United States Naval Flight Surgeon Handbook
2nd Edition 1998

Aircraft Mishap Planning

The Changing Role of the Armed Forces Institute of Pathology
Due to budget and manpower constraints, the Armed Forces Institute of Pathology (AFIP) will no longer be able to dispatch a team of investigators to every fatal mishap. AFIP will continue to provide consultation and laboratory support to medical investigators. They will also review Flight Surgeons' Reports (FSR), Mishap Investigation Reports (MIR), and autopsy protocols. However, the collection and preservation of medical evidence will fall to the on-scene investigators.

Historically, few Flight Surgeons investigate more than one fatal mishap in their careers. The vast majority leave Flight Surgery at the end of their first tour for clinical specialties. These factors impair the development of a "corporate memory" in the community. Aerospace Physiologists (AP), especially the Aerospace Medical Safety Officers (AMSO) remain in the field for several tours and are likely to investigate many mishaps. Their assistance and experience can be extremely helpful to the junior FS as he approaches his first smoking hole.

The Flight Surgeon's Role in Aircraft Mishap Investigation
Although this section will focus on the responsibilities of the Flight Surgeon in mishap investigations, and the resources available to assist him in meeting these responsibilities, several pre-mishap planning issues will be addressed. Each Service has its own guidance regarding investigation of aircraft mishaps. These are:

• OPNAVINST 3750.6Q The Naval Aviation Safety Program

• DA Pam 385-40 Aircraft Accident Investigation and Reporting

• AFP 127-1V1 US Air Force Guide to Mishap Investigations

• AFI 91-204 Safety Investigations and Reports

Familiarity with the entire Navy instruction is extremely important. It is especially important to have those sections addressing your responsibilities readily available and to review them regularly; especially when changes are issued. The senior flight surgeon at each facility should ensure that all new personnel are oriented to their responsibilities, and that any local procedures are clarified.

Additionally, each facility is well advised to have a copy of the other Services procedures handy; you never know when a stranger may "drop in" on you. As a Naval Flight Surgeon, the author was extremely impressed and grateful when upon arrival to an AFB to investigate a USMC mishap, all required medical evaluations, interviews, and biological sample required by the Navy instruction were presented in one neat packet. The USAF Senior Flight Surgeon had provided his subordinate with excerpts from the Navy instruction, outlining these requirements (which were subtly different from USAF procedures). Could your facility do as well?

Reprinted from:

"The Role of the Flight Surgeon in Aircraft Mishap Investigation"; WRC Stewart; Navy Physiology Supplement; 2nd - 3rd Qtr, 1988, Naval Air Systems Command, Washington, DC; presented to 1988 FAILSAFE Meeting, Yuma AZ.

Flight Surgeon participation in pre-mishap planning
Upon arriving at a new duty station, the FS should meet the persons with whom he will be working. The "old hands" should aid him in this endeavor whenever possible. He should study the local mishap plans with special attention to Medical Department responsibilities and participate in local mishap planning meetings. This is where many "what if's" should be addressed.

SAR response and FS responsibilities must be clear to all involved. The FS must be familiar with the emergency equipment he will have available, and the qualifications of support personnel to assist him.

Agreements with MTF's for care of casualties, and collection of biological samples must be addressed. Very specific, brief instructions should be provided to those facilities, especially ER's and labs, where the person on duty at the time of the mishap may be unfamiliar with the requirements. These must be readily available to the duty personnel; a special folder for the duty desk with a covering checklist may be helpful. Appendix 2 is an example of such an instruction for USN mishaps. These "go-by" notes must be reviewed and updated, especially when Service instructions are modified.

Especially important is settling who has jurisdiction over remains of anyone killed in a mishap in your operating area. Letters of agreement should be executed if possible so that all parties concerned know what is expected of them. Many Medical Examiners will welcome assistance from the Aerospace Pathologists from the Armed Forces Institute of Pathology (AFIP). Some may be happy to relinquish jurisdiction outright, while others will permit varying degrees of participation by AFIP or other military pathologists. The Medical Examiner may wish to retain certain "sensitive" cases. However, liaison and establishment of rapport before a mishap is more likely to produce co-operation than unprofessional haggling over the remains at the mishap site. The local Judge Advocate General Officer can assist you in researching this issue and drafting any agreement. Most states take a dim view of "body snatching", so prior resolution of this issue is very important.

Identification of fatalities and notification of next of kin will require the efforts of many persons. Avoidance of errors is critical for obvious reasons, but so is prompt resolution of the question. Dentists and law enforcement agencies such as Naval Investigative Service or the Provost Martial Office may have useful expertise in identification. The Decedent Affairs Officer can assist with notification of next of kin. Clear delineation of the responsibilities and authority of those involved can prevent confusion during such an event.

