M I L I TA R Y AV I AT I O N L O S S E S F Y 2 0 1 3 – 2 0 2 0

224 Lives
$11.6 billion
186 aircraft

National Commission on
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Report to the President and the Congress of the United States

DECEMBER 1, 2020
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National Commission on
Military Aviation Safety

Report to the President and the Congress of the United States

DECEMBER 1, 2020

Cover image: U.S. Air Force F-22 Raptors from the 199th Fighter Squadron Hawaii
Air National Guard and the 19th Fighter Squadron at Joint Base Pearl Harbor-
Hickam perform the missing man formation in honor of fallen servicemembers during
a Pearl Harbor Day remembrance ceremony. The missing man formation comprises
four aircraft in a V-shape formation. The aircraft in the ring finger position pulls up
and leaves the formation to signify a lost comrade in arms. (Department of Defense
photo by U.S. Air Force Tech. Sgt. Michael R. Holzworth.)
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The National Commission on Military Aviation Safety dedicates its work

to the men and women who serve in the aviation units of the U.S. Army,
U.S. Navy, U.S. Marine Corps, and U.S. Air Force.

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Letter from the Commission

OUR COMMITMENT

M ore than 6,000 U.S. noncombat military aviation

mishaps occurred between 2013 and 2018. These
mishaps occurred during training or routine operations.
and roundtables, servicemembers shared their experiences
and concerns. The insights and information they shared
with us aligned with trends we saw in the empirical
They claimed the lives of 198 servicemembers and civilians data. We came away from our visits impressed with the
and cost the nation more than $9.41 billion in damages, patriotism, dedication, and level of effort throughout
including 157 destroyed aircraft. the ranks of America’s military aircrews and maintainers.
The U.S. Congress created the National Commission We also came away deeply troubled by the chronic
on Military Aviation Safety in 2019 to examine the rates fatigue we saw among these brave servicemembers. The
and causes of mishaps and recommend ways to improve current operations tempo (OPTEMPO) is leading to
aviation safety. While this Commission was conducting its unsafe practices and driving experienced aviators and
study, military aviation mishaps claimed another 26 lives, maintainers out of the force.
29 aircraft, and $2.25 billion. In addition to the operational demand, our findings
The seven commissioners represent a diversity of focus on four areas where Congress and the Department
individual experiences in military operations, national of Defense can take immediate steps to reduce aviation
defense policy, aircraft manufacturing, and aviation mishaps: Pilots should fly; maintainers should maintain;
safety. We share a devotion to saving lives and improving data can save lives; funding should be consistent.
readiness in the Services’ aviation units. Supported by a We, the members of the National Commission on
dedicated staff led by Major General Gregory A. Feest, Military Aviation Safety, thank the Services’ safety centers
U.S. Air Force Retired, this Commission reviewed the for their assistance to the Commission throughout the
military aviation mishap reports from 2013–2018, course of this study. We thank the commanders who
consulted previous studies, interviewed experts in hosted us and provided unfettered access to the people
military and commercial aviation safety, and met with serving in their units. We thank every one of those
servicemembers in aviation units across the Services. men and women for their service and for their candid
We visited more than 200 aviation-related military comments. Protecting their safety is a moral imperative
and civilian organizations across the spectrum of and critical to ensuring that they can continue to serve
missions and aircraft, meeting with thousands of aviation the United States of America as effective, experienced
professionals of all ranks. In nonattributional town halls aviation professionals so essential to our national security.

General Richard A. Cody (USA, Retired), Chairman The Honorable Richard F. Healing, Vice Chairman

The Honorable Scott C. Donnelly General Raymond E. Johns (USAF, Retired)

The Honorable Preston Geren The Honorable Dabney R. Kern

The Honorable Joseph W. Hagin

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TABLE OF CONTENTS
Our Commitment i Chapter 6: Sustaining the Machine 37
Aviation Supply System 37
Executive Summary v Overcoming Supply Deficiencies 38
Aircrews and Maintainers v Depot Maintenance 38
Data Deficiencies and the Need for Facilities 38
a Joint Safety Council vi
Aircraft Transition Issues 39
Consistent and Predictable Resourcing vi
Conclusion vii Chapter 7: The Need for Consistent and
Predictable Funding 41
Mission and Method 1 Continuing Resolutions 41
Conducting Its Study 2
The Human-Machine-Environment Framework 3 Chapter 8: The Demand Environment 45
More Demand than Capacity 45
Chapter 2: Assessing Mishap Rates 5 Additional Duties 47
Assessing and Characterizing Mishap Rates 5
Visualizing and Contextualizing the Rates 5 Chapter 9: Maintainers as Aviation
Comparing the Period Means 9 Professionals 51
Identifying Troubling Trends 10 Measuring Training Efficacy 52
The Commission’s Assessment and Findings 12 On-the-Job Training 52
Additional Assessment 13 Experience Matters 53
Talent Management for Aviation Maintainers 55
Chapter 3: Military Aviation Safety Data 15 Maintainers Want to Maintain 55
Assessing the Causes and Contributing
Factors of Mishaps 15 Chapter 10: Protecting Investment
The Human Factors Analysis and in Aircrews 59
Classification System (HFACS) 15 Pilot Training 59
The Limitations 16 The Right Training Medium 62
Preemptive Aviation Safety Data Collection 20
In Memoriam 67
Chapter 4: The Joint Safety Council 23
The Safety Success of Commercial Aviation 23 Appendixes
Establishing a Joint Safety Council 25 A. Congressional Charter for the National
Commission on Military Aviation Safety A-1
B. Recommendations B-1
Chapter 5: The Human/Machine Interface 29
C. Commissioners and Staff C-1
Physiological Episodes 29 D. Commission Engagements D-1
No Single Problem, No Single Solution 29 E. Bibliography E-1
Prioritizing the Human 32 F. Technical Appendix F-1
G. Key Military Aviation Safety Policy
Guidance G-1
H. Joint Safety Council Proposed Legislation H-1
I. Glossary and Acronym List I-1

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List of Graphics Figure 9-1: Army AH-64 Helicopter Maintainer Average
Months of Service by Skill Level and
Figure 1-1: Mishaps, Fatalities, Destroyed Aircraft,
Fiscal Year 53
and Estimated Costs Across DoD for Fiscal Years
2013–2018 1 Figure 9-2: Army Aircraft Maintenance Senior Sergeant
Average Months of Service by Skill
Figure 1-2: Mishap Classifications During Study
Level and Fiscal Year 54
Period, Fiscal Years 2013–2018 2
Figure 9-3: Air Force Refuel/Bomber Aircraft Maintainer
Figure 1-3: Human-Machine-Environment Framework 3
Average Years of Service by Skill
Figure 2-1: Visualizing Class A Mishap Rates 6 Level and Fiscal Year 54
Figure 2-2: Class A Aggregate Mishap Estimated Figure 10-1: Army AH-64D Course Changes 59
Derived Costs (in Millions) by Service for Fiscal
Figure 10-2: Navy and Marine Corps F-18
Years 2007–2018 6
Course Changes 59
Figure 2-3: Visualizing Class B Mishap Rates 7
Figure 10-3: Air Force F-16 Course Changes 59
Figure 2-4: Class B Aggregate Mishap Estimated
Figure 10-4: Examples of Cost Comparison of Actual
Derived Costs (in Millions) by Service for Fiscal Years
Flight Hours to Simulators, Fiscal Year 2019 62
2007–2018 7
Figure F-1: Class A Mishap Rates F-1
Figure 2-5: Visualizing Class C Mishap Rates 8
Figure F-2: Class B Mishap Rates F-2
Figure 2-6: Class C Aggregate Mishap Estimated
Derived Costs (in Millions) by Service for Fiscal Figure F-3: Class C Mishap Rates F-2
Years 2007–2018 8 Figure F-4: Class A–C Mishap Rates F-3
Figure 2-7: Comparing the Fiscal Years 2007–2012 Figure F-5: Fatalities and Destroyed Aircraft
and Fiscal Years 2013–2018 Rate Means Across by Service for Fiscal Years 2007–2018 F-4
the Services and Mishap Classes 9 Figure F-6: Mishap Classification Criteria Changes
Figure 2-8: Class A Mishap Rates and Rolling per DODI 6055.07, Mishap Notification,
Averages by Service for Fiscal Years 2007–2018 10 Investigation, Reporting, and Record Keeping F-5
Figure 2-9: Class B Mishap Rates and Rolling Figure F-7: Army Top 10 HFACS Applications
Averages by Service for Fiscal Years 2007–2018 11 in Class A Mishaps for Fiscal Years 2013–2018 F-6
Figure 2-10: Class C Mishap Rates and Rolling Figure F-8: Air Force Top 10 HFACS Applications
Averages by Service for Fiscal Years 2007–2018 11 in Class A Mishaps for Fiscal Years 2013–2018 F-6
Figure 2-11: Visualizing Class A-C Mishap Rates 12 Figure F-9: Navy Top 10 HFACS Applications
Figure 2-12: Mishap Rates for Fiscal Years 2013–2019 13 in Class A Mishaps for Fiscal Years 2013–2018 F-7

Figure 3-1: Aviation Mishap Categories and Figure F-10: Marine Corps Top 10 HFACS Applications
Subcategories 16 in Class A Mishaps for Fiscal Years 2013–2018 F-7

Figure 3-2: Flight, Flight-Related, and Ground Mishaps Figure F-11: Army Top 10 HFACS Applications in
by Class and Service for Fiscal Years 2013–2018 17 Class B Mishaps for Fiscal Years 2013–2018 F-8

Figure 3-3: The DoD HFACS 18 Figure F-12: Air Force Top 10 HFACS Applications
in Class B Mishaps for Fiscal Years 2013–2018 F-8
Figure 5-1: Air Force Physiological Episodes by
Aircraft Type for Fiscal Years 2013–2018 30 Figure F-13: Navy Top 10 HFACS Applications in
Class B Mishaps for Fiscal Years 2013–2018 F-9
Figure 5-2: Navy and Marine Corps Physiological
Episodes by Aircraft Type for Fiscal Years 2013–2018 30 Figure F-14: Marine Corps Top 10 HFACS Applications
in Class B Mishaps for Fiscal Years 2013–2018 F-9
Figure 5-3: Air Force Physiological Episodes in Fighter
and Trainer Aircraft for Fiscal Years 2013–2018 30 Figure F-15: Army Top 10 HFACS Applications in
Class C Mishaps for Fiscal Years 2013–2018 F-10
Figure 5-4: Navy and Marine Corps Physiological
Episodes in Fighter and Trainer Aircraft for Fiscal Figure F-16: Air Force Top 10 HFACS Applications
Years 2013–2018 30 in Class C Mishaps for Fiscal Years 2013–2018 F-10

Figure 5-5: Human Systems Integration in Figure F-17: Navy Top 10 HFACS Applications
the Acquisition Planning Process 34 in Class C Mishaps for Fiscal Years 2013–2018 F-11

Figure 7-1: Days Under a Continuing Resolution: Figure F-18: Marine Corps Top 10 HFACS
Department of Defense, Fiscal Years 2002–2019 42 Applications in Class C Mishaps for Fiscal Years
2013–2018 F-11
Figure 8-1: OPTEMPO 46

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Marines with Marine All Weather Attack Squadron 224,

Marine Aircraft Group 31, 2nd Marine Aircraft Wing, prepare
iv an F/A-18 for flight at Naval Air Facility El Centro, California.
(Department of Defense photo.)
EXECUTIVE SUMMARY

“What do you think will cause the next in concert. In this report, the Commission took special
aviation mishap?” care to balance competing and sometimes conflicting
priorities, and its recommendations are proposed with an
The National Commission on Military Aviation Safety
understanding of the importance of harmonization.
asked thousands of pilots and maintainers this question
Our findings and recommendations focus on four
during visits to military flight lines. Across the country,
areas where Congress and the Department of Defense can
certain answers were consistently repeated, regardless
take immediate steps to reduce aviation mishaps: Pilots
of Service, rank, or airframe: insufficient flight hours,
should fly; maintainers should maintain; data can save
decreasing proficiency levels, inadequate training
programs, excessive administrative duties, inconsistent lives; and funding should be consistent.
funding, risky maintenance practices, and a relentless
operations tempo. Aircrews and Maintainers
The Commission also independently assessed this
same question. The Commission reviewed thousands of The Commission found that aviation and maintenance
mishap reports, consulted volumes of secondary research, experience, the key to doing a job safely and efficiently,
and conducted data analysis to determine why mishap is declining. Newly trained pilots and maintainers are
rates have increased. The Commission also utilized its reporting to operational units without basic skills.
resident knowledge and experience: two retired four- Flight hours are being replaced with simulator hours,
star military aviators; a former member of the National yet the simulators are often outdated, out of service,
Transportation Safety Board and Director of Safety and or unavailable. Aircrews and maintainers are saddled
Survivability for the Navy; a former Secretary of the with additional nonaviation duties that are more valued
Army who had previously served as Acting Secretary of than their primary duties for purposes of promotion.
the Air Force and as a member of Congress; an engineer Furthermore,
turned CEO for major aircraft manufacturers; a White on top of their
House Deputy Chief of Staff for Operations who served experience gaps,
four presidents; and a former Navy helicopter pilot who some aircrews “Additional Duties. . . We
oversaw Air Force One and Marine One while director of are experiencing have an instructor pilot
the White House Military Office. physiological trying to get a forklift
This report shares critical perspectives from the episodes when license.”
flight line and addresses the safety concerns that so many an aircraft’s —USAF Junior Officer
aviators and maintainers candidly shared. This report environmental
also covers broader topics in the Commission’s statutory systems fail to
charter, such as aviation mishap rates, unexplained meet the needs of
physiological episodes, and aviation maintenance delays. the pilot.
The complete list of the Commission’s recommendations This report addresses these issues in detail. Two
is provided in Appendix B. chapters address the shortcomings in initial training,
During its study, the Commission realized that follow-on training, and personnel management of
many aviation safety issues are uniquely interconnected aircrews and maintainers. One chapter examines the
and require collaborative, cross-cutting solutions. For effects of a relentless pace on military aviation for both
example, increasing spare parts inventories does little machine and personnel. Another chapter discusses the
good if there are not enough experienced maintainers to human-machine interface and recommends changes in
install them. Fixing one issue may require fixing several the acquisition process to better meet the needs of the
related issues, and all solutions must be crafted to work pilot during aircraft design and modification.

