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Senior Member Guide

 

Field Investigation

 

 

The Second Day and Beyond

        The Board will be drawn in different directions by simultaneous efforts to examine artifacts at the crash site and to pursue compelling aspects of the investigation elsewhere. Each can go on concurrently...and should.

        The following section is broad advice to the Senior Member. The essence is to encourage a wide perspective and discourage preoccupation with inviting targets better delegated to members or surrogates for the Board.

• Make and carry a grocery list: tasks, questions, observations come at a rush. Your attention will be saturated to the neglect of the big picture unless you keep track.
• Howgoesit must be continuous. Note progress. Assess what needs doing now and next, what can be done with assets at hand, how and by whom.
• Do not dwell on the difficult or impossible. This is a clue you need competent assistance.

Review Yesterday's Activity

       Consider what was done, what was initiated but is incomplete, and what was deferred. Aside from the wreckage, candidates for the Board's continuing attention include further site assessment, photography, augmentation/assistance requests, and witness/documentary evidence gathered but not yet digested.

• Site-and-wreckage: assessment of stability and accessibility were initial concerns. Determining the extent of wreckage scatter, and documenting it will run into the second day. Reading site and wreckage for clues come next. Excavation, disassembly, pickup and removal from the site come later.
• Photography: if a complete suite of as-found photos was not made on day one, today is the next best opportunity. - Assistance: acknowledge the limits of the Board's collective capability and reach out for the help you need. Request early. Make the system work. See the section on technical assistance.
• Witnesses. Yesterday you found them and requested a statement or held a hasty interview. Today read their statements. Begin interviews in earnest, starting at the top of a prioritized list. Interviews are discussed below.
• Review impounded documentary evidence and recordings. These were sequestered at your request yesterday and will be available for review on-call. Detail a member to sample tapes and be satisfied whether (1) there is information of use and (2) further processing or analysis will be required. Likewise with other records and documents.

Photography

       Aside from documenting conditions as found, photos can record the Board's manipulation of the wreckage. Additional items will appear as work continues at the site.

       Have a photomate detailed to the AMB for the first day after a mishap. Need for a dedicated photographer diminishes quickly. You can shoot your own. It is economical of personnel and transportation for a Board member to shoot, then present his film to the station photo lab for development.

       It is not enough to tell someone, "Shoot this," and walk on. The photographer's product will be of better use if everyone who requests a shot also tells the shooter what the picture is supposed to show. Specify the following as appropriate: closeup or wide angle, background (in-focus or not), light (more, less), viewing angle, other object in view for scale, anything to make a picture a better exhibit.

      Obtain shots of anything that excites interest, but ensure you have a before view of everything likely to be disturbed by man ipulation (yours or others'). The cockpit (switches, levers, gages) springs to mind; engine control linkage (input and feedback mechanism) are another favorite.

      Shoot liberally: until the investigation is far advanced, no one knows which photos will be the best exhibits for a report, but opportunity might have passed. Multiple 8x10 glossies of every shot are wasteful: you will be inundated with excess material, and your welcome at base photo will wear out early. Request a proof sheet of each roll, then select the views you want produced in full size. New digital copiers make excellent reproductions, so obtaining multiple prints of photos for desired MSIR enclosures is possible from one master on file. Unless a photo represents a speculative association staged by the AMB, it may be considered real evidence and shared with concurrent investigations, and with the engineers or technical representatives you consult.

Documents, Records

      Some boards go days without sifting and appreciating pivotal information already in hand. The first day's impound will have yielded a substantial collection. Mine these resources. Go back to their sources promptly with questions they stimulate, while memories are fresh.

      Evidence in hand has three potential consequences: it can verify what has been offered or presumed thus far, indicate a new course for investigation, or permit closing an area of the investigation. Some inquiries simply affirm situation normal. When you are satisfied you have that affirmation and there are negligible indications otherwise, make note and move on to the next area needing attention. Having reviewed these, organize and securely store the evidence you collect.

Assistance with Field Investigation

      What is needed will depend on circumstances unique to the mishap. Most mishaps require people at the crash site to assist the Board with reading the wreckage and, later, to accomplish a recovery. Some mishaps justify bringing subject-matter experts to the site for detailed examination before evidence is disturbed or to guide removal of exhibits for examination elsewhere.