Since you will want to make photographs of the mishap site, liaison with the base photo activity is recommended. These professionals can probably provide better quality photos than you can take on your own. However, they will need to be shown what you want photographed, and what the picture is supposed to demonstrate. Also, remember that the photographer will likely be unaccustomed to the proximity of dead bodies, so be sensitive to his reaction.

Pictures should also be taken during the autopsy. If no medical photographer is available, ask the photographer to shoot color strips for each roll, and bracket the exposure for each shot. Begin with the remains before removing the flight gear, then the exposed body. Ask the pathologist conducting the autopsy to point out all significant findings, and make pictures whenever possible. If no photographer is available, shoot your own. Use prudence, but don't be stingy with the film - it's the cheapest part of the investigation! Take any shots you might reasonably need and extras of critical items. Contact sheets of each roll can be made quickly and can help you decide which shots you want printed.

Aerial views of the mishap site can usually be obtained from a helo. An extra circle of the site on the way in or out will allow the photographer to get the shots you need. Additional aerial photos with infra-red film thru a #12 yellow filter can often provide information not visible on standard photos. The photo facility can obtain and store this film for you until needed. AFIP can assist with interpretation of the infra-red photos.

Post-mishap considerations:
Care of casualties takes priority over collection of evidence. However, proper prior planning can maximize efficiency of both. Although the injured require prompt evacuation for treatment, obvious fatalities (eg, decapitated, incinerated, etc.) need not be removed from the wreckage immediately, unless additional fire, explosions or other damage is likely.

Accident reconstruction will be easier if the position of the fatally injured is documented. Pictures can be valuable, but notes can be of great help in interpreting them, especially if the quality is less than ideal. Engineers can help survey the crash site and make accurate drawings of the location of wreckage and bodies.

Flight gear should be left on the bodies until the postmortem. This permits corelation of injuries, damage to flight gear, and trace evidence from the aircraft to reconstruct the crash. Explosive devices (flares, ejection seats, etc.) should be "safed" before removing the fatalities. If there will be a delay before autopsy, the remains should be refrigerated, not frozen.

AFIP assistance must be requested; it is not automatic for all fatal mishaps. Check OPNAVINST 3750.6 to determine how to get them launched to you. Remember they will be limited to working with the physical evidence that you collect and protect. Avoid disturbing such evidence to the greatest degree possible.

Inform the CO of the severity of the injuries ASAP. As soon as fatalities are identified, execute previously agreed upon responsibilities to allow notification of next of kin. Allow survivors to speak with family as soon as practical, but caution them to avoid discussing injuries of other crewmembers or starting rumors.

Histories of the events preceeding a mishap are routinely collected by the FS examining survivors. Statements should be obtained from aircrew, support personnel, and witnesses as soon as possible. Tape recording is preferred, but a written outline should be made if a recorder is not available. In the case of fatalities, family, friends, and co-workers are interviewed. The art of such interviews is beyond the scope of this paper. However, a FS who gains the respect of the interviewees prior to the mishap is more likely to receive co-operation from surviving aircrew, squadron mates, or next of kin.

Although most Flight Surgeons receive little to no formal training in ergonomics, dynamic cockpit workload evaluation, or system safety engineering, they are expected to be the human factors expert for the AMB. Even the "medical" factors in a mishap may require specialist knowledge of such esoterica as the effect of presbyopia on accomodation time of the night myope in low illumination conditions. Each Service has its own experts in aviation life support systems (ALSS), who can compliment the FS medical knowledge. In the Navy, Aerospace Physiologist AMSO's are far more experienced in this area than most FS. Their assistance can enhance the quality of the investigation and report. USAF Safety and Inspection Center and the Army Safety Center also have ALSS experts. Additionally, these experts know experts in related fields such as ejection seats, parachutes, etc. If you have a question whether any such factors might have contributed to the accident or injuries, timely contact may be able to resolve the issue. The FS should ensure that design flaws that aggravate injury or impede safe egress are appropriately addressed.

Perhaps the most under utilized resources are the Aerospace Medical Specialist Senior FS who can assist the new guy by helping him organize the available information, focus his investigation, and request other "specialists" to assist as necessary. Collecting and analyzing all this data, and evaluating the effect on the Aviator's cockpit performance at the time of the mishap is a bit much to expect of a first tour Flight Surgeon who may also be grieving the loss of a friend and squadron mate. Several recent MIR's reflect the inexperience of the AMB Flight Surgeon. Providing him with a more experienced colleague, who has participated in several investigations can produce a better investigation and report.