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However, while addressed in separate chapters, capabilities to reduce risks and improve safety, while the
these are compounding problems. A reduction in flight Services lack standardized procedures and consistent
hours for new pilot training adds to the requirements for processes in their mishap reporting. Another chapter
operational units. These units, already overtasked from examines how improved pilot monitoring could
a high operations tempo, must then conduct training help identify, understand, and reduce unexplained
to develop basic physiological episodes. Additional chapters discuss the
skills for new need for improved data collection to measure training
personnel. This “We are doing 12-hour efficacy for pilots and maintainers.
stagnates the units’ days, five days a week, In studying these issues, the Commission reviewed
ability to conduct and hardly flying.” the current practices of commercial aviation, which has
high-level training. —F-22 Pilot successfully used data analytics to identify and reduce
In other words, safety risk. While certain commercial practices are
junior pilots and limited in their applicability to military aviation, the
maintainers are starting their careers a lap behind, and Commission identified policies and practices that offer
then never catching up, all while their units buckle under opportunities to
the additional stress of getting them up to speed. This, reduce risk and
in turn, leads to further costs. By being overworked, improve safety.
“Guys are going to take
overstressed, and overloaded with additional duties For example,
risks they don’t even
unrelated to aviation, the morale and readiness of compared to the
know is a risk.”
aircrews and maintainers erode. Experienced aircrews commercial sector,
—Marine Supervisor
and maintainers leave the Services and are replaced the Commission
by personnel with no expertise. The average level of determined that
experience falls, and the cycle repeats. the Department
To address these issues, the Commission of Defense is not properly organized to conduct data
recommends a multipronged approach. As outlined in analytics, coordinate aviation safety activities, develop
the report, the Services must improve the training of safety standards or data collection requirements, or review
new pilots and maintainers to broaden their experience the Services’ implementation of aviation safety programs.
and limit the burden on operational units. Additionally, The Commission recommends creating a Joint Safety
the Services must increase the retention of experienced Council. Reporting to the Deputy Secretary of Defense,
aircrews and maintainers through better personnel the council would be responsible for establishing military
management, increased bonuses, and better schooling aviation safety standards, collecting and analyzing
opportunities. The Services, having invested years and safety data, and developing safety priorities. Led by
millions of dollars in initial, on-the-job, and advanced safety officials from the Services, the council would
training, must focus the careers of aviation professionals have the necessary expertise and authority to monitor
on their aviation duties. Furthermore, to increase safety and coordinate aviation safety programs across the
and readiness, the Services must ensure that aircraft are Department. This recommendation is further outlined
designed to match the needs of the aircrew who fly them. in Chapter 4, and a legislative proposal is contained in
Without such complementary solutions, the U.S. military Appendix H.
could be left with the worst of all worlds: increased costs,
decreased readiness, and eroded safety margins.
Consistent and Predictable Resourcing
The question of the next mishap was not hard to
Data Deficiencies and the Need for a Joint
answer at one Marine base, where a junior Marine told
Safety Council
the Commission that his unit was reusing expendable
During its study, the Commission identified numerous $5 filters on aircraft. The unit, he explained, still had
data deficiencies in military aviation. Due to poor data missions to do even if there was no money to purchase
collection and analysis, the Services and the Department new filters. This was one of the egregious examples the
of Defense are missing out on valuable opportunities Commission found, and it was a direct result of funding
to reduce risk, prevent mishaps, and optimize human suddenly being withdrawn to meet other priorities.
performance. This is repeatedly referenced in the report. Inconsistent funding, and the tolerance it fosters for
For example, one chapter explains how the Department maintenance shortcuts, were the likely causes of the
lacks sufficient data collection methods and analysis next mishap at this unit.

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 Executive Summary

A lack of consistent funding is especially pernicious virtually every aspect of military aviation. However,
to military aviation safety. Flying, like surgery and empirical research on the impact of continuing
other highly technical professions, is a perishable skill resolutions is lacking. Therefore, while the Commission
that needs first recommends that the Department of Defense and
routine practice Congress resource military aviation in a consistent and
to maintain “I can always use predictable manner, the Commission also recommends
proficiency. When more money, but the that Congress require a comprehensive, data-driven
a unit’s funding thing I really need is analysis of continuing resolutions’ impact on military
is restored in the predictability: budget for aviation.
last part of a fiscal five years, [and] get it on
year, it simply October 1.” Conclusion
cannot make up —Senior USAF Leader
for lost training In line with the Commission’s statutory charter, this
and deferred report provides a comprehensive review of military
maintenance. aviation safety. The issues outlined above remain
Late funding, no matter the amount, cannot reverse the illustrative, not exhaustive. Overall, this report addresses
impact of months of insufficient flying hours, missing numerous topics related to military aviation, including
parts, and deferred maintenance. Timing is everything. mishap rates, safety data, unexplained physiological
By far the greatest and most preventable source of effects, sustainment management systems, funding,
unpredictable funding is Congress’s use of continuing operations tempo, training, and talent management. Each
resolutions. The Department of Defense has begun the of these topics warrants careful review and attention,
fiscal year with a continuing resolution for 13 of the past particularly due to the stakes involved.
18 fiscal years. As continuing resolutions have become During the Commission’s six-year study period,
more common, their average duration has also increased. aviation mishaps cost the U.S. military 198 lives, 157
There is near universal agreement that continuing aircraft, and well over $9 billion in damages. To reduce
resolutions significantly degrade readiness, waste money, these unacceptable costs, the Commission stresses that
and put the lives of Servicemembers at unnecessary risk. systemic problems require integrated solutions that
The Commission concurs and heard examples from prioritize safety. The cost of doing anything else is simply
every Service of how inconsistent funding degrades too high.

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Photo that sets the tone for the chapter. TBD

Members of the National Commission on Military Aviation Safety speak with

an advanced individual training student at Joint Base Langley-Eustis, Virginia.
(U.S. Air Force photo by TSgt. Robert Hicks.)
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Chapter 1:

MISSION AND METHOD

O ne hundred ninety-eight military personnel and

civilians died in U.S. military aviation mishaps
between fiscal years 2013 and 2018 in non-combat
symptoms). As investigators struggled to find the root
causes for these episodes, both the Air Force and Navy
grounded their fleets of T-6 trainers.
operations. The total cost of equipment lost or damaged This spate of fatal mishaps combined with the
in these mishaps was more than $9.41 billion, including increase of reported physiological episodes prompted
157 aircraft destroyed (Figure 1-1). the U.S. Congress to establish the National Commission
Beginning in the summer of 2017, all of the Services on Military Aviation Safety in the John S. McCain
experienced a series of high-profile mishaps over the next National Defense Authorization Act (NDAA) for Fiscal
12 months that called into question the overall state of Year 2019. The Commission’s charter, as spelled out
military aviation safety. A Marine Corps KC-130 came in that law, charged the commissioners to “undertake
apart in the sky over Mississippi, killing 15 Marines a comprehensive study of United States military
and one Navy corpsman. An Army UH-60 crashed into aviation mishaps that occurred between fiscal years
the sea during a night exercise off the coast of Oahu, 2013 and 2018.” The charter (see Appendix A) gave the
Hawaii, killing all five aboard. A Navy C-2A Greyhound Commission five tasks to accomplish in its study:
ditched into the Philippine Sea with three fatalities. An 1. to assess the rates of military aviation mishaps
Air Force Thunderbird F-16C crashed in Nevada, killing between fiscal years 2013 and 2018 compared to
the pilot. A Puerto Rico Air National Guard C-130H historic aviation mishap rates;
Hercules on its retirement flight to Davis-Monthan Air 2. to assess the underlying causes contributing to
Force Base, Arizona, crashed after takeoff in Georgia, the unexplained physiological effects;
killing all nine aboard. During the same time period, Air 3. to assess the causes contributing to delays in
Force and Navy pilots experienced a mysterious spike aviation maintenance and limiting operational
in unexplained physiological episodes (hypoxia-like availability of aircraft;

Figure 1-1:
Mishaps, Fatalities, Destroyed Aircraft, and Estimated Costs Across DoD for Fiscal Years 2013–2018

2013-
2013 2014 2015 2016 2017 2018
2018

Number of Class A Mishaps1 48 49 53 42 52 56 300

Number of Class B Mishaps1 78 80 85 90 83 82 498

Number of Class C Mishaps 1

786 836 869 909 982 899 5,281

Number of Class A-C Mishaps1 912 965 1,007 1,041 1,117 1,037 6,079

Number of Fatalities 2
24 22 38 39 36 39 198

Number of Destroyed Aircraft2 30 27 24 28 27 21 157

Class A–C Mishaps Estimated Total

$1.57 $1.48 $1.31 $1.78 $1.87 $1.39 $9.41
Derived Costs (in billions)2

Source: 1Service safety centers; 2Force Risk Reduction database.

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4. to assess the causes contributing to military Figure 1-2:

aviation mishaps; and Mishap Classifications During Study Period,
5. to make recommendations on the modifications, Fiscal Years 2013–2018
if any, of safety, training, maintenance,
personnel, or other policies related to military Class A At least $2 million in damage and/or death or
aviation safety. permanent disability.

Class B More than $500,000 but less than $2

The charter also directed the Secretary of Defense, million in damages, and/or permanent
in coordination with the Secretary of each military partial disability or three or more people
department, to submit, within 120 days from the hospitalized.
Commission’s delivery of its report, an assessment of the
Commission’s findings and conclusions and a plan for Class C At least $50,000 but less than $500,000,
and/or nonfatal injuries that require time off
implementing the recommendations.
from work.

Class D At least $20,000 but less than $50,000,

Conducting Its Study
and/or recordable injury or illness that
The Commission approached these tasks with an cannot be classified as an A, B, or C mishap.
understanding that readiness is inextricably tied to safe Class E Depends on Service definition.
operations. The Commission’s view of aviation mishaps
encompassed both the events leading directly to the
Additional data the Commission gathered included
mishaps as well as the incidents themselves. The study
flight hours, staffing levels, readiness rates, maintenance
analyzed the full spectrum of operational conditions and experience levels, changes in training syllabi, and DoD
institutional factors far beyond quantitative data. budgets. To broaden its analytical efforts, the Commission
The Commission conducted its own primary employed the Research and Analysis Center at the Naval
research and analysis to arrive at its assessments and Postgraduate School in Monterey, California, drawing on
recommendations. The study focused on three streams the resources of the multi-Service Research Facilitation
of information: analyzing the mishap reports and Laboratory.
quantitative data; consulting volumes of secondary
research; and, most importantly, traveling to 82 locations Literature and Document Review
to meet with aviation professionals. In addition to The Commission also benefited from consulting an
extensive quantitative data, the Commission found abundance of studies, directives, and instructions covering
significant value in hearing personal experiences and military aviation safety over the past 25 years. Studies came
concerns directly from Service personnel. The Services’ from government sources (Congress, the Congressional
safety centers connected the Commission with points of Research Service, the Office of Management and Budget,
contact for the site visits and with subject matter experts the Congressional Budget Office, the Government
and other data sources. Accountability Office, and professional military education
institutions), federally funded research and development
Mishap Reports and Quantitative Data centers (CNA, RAND, and IDA), think tanks, academic
The Commission reviewed Class A, B, and C mishap and research institutions, and government-commissioned
evaluations produced by consulting and professional
reports (see Figure 1-2) from the military departments’
services organizations. A bibliography is included in
safety centers for the 2013–2018 time period of the study,
Appendix E. The Commission also elicited information,
plus data from fiscal years 2007 through 2012 for historical insights, advice, and recommendations from subject matter
comparison. The Commission studied and analyzed all of experts inside and outside the Department of Defense.
the mishap reports and looked for trends in the types of
mishaps and the circumstances that directly or indirectly Flight Line Experience
contributed to these incidents. The Commission did not The Commission met with more than 200 organizations
reinvestigate or re-adjudicate any incident, investigation, and military aviation units, reaching all of the many
or Service determination: the Commission accepted the different types of flying communities in each of the
thousands of mishap reports’ narration and findings as Services, a distinction that separates this report from
presented. previous studies. The Commission hosted hundreds of