      Get the support you want. The chain of command and your community want you to succeed (find the cause(s)) and are willing to help. They can not read minds. Make your needs known to people who can deliver assistance.

      Technical Assistance. If you decide you need assistance, ask for it pronto. A telephone call is usually sufficient to bring subject-matter experts to your location. Requests for equipment, materials or personnel not organic to your chain of command (e.g., salvage) should be conveyed in an amended Mishap Data Report (in paragraph 7) requesting your controlling custodian obtain them. Assistance from outside the Department of the Navy can be arranged by contacting the Naval Safety Center. Technical assistance and salvage are discussed in detail in separate sections of this guide.

      Work Details. Working parties are a necessity. Tasks vary with mishap circumstances and condition of the aircraft, so requisite qualifications can vary from fitness for heavy lifting to the systems acquaintance of a QAR. Personnel are usually drawn from the mishap squadron or contract maintenance provider. When exploiting wreckage for evidence, maintenance personnel are a great aid in name-that-part and how-it-works discussions which go with examination.

      Be wary of overtasking anyone. Reserve risky jobs to professionals capable of handling them: a logger fells trees, an equipment operator runs machinery, and so forth.

      It is possible to muster too much help or help which cannot be used...yet. Some activities depend on preceding work: stack them for serial accomplishment. If an aircraft sits in a crater in a forest, little investigating can be done until the hole is excavated. That waits until trees are felled and a trail blazed for digging machinery to reach the site. A backhoe operator will refuse to dig while people are in the hole or loitering within the arc his bucket can swing. Mechanics to help examine wreckage need not be on site until the aircraft is above ground. Keep excess players in the dugout until they are next at bat.

      Take care of the troops. People need guidance at unfamiliar employment: tell them what to look for, what to avoid, how to conduct themselves on the site.

      Invite their input. Everyone who works on aircraft has some kind of expertise. Expand your grasp and view by asking the working party to look for and call to your attention distinctive signatures or unusual damage on the wreckage as they handle it.

      People need food, water, protective clothing, toilet, transportation, lodging and rest. Have ample potable water to serve everyone through the day and into the night watches. In hot weather, replenishing electrolytes is essential. If the crew will eat on site, stage more water to permit washing before eating. Position food, water and utensils upwind, at a distance from wreckage or excavation. Call everyone off the wreck for a break and let them rest while they eat. If rain threatens, set up service and eating areas under a tent or tarp.

      All on site will be doing hard, dirty work; they will perform better if comfortably clothed and adequately equipped. A standard uniform might not be appropriate for the climate or for the work performed; augment or modify it. Obtain and issue foul weather gear, protective clothing, accessories as needed.

      Don't have a mishap while investigating one. There are hazards aplenty to unfamiliar work in unaccustomed surroundings. Consider the brew of heavy objects, jagged metal, mysterious residue, combustibles, explosives, rough terrain, weather. Think about self-preservation, then extend that to your shipmates in spades. A spirit of volunteerism underlies public and internal response to a mishap. Can-do runs high on a crash site; enthusiasm will overrun caution if permitted to do so. Do not take the unfit or infirm to the field. Digging, lifting and toting in the wild will tax the most fit. Have a corpsman at the site so long as potential exits for injury during work details. Have communication from site to rear (base CFR/sheriff/forest service...) and transportation to the nearest emergency medical facility.

Plots, Diagrams, Surveys

      A representation of the mishap site is not a required enclosure to the SIR; it may be an enclosure if you find it helpful. Regardless of whether one goes into the final report, it can be an aid the Board proper. A record will show how and where things were found (when you sit down to write); it can be an analytical tool to figure aspects of ground collision and breakup. The decision is yours. Method, formality and level of precision are not assigned. Do what best suits your need and purpose.

      If you forego the opportunity early, it will be difficult to recapture. Ground scars disappear under vehicle and foot traffic or precipitation; parts' original locations are lost when they are picked up.

      For wide scatter (high speed/low angle impact, in-flight breakup, midair collision) consider using GPS to plot wreckage. For more confined distribution (vertical entry, flat spin, slow speed), a simple grid or heading/distance-from-center might do. For a site of a few acres with extremities in the hundreds of feet, a long tape and a compass will suffice; record observations on graph paper or in a notebook.

