Senior Member Guide
First 24 Hours
The First Day
An aircraft is down. You are the senior member of the Aircraft Mishap Board. Competing demands erupt, and it seems everyone is looking to you for answers and action.
What happens on the first day amounts to people and agencies executing planned responses to a disaster. Think of it as the memory steps for an immediate-action emergency procedure.
The mishap squadron has duties to attend to immediately in the wake of a mishap. The following have precedence over AMB activity. Initiate rapid response (crash/fire/rescue, emergency medical, security). Make internal notifications (CO, XO, department heads, staff). Notify the operational chain of command (OPREP-3, by telephone and message). Commence casualty notification to BUPERS/CMC and to the next-of-kin of those injured, missing or dead. Stand clear of squadron executive, admin or ops personnel performing these essential duties.
When those obligations have been initiated, make a telephone notification to the Naval Safety Center (NLT 1 hour for Class A mishap) and back it up with an initial Mishap Data Report message (within 4 hours for Class A & B).
Who's in Charge?
You are. Whether you’re an interim senior member awaiting relief or an externally appointed senior member, the first on scene is the senior member for the purpose of this discussion of immediate response.
An interim senior member has authority and responsibility to direct the AMB until replaced by another face-to-face. He must not delay proceeding out of concern about what a relief might want. Some evidence is perishable and best gathered fresh. Do not wait for someone whose arrival might be indefinite.
First things first. You will not solve the mystery on Day One. The day's activity will be spent doing what needs doing: taking care of the living, putting out fires, evacuating the dead, establishing AMB presence, and making the mishap site secure.
Resist the temptation to rush to the mishap scene. Although the Board will be itching with curiosity, its first response is not to scramble to the site. Crash/fire/rescue, medical and security personnel constitute the first wave to a crash site. The site will be in goods hands until you arrive a little later and better organized.
Convene the Board.
Assemble and Organize
Gather to count noses and pool information. Assess your situation, then move with direction and purpose.
Take notes. This parenthetical consideration applies throughout an investigation. The information each member acquires, the observations each makes will quickly exceed short-term memory and be lost. To prevent wasting time in recapturing the same information, take notes. A pocket-sized notebook and pen are an investigator's most valuable tools.
Counting noses. You need operations, maintenance, medical and safety members at a minimum; one must be a pilot qualified in model. The senior member must be senior to the pilot-in-command and mission commander of the mishap aircraft. Other members may be added for subject matter expertise as the mishap context becomes known, or to simply distribute workload. Refer to ONI 3750.6R, paragraph 206 for detail on board composition and exceptional circumstances.
If any member is not available or disqualified by context from the investigation at hand, the senior member must weigh how tasks can be redistributed (short-term) and where to seek replacement. Canvas Board members for the following: • availability through the investigation's expected duration (30 days is typical)
• direct involvement in the mishap
• a personal interest in the mishap which might impede objectivity or impartiality while performing AMB duties
If the senior member finds the membership of the Board inadequate to existing or foreseeable requirements, he should contact the reporting custodian (squadron CO) for suitable replacement. In the event the reporting custodian cannot populate an adequate AMB, he should request assistance or relief from the controlling custodian, as explained in OPNAVIST 3750.6R, paragraph 605.
Pooling information. Here begins the rigor of evaluating information: is it authoritative, first-hand, without speculation? It will be incomplete. Notice or rumor of a mishap can come from any quarter: ATC, base radio, police, news media, a bystander. Obtain as much detail as your informant has: location, time, damage/injury, survivors, agencies responding or on-scene.
Maintain an intellectual detachment: some of what passes for "known" shortly after a mishap turns out to be inaccurate, even wildly so.
Grasp the following if information permits: mishap context (mission, equipment, stores, route, mishap locale, weather); damage to aircraft and surroundings; survivors and casualties (crew, passengers, personnel on the ground). You will notice the elements of information form only a distant view of what happened, where and to whom as opposed to why, how and by whom. The latter describe cause, are harder to resolve and require more information before you can form authoritative conclusions. You're not there yet. Other matters are pressing, so don't linger over missing details.
Take the reins, and go to work
Verify the squadron has commenced initial reporting (OPREP, next-of-kin notification). The Board should not compete for the attention of personnel accomplishing these. This caution against interference expires quickly.
Confirm safety reports (by telephone & message) have been made, or designate someone to do so. The ODO might have done both already; safety and ops members are capable of doing it.
Briefly consider the prior division of duties among Board members. Lists in various guides divide investigation activity; this coordinates action to cover a lot of territory in quick time. Unless otherwise amended, those lists constitute the plans of respective members once adjourned. Mishap circumstances might necessitate a change in items' priorities or might eliminate some altogether.