Two questions frequently asked about a fatal mishap are, "what killed him ?" and "was it potentially survivable ?" Mishap survivability is a complex subject, but can be approached systematically. Survival depends on several factors for which the acronym "CREEP" has been coined:

Crash forces
There are several technics for the determination of crash forces. Some involve mathmatical modeling, other are based on autopsy findings. AFIP and the Safety Center can assist in determining whether the crash forces were in the potentially survivable range. Many Aerospace Medicine Specialists, and AMSO's attend a 2 week course in this subject as part of their training. If this is a pertinent part of any mishap investigation, especially those near the edge of the survivability envelope, don't hesitate to ask for assistance.

• Container; refers to the integrity of the airframe during and after a crash.

• Restraint systems; failure in an otherwise survivable mishap is certainly worth reporting.

• Environment; includes occupiable space, intrusion of objects into this space, in-flight fire, fumes, etc.

• Energy absorbtion; stroking seats, deformation of the aircraft, etc. which decreases the creash forces applied to the occupant.

• Post-crash factors; fire, blocked exits, or drowning which may kill persons surviving the crash itself.

Depending on the condition of the remains, autopsy may be able to determine the cause of death, and relate the findings to the evidence in the wreckage. If there is any question whether an autopsy might be illuminating, telephone (or message) consultation with AFIP should be accomplished. Although the pathologist can rarely work miracles with 8 ounces of incinerated tissue, in appropriate circumstances, an autopsy can be most helpful in reconstructing what happened. The investigating FS should attend the postmortem if possible. If the autopsy is not performed by AFIP, the FS should ensure that the following specimens are obtained at autopsy whenever possible:

• Whole body X-rays

• Blood (note source)
  - 2 large red top tubes
  - 2 large purple top tubes

• Urine 50 ml.

• Vitreous

• CSF

• Other tissues (liver, lung, brain, etc) as available.

The pathologist may brief Board members, if they are available, and will submit a report, but participation by the FS will allow him to answer other question raised by Board members later. AFIP conducts an Aerospace Pathology course annually.

In addition to the exceptional in-house laboratory services, AFIP can tap the resources of several other agencies. When appropriate, the FBI or the Bureau of Alcohol, Tobacco, and Firearms can assist with identification, or when hijacking, sabotage, or other explosion is a possibility. NTSB has computer capability to reconstruct a 3-D projection of the flight path from radar tapes. The more tracking stations providing data, the better the output. They can also provide assistance in evaluating crash forces as described above. Some of the Service research labs can provide assistance in answering specific questions. Simulators may offer insights into what the pilot was experiencing prior to the crash and direct the investigation along fruitful lines (e.g. disorientation, GLOC). Re-flying the mission profile (with appropriate safety checks) may be similarly helpful. In summary, when considering the mishap scenario, think of evidence which would support or reject a hypothesis; try to imagine or ask experienced investgators how such evidence might be obtained; and consult with the Board to determine whether that line of investigation is likely to be fruitful. If the answer is "yes", ask for assistance.

Pre-mishap Planning Checklist

• OPNAVINST 3750.6Q The Naval Aviation Safety Program reviewed

• NAVSAFECEN Flight Surgeon's Pocket Checklist (FS-PCL) reviewed

• Local mishap plan reviewed

• Local civilian Medical Examiner/Coroner contacted:

  • Jurisdiction addressed, and MOU reviewed by JAG

• Instructions for other Services available and reviewed

  • DA Pam 385-40 Aircraft Accident Investigation and Reporting

  • AFP 127-1V1 US Air Force Guide to Mishap Investigations

  • AFI 91-204 Safety Investigations and Reports

• Liaison with key personnel:

  • Station CO, XO, OpsO, SafetyO

  • Wing CO, XO, OpsO, SafetyO

  • Squadron CO, XO, OpsO, SafetyO

  • Aerospace Medical Safety Officer (AMSO)

  • Public Affairs Officer (PAO)

  • SAR personnel

  • Crash & Salvage/Fire Department

  • Explosive Ordinance Disposal (EOD)

  • Aircrew equipment specialists

  • Medical Treatment Facility CO/OIC

  • Medical colleagues (Medical staff meeting)

  • Medical support personnel

  • Photographer - Infrared film & #12 yellow filter for aerial photos.