      Maps. The largest scale (small area, high level of detail) map available is usually best. Scale 1:50,000 is marginal; 1:25,000 or lower is better. Infantry units have them. Federal and state agencies overseeing public land have limited stock. Sporting goods stores stock maps for hunters and hikers. Base civil engineers can print custom-scaled maps for facilities they manage (helpful for mishaps on or near a runway). Stores with computer software will have maps-on-CD programs; these maps might be of national scope and short of detail when pushed to close views. Try before you buy, or read the wrapper carefully, to ensure it will support the level of topographic detail you desire

Site Security

      Previously discussed, but worth emphasis. People who were deferential to the emergency response the first day might be bolder today. Day Two crowds will be the indefatigably curious, including idle military personnel. Be prepared for flimsy pretexts advancing on your perimeter. Back up the security detail, or become a tour guide.

      Supervise those admitted inside the perimeter. Manufacturers' representatives should travel with a board member or engineer from the cognizant field activity and competent on the system of interest. Contract maintenance personnel should work under supervision of a board member or trusted agent (e.g., NATAMSACT).

      Uniforms make your presence separable from onlookers and diminish crowd control problems by distinguishing players from spectators.

Inquiring Minds Want to Know

       The Senior Member is the communications focal point for the investigation. Assume the safety reporting load from the SDO/ODO at your earliest convenience.

       Not all inquiries to the Board merit a personal reply; some merit none. It is sufficient to inform the appointing authority and reporting custodian of the investigation's progress (nonprivileged, factual information) and of assistance required. Some few others might need selected information to provide assistance you want of them. The rest can read of the investigation's progress in Amended Mishap Reports.

       Some external pressure is real; much is imagined. The precedent you establish in external contacts will encourage or deflect return visits. If you are a 'soft touch,' expect to be touched often. Focus on these three facts:

• Senior Member answers to appointing authority (actual).
• The Board works at the direction of the senior member.
• The investigation takes precedence over other duties.

      It is that simple. Middlemen or staff do not wear the boss's rank. Board members approached by interested outsiders should tactfully decline intrusion on AMB proceedings or request for disclosure. Should the requestor be persistent, he should be referred to the Senior Member or to the appointing authority.

      It is necessary to communicate with the JAG investigator. The JAG may observe wreckage at the site or layout, observe its handling and components' disassembly. JAG needs access to documentary evidence (logs, records, ATC tapes); this does not extend to AMB work product. Access should be arranged for mutual convenience. The AMB is obliged to disclose witnesses' names; their privileged statements or interviews may not be shared.

      If the Board discovers a hazard which poses an imminent threat requiring immediate notice (before the investigation report comes out), an urgent hazard report should be issued as described in OPNAVINST 3750.6_. Otherwise save findings and conclusions for the SIR.

      It is a PAO's job to represent the Navy or Marine Corps to the press. Leave press commentary to a pro. If approached, board members should refer inquiries to the serving PAO by name and phone number. 

Hurry Up

       Most deadline dread is self-inflicted. A mishap investigation is an unfamiliar job, and you will not be master of all resources. Some projects' outcome and completion are hard to predict because they are ill-defined, layered or infrequently practiced. For example, a backhoe operator tries to please when he estimates time to excavate the crater where your wreckage rests. But craters are not a standard commodity: no one can know how deep one is until the bucket stops scooping parts. Don't recycle his cheery estimate to others by announcing the wreckage will be out of ground by 1200; don't commit dependent plans to execute at 1201. Conservative estimates and flexible plans. 

Interviews

      Not all witnesses need be interviewed. Weigh the merit of spending time with selected witnesses. How? Read their statements. A written statement aids in determining which witnesses don't have much detail to offer, but it is not foolproof.

      Writing is difficult for some. Some witnesses know more, but write little. If you expect a witness knows more than he wrote (or ought to), interview. Some witnesses warrant interview regardless: crew, best vantage point, pivotal position in the mishap's background, aviation-acquainted eye-witness.

      A purported eyewitness whose account begins, "I heard an explosion, turned and saw a fireball...," can vouch only time and weather. The rest likely will be borrowed or speculative. The best question for such a witness is, "Can you provide me the names of any others who saw the mishap?" Ask by phone.

     Rank witnesses and start interviews with the best prospects. Not all the Board need attend. A large audience intimidates. A small audience is more likely to put a witness at ease and elicit cooperation. Listen to and learn from each witness. Let your witness tell his story in narrative fashion, without interruption. As the witness speaks, take note of details you want amplified, but reserve your questions until he has finished his narrative.