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 Chapter 1: Mission and Method

town halls and roundtable discussions with thousands The Human-Machine-Environment

of Service personnel. The purpose was to hear firsthand Framework
the experiences and concerns of aircrews and maintainers
Early in this process, the Human-Machine-
across all Services, components, and ranks. In addition to
Environment interface emerged as the framework for
meeting with each unit’s senior leaders, the Commission
the Commission’s study (see Figure 1-3). The Human
intentionally sought out junior personnel for their insights.
includes not only the physiology, experience, proficiency,
To encourage candor from participants, commanders did
and currency of aviators and maintainers, but also the
not attend the town halls with their subordinates, and
ethos that comes with being a Soldier, Sailor, Marine,
comments were noted without direct attribution. This
or Airman: a devotion to duty, a make-it-work attitude,
fostered open and uninhibited dialogue. Additionally, the
and an earnest commitment to professionalism and
Commission visited major air carriers, civilian helicopter
leadership. The Machine is the aircraft, the complex
operators, Federal Aviation Administration officials,
technical platform designed to accomplish a wide array
and aircraft manufacturers to explore best practices in
of missions, and the equipment needed to sustain it. The
commercial aviation and safety-related trends in aviation
Environment includes operations ranging from peacetime
technology. A list of the Commission’s site visits and other
training to combat preparation during which aircrews
engagements is in Appendix D.
accomplish their mission and maintainers sustain the
aircraft. Environment also includes the institution
and infrastructure that support these operations:
resources, policies, budgets,
organizational structures, logistics,
facilities, accountability, and
Figure 1-3:
operations tempo (OPTEMPO).
Human-Machine-Environment Framework
The Human, Machine, and
Environment must work together
E nv in harmony to optimize safety and
ir o
an n readiness. The Commission found
um that any imbalance, misalignment,
m

or disharmony increases the risk of

H

en

Multigenerational Culture Policy, Processes, a mishap. A system of systems is at

t

Workforce and Systems play, with interdependencies and

Training vital connections among them.
Human Personnel Resources
Factors
Budget
Maintenance

OPTEMPO
Equipment Supply
Data
Chain
Physiological
Episodes

5th Generation
Aircraft

Aging Aircraft

M a chi n e
Source: National Commission on Military Aviation Safety

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A pilot with Marine Fighter Attack Squadron 211 completes preflight checks in
an F-35B Lightning II Joint Strike Fighter aboard HMS Queen Elizabeth at sea.
(Department of Defense photo.)
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Chapter 2:

ASSESSING MISHAP RATES

A dvancing technology and concerted safety efforts

have made recent years the safest period in aviation
history. According to the Bureau of Transportation
and (2) are mishap rates moving in the right direction?
This chapter’s purpose is to show what the rates are and
how they have changed over the years.
Statistics, the U.S. air carrier total accident rate per
100,000 flight hours has decreased from 1.77 in 1965
Assessing and Characterizing Mishap Rates
to 0.20 in 1990 and reached 0.17 in 2017. A 2020
Massachusetts Institute of Technology study finds that The Commission used a widely accepted standard
the risk of traveling on commercial airlines has dropped for measuring mishaps: mishaps per 100,000 flight
from one death per 350,000 boardings globally from hours. Each of the Services’ safety centers provided the
1968–1977 to one death per 2.7 million boardings from Commission with historical mishap data and flight hours.
1998–2007 to a current rate of one death per 7.9 million The Commission calculated the mishap rates for each
boardings. Similarly, military aviation has recorded Service as well as an aggregated rate for DoD.
substantial improvements in mishap rates since the
1950s. Mishap Rate = (# of mishaps per year / # of flight
Within this broader context, Congress tasked this hours per year) x 100,000
Commission “to assess the rates of military aviation
These calculations allowed the Commission to
mishaps from fiscal years 2013 through 2018 compared to
compare mishap rates across the Services using a
historic aviation mishap rates.” The Commission calculated
common standard while accounting for differing flight
mishap rates by Service and across the Department of
hours among the Services. The mishap rate reflects the
Defense for fiscal years 2013–2018, comparing the rates of
occurrence of a mishap and is not influenced by the
those years against the previous six fiscal years, 2007–2012.
number of fatalities or extent of damage. A mishap that
The Commission’s assessment addressed two questions: (1)
results in more than one fatality is counted as a single
Are mishap rates higher or lower in fiscal years 2013–2018,
mishap.
The Commission used visualizations, basic
descriptive statistics, and rolling averages to better
understand the characteristics and relationships among
CURRENCY AND PROFICIENCY the mishap rates. The Commission examined Class A,
Aviators and maintainers depend on being current and Class B, and Class C mishaps, the costliest as measured
proficient in their tasks to limit their risk for a mishap. by deaths, injury, and aircraft repair costs. Reporting
for the less severe Class D and Class E mishaps was
Currency, or being current, describes having inconsistent throughout fiscal years 2007 to 2018 and
successfully demonstrated a skill or maneuver within not included in this analysis.
a certain period of time.
Visualizing and Contextualizing the Rates
Proficiency, or being proficient, emphasizes how skilled
an individual is at performing a task or maneuver, not The bottom line is that overall DoD mishap rates
whether the individual is able to perform the task. increased in fiscal years 2013–2018. These higher
Each of the Services assess proficiency with a tiered rates are largely due to an increase in Class C mishaps.
scale describing the level of skill at which an individual However, as outlined below, the increase in Class C
is able to successfully complete a task. mishaps could be a harbinger of more serious safety
issues. Indeed, the 2019 fiscal year data substantiates the
Commission’s concerns.

5
National Commission on Military Aviation Safety

The following visualizations

illustrate the changes in the mishap rates Figure 2-1:
by class and by Service for fiscal years Visualizing Class A Mishap Rates
2007–2018. They are supplemented by
tables providing the annual estimated All DoD Army Air Force Navy Marine Corps

costs of mishaps by class and by Service

for context and perspective. 6 All DoD

Figure 2-1 shows the Army, Army

Air Force, and Navy had moderate 5

Air Force

fluctuations in Class A mishap rates Navy

during the fiscal years 2013–2018 Marine Corps

4
study period. However, the Marine
Corps consistently had higher Class A
mishap rates. The higher mishap rates 3

in the Marine Corps are consistent with

problems the Commission observed 2
during site visits. These included low
morale, pilots struggling to maintain
1
enough flight hours for currency,
over-stressed aircrew and maintenance
personnel overloaded with additional 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
duties, poor facilities, and a pattern of
using shortcuts to keep aircraft flying.
Note: The vertical line delineates the Commission’s chartered study period of fiscal years
The Commission assesses that these 2013–2018 from the comparison period of fiscal years 2007–2012
issues contributed to the spike in Class A

Figure 2-2:
Class A Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007- 2013-
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2012 2018

Army $311.7 $126.6 $128.1 $237.7 $164.4 $162.9 $42.0 $263.6 $141.8 $167.9 $228.8 $194.1 $1,131.3 $1,038.1

Air
$364.4 $2,158.6 $470.8 $462.6 $325.5 $498.3 $899.2 $214.1 $405.6 $435.4 $242.0 $489.1 $4,280.2 $2,685.4
Force

Navy $227.0 $616.0 $225.4 $265.8 $201.0 $435.2 $196.1 $538.1 $295.8 $431.1 $367.5 $230.0 $1,970.4 $2,058.6

Marine
$160.6 $217.0 $161.1 $232.4 $232.2 $261.3 $259.7 $292.6 $274.8 $542.8 $832.8 $283.6 $1,264.6 $2,486.3
Corps

All DoD $1,063.7 $3,118.2 $985.4 $1,198.4 $923.0 $1,357.8 $1,396.9 $1,308.4 $1,118.0 $1,577.2 $1,671.1 $1,196.7 $8,646.5 $8,268.4

Source: FR2 Database

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.

6
 Chapter 2: Assessing Mishap Rates

mishaps from fiscal year 2015 to 2017.

Figure 2-3: Chapters 9 and 10 explore in greater
Visualizing Class B Mishap Rates detail the challenges aviation maintainers
and aircrew face.
All DoD Army Air Force Navy Marine Corps Figure 2-2 shows that the aggregate
mishap materiel costs for Class A mishaps
8 exceeded
All DoD $1.1 billion during each year
ofArmy
the study period. A single $1.4 billion
7
mishap
Air Force destroying a B-2 Stealth Bomber

6 inNavy
2008 drove the higher total DoD-wide
costs
Marinefor fiscal years 2007 through 2012.
Corps

5 Figure 2-3 shows that fiscal year

2009 had a massive spike in Class B
4 mishaps. While that year is outside
the Commission’s study period, the
3
Commission notes this spike may be
2
partially attributable to a change in
how mishaps were classified that year
1 (additional explanation provided in
Appendix F). During the fiscal years
0 2013–2018 study period, Class B
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 mishap rates were generally stable
across the Services with the exception
Note: The vertical line delineates the Commission’s chartered study period of fiscal years
2013–2018 from the comparison period of fiscal years 2007–2012
of the Navy, which had a continuous
increase in Class B mishaps from fiscal
years 2014–2018. The Navy increase

Figure 2-4:
Class B Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007- 2013-
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2012 2018

Army $5.61 $6.48 $10.20 $10.50 $13.95 $10.49 $5.99 $6.12 $13.20 $11.95 $3.51 $8.54 $57.24 $49.31

Air
$42.64 $55.84 $69.06 $36.95 $62.76 $34.03 $42.95 $47.48 $47.88 $49.35 $40.43 $49.52 $301.30 $277.62
Force

Navy $13.54 $15.23 $14.24 $10.14 $12.63 $13.64 $16.35 $13.84 $12.41 $16.83 $21.69 $26.31 $79.42 $107.43

Marine
$5.87 $3.63 $8.74 $5.65 $6.74 $9.22 $3.89 $4.47 $6.06 $6.13 $5.89 $4.86 $39.85 $31.31
Corps

All DoD $67.67 $81.19 $102.25 $63.24 $96.08 $67.38 $69.18 $71.92 $79.56 $84.26 $71.53 $89.22 $477.80 $465.67

Source: FR2 Database

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.

7
National Commission on Military Aviation Safety

coincided with an inordinate increase

Figure 2-5: in the number of F/A-18 variants
Visualizing Class C Mishap Rates experiencing Class B mishaps, both in
flight and on the ground, compared
All DoD Army Air Force Navy Marine Corps to the rest of the fleet. A Navy Safety
Center investigation found no
50 “smoking
All DoD gun” but pointed to potential
environmental
Army factors, such as foreign
object
Air Forcedebris (FOD) and bird strikes.
40
The
Navy majority of ground mishaps, which

disproportionately
Marine Corps happened during
night operations, occurred when moving
30
aircraft.
Figure 2-4 shows that the costs of
20 Class B mishaps during the study period
were generally lower than the previous
six years. The total cost of mishaps across
10 DoD declined when comparing the
six-year study period to the previous six
years.
0 Figure 2-5 illustrates a steady increase
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 in DoD Class C rates from fiscal years
2013 through 2018. These increases
Note: The vertical line delineates the Commission’s chartered study period of fiscal years
2013–2018 from the comparison period of fiscal years 2007–2012
are concerning and are consistent with
the Commission’s observations. Many
Class C mishaps are aviation ground

Figure 2-6:
Class C Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007- 2013-
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2012 2018

Army $6.18 $7.57 $6.45 $6.97 $12.91 $11.56 $6.10 $8.87 $9.61 $7.64 $8.52 $7.99 $51.65 $48.73

Air
$38.77 $37.49 $46.98 $70.66 $68.52 $68.92 $72.69 $70.20 $80.79 $78.09 $86.24 $72.42 $331.34 $460.43
Force

Navy $7.74 $5.65 $7.75 $14.80 $12.96 $14.20 $16.42 $17.47 $18.91 $22.75 $26.15 $19.89 $63.10 $121.60

Marine
$1.71 $3.87 $2.83 $8.06 $5.37 $4.72 $6.13 $7.40 $7.04 $7.99 $9.47 $8.29 $26.57 $46.32
Corps

All DoD $54.40 $54.57 $64.01 $100.50 $99.77 $99.40 $101.34 $103.95 $116.35 $116.47 $130.38 $108.60 $472.65 $677.08

Source: FR2 Database

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.