  • Local civil engineers (site survey capabilities)

• Brief instructions provided to supporting facilities:

  • ER

    • Drawing of samples

    • Handling of flight gear

  • Lab

    • Drawing & handling of samples

  • Morgue

    • AFIP autopsy protocol

    • Total body X-rays

    • Handling of samples for toxicology

  • Photo

    • Infrared and color film for on-site photos

    • Photos of autopsy

    • Special handling required by OPNAVINST 3750.6Q

    • Others as required
      

• SAR equipment inventoried & inspected

  • Personnel trained in use

• Flight Surgeon's Pocket Checklist in mishap investigation kit

• Mishap investigation equipment inventoried regularly;(See FS-PCL for recommended contents.)

• Identification of fatalities; support personnel identified

  • Dental

  • MP's

  • Others

• Notification of next of kin; policy reviewed and roles identified

  • Decedent Affairs Officer

  • Casualty Assistance Care Officer (CACO)

  • CO appointed Command representative

  • Chaplain

• List of Key phone numbers and points of contact

  • Safety Center (Duty Officer) DSN 564-3520 COM (757) 444-3520

  • AFIP (Medical Examiner) DSN 662-2626 COM (301) 319-0000

  • Local Medical Examiner/Coroner

  • Wing

  • TYCOM

Medical and Laboratory Procedures Required Post-Mishap
1. Physical Examinations.
While the responsibility for performing the required physical examination lies with the first "Flight Surgeon" to examine the survivors and victims, an initial examination should be conducted by the first member of the medical department to contact the survivors/victims according to the following order of preference:

1. U.S. Naval Flight Surgeon

2. Other service flight surgeon

3. Physician

4. Senior Independent Duty Hospital Corpsman

5. Other Hospital Corpsman

• NOTE: These examinations shall be performed on all flight crewmembers, and on passengers and flight support personnel (e.g. controllers, LSO, line handlers) as appropriate.

2. Radiographs (X-Rays).
Radiographs (x-rays) shall be performed as clinically indicated. After all ejections, bailouts, and crashes with or without suspected back injuries, full spinal x-rays are required.

3. Biological Samples.
While biological/laboratory samples are required only for Class A and B mishaps, and those Class C mishaps which are investigated by a Flight Surgeon, the exact class of the mishap is frequently not known until it is too late to obtain meaningful laboratory samples. For this reason, the following rule of thumb should be used: obtain laboratory samples any time there is damage of any extent to an aircraft or other government property, or any time someone is injured in association with flight operations. Samples which are later determined to be superfluous may be discarded.

• WARNING: Clean venopuncture site with Betadine solution, NOT ALCOHOL SWAB which can give false positive for blood alcohol!

1. SAMPLES

   Sufficient blood and urine shall be drawn from each member of the flight crew and from support personnel such as handlers, controllers, or LSO's, who may have been involved in the mishap, for the determination of:

   1. Blood alcohol - 2 gray topped tubes (fluoride)

   2. Lactic aid - 2 gray topped tubes (fluoride)

   3. CBC & differential - 2 lavender topped tubes
      (Make 4-5 smears on glass slides with Wright's stain ASAP)

   4. Carbon monoxide - lavender topped tubes

   5. Glucose - 1 red topped tube

   6. Drug levels - 2 red topped tubes

   7. Misc. (extra) - 2 red topped and 2 green topped tubes (heparin)

2. HANDLING PROCEDURES:

   1. Blood alcohol - refrigerate only - DO NOT CENTRIFUGE

   2. Lactic acid - centrifuge ASAP - remove and freeze plasma ASAP

   3. CBC - refrigerate only - DO NOT CENTRIFUGE OR FREEZE

   4. Carbon monoxide - refrigerate only - DO NOT CENTRIFUGE

   5. Glucose - centrifuge ASAP - remove and freeze plasma ASAP

   6. Drug levels - centrifuge, remove and freeze plasma

   7. Misc. - refrigerate only

The above samples should be labeled with NAME, SSN, DATE, AND TIME COLLECTED and turned over to the flight surgeon for submission to appropriate laboratories. A legal chain of custody is not required, but samples should be secure from damage or tampering.

4. Other:

1. Identify and preserve all flight gear, helmets, LPA, etc.

2. Have all aircrew begin writing a detailed 72 hour history as soon as practicable; include meals, rest, activities, etc

3. Recovered bodies or body parts should be placed in body bags and refrigerated; DO NOT REMOVE FLIGHT GEAR OR CLOTHING.

4. Aircrew should not return to flight duty until examined and cleared by a Naval Flight Surgeon. They may be transported by air (as pax or patients) if necessary.

United States Naval Flight Surgeon Handbook: 2nd Edition 1998

The Society of U.S. Naval Flight Surgeons