Some actions are deferrable: they will keep until you get to them a day or two later. Take documentary and real evidence (records, ATC tapes, preflight fluid samples) for example. While it is important to isolate these as a snapshot of conditions preceding or at the mishap, the information they contain is not perishable. Gather them for safekeeping until time permits review or analysis. Squadron records or samples can be gathered in an hour by one person. A call to the supervisor of a military radar facility (terminal, tower, target) will reserve radar and voice recordings for later use. For the same from FAA facilities, contact the military liaison at the respective FAA regional headquarters.
A contrasting example is witness information. Accounts change as witnesses reflect, compare accounts with others, and read (news, NATOPS, MIM). Get witness information before it is contaminated. On the first day, it might be sufficient to identify witnesses, make contact and request from each a written statement. An AMB member can return for an interview, but should do something immediate to preserve details each witness might have uniquely; a timely, written statement helps to do that. Some high-value witnesses (aircrew, aviation-acquainted eyewitness) ought to get the full treatment at your mutual, earliest opportunity. This is a calculated bet; at stake is precious time you might spend doing something else.
Look over the first-day checklists or have each member state his intentions. Affirm or succinctly alter near-term (today's) tasks. If you add or redirect a task, name who is to do it and its precedence among his other tasks.
Appoint a time and place for your next meeting
Arrange transportation to the site. Members who are not needed elsewhere should accompany. If no member has an adequate camera, reserve a seat for a photographer unless one is on site already.
Going out the door, you will have what you are wearing, possibly what the unit staged in its crash kit. Expect the kit to be short some gear; not all wrinkles will have been foreseen. Knowing where to get something quickly is good enough. You might have to visit base supply, a sporting goods store or hardware en route for items not in the kit. Keep your receipts and hope the disbursing folks are reasonable.
Do not count on hot-and-cold running transportation unless the keys are yours. Corollary to Murphy's Law: the more inaccessible the site---the higher the likelihood of being stranded. Think about precipitation (clothing) and RON (water and food). Like the Boy Scouts, Be Prepared.
Scratch the itch. Adjourn the meeting and go to the site.
Board members benefit from a first-hand visit. Seeing accelerates comprehension and is essential to describing the mishap in your report.
Exercise caution and restraint. The site and wreckage will have hazards unfamiliar to visitors, and visitors are inherently a hazard to evidence. No one from the Board or its working party should be on the wreckage until it cools to outside air temperature.
Consider your first visit a reconnaissance. Withhold hasty judgments: understanding will take time and complimentary evidence not at the crash site. Resist the delusion of solving the mystery before sundown: you are likely to jump to a wrong conclusion. Patience. See the forest before barking up trees.
Walk wide around wreckage and ground scars to see the site from every angle. Look for indications of flight direction and descent angle, then imagine the cockpit view. Take in the BIG picture, and have the photographer do likewise.
Satisfy yourself the aircraft is present or accounted for: missing parts might be cause to expand the search back along the flight path. If the four corners (nose, tail, wingtips) are on site, the structure between them is too; still, bits (aileron, stores, turbine wheel, etc.) can have departed before impact. Helos have more than four corners, so the process is more difficult: blades (extremities to count) usually fragment on contacting ground and can hurl hundreds of feet from the airframe.
Keep your hands in your pockets. Do not charge into the wreckage to open panels, flip controls or try switches. Disorganized, undisciplined handling of the wreckage disturbs evidence and leaves no record of condition as-found. The safety investigation has precedence over other concurrent investigations, but the AMB must take care not to spoil evidence which others will also need to view. Sifting through the wreckage will keep until the AMB has a coherent plan to examine it by layers, like peeling an onion. Your initial focus is the large view, a reconnaissance. Assess the environs, the distribution and condition of wreckage.
Assess whether the wreckage is safe to begin work: fire out, ordnance and pressurized vessels made safe, fuel siphoned off. On sloping or forested sites, be wary of deadfalls: parts in trees, tree trunks/limbs severed but not fallen to ground, rocks precariously ready to tumble. Determine what will be needed to guard the site, to find, look at and plot the scattered wreckage. Consider equipment and working parties needed to work the site, then consider how both will get to the site.
For the present, the higher concern is to exploit the wreckage in place for information it will yield as it lays, information which might be lost when you begin to disturb it. When that course has been exhausted, concerns will turn to removing the wreckage to accomplish what could not be done in the wild or what is better done under controlled conditions.
The whole Board need not stay at the mishap site longer than is required to appreciate the big picture, make initial assessments and post security. Once all have had a look, get down to business. Only one or two members need remain at the site to continue working or direct others there. Consider who is better employed on the site, who has more urgent tasks elsewhere.
