MISHAPS
Maj Rick Ludtke, USAF, MC, FS
NGB/SGPF
USAF FY14 Aviation Mishap Reviewver6 Mar 2015
2014 was “best year for safety in the Air Force” Historical average of 10.7 aircraft
destroyed/year2014: 2
Historical average of 8.2 fatalities/year2014: 10
Costs at highest level since FY07 at $65MNote: Partially due to change in Cost Per Injury Type
Estimate (all comers @ $8.7M; previously tiered)
2014 – Safest Year for the Air Force
X7
Cited Human Factors in FY14 #1 Inattention
Most cited causal human factor in all USAF Class A-E flight mishaps (260)
Most frequently reported contributory human factor in all Class A-D flight mishaps (45)
#2 MiscommunicationTop contributory human factor in Class E
flight mishaps
Recent Changes
Change in Cost Per Injury Type EstimateAll fatalities valued @ $8.7MPreviously, fatality cost was differentiated
based on expected lifetime income (i.e., TIS, rank, age, etc.)
Human Factors (HFACS) 7.0 releasedRarely used or confusing HFACS removedHFACS remaining reorganized into
categories
Mishap Classification
Ground vs Aviation Categorized into Class based on
estimated cost and/or extent of injuries (A-E; A>E)A = worst personal or financial costE = least personal or financial cost
Investigation Timelines Safety investigation should be completed
within 30 days of mishapDeadline can be extended in the interest of
producing a thorough, complete and accurate safety report
Outbrief to LtGen Clarke will be performed 2 weeks following de-convening of board
Secretary or Assistant Secretary of Air Force wish to be present for fatality outbriefs
Various Boards Interim Safety Baord (ISB)
Convened immediately upon notification of mishapClosest AD installation to mishap responsiblePurpose is to collect and preserve evidence
Safety Investigation Board (SIB)Convened days after mishap notificationResponsibility of “gaining” MAJCOM (think
operational owner)Purpose is to prevent another mishap
Various Boards
Aviation Investigation Board (AIB)Legal boardPurpose is to determine blame