     A witness is a frail source of information, neither right nor wrong. A witness will take cues if you are unwise enough to give them. Audible cues and body language can indicate validation or disagreement, subtly smothering his account. The best technique to cultivate a witness' candor is to pay rapt attention, but maintain a benign poker face.

     Talk directly to the witness at his level of sophistication. Phrase questions in the witness' words: if he calls a drop tank a 'big gray thing,' you call it the same. Avoid contaminating the witness with information he has not offered. For example, if he has not mentioned fire, do not imply there was one by asking, "Where was the fire?" Instead ask, "Did you see smoke or flame?"

      Allow an eyewitness to manipulate a model or use a picture or map to show what he lacks words to convey. Classic example: 'spin' has specific meaning to a flyer, but a witness without aviation background might apply that term to movement about any axis. In like fashion "It went straight down" has been offered for every angle on a protractor, not just vertical entry. A model allows the witness to represent what he saw, even though unfamiliar with aviation terms. The same applies to taking an eyewitness to the place from which he saw the mishap: he might point out what he could not articulate with precision.

     Give precedence to the first version. You will revisit some witnesses because new information you acquire will stimulate new questions. A witness will have had opportunity to reflect, absorb information from other sources and rationalize. Stories change. As witnesses confer, there is a tendency to a consensus account as each adopts detail from others, and loses or suppresses what had been a distinctly individual perspective. This is not necessarily devious, just a natural tendency to fill in blanks and cope with a sensational event.

Reconvene

     Quit before dark and convene at day's end. Close down the site and post security. Finish business with your working party and technical assistants. With working party supervisors and technical assistants, summarize activity and plan into tomorrow. When this is finished, excuse all who are not open to privilege.

     Have board members summarize their findings and work started or done, one by one. Check progress and difficulties. Close off finished business and note findings to avoid later having to reconstruct the same (it happens). Assess which matters need further development, possibly additional personnel. Task as necessary.

     Unless guided, meetings can digress to speculation on cause. The temptation goes with the territory. Until the investigation is well underway, discipline yourself and members to remain at the task of discovering evidence. The Board may entertain possibilities at any point, but must make judgments only in light of sufficient evidence.

     Adjourn. Let all shower, change, get a hot meal and sleep before you do it again.

Wreckage Recovery

     Not on Day One, rarely on Day Two, but sometime...the Board will foresee an end to working with the wreckage at the crash site. Plan a recovery, then stay engaged (directly or with another member as proxy) at the site to supervise its execution. Remember many of your assisting Some of the work will be performed by personnel whose only qualifications are availability and fitness for heavy lifting.

     Consider where the relocated wreckage will go. This depends on what more the Board wants to do with or to it. A layout (reconstruction) might occupy 4 times the floor space of an intact aircraft. A less extensive reconstruction or handling to remove engines or actuators for examination takes less. Final storage for packed boxes and chunks of aircraft takes the least space. A crane or forklift requires headroom to lift and clear space at the sides to maneuver. When you have decided the level of activities, arrange secure space accordingly.

      Wreckage will have been located; small parts might have been flagged or marked with surveyor's tape to make their locations more noticeable. Decide how to collect it. The pickup process usually involves people for small parts and machines for heavy lifting. Boxes on pallets staged throughout the site facilitate pick up by hand and deposit without a long trot. Whether you fill boxes according to location (crater, secondary impact site, periphery) or by types of parts (airframe, engine, controls, etc.) is a matter of choice. Objects too big for boxes can be palletized or lifted directly. Laden pallets and big objects should be lifted by rough terrain fork lift, crane or by helo.

      Transport. Flatbeds for long, wide or tall pieces; stake-beds suffice for the rest. If some disassembly is required, consider carefully beforehand because doing so might separate items whose association should be noted before evidence is lost. It is helpful to line a flatbed with a big, throwaway tarpaulin and wrap it up-and-over the load before tightening the load straps; this prevents small parts (it's all evidence) from becoming highway litter. The tarp will be junk when the job is done due to tears and leaking fluids. Avoid rush hour traffic.

      Offload and place boxes and objects to facilitate access for further work. For example, make room to maneuver hoists, toolboxes, engine stands and so forth.


Contact Info: 757-444-3520 Ext: 7813 | POC: SAFE_Code13@navy.mil
Last Reviewed February 26, 2013