The Naval Flight Surgeon's Pocket Reference to Aircraft Mishap Investigation


Aircraft mishap investigation can be extremely difficult, time consuming, stressful, but also rewarding when we recognize that the contributions we make will improve aviation safety. A thorough mishap investigation is absolutely necessary to determine the cascading events causal to a mishap and recommending corrective actions to prevent recurrence.

This edition of the Pocket Reference introduces a new tool in accident investigation, the Human Factors Analysis and Classification System (HFACS). HFACS provides the accident investigator with a proven template that aids in organizing the investigation while providing a detailed analysis of human error for post-hoc mishap data analysis, revealing previously unidentified trends and hazards.

Historical data has shown that human error, by itself or in combination with other factors, is present in about 80% of aircraft mishaps, and is therefore the single greatest aviation hazard. As a member of an Aircraft Mishap Board (AMB), the Flight Surgeon is responsible for doing an exhaustive investigation in an area most likely to yield results: the medical and human-factors portion. Past investigations have shown that human factors are not limited to just pilot error. Human factors extend to aircraft maintainers, air-traffic controllers, the Squadron chain of command, Airwing, TYCOM, and can continue to CNO. The role of an investigating Flight Surgeon is not limited solely to an in-depth analysis of the individuals directly involved in the mishap, it must include all of the individuals and events that, through careful analysis, reveal the entire mishap chain.

How the Flight Surgeon meets the duties and responsibilities of a mishap investigation will affect his appraisal by his peers and seniors in the Navy as an officer, a Flight Surgeon, and a physician, perhaps to 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 Surgeon in his role as a personal physician. If, by his efforts as a physician and mishap investigator, a Flight Surgeon prevents one aviation mishap in a 20-year Naval career, he will have saved the Navy more than his entire career pay. While a Flight Surgeon may never have absolute proof that he prevented a mishap, he must always do his best to prevent damage, injury, or death.

Developing and maintaining sharp mishap-investigation skills is difficult, since most Flight Surgeons investigate mishaps infrequently. Consequently, it is easy to commit errors due to lack of experience and the rapid pace of the mishap investigation. And, as most mishaps occur at inconvenient times, to say the least, preparedness is paramount. This reference was compiled to help the Flight Surgeon avoid some of the common pitfalls encountered in these infrequently, but chaotic situations.

The Flight Surgeon is both the Human Factors and Medical expert for 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 team from biological, chemical, physical and environmental hazards. We have included a number of sections discussing biological and material hazards encountered during an investigation. Some hazards are not covered in this text. We advise that you work with your local fire/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 govern mishap investigation and is not meant to supplant the other references that address aeromedical aspects of mishap investigation. Use this guide as a ready reference in the field to make sure that your data retrieval is complete and that you preserve perishable evidence. It also may serve as a source for obtaining additional assistance.


The Naval Safety Center, Aeromedical Division, In conjunction with Dedicated Aerospace Medicine Professionals
Fifth Edition

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This website is dedicated to the development and dissemination of medical information that may be useful to those who practice Operational Medicine. This website is privately-held and not connected to any governmental agency. The views expressed here are those of the authors, and unless otherwise noted, do not necessarily reflect the views of the Brookside Associates, Ltd., any governmental or private organizations. All writings, discussions, and publications on this website are unclassified.

© 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved


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