8
 Chapter 2: Assessing Mishap Rates

mishaps due to mishandling of aircraft by inexperienced Figure 2-7:

maintenance personnel and insufficient supervision. That Comparing the Fiscal Years 2007–2012 and Fiscal
cause is most apparent in the noticeable increase in Navy Years 2013–2018 Rate Means Across the Services
and Marine Corps Class C rates. Figure 2-5 also shows that and Mishap Classes
Air Force Class C rates are notably higher than the other
Services and varied between 35 and 40 Class C mishaps FY07-12 FY13-18
MISHAP RATE
per 100,000 flight hours during the fiscal years 2013–2018 CATEGORY
SERVICE MISHAP MISHAP
period. The Commission attributes these consistently RATE MEAN RATE MEAN
higher rates, in part, to the higher repair cost of Air Force Army 1.77 1.19
aircraft. The Army Class C rate remains low compared to
the other Services, which may be attributed to the lower Air Force 1.15 1.11
cost of repairing damage to the aircraft operated by the Class A Navy 1.15 1.34
Army.
Figure 2-6 shows that as Class C mishap rates Marine Corps 2.43 3.30
have increased within DoD, so have the aggregate costs All DoD 1.41 1.33
to repair the damage. Overall, Class C mishap costs
increased during the study period and peaked at over Army 1.33 1.03
$130 million in DoD-wide costs in 2017. Air Force 4.21 2.62
“It is a matter of inches or seconds that make
the difference between a Class C or a Class A,” the Class B Navy 2.55 2.50
commanding general of the Army’s Combat Readiness Marine Corps 3.29 2.78
Center said in June 13, 2018, testimony before a House
subcommittee. All DoD 3.00 2.23
The Commission is concerned with the Class C Army 7.16 6.47
trends, which can be leading indicators of more serious
Class A and B mishaps. Commercial aviation enterprises Air Force 33.44 36.18
thoroughly record and closely track minor mishaps and Class C Navy 9.44 16.54
near misses as a way to prevent major accidents.
Marine Corps 9.70 20.69

Comparing the Period Means All DoD 19.45 23.37

To directly compare the mishap rates of fiscal years

Source: National Commission on Military Aviation Safety analysis
2013–2018 with those of fiscal years 2007–2012, the
Commission calculated a mean rate for the two periods.
This statistic takes into account any changes across the
period and does not emphasize any one year.
Period Mean Mishap Rate = (sum of # of mishaps in
period / sum of # of flight hours in period) x 100,000

The Commission calculated the mean for each period

by Service and by mishap class, as shown in Figure 2-7.
The changes in the means help answer whether the
rates for fiscal years 2013 through 2018 have increased,
decreased, or stayed the same compared to fiscal years
2007 through 2012. Figure 2-7 shows that the Army
experienced decreases in all mishap classes with the
greatest rates of reduction in the Class A and B rate
means. The Air Force had a small decrease in Class A
rate means, a larger decrease in Class B means, and an
increase in Class C means. The Navy and Marine Corps
both experienced increases in Class A and Class C rate
means, with a dramatic increase for the Marine Corps.

9
 Figure 2-8:
Class A Mishap Rates and Rolling Averages by
National Commission on Military Aviation Safety Service for Fiscal Years 2007–2018
ARMY
3

Overall, Navy and Marine Corps Class B means both 2

decreased, a small decrease for the Navy and greater
decrease for the Marine Corps. The largest increase was
1
in Class C mishap rates, particularly the Marine Corps,
which more than doubled its mishap mean between the
two periods. The Navy also had a significant increase. 0

07
08
09
10
11
12
13
14
15
16
17
18
20
20
20
20
20
20
20
20
20
20
20
20
Identifying Troubling Trends
Class A Mishap Rate
The Commission also calculated four-year rolling Class A 4-Year Rolling Average
averages to identify trends and determine if rates were
AIR FORCE
heading in the right direction.
2
A 4-Year Rolling Ave
Rolling Average = (Mishap rates of the current year +
A Mishap Rate
prior year + two years prior + three years prior) / 4 1.5

In Figures 2-8, 2-9, and 2-10, the scales of the vertical

1
axes vary among the graphs to more easily visualize trends.
The Commission concentrated on the rolling averages for 0.5
fiscal years 2016–2018 because it includes data entirely
from the Commission’s assigned study period. 0
The Army Class A rolling averages have largely
07
08
09
10
11
12
13
14
15
16
17
18
decreased since fiscal year 2007. The Air Force similarly
20
20
20
20
20
20
20
20
20
20
20
20
showed decreasing rolling averages, a trend that is Class A Mishap Rate
threatened by the increase in Class A mishaps in fiscal Class A 4-Year Rolling Average
year 2018. In the Navy, the trend of decreasing rolling
averages ended in fiscal year 2013 and has been generally NAVY
increasing since. Likewise, while the Marine Corps had a 2
A 4-Year Rolling Ave
notable drop in its fiscal year 2018 Class A mishap rate,
A Mishap Rate
its increasing rolling averages are concerning. 1.5
The Class B rolling averages for the Navy increased
for fiscal years 2015–2018, and increased for the Marine 1
Corps for fiscal years 2016–2018. By contrast, the
Air Force Class B rolling averages decreased for fiscal 0.5
years 2016–2018. The Army rolling averages remained
consistently low, but did increase in fiscal years 2014 and 0
2018.
07
08
09
10
11
12
13
14
15
16
17
18
20
20
20
20
20
20
20
20
20
20
20
20

Most notably, the Air Force Class C rolling averages

are substantially higher than the other Services, and Class A Mishap Rate
the Navy and Marine Corps Class C rolling averages Class A 4-Year Rolling Average
significantly increased during fiscal years 2013–2018. The MARINE CORPS
Army rolling averages have remained consistently low,
5
particularly when compared to the other Services, but did
increase for fiscal years 2016–2018. 4
Further information and charts are in Appendix F.
3

0
07
08
09
10
11
12
13
14
15
16
17
18
20
20
20
20
20
20
20
20
20
20
20
20

Class A Mishap Rate

Class A 4-Year Rolling Average
Note: The scales of the vertical axes vary to more easily visualize trends.
10 To compare across the Services or see the overall perspective, please refer
to Figure 2-1.
Figure 2-9: Figure 2-10:
Class B Mishap Rates and Rolling Averages by Class C Mishap Rates and Rolling Averages by
Service for Fiscal Years 2007–2018 Chapter
Service for Fiscal Years 2: Assessing Mishap Rates
2007–2018
ARMY ARMY
2 10
B 4-Year Rolling Average
9
B Mishap Rate 8
1.5
7
6
1 5
C 4-Year R
4
3
0.5 C Mishap
2
1
0 0

07
08
09
10
11
12
13
14
15
16
17
18
07
08
09
10
11
12
13
14
15
16
17
18

20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
Class B Mishap Rate Class C Mishap Rate
Class B 4-Year Rolling Average Class C 4-Year Rolling Average

AIR FORCE AIR FORCE

7 50
6
40
5
4 30

3 20
2
10
1
0 0
07
08
09
10
11
12
13
14
15
16
17
18

07
08
09
10
11
12
13
14
15
16
17
18
20
20
20
20
20
20
20
20
20
20
20
20

20
20
20
20
20
20
20
20
20
20
20
20
Class B Mishap Rate Class C Mishap Rate
Class B 4-Year Rolling Average Class C 4-Year Rolling Average

NAVY NAVY
4 25
B 4-Year Rolling Average
B Mishap Rate 20
3
15
2
10
1
5

0 0
07
08
09
10
11
12
13
14
15
16
17
18
07
08
09
10
11
12
13
14
15
16
17
18

20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20

Class B Mishap Rate Class C Mishap Rate

Class B 4-Year Rolling Average Class C 4-Year Rolling Average

MARINE CORPS MARINE CORPS

7 30
6 25
5
20
4
15
3
10
2
1 5

0 0
07
08
09
10
11
12
13
14
15
16
17
18
07
08
09
10
11
12
13
14
15
16
17
18

20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20

Class B Mishap Rate Class C Mishap Rate

Class B 4-Year Rolling Average Class C 4-Year Rolling Average
Note: The scales of the vertical axes vary to more easily visualize trends. Note: The scales of the vertical axes vary to more easily visualize trends.
To compare across the Services or see the overall perspective, please To compare across the Services or see the overall perspective, please 11
refer to Figure 2-3. refer to Figure 2-5.
National Commission on Military Aviation Safety

The Commission’s Assessment

Figure 2-11: and Findings
Visualizing Class A-C Mishap Rates
To address any questions about general
All DoD Army Air Force Navy Marine Corps
trends in mishaps between the study
period and the historical period, the
60
Commission
All DoD
looked at the Class A-C
aggregate
Army
results. Overall, mishap rates in
DoD increased
Air Force
in fiscal years 2013–2018
50
(Figure
Navy
2-11). As the previous sections
demonstrated,
Marine Corps
the higher rate is largely
40 due to an increase in Class C mishaps.
In reflecting on the totality of its
30
assessment, the Commission is particularly
concerned with the increases in Navy
and Marine Corps Class A mishap
20
rates, especially Marine Corps Class A
mishap rates. The higher mishap rates
10 in the Marine Corps are consistent with
Commission site visits where Marine
0
Corps aviation units were some of the
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
most over-tasked, over-stressed, and
under-resourced units the Commission
Note: The vertical line delineates the Commission’s chartered study period of observed.
fiscal years 2013–2018 from the comparison period of fiscal years 2007–2012 The Commission heard concerns
from many in the field that the conditions
were set for a potential increase in mishap
rates. Subsequent chapters provide
greater explanation of where latent risk
resides throughout the Human-Machine-
Environment framework and conclude
with recommendations to abate the risks,
hopefully in time.

12
 Chapter 2: Assessing Mishap Rates

Additional Assessment The Marine Corps Class A mishap rate also increased
in fiscal year 2019 and continued to be the highest of
Although Congress ended the Commission’s study
any Service, but was still lower than in fiscal year 2017.
window at 2018, the mishap rate data for fiscal year 2019
became available as the Commission continued its work Additionally, the Marine Corps Class B mishap rate more
through 2020 (Figure 2-12). The Commission reviewed than doubled from fiscal year 2018 to 2019, which easily
the fiscal year 2019 data and found that it underscored constituted the highest Class B mishap rate of any Service
the concerns the Commission heard on its site visits. during the Commission’s entire study period.
The Army and Air Force mishap rates in fiscal year Class A-C mishaps resulted in 198 fatalities and cost
2019 did not significantly change the Commission’s the Services more than $9.4 billion between fiscal years
assessment discussed earlier in this chapter. However, the 2013 and 2018. These are human and financial costs that
Navy and Marine Corps both had significant increases should not be trending upward by any percentage. These
that warrant discussion. Most notably, the Navy’s 2019 trends can be reversed if the full range of causes for all
Class A mishap rate was higher than any other year classes of mishaps are fully understood and addressed.
the Commission examined (fiscal years 2007–2018). The first step is identifying those causes.

Figure 2-12:
Mishap Rates for Fiscal Years 2013–2019

FISCAL YEAR 2013 2014 2015 2016 2017 2018 2019

Army A Mishap Rate 0.90 1.56 1.45 0.93 1.03 1.31 1.38

Air Force A Mishap Rate 1.21 0.72 1.17 0.96 1.03 1.58 1.54

Navy A Mishap Rate 1.06 1.78 1.28 0.93 1.55 1.44 2.41

Marine Corps A Mishap Rate 2.98 2.28 3.29 3.81 5.19 2.49 3.36

All DoD A Mishap Rate 1.21 1.29 1.39 1.13 1.41 1.55 1.82

Army B Mishap Rate 0.81 0.68 1.67 1.27 0.69 1.07 0.92

Air Force B Mishap Rate 2.58 3.18 2.50 2.95 2.41 2.11 2.06

Navy B Mishap Rate 2.12 1.54 2.09 2.43 3.33 3.49 2.29

Marine Corps B Mishap Rate 2.23 2.66 2.88 2.54 3.03 3.32 7.14

All DoD B Mishap Rate 1.96 2.11 2.24 2.42 2.25 2.27 2.17

Army C Mishap Rate 5.11 4.98 6.68 6.37 7.81 8.59 5.06

Air Force C Mishap Rate 34.00 37.90 35.05 36.13 38.77 35.31 36.32

Navy C Mishap Rate 11.57 12.92 15.24 19.01 21.05 19.48 17.62

Marine Corps C Mishap Rate 14.51 16.69 19.32 22.46 26.80 25.75 21.85

All DoD C Mishap Rate 19.79 22.00 22.86 24.40 26.66 24.85 23.80

Source: Services’ safety centers

13
National Commission on Military Aviation Safety

A Naval Aircrewman prepares for a training flight in an

MH-60S Knighthawk assigned to the “Black Knights” of
Helicopter Sea Combat Squadron 4, during a training exercise
at Naval Air Facility El Centro, California. (U.S. Navy photo by
14 Chief Mass Communication Specialist Shannon Renfroe.)
 En
vi
an

ro
m

nm
Hu

en
t
Machine

Chapter 3:

MILITARY AVIATION
SAFETY DATA
T o make an assessment of causes contributing to
military aviation mishaps, the Commission took an
expansive look at aviation data collection practices within
DoD and the Services collect safety-related data in
varying ways with equally varying degrees of success and
utility for improving safety. Service safety center leaders
the Department of Defense (DoD). The Commission noted a decrease in aviation mishaps over the past few
first reviewed more than 6,000 mishap reports from decades, but that the same mishaps continue to occur
fiscal years 2013 through 2018. Second, the Commission year after year. In an era of limited financial resources
studied military and civilian data collection methods and manpower, the ever-escalating price tags of modern
aimed toward preventing or mitigating aviation losses. aircraft and the cost of training aircrew and maintainers
Throughout this effort, the Commission found a number require constant vigilance to keep aviation personnel and
of issues and concerns for present and future military assets safe. The Department and Services have failed to
aviation safety. Aviation safety data collection, processing, take full advantage of commonly available trend analysis
and analysis must be improved before the data can be models and tools that could give them the ability to
used effectively to improve military aviation safety across effectively collect, analyze, and operationalize safety data.
the DoD. As we have learned from industry and society at large,
In reviewing and analyzing aviation safety data good data is the starting point for best practices and for
collection within the Defense Department, the making actionable military aviation safety decisions.
Commission:
• Utilized Class A through Class C military aviation
Assessing the Causes and Contributing
mishap reports provided by the Services’ safety
Factors of Mishaps
centers and DoD’s safety database, the Force Risk
Reduction (FR2) database managed by the Office As the Commission turned to understanding the “causes
of the Undersecretary of Defense for Personnel and contributing to military aviation mishaps,” it used some
Readiness; of the standard fields that are required to be included
• Studied safety investigation reports for Class A for all mishaps. First, it analyzed the type of mishap,
mishaps to identify trends in the most severe mishaps; categorized as flight, flight related, and ground mishaps
• Reviewed relevant DoD and Service directives and (see Figure 3-1).
memorandums; Figure 3-2 indicates that flight mishaps were the
• Researched military aircraft and aviation personnel most frequent category among Class A mishaps while
data collection equipment and programs; ground operations mishaps were most frequent among
• Reviewed previous government and academic reports; Class C mishaps. The number of flight-related mishaps
• Interviewed DoD and Service leaders about their was significantly lower for all classes than the other
safety programs; two categories. The vast majority of flight mishaps
• Collaborated with the individual Service safety are attributed to aircrew errors. Service safety officials
centers on data collection and analysis; reported that most ground operations Class C mishaps
• Elicited input from aviators, maintainers, unit are related to maintenance incidents.
commanders, and senior military leadership;
• Interviewed academic and commercial aviation
The Human Factors Analysis and
experts on safety best practices and the Human
Classification System (HFACS)
Factors Analysis and Classification System (HFACS);
• Visited several commercial aviation companies; In its review of mishap safety data, the Commission
• Consulted with the Federal Aviation Administration found the information provided a historical perspective
to review their safety management systems, data on individual mishaps. Historical records show that 80
collection processes, and analysis of mishap data. percent of aviation mishaps are attributed to human

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National Commission on Military Aviation Safety

Figure 3-1:
Aviation Mishap Categories and Subcategories

SUBCATEGORY SUBCATEGORY CHARACTERISTICS

A mishap where there is intent for flight and damage to DoD aircraft. Explosives, chemical agent, or missile
events that cause damage to an aircraft with intent for flight are categorized as flight mishaps to avoid dual
Flight
reporting. (Mishaps involving factory-new production aircraft until successful completion of the post-production
flight are reported as contractor mishaps.)

A mishap where there is intent for flight and no reportable damage to the aircraft itself, but the mishap involves
Flight fatality, reportable injury, or reportable property damage. A missile that is launched from an aircraft, departs
Related without damaging the aircraft, and is subsequently involved in a mishap is reportable as a guided missile
mishap.

A mishap where there is no intent for flight that results in damage to an aircraft or death or injury involving an
Ground
aircraft. This applies to aircraft both on land and on board ship. Damage to an aircraft when it is being handled
Operations
as a commodity or cargo is not reportable as an aircraft mishap.

Source: DoD Instruction 6055.07, June 6, 2011 Table 1

factors (aircrew and maintenance errors). The remaining was 43 percent as Acts, 38 percent as Preconditions,
20 percent of mishaps are attributed to aircraft issues 10 percent as Organization, and 9 percent as Supervision.
(malfunctions or design errors) and nature-related issues Looking at the next lower echelon, “Performance-
(bird strikes or weather). Based Errors” and “Judgment and Decision-Making
Like the Services and DoD, the Commission used Errors” were the most common errors cited by mishap
the DoD Human Factors Analysis and Classification investigators.
System (HFACS) codes to understand the causal and Analysis at the code level revealed the top three most
contributing factors in its analysis of the human element commonly applied codes are “Procedure Not Followed
of mishaps. DoD’s HFACS is a solid framework and Correctly” (AE103), “Inadequate Real-Time Risk
a key component of every investigation. This system Assessment” (AE 201), and “Wrong Choice of Action
identifies a broad range of human errors within 1) unsafe during an Operation” (AE206). Charts with the most
acts of operators (e.g., aircrew), 2) preconditions for commonly applied codes by mishap class and Service
unsafe acts, 3) unsafe supervision, and 4) organizational during the study period, the Commission’s most granular
influences. The goal of HFACS is not to attribute blame analysis, are in Appendix F.
but to understand the underlying operational or cultural All these codes can lead the safety center investigators
factors that led to a mishap. Such knowledge can spur to research underlying causes for these occurrences,
measures that prevent future mishaps. which, in turn, could lead to studying such factors as
A single mishap may include many codes from training, staffing, maintenance delays, and other core
various categories or bins as investigators identify all issues that led to that mishap and remain present and
of the events, decisions, and conditions leading to the unaddressed.
mishap. Comprehensively identifying even second- and
third-level causes are key to identifying trends that create
The Limitations
risks, paving the way for proactive preventive measures.
As Figure 3-3 on pages 18-19 shows, individual
HFACS codes are grouped into four larger categories (the Military Mishap Data Collection
boxes with orange headings) and subdivided into smaller Precise data collection from an aviation mishap is
bins (the boxes with gray headings). They are given an critical in understanding what happened and can be a
individual alphanumeric code to indicate their category valuable source of information to prevent future mishaps.
and bin. The Services’ safety centers usually conduct extensive
Based on the Commission’s review of all Class A investigations on Class A and B mishaps. Safety officials
mishap reports from fiscal years 2013 through 2018, the at the command or unit level perform investigations of
distribution across the four largest HFACS categories Class C and below mishaps. Causal and contributory

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 Chapter 3: Military Aviation Safety Data

Figure 3-2:
Flight, Flight-Related, and Ground Mishaps by Class and Service for Fiscal Years 2013–2018

    CLASS A MISHAP COUNTS CLASS B MISHAP COUNTS CLASS C MISHAP COUNTS

FISCAL AIR MARINE AIR MARINE AIR MARINE

  ARMY NAVY ARMY NAVY ARMY NAVY
YEAR FORCE CORPS FORCE CORPS FORCE CORPS

2013 10 19 4 8 8 32 10 3 44 264 57 19
2014 15 7 15 5 6 37 1 7 42 289 51 19
2015 12 20 9 8 14 36 9 4 45 290 57 19
Flight
2016 7 12 7 8 11 38 13 2 38 281 80 21
2017 9 12 9 10 6 36 17 3 52 323 75 22
2018 10 23 8 5 8 26 21 5 54 273 49 22
2013 0 1 3 0 1 0 1 0 4 30 3 3
2014 1 2 0 1 1 2 2 0 3 24 4 5

Flight 2015 1 1 0 0 1 0 1 0 3 29 5 3
Related 2016 0 2 0 0 0 0 2 0 6 27 2 4
2017 0 1 1 0 0 0 1 0 7 21 8 1
2018 1 0 2 0 1 0 1 0 3 31 4 3
2013 0 1 2 0 0 13 7 3 9 298 38 17
2014 0 3 0 0 0 14 10 0 6 319 54 20
2015 0 0 2 0 0 9 8 3 12 312 69 25
Ground
2016 1 3 1 1 0 14 6 4 11 329 82 28
2017 0 5 3 2 0 6 10 4 9 331 94 39
2018 0 4 2 1 0 10 7 3 15 299 109 37

information for Class A and B mishaps generally is of the Secretary of Defense] on aviation mishaps,” the
comprehensive. However, the Commission noted a lack GAO report said. “However, there are several gaps in its
of standardization and inconsistent reporting structures current approach to collecting, reporting, and analyzing
across the Services even in the Class A mishap reports, aviation mishap data. Specifically, because standardized
which are prepared with the highest degree of expertise data elements are not being collected across the safety
among the mishap classes. Reporting on Class C centers, DoD is limited in its ability to compare mishap
investigations also is inconsistent and often incomplete, data across the military services and must engage in
though Service safety leaders note that Class C mishaps inefficient and time-consuming efforts to align the
are potentially the best indicators of elevated risk for data with reporting requirements.” The Commission
more serious mishaps. Commercial enterprises actively confirmed these findings are still true of the data reviewed
track and react to Class C-type incidents as a preventive for this study. Until this problem is addressed fully, the
measure and to promote a reporting culture. Military DoD safety program will languish and continue to repeat
aviation does not. Given the increasing numbers of Class its safety and mishap mistakes.
C mishaps described in the previous chapter, this is an The Services cited inconsistencies in how
area of concern the Services should address. investigations are conducted when they cautioned the
Both a 2003 Congressional Research Service report Commission against using only the mishap reports for
to Congress and a 2018 Government Accountability analysis and conclusions, especially for Class C mishaps.
Office report also identified these problems. “DoD has An official at a safety center said the system is not
taken a number of steps to ensure that the safety centers appropriate for data mining because people do not fill
provide more complete and consistent data to [the Office in the data fields correctly. “The reports are only as good

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National Commission on Military Aviation Safety

Figure 3-3:
The DoD HFACS
ORGANIZATIONAL INFLUENCES

Resource Problems Personnel Selection Policy & Process Issues Climate/Culture Influences
& Staffing
OR001 Command & Control OP001 Pace of OPTEMPO/Workload OC001 Organizational Culture
Resources are Deficient OS001 Personnel OP002 Organizational Program/Policy (attitude/actions) Allows for
OR003 Inadequate Infrastructure Recruiting & Selection Risks not Adequately Assessed Unsafe Task/Mission
Policies are Inadequate OC003 Organizational
OR005 Failure to Remove OP003 Provided Inadequate Procedural
Inadequate/Worn-out Equipment OS002 Failure to Provide Guidance or Publications Over-confidence or
in Timely Manner Adequate Manning/ Underconfidence in
Staffing Resources OP004 Organizational (formal) Training is Equipment
OR008 Failure to Provide Inadequate or Unavailable
Adequate Operational Information OC004 Unit Mission/Aircraft/
OP005 Flawed Doctrine/Philosophy Vehicle/Equipment Change or
Resources
OP006 Inadequate Program Management Unit Deactivation
OR009 Failure to Provide
Adequate Funding OP007 Purchasing or Providing Poorly OC005 Organizational
Designed or Unsuitable Equipment Structure is Unclear or
Inadequate

SUPERVISION

Supervisory Violations Planned Inappropriate Operations Inadequate Supervision

SV001 Failure to Enforce SP001 Directed Task Beyond Personnel SI001 Supervisory/Command Oversight Inadequate
Existing Rules Capabilities SI002 Improper Role-modeling
SV002 Allowing Unwritten SP002 Inappropriate Team Composition SI003 Failed to Provide Proper Training
Policies to Become Standard SP003 Selected Individual with Lack of SI004 Failed to Provide Appropriate Policy/Guidance
SV003 Directed Individual to Current or Limited Experience
Violate Existing Regulations SI005 Personality Conflict with Supervisor
SP006 Performed Inadequate Risk
SV004 Authorized Unqualified Assessment -Formal SI006 Lack of Supervisory Responses to Critical
Individuals for Task Information
SP007 Authorized Unnecessary Hazard
SI007 Failed to Identify/Correct Risky or Unsafe
Practices
SI008 Selected Individual with Lack of Proficiency

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 Chapter 3: Military Aviation Safety Data

PRECONDITIONS

Teamwork
Environment
PP101 Failure of Crew/Team Leadership
PP103 Inadequate Task Delegation
Physical Environment Technological Environment PP104 Rank/Position Intimidation

PE101 Environmental Conditions PE201 Seat and Restraint System Problems PP105 Lack of Assertiveness
Affecting Vision PE202 Instrumentation & Warning System Issues PP106 Critical Information Not Communicated
PE103 Vibration Affects Vision or PE203 Visibility Restrictions (Not Weather PP107 Standard/Proper Terminology Not Used
Balance Related) PP108 Failed to Effectively Communicate
PE106 Heat/Cold Stress Impairs PE204 Controls and Switches are Inadequate PP109 Task/Mission Planning/Briefing Inadequate
Performance
PE205 Automated System Creates Unsafe
PE108 External Force or Object Situation
Impeded an Individual’s Movement
PE206 Workspace Incompatible with Operation
PE109 Lights of Other Vehicle/Vessel/
Aircraft Affected Vision PE207 Personal Equipment Interference