Do not work a crash site without light. Doing so poses risk to personnel and evidence, with low prospect for reward. Post security and retire from the site before dusk (or make provision for abundant artificial lighting). Allow time for departing personnel to pick their way back to a roadhead before light fails. You will not finish an investigation in a day, so keep your personnel fresh for tomorrow and beyond.
While touring the site or riding back, exploit your captive audience and their newfound common focus. Pose questions. What can be determined (speed, flight path, attitude, configuration) from the lay of the wreckage, ground scars and degree/location of aircraft deformation? To what extent can the wreckage be examined where and as it sits? What are the local maintenance or engineering capabilities (OMA/IMA/NADEP), and what assistance is needed on site? What personnel, equipment or items will facilitate the following days' activities? Have a member take notes: these form a list things to do, things wanted but deferred, and support the Board will request.
Offsite. Briefly reconvene the Board. Members might have gone about tasks separately, but their product is necessary for common information. Have each member present his progress and findings since last convened, to bring all abreast of developments and to build the Board's grasp of available evidence. Confine discussion on the mishap to observations and facts.
Assess what will be needed for the continuing field investigation. As discussed above, you first exploit the wreckage where and as it is. Excavation, lifting, carriage, relocation and disassembly follow in due course...later. Confine discussion on the mishap to observations and facts, and how to get more. Without a substantial body of evidence, deliberations on cause are premature.
Plan. Make assignments. Do not count on all going to the site daily. Once all have seen it and have a common foundation, employ each according to his talents and availability.
Consider whether the AMB needs augmentation with additional members, or whether it needs on-site technical specialists (not admitted to membership or privileged access). Initiate requests for such augmentation or assistance to appropriate sources. The squadron CO might be the appropriate source for another member with specific crew qualification; the group or wing can provide a physiologist. The type commander might be the nearest source for an ATC specialist. Technical expertise may be obtained from the cognizant engineering activity (usually a Naval Aviation Depot) or from respective aircraft/component manufacturers.
Preview tomorrow's activity. • Interview witnesses. For those from whom you have gathered statements, read them before scheduling an interview. It serves no purpose to reserve the time, then find a witness has nothing to contribute.
• Diagram/survey/plot site and wreckage as appropriate.
• Review records, tapes, radar data in order of their likely potential (varies by mishap context).
• Outline wreckage examination on site (items and sequence). List tools/people required.
Designate a board room where you can continue to meet and conduct business. You need exclusive-use space, secure file storage (or keys to the room), telephone, work table, blackboard (or equivalent), and access to a copier. A computer is helpful, as is a clerk typist who tells no tales. If you lack any of the preceding, exercise your O-5 horsepower tomorrow to get as many as you can. For a mishap too remote to shuttle from a base, your parent command may authorize renting a meeting room or hotel suite. Equipment can be rented.
Adjourn in time to allow members to do their independent work, eat and rest. Take a long view: you're in this for more than a few days. Begin to pace yourself and the Board.
Anticipate a crowd: a disaster site is a magnet for the curious. Anyone on site who is not part of a solution (CFR, EOD, investigation, security, working party) is a hindrance, at risk to their safety and yours. Tactfully, but firmly, dissuade visitors regardless of rank.
Most people are deferential to uniformed personnel and respectful of roadblocks, gate guards and a marked perimeter.
Some people require reminding. Site guards will take your lead. When you take charge of a site, brief security personnel who (by name, affiliation or capacity) may be admitted; a list alleviates confusion for subsequent reliefs. Be prepared to back them up, because there will be requests for exception. Requests will come from press, government functionaries and military personnel who drop by. The site is yours to conduct an investigation; you are not obligated to run tours. Refer press to the serving PAO. Ask government officials and military personnel their jurisdiction/capacity and "What can you do for me?" Commanding officers of involved units are worthy; all others are suspect. If the visit has merit, provide escort, keep it short and do not disclose privileged information. If someone's purpose is eyeball liberty, let him to do it outside the perimeter.
Personnel conducting a concurrent investigation (JAGMan) may legitimately have access to the site to view the wreckage. They should not proceed to disturb evidence without prior consultation and your consent.
Military personnel may not exercise police authority off-base. Be prepared to engage (mooch...hire, if necessary) police or sheriff's auxiliary for security off a federal reservation.
A landowner can make trespassers unwelcome, alleviating some of the security and crowd-control burden. He can authorize your cutting a fence or blazing a trail through his green corn. Or he can tell you to hike all the way around a quarter-section for a less advantageous access. Be nice to the landowner. Corollaries apply when working with state/national forest agencies, Bureau of Land Management, and so forth.
Contact Info: 757-444-3520 Ext: 7813 | POC: SAFE_Code13@navy.mil
Last Reviewed February 26, 2013