report all agreed-upon data elements to OSD, including the causal factors related to aviation mishaps. The disagreement between the safety centers and OSD on data also included the reporting of contributing human factors, such as mental awareness, that may have caused mishaps.
According to OSD officials, because of the lack of reporting, the OSD has been unable to conduct analysis on patterns in human factors – including those that may “cross cut,” or have an impact on more than one, military service.
Inconsistent training dataFurther – while recent studies suggest that training shortfalls are a potential indicator of aviation mishap trends – the safety centers do not consistently report, nor does the DoD consistently collect and analyze training data from all mishap investigations, such the pilot’s recent flying experience or training proficiency in the task or mission performed during the mishap.
Moving forwardThe DoD is limited in its ability to compare mishap data across the military services and has had limited access to mishap causal data. According to the GAO, this further limits DoD’s ability to conduct analyses on patterns in mishaps that apply across the military services.
The GAO made three recommendations for the safety centers and DoD, including take interim steps to ensure that standardized aviation mishap data elements are collected by the safety centers; update department-wide and service instructions and policies to clarify the responsibility of the OSD for conducting analysis and its access to the military services’ information on human factors that contributed to aviation mishaps; and identify relevant training-related data to collect as part of any update of the aviation mishap data elements and incorporate these data into future analyses.
The GAO’s final report, expected in early 2019, will include information related to rotary-wing aviation mishaps, along with any additional findings.
William Kucinski is content editor at SAE International, Aerospace Products Group in Warrendale, Pa. Previously, he worked as a writer at the NASA Safety Center in Cleveland, Ohio and was responsible for writing the agency’s System Failure Case Studies. His interests include 'literally anything that has to do with space,' past and present military aircraft, and propulsion technology. And also sportscars.
Contact him regarding any article or collaboration ideas by e-mail at firstname.lastname@example.org.
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