PE110 Noise Interference PE208 Communication Equipment Inadequate

Physical and Mental State

Physical Problem State of Mind Sensory Misperception Mental Awareness

PC302 Substance Effects (Alcohol, Supplements, PC202 Psychological PC501 Motion Illusion - PC101 Not Paying Attention
Medications, Drugs) Problem Kinesthetic PC102 Fixation
PC304 Loss of Consciousness (Sudden or Prolonged Onset) PC203 Life Stressors PC502 Turning Illusion/ PC103 Task Over/Under
PC305 Physical Illness/Injury PC204 Emotional State Balance - Vestibular Saturation
PC307 Fatigue PC205 Personality Style PC503 Visual Illusion PC104 Confusion
PC310 Trapped Gas Disorders PC206 Overconfidence PC504 Misperception of PC105 Negative Habit Transfer
Changing Environment
PC311 Evolved Gas Disorders PC207 Pressing PC106 Distraction
PC505 Misinterpreted/
PC312 Hypoxia/Hyperventilation PC208 Complacency Misread Instrument PC107 Geographically Lost
PC314 Inadequate Adaptation to Darkness PC209 Motivation PC507 Misinterpretation of PC108 Interference/Interruption
PC315 Dehydration PC215 Motivational Auditory/Sound Cues PC109 Technical or Procedural
PC317 Body Size/Movement Limitations Exhaustion (Burnout) PC508 Spatial Disorientation Knowledge Not Retained After
Training
PC318 Physical Strength & Coordination (Inappropriate PC511 Temporal/Time
for Task Demands) Distortion PC110 Inaccurate Expectation

PC319 Nutrition/Diet

ACTS

Performance-Based Errors Judgment & Decision-Making Errors Violations

AE101 Unintended Operation of Equipment AE201 Inadequate Real-Time Risk AV001 Performs Work-Around
AE102 Checklist Not Followed Correctly Assessment Violation

AE103 Procedure Not Followed Correctly AE202 Failure to Prioritize Tasks Adequately AV002 Commits Widespread/
AE205 Ignored a Caution/Warning Routine Violation
AE104 Over-Controlled/Under-Controlled Aircraft/Vehicle/System
AE206 Wrong Choice of Action During an AV003 Extreme Violation –
AE105 Breakdown in Visual Scan Lack of Discipline
Operation
AE107 Rushed or Delayed a Necessary Action

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National Commission on Military Aviation Safety

Aggregating and Analyzing at Higher Levels

LEARNING FROM A NEAR MISS Current DoD policy requires the Services to provide
information to DoD that could identify risk, recommend
The difference between a near miss and a Class mitigation strategies, and offer lessons learned
A mishap could be as little as inches or seconds. throughout the Department and outside agencies as
Administratively, the difference is a Safety appropriate. However, the lack of data standardization
Investigation Board (or Aircraft Mishap Board) for a across the Services creates interpretation challenges for
Class A and a hazard report for the near miss. “If you any comprehensive study of military aviation safety.
treat the near-miss as a task that you want to just get Several safety experts in DoD and the Services expressed
out of the way because it’s a hazard report, you are concern to the Commission that the differences in data
doing a disservice to the enterprise,” said CAPT John collection, reporting methodologies, and investigation
D. Boone, director of the Naval School of Aviation standards within the Services stymie attempts to achieve
Safety at Naval Air Station Pensacola, Florida. clear analysis from mishap report data. Even the structure
of the reports and the manner in which they are recorded
He is not suggesting treating every hazard report as a and presented hampered the work of the Commission, as
Class A or B investigation, but because the squadron it has other DoD-level organizations attempting to make
Aviation Safety Officer could use the hazard as a comparisons and improve aviation safety. Army mishap
standing Class A and B learning event, “Why not take reports, for example, require cross-referencing up to
one of those near misses and use that as a Class A or three different documents to get all available information
B exercise?” Doing a full mishap investigation on that on one single mishap. The Commission sees value in a
near miss would then serve the unit as lessons learned. standard form or cover sheet that includes standardized
data and HFACS checkboxes that can expedite ongoing
data collection and analysis across all the Services. While
as what they put into it,” echoed an official at one of the the investigations provide causal and contributory
other Service safety centers about Class C investigations. information on a mishap, they fall short in providing
A human factors expert at a Service safety center told DoD or the Services the standardized, comprehensive
the Commission that this is a DoD-wide issue, pointing analysis and information needed to build a mishap
out that about seven of ten Class A mishap investigation prevention program comparable to commercial aviation.
reports cite at least one HFACS code, but only three out The Commission finds that after years of attempts
of ten Class C mishap reports cite an HFACS code. to coordinate efforts, and despite the requirements in
The Commission found that the mishap reports do current policy, the Services have fallen short of what is
not fully or consistently utilize the HFACS framework needed. A new organizational approach is necessary in
that can reveal potentially larger or institutional causes gathering and analyzing data to effectively improve safety
contributing to mishaps. In addition to needing complete and reduce mishaps in military aviation.
data in the mishap reports, analysts need access to
supplemental personnel, training, acquisition, and certain Preemptive Aviation Safety Data Collection
operational data to develop predictive and actionable
safety plans. For example, personnel shortages leading to The Services’ investigations and mishap reports should
improperly trained personnel could contribute to a flying be a more effective tool in proactively preventing
or maintenance mishap. Safety center investigators do further mishaps. The Department and the Services have
not consistently access that information to assess causes some preventative safety programs in place. However,
or contributing factors. Initiatives are underway by each consistency and standardization in collecting mishap
of the safety centers to improve its utility of data, but that prevention program data are needed. DoDI 6055.19
will require broader Service data collection, access, and establishes the standards for effective data collection
analytical support to develop an effective predictive and programs. The Services need to follow that guidance
actionable aviation mishap prevention program. to execute an effective mishap mitigation program.
The Commission heard from the Services’ safety Data gathering and regular analysis are essential to
centers that if the HFACS limitations were corrected and an effective safety program. As the data grows, its
the system used as designed, the mishap reports would diagnostic, predictive, and prescriptive analytic power
provide a clearer connection to other important factors, grows as well.
including operations tempo, funding, supply chains, Current DoD instructions direct the Services
training, and personnel shortages. to develop and implement safety programs aimed at

20
 Chapter 3: Military Aviation Safety Data

THE ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING REVOLUTION

Artificial intelligence algorithms can analyze vast amounts The advanced analytics available through artificial
of data: the more quality data, the better the output. intelligence and machine learning could improve safety
The Services and DoD underutilize artificial intelligence by providing commanders visibility into safe and unsafe
and machine learning, which offer untapped potential to practices. Across an organization as large as the
improve safety. Department of Defense, these analytics could reduce
human error by better understanding pilot task saturation
Three types of analytics could be applied to aviation and limitations.
safety. Diagnostic analytics can explain past events and
make visible what was previously invisible. Predictive Though much of the data gathered through aircraft
analytics model future outcomes, such as determining recorders, pilot sensors, and simulator programs might
a pilot’s likelihood of success completing specific tasks. not be immediately applicable, its value for diagnostic,
Prescriptive analytics enhances decision making by, for predictive, and prescriptive analytics will grow as the
example, optimizing the pace of a pilot’s training. amount and quality of data grows.

analyzing safety-related issues before a mishap occurs. DoDI 6055.19 has not been and currently is
These safety management system programs, such as not enforced across the Department. The Services
military flight operations quality assurance (MFOQA), established safety programs but failed to implement the
aviation safety action program (ASAP), line operations tools directed by policy, which could have significantly
safety audit (LOSA), and simulator operations quality improved their programs. If all the Services fully
assurance (SOQA) are aimed at gathering information employed MFOQA, ASAP, LOSA, and SOQA equally,
from the machine and the human to improve safety. The DoD and the Services would have an invaluable
use of these prescriptive tools would help leaders develop collection of data that would support the development
solutions to mitigate risks before they become mishaps. of predictive analysis safety programs. That could lead
See Appendix G for more information on DoD’s efforts to the reduction or even the elimination of repeated
to initiate such programs. mishaps.

21
National Commission on Military Aviation Safety

A pilot from Company F, 2nd Battalion, 238th Aviation Regiment, 40th Combat Aviation
Brigade, finishes a mission aboard a UH-60 Black Hawk helicopter at Camp Buehring, Kuwait.
22 (U.S. Army photo by SSgt. Ian M. Kummer.)
 En
vi
an

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nm
Hu

en
t
Machine

Chapter 4:

THE JOINT SAFETY COUNCIL

T he Commission sees a seesaw pattern of effort and

focus with regard to military aviation safety. The
Services aggressively apply attention and resources when
Security. Both commissions recommended numerous
changes to improve aviation safety.
These commissions provided the framework to
there is a major incident, but once the spotlight fades, establish the Commercial Aviation Safety Team (CAST),
leadership focus and resources move elsewhere. While a government-industry partnership that developed an
over the long term mishap rates have declined, recent integrated, data-driven strategy to reduce commercial
progress has flattened and, in some cases, reversed. aviation risk in the United States. CAST’s goal was
Military aviation faces a complex series of to reduce the U.S. commercial aviation fatal accident
challenges in seeking further improvements. As the rate by 80 percent in 10 years. The results speak for
previous chapters have established, flight and mishap themselves: CAST exceeded its aggressive goal as the
data collection across the Services is insufficient for fatal accident rate fell 83 percent by 2007. Seeking
effective predictive analysis. Additionally, without opportunity for further improvement, CAST has
organizational change, the Services are limited in their raised its goal and is seeking to reduce the remaining
efforts to predict and avoid the next mishap. To help fatality risk an additional 50 percent by 2025. A closer
chart the path forward, the Commission looked at examination into CAST’s success highlights potential
how the commercial aviation community addressed a improvements for military aviation.
comparable situation.
CAST and ASIAS
FINDING CAST’s mission is to build a continuous improvement
framework by proactively identifying safety risks followed
Military aviation safety is inconsistently prioritized by developing mitigation strategies and monitoring
by the Department and the Services. The chorus of the effectiveness of implementation. CAST’s members
concerns heard on site visits coupled with the trends are commercial airline trade associations, aircraft
in mishap rates are evidence that a data-driven, manufacturers, airline and air traffic control employee
organization-wide approach to achieve proactive associations, and U.S. and Canadian government aviation
aviation safety is warranted. agencies, including the U.S. Department of Defense.
To accomplish its mission, CAST works closely with the
FAA’s Aviation Safety Information Analysis and Sharing
(ASIAS) program, a collaborative initiative based on data
analysis and information sharing designed to discover
The Safety Success of Commercial Aviation
safety concerns before an accident occurs.
Nearly 25 years ago, civil aviation safety was in a similar CAST uses a disciplined, data-driven approach
situation to what the Services face today. The accident to analyze safety information; identify hazards and
rate had significantly declined over time, but by the mid- underlying contributing factors; develop safety
1990s it had largely flattened, and the rapidly increasing enhancements to address risk; and continuously
civilian air traffic necessitated additional improvements monitor implementation and effectiveness of the
to avoid an increase in the number of accidents. Simply safety mitigations. CAST also charters joint working
put, the accident rate was good, but a “flat” accident rate groups that analyze a variety of systemic safety issues in
in a rapidly growing industry ultimately means more commercial aviation. Significantly, commercial aviation
accidents. Following a rash of commercial air disasters in is persistent in focusing on and resourcing safety.
1994, Congress established the National Civil Aviation The Commission met with FAA officials about CAST
Review Commission and the President established the and was impressed by the program’s collaborative success
White House Commission on Aviation Safety and and the functional utility of ASIAS. Despite significant

23
National Commission on Military Aviation Safety

CIVIL AVIATION COMMISSIONS

The Federal Aviation Reauthorization Act of 1996 established To avoid such heavy costs, the Commission recommended
the National Civil Aviation Review Commission, which, pursuant “broad and sweeping changes in the ways the FAA is
to its statutory charter, established task forces related to managed, sets its priorities, assesses and achieves
aviation funding and aviation safety. The task forces produced performance outcomes, and is financed.” To reduce
individual reports, which were then combined into the the accident rate, the Commission recommended “a
Commission’s final report in December 1997. comprehensive and concerted program by government and
industry that will require new ways of doing business with
Titled “A Consensus for Change,” the report highlighted each other and a greater emphasis on cooperation and
the looming aviation gridlock due to increased growth and collaboration.”
demand. “If this gridlock is allowed to happen, it will result
in a deterioration of aviation safety, harm the efficiency As one example, the Commission recommended the FAA
and growth of our domestic economy, and hurt our position and aviation industry “develop a strategic plan to improve
in the global marketplace.” The report also noted the safety, with specific priorities based on objective, quantitative
catastrophic impact of a flat accident rate. “If there is no analysis of safety information and data.” A recommendation
change in the accident rate, and the anticipated growth for improving aviation safety programs included looking
occurs, there will be a large airliner accident somewhere in “deeper than accidents and incidents to identify latent and
the world every 7–10 days by the year 2010.” emerging problems and fix them before a mishap occurs.”

differences between the commercial and military aviation capability. Military aviation requires a careful balance
communities, adopting many of the attributes of these between military mission and aviation safety.
commercial safety practices is possible in military aviation. In studying military aviation mishaps, the
Commission found that the overwhelming majority of
FINDING mishaps could not be attributed to the inherent risk of
military aviation. Avoiding mishaps caused by pilot error,
Facing a similar situation 25 years ago, the mechanical failures, or inadequate training does not
nation’s commercial aviation community created require lowering standards or abandoning the warrior
CAST (the Commercial Aviation Safety Team), a ethos. In fact, just the opposite is true.
collaborative, government-industry partnership that To achieve success comparable to civil aviation,
was successful in driving down commercial aviation the military aviation community needs to reexamine
fatal mishap rates. It employed comprehensive data how it approaches safety. Identifying risks and reducing
analysis and sharing to proactively identify and fatalities require accumulating and analyzing data
implement safety enhancements before an accident to facilitate accident mitigation and prevention.
occurs. Based on the tenets and success of that Additionally, DoD has no central clearinghouse to
program, the Commission has determined that the analyze this data. There needs to be a single organization
Department of Defense needs a similarly focused that empowers the Services’ safety officials, has attention
program tailored to the military’s unique missions from the highest echelons of Department leadership,
and organizational structure. closely coordinates aviation safety efforts, and monitors
their sustained implementation.
The potential savings in lives and materiel from
effective safety initiatives could be enormous. As outlined
Different Missions, Different Organizations in Chapter 2 and Appendix F, Class A mishaps cost
Military aviation, by its nature, will always involve the Department of Defense 450 lives and almost $17
more risk than commercial aviation. To reduce risk billion from fiscal years 2007 to 2018. These losses can
in combat, military aircrews accept greater risk in be reduced by adopting key lessons from commercial
training. Unlike commercial aviation, additional safety aviation. For example, if the military were nearly as
features on aircraft must be weighed against the cost successful in implementing a CAST model to reduce
to the combat mission. Since space on the aircraft is Class A mishaps, it would save over two dozen lives and
limited, additional safety systems may mean less combat more than a billion dollars each year. Achieving such

24
 Chapter 4: The Joint Safety Council

The White House Commission on Aviation Safety and Several of these recommendations addressed data collection
Security, established by Executive Order 13015 on August and training. For example, the Commission recommended
26, 1996, was tasked with developing “a strategy designed the FAA “work with the aviation community to develop and
to improve aviation safety and security, both domestically protect the integrity of standard safety databases that can be
and internationally.” Six months later, the White House shared in accident prevention programs.” In explaining this
Commission released its final report. recommendation, the Commission pointed out “[t]here are a
number of separate safety data collection efforts,” but
For aviation safety, the Commission determined “the principal “[m]any of these efforts either duplicate existing data,
focus should be on reducing the rate of accidents by a report the same information, or are not interconnected or
factor of five within a decade.” To achieve this ambitious integrated.” In another recommendation, the Commission
goal, the Commission proposed focusing “on several key highlighted the prevalence of flight crew errors and
areas: expanded use of partnerships; reengineering of the determined that additional “[r]esearch, technology, training,
FAA’s regulatory and certification processes; greater focus and sharing of safety data can reduce human error.”
on human factors and training; and the faster introduction Furthermore, the Commission recommended the FAA
of proven new technologies.” The Commission provided 14 “develop better quantitative models and analytic techniques
recommendations related to aviation safety. to inform management decision-making.”

success is certainly easier said than done. Any attempt Establishing a Joint Safety Council
to adopt safety practices from commercial aviation must
To help bridge the gap between commercial aviation
consider how it differs from military aviation.
practices and military aviation realities, the Commission
In June 2003, DoD chartered the Defense Safety
recommends that Congress establish a Joint Safety Council
Oversight Council (DSOC) to “provide governance on
(JSC) to provide DoD leadership the information needed
DoD-wide efforts to reduce mishaps, incidents, and
to strengthen DoD aviation safety initiatives and coordinate
occupational illnesses and injuries.” The DSOC, chaired
aviation safety activities across the Department and the
by the Under Secretary of Defense for Personnel and
Services. The JSC will develop aviation safety standards
Readiness, was directed to meet quarterly to discuss
and evaluate the Services’ implementation of aviation safety
safety and occupational health issues. Over the years, the
programs. A legislative proposal for establishing the Joint
DSOC lost its top-level support, resulting in diminished
Safety Council is provided in Appendix H.
stature and impact. The DSOC did not meet from fiscal
Recognizing that the successful implementation of
year 2010 to July 2018.
aviation safety programs requires cooperation from the
It is this Commission’s assessment that DoD needs
Services, the Commission recommends that the JSC be
a fully funded aviation safety organization with greater
composed primarily of Service representatives. This will
visibility within the Office of the Secretary of Defense.
ensure that the JSC’s directives, recommendations, and
programs properly account for each Service’s unique
FINDING
aircraft, culture, and mission. The Commission’s intent
The Department of Defense currently lacks a single
is for the JSC to augment and support, not supplant, the
authority focused solely on aviation safety. Without
Services’ existing safety programs.
empowered leadership focused on aviation safety at
a high level within the Department, aviation safety
FINDING
will never get the consistent emphasis and resourcing
The military departments’ safety centers are best
it needs to make saving lives and protecting
positioned to investigate their aviation mishaps and
investments in personnel and equipment a priority.
manage the Services’ safety programs. A formal
collaborative effort among the Services, working with
the Department of Defense, will result in better data
management and analysis and the infrastructure to
support improvement in aviation safety.

25
National Commission on Military Aviation Safety

This intent is further demonstrated by the JSC’s Council report to the Deputy Secretary of Defense and
proposed voting structure. The voting members of the that each of the Services’ directors of safety be an officer
Council would be each military Departments’ directors in the grade of O-8. The Council’s duties would include
of safety and an additional member from each military setting DoD standards for aviation safety, identifying
Service. A member of the Senior Executive Service (SES) and prioritizing aviation safety programs throughout the
would serve as a full-time JSC deputy, assisting the chair Department, and overseeing and inspecting the Services’
in managing the responsibilities of the JSC. One of the implementation of such programs.
directors of safety would serve as the chair and be dual While this Commission’s mandate is limited to
hatted as DoD’s Director of Aviation Safety. The deputy proposing recommendations for improvements to
would serve as vice chair of the council. aviation safety, Congress should consider expanding this
To ensure sufficient status, oversight, and Commission’s recommendation to all military operational
accountability, the Commission recommends that the safety.

26
 Chapter 4: The Joint Safety Council

RECOMMENDATIONS

The Department of Defense must establish aviation safety responsibilities within the Office of the Secretary
of Defense to ensure sufficient status, experienced and highly qualified personnel, and adequate funding to be
effective in preventing injury, death, and damage. The following recommendations will create a coordinated,
robust, proactive, data-driven aviation safety program that incorporates the best aviation safety practices from
all relevant sources to become effectively predictive and preventive instead of reactive.
The Commission recommends:

4.1 Congress mandate, authorize, and fund 4.3 The Joint Safety Council set the
the creation of a Joint Safety Council requirements for mishap investigations
that reports to the Deputy Secretary of in each of the Services to include the
Defense. The Joint Safety Council would same Human Factors Analysis and
support and coordinate the capability of Classification System (HFACS) codes
the Services’ safety centers to identify and for all Class A, B, and C mishaps. The
mitigate safety risks to reduce the number Secretary of Defense will mandate that
of aviation mishaps. The Joint Safety Class C mishap investigations use DoD
Council must be fully funded, staffed, and reporting standards and data collection
charged with developing and overseeing fields including HFACS codes.
Defense-wide safety policies for the
Secretary of Defense. It must have funding 4.4 That members of the Joint Safety Council
as a program element and unlimited access will be the military Departments’ chiefs
to the requisite databases. of safety, all of whom should be the grade
of O-8, and an additional representative
4.2 The Joint Safety Council oversee the from each of the military Services.
Services’ implementation of robust The chair, selected among the military
Safety Management Systems that include Departments’ chiefs of safety every two
programs such as MFOQA (military flight years, would serve in a dual-hatted role as
operations quality assurance), LOSA (line the Department of Defense’s Director of
operations safety assessment), HUMS Aviation Safety. The vice chair should be
(health and usage monitoring system), a career Senior Executive Service position
and CVFDR (cockpit voice and image appointed by the Secretary of Defense.
flight data recorders) from aircraft; SOQA The vice chair’s responsibilities should
(simulator operational quality assurance) be focused entirely on the mission and
from simulators; in-flight physiological activities of the Joint Safety Council. The
data from aviators; and ASAP (aviation vice chair will report to the chair.
safety action programs) from aviators and
maintainers. These programs should be
based on best practices from commercial
and military enterprises.

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An F-35B pilot connects an air
hose to her flight suit at Marine
Corps Air Station Beaufort.
(U.S. Marine Corps photo by
Sgt Ashley Phillips.)
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Chapter 5:

THE HUMAN/MACHINE
INTERFACE

A s aircraft become more technologically advanced,

the need for a better understanding of the Human-
Machine interface grows. For the past 10 years, the
interviewed engineers and managers developing the next
generation of Air Force aircraft.
Technological advancement incorporated in new and
Services have been aggressively pursuing unexplained in-development aircraft is critical to developing the most
physiological episodes (UPEs) in military aircraft. For effective warfighting capabilities possible. Still missing
the next generation of aviators, aircraft will reach new is a full understanding of the physiological limits of
levels of performance and pose increasing physiological human performance. The Commission found that even
challenges. Keeping the aviator safe while performing the newest aircraft in the inventory lack the sensors and
at the highest levels requires a fuller knowledge of the recorders required to achieve that understanding.
human in high-performance flight in order to build both
human and machine survival into the aircraft’s design. Physiological Episodes
Congress tasked the National Commission on
Military Aviation Safety to assess the underlying causes In 2011, the Air Force grounded the F-22 for five
contributing to unexplained physiological episodes in months because of the increasing number of unexplained
military aircraft, a major safety issue that surfaced with physiological episodes. What initially surfaced as a fifth-
F-22 pilots experiencing an unusual number of hypoxia- generation platform’s problem quickly proliferated as
like episodes around 2010. pilots began to report similar hypoxia-like symptoms in
other aircraft, new and old, and across multiple Services
The Commission pursued several avenues of
and communities: the F-15, F-16, F/A-18, and F-35
information. It examined the studies and mitigation
fighters; the T-6, T-45, and T-38 trainers; the low-altitude
efforts of the Department of Defense spanning the
A-10 attack jet; even C-130 transports. Different oxygen
past nine years in numerous aircraft communities. The
systems, different cockpits, different missions, different
Commission met with organizations researching the
ages of airframes, all had aircrews experiencing varying
physiological episodes: the Air Force’s 711th Human degrees of physiological episodes.
Performance Wing; the Navy Medical Research Unit From fiscal years 2013 through 2018, the Air Force
Dayton; the Air Force Life Cycle Management Center; experienced 718 physiological episodes. The Navy and
the Army Aeromedical Research Laboratory; the Marines experienced 699 physiological episodes. Figures
Navy Physiological Episodes Action Team (PEAT); 5-1 and 5-2 show which fighter and training aircraft
the Air Force PEAT; the Air Force, Army, and Navy experienced the most physiological episodes; Figures 5-3
safety centers; and members of the NASA Engineering and 5-4 display the top five aircraft per fiscal year.
and Safety Center. The Commission gained valuable
information and understanding from members of a
collaborative ad hoc working group called Characterizing No Single Problem, No Single Solution
and Optimizing the Physiologic Environment in Fighters Although initially unexplained, the overwhelming
(COPE-Fighter), comprised of medical practitioners, majority of physiological episodes have been explained
physiological experts, aviation researchers, engineers, with in-depth research. The physiological symptoms
and aviators. The Commission also discussed the issue arising from these episodes, in addition to hypoxia-
with military personnel on visits to operational units and like symptoms, include dehydration, temporal

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National Commission on Military Aviation Safety

distortion, mental exhaustion, spatial disorientation, better understand what is happening to the individual
and hyperventilation. The broad range of physiological inside the aircraft.
episodes made finding root causes extraordinarily
challenging for researchers. They are unpredictable and FINDING
inconsistent, even when the same aviator is flying the
same aircraft and executing the same maneuvers. They No single cause is responsible for physiological
also are not easily replicable by researchers trying to episodes.

Figure 5-1: Figure 5-3:

Air Force Physiological Episodes by Aircraft Air Force Physiological Episodes in Fighter and
Type for Fiscal Years 2013–2018 Trainer Aircraft for Fiscal Years 2013–2018
250 120 A-10
220 T-38
100 F-15
200 T-6
175 F-16
149 80
150

60
100
40
52 48
50 36 20
21 16
0 0
2013

2014

2015

2016

2017

2018
F-16

T-6

F-15

T-38

A-10

F-22

F-35

T-1

Figure 5-2: Figure 5-4:

Navy and Marine Corps Physiological Episodes Navy and Marine Corps Physiological
by Aircraft Type for Fiscal Years 2013–2018 Episodes in Fighter and Trainer Aircraft
200 for Fiscal Years 2013–2018
50 EA-18G
152 150 F/A-18F
150 T-45C
125 40 F/A-18C
F/A-18E
104
100 97
30

50 20
38

10 6 10
0
F/A-18E

F/A-18C

T-45C

F/A-18F

EA-18G

F/A-18D

F/A-18A

T-6B

0
2013

2014

2015

2016

2017

2018

Source: National Commission on Military Aviation Safety Source: National Commission on Military Aviation Safety

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The Services have made significant progress in As researchers identify potential solutions, their
addressing the problem, with almost 94 percent of reported findings and recommendations move to aircraft program
physiological episodes now explained. The Services used offices where they must compete with other priorities for
directed funding from Congress and reallocated resources limited resources. Despite the unexplained physiological
to mount collaborative research initiatives and address issues impacting the jet aircraft community, and the
specific issues, community by community. The Navy and efforts the Navy and Air Force have undertaken to find
Air Force Physiological Episodes Action Teams responded and mitigate root causes, no program of record has been
to physiological episodes as they occurred, finding causes established to coordinate efforts directly focused on
and developing solutions for many of the previously eliminating the problem.
unexplained physiological episodes. The PEATs visited
installations to provide training for aviators, maintainers, Factoring In Humans
and their families. The Commission found that military aviators at all levels
The Commission considers the co-location of the Air of flying experience remain concerned about physiological
Force Research Lab, the 711th Human Performance Wing, episodes. Some aviators expressed reluctance to report
and the Navy Medical Research Unit Dayton at Wright- physiological episodes, concerned that the resulting
Patterson Air Force Base, Ohio, a best practice. The ability medical attention would lead to grounding or greater
to share resources, researchers, and results have greatly scrutiny. There is a widespread perception that episodes are
advanced physiological studies for the benefit of all the the pilot’s fault, not a failing or inadequacy of the machine
Services. or training. Given that some pilots also are unaware
they have had a physiological episode, the Commission
FINDING is confident, and operational aviators corroborate, that
an undeterminable number of episodes go unreported.
Several organizations and ad hoc groups have Unreported physiological episodes will continue without
aggressively pursued this issue. The Commission some means of monitoring the aviator in flight.
finds that more seamless collaboration and Experts in every organization expressed a common
integration among stakeholders could spur further refrain: “More study is needed on the human.” Much of
and faster advancement in the discovery of the an aviator’s mission performance in flight is measured and
remaining unexplained root causes for physiological assessed; however, the physiological response of the aviator
episodes. is not. Measuring difficulty with breathing is complicated
by factors such as altitude, tactical maneuvers, G-suit
constrictions, and the aviator’s physiology and physical
In 2017, the T-6 began experiencing issues with condition at the time of flight. The research laboratories
its Onboard Oxygen Generating System (OBOGS). can neither replicate all conditions of flight nor capture the
Studies by the Navy and other government and academic full range of physical conditions aviators encounter over a
institutions revealed problems in the OBOGS hose succession of flights.
component. In 2019, to resolve the issue, the Navy Lacking physiological recording devices,
altered cleaning procedures for the system. The Air researchers are unable to persistently gather objective
Force later adopted the procedures. Aircrews also data from aviators in flight sufficient to enhance their
received additional briefings to recognize and respond to understanding of physiological episodes. Researchers
physiological episodes and mitigate their effects. are exploring biometric monitoring systems that can be
integrated into flight suits, helmets, and masks in order
FINDING to collect the necessary data without interfering with
the aviator’s operation of the aircraft. In the interim,
After the causes of physiological episodes have been the Services are using commercially available data
determined, the Services have taken aggressive collection tools, such as “slam sticks” that measure cabin
action to alleviate the problem through equipment pressure, and smart watches that measure blood pressure
fixes or mitigating practices by aircrew and and heart rate. A more promising step in studying the
maintenance. Long-term fixes sometimes encounter human in flight is a joint U.S. Navy/NASA initiative
funding challenges. placing sensors inside the mask that measure pressure,
temperature, and CO2 concentration.

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FINDING FINDING

The most effective means to understand and The most effective investment in preventing
prevent future unexplained physiological episodes physiological episodes occurs in the design,
is to gather and evaluate data on what is happening development, and test phases. Instrumentation that
real time to aircrew during actual flight, from initial monitors the pilot in flight as part of the weapons system
aircraft development throughout the operational provides early problem detection and at the lowest cost
life cycle—akin to a “black box” for the pilot. Greater to resolve human-machine interface problems.
understanding of the warfighter’s capabilities—
including the task of breathing—during actual flight is
as important as measuring the machine’s capabilities.
Such data also offers other benefits, such as
Prioritizing the Human
establishing substantive physiological standards or The Commission identified challenges in using
accommodations for aircraft assignments. standards set for an outdated notion of a military pilot,
first established in the 1940 Pensacola Study of Naval
Aviators when virtually all military pilots were male.
Until recently, minimum size design specifications for Air
The Commission heard many comments from Force acquisitions were based on a 1967 male-only pilot
experts about the lack of in-flight biometric monitoring survey. Today’s diverse community of military aviators
of the pilot. The aircraft is fully wired to document its is not the same homogeneous group as in the past. The
performance through a wide range of maneuvers and Services need to match 21st century aviators to their
conditions; yet the operator is not monitored. Such data 21st century machines. Systems need to work for a wider
collection is integral to understanding the pilot’s experience. anthropometric and demographic range of individuals—
With that information, the pilot can be properly equipped male and female, short and tall, those who breathe faster
and prepared to carry out missions, allowing the Services to or slower. Such factors should be built into the standard
protect their multibillion-dollar investments in both pilot rather than treated as deviance from the norm. Designing
and machine. systems for the full range of today’s aviators will improve

FEMALE FIT OF EQUIPMENT

Women military aviators must often use equipment official said. “We are doing exoskeletons for loadmasters
designed for men. Uniforms, body armor, and facilities that to help them carry heavy loads. We are looking for vests
were neither designed nor intended for women impact for women in particular. They are currently unisex and that
their safety, readiness, and proficiency. really means male. We are looking to find a better fit for
them that works with the body armor they need.”
Female fighter pilots have issues with G-suits, the over-
garment designed to help pilots maintain consciousness One female Air Force squadron commander told the
in high performance aircraft. The Air Force Life Cycle Commission that logistics cannot effectively manage female-
Management Center told the Commission that only limited tailored equipment. “They don’t have women’s [size] boots. I
sizes were available. “If a G-suit is impinging on your lungs, wore 60 pounds of gear, running in shoes that don’t fit me.”
it will impact your breathing,” said an official there. A pilot During the Commission’s visit to NAVAIR, a representative
told the Commission of a female pilot who was being described two primary problems: “There’s either a lack of
medically retired because of nerve damage resulting from knowledge of customizable solutions, or women do not take
wearing an issued G-suit that was not designed for her body. the other solutions because they want to fit in.”
The Commission also heard about women having problems
with bladder relief systems, survival vests, harnesses, and Lagging efforts to remedy these issues are unacceptable.
ejection seats. As a female Air Force pilot said, “When we talk aviation
safety, it isn’t just mishaps. It is also about making sure
The Services are addressing fit for all sexes, heights, and our equipment doesn’t hurt us and works for us.” The
body types, the Air Force Life Cycle Management Center Commission agrees.

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human performance and prevent the expenditure of

hundreds of millions of dollars to retrofit aircraft systems FORCE PROTECTION KPP STANDARDS
after production. OF PROTECTION
Acquisition Standards and Processes
The Force Protection KPP includes protection from
The Commission closely reviewed new aircraft in environmental effects, which covers standards for
development to see if the lessons learned from the acceptable pressure/oxygen levels for personnel,
Services’ analysis of physiological episodes in today’s including pressurization and/or supplemental oxygen;
aircraft are being applied to tomorrow’s aircraft. The acceptable temperature limits for personnel (with or
Commission found that in the early stages of aircraft without PPE); standards for acceptable vibration/acoustic
development, programs remain overly focused on limits for personnel (with or without PPE); and acceptable
aircraft capabilities without the proper consideration of G-force loading limits for personnel (with or without
the human. There must be a balance. The Commission PPE) under normal operations. Protection from crash
sees two areas where this imbalance could be addressed: events attributes include standards for crash survivable
by adding aircrew safety into the force protection key G-force loading limits for personnel (with or without PPE);
performance parameter; and by incorporating human protection from impact trauma, including seats and
systems integration, safety technologies, and data- retaining systems; preservation of occupied space; and
collecting systems earlier in the design process. protection from post-crash fuel spills and fires.

Key Performance Parameters

Key Performance Parameters (KPPs) are the evaluation
criteria that systems must meet or exceed to be credited as
meeting operational goals. Currently, DoD’s acquisition saved the lives of 11 Air Force pilots. Similarly, cockpit
process has four mandatory KPPs: system survivability, voice and flight data recorders and military flight
force protection, energy, and sustainment. KPPs are operations quality assurance (MFOQA) systems discussed
specified in the Capabilities Development Document in Chapter 3 have proven to produce critical information
that directs requirements for system-level performance needed to improve safety performance through incident/
attributes. After gathering information from the Joint mishap reconstruction, training, procedural changes, and
Staff J8 Force Protection Division, the Commission predictive maintenance.
determined that the force protection KPP is the best
place to incorporate additional requirements to give FINDING
greater priority to human safety.
From the earliest stages of acquisition, the machine’s
Updating the KPP would enhance the performance
operational capabilities dominate the development of
of the aircrew in the aircraft and provide better protection
aircraft while aircrew safety gets too little attention.
against injury or death for the occupants. Mishap
Current acquisition practice does not give enough
prevention measures could include systems for ground
consideration to the cost avoidance and savings that
and aircraft collision avoidance and spatial disorientation
mishap avoidance systems and aircraft and simulator
recovery. With the vital need for data collection to
data collection and analysis processes can provide
enhance predictive initiatives, the force protection
when prioritizing capabilities.
KPP should also include cockpit voice and flight data
recording systems as well as biometric sensing for the
aircrew.
The technology for such systems already exists. To
fully evaluate costs and benefits, acquisition officials Human and Safety Systems Integration
should factor in the potential for achieving long-term
lifecycle savings. For example, the Air Force has fielded Two engineering disciplines, system safety engineering
in its F-16 Block 40/50 aircraft the Automatic Ground and human factors engineering, should play an essential
Collision Avoidance System (Auto-GCAS), which role in balancing the human and machine from the
prevents controlled flight into terrain (CFIT). Air Force beginning of the requirements and acquisition process.
statistics show that CFIT was responsible for 75 percent According to Military Standard 882E, human systems
of all F-16 pilot fatalities. Since being fielded in 2014, integration (HSI) is “the integrated and comprehensive
Auto-GCAS has prevented the crash of 10 aircraft and analysis, design, assessment of requirements, concepts,

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and resources for system manpower, personnel,

SYSTEMS ENGINEERING DISCIPLINES training, safety and occupational health, habitability,
personnel survivability, and human factors engineering.”
Department of Defense Directive 5000.01, The Defense
System Safety Engineering is a discipline that Acquisition System, September 9, 2020, states that
employs specialized knowledge and skills in applying “Human systems integration planning will begin in the
scientific and engineering principles, criteria, and early stages of the program life cycle. The goal will be to
techniques to identify hazards and then to eliminate optimize total system performance and total ownership
those hazards or reduce the associated risks when the costs, while ensuring that the system is designed,
hazards cannot be eliminated. operated, and maintained consistent with mission
requirements.” The timeline in Figure 5-5 shows where
Human Factors Engineering is a multidisciplinary human systems integration subject matter experts and
effort to generate and compile information about strategies can be employed for significant positive impact
human capabilities and limitations. This information on system development.
is applied to equipment, systems, software, facilities, The Commission reviewed recent and current
procedures, jobs, environments, training, staffing, and aviation acquisition programs and found that the
personnel management to produce safe, comfortable, recommendations in the Air Force Human System
and effective human performance. It focuses on how Integration Guidebook were often overlooked during the
people interact with tasks, machines or computers, requirements process.
and the environment. The latest jet fighter to enter the Services’ inventory,
[Source: AcqNotes.com.] the F-35 Joint Strike Fighter, first flew in 2006, before
unexplained physiological episodes began surfacing with

Figure 5-5:
Human Systems Integration in the Acquisition Planning Process

Materiel Design
Development Readiness
Decision A B Review C

CAPABILITIES MATERIEL TECHNOLOGY ENGINEERING AND

BASED SOLUTION DEVELOPMENT MANUFACTURING
ASSESSMENT ANALYSIS DEVELOPMENT

ICD CDD CPD

HSI Subject AoA AoA
Matter Expertise Plan
• DOTMLPF
Analysis
HSI
• Analysis of HSI Subject Matter Expertise
Considerations
Materiel and
non-Materiel
Approaches
DOTMLPF = Doctrine, Organization, Training, Materiel, ICD = Initial Capabilities Document
Leadership and Education, Personnel and Facilities CDD = Capability Development Document
AoA = Analysis of Alternatives CPD = Capability Production Document

Source: Department of Defense Directive 5000.01, The Defense Acquisition System, September 9, 2020

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the F-22. The Services began taking possession of F-35 The Commission believes every multimillion-dollar
variants in 2015. To date, a total of 49 physiological investment in weapons systems and aviator training must
episodes have been reported across the three variants. be accompanied by proactive efforts to ensure that the
Better human systems integration could have mitigated pilot is physiologically capable of safely operating the
or even prevented these physiological episodes. aircraft through all of its designed flight regimens.

RECOMMENDATIONS

With modern aviation machines placing unprecedented stress on human physiology, the Department of
Defense and the Services must adopt an aggressive, proactive approach to understanding the physiological needs
of aviators and to developing additional capabilities that improve the human-machine interface, including
aircraft and cockpit design, testing, and subsequent modifications.
The Commission recommends:

5.1 The Joint Safety Council (Commission training to ensure that the pilot/operator
recommendation on page 27) lead a is able to successfully perform at optimal
robust review into the effects on humans levels across the spectrum of the weapons
in aviation operational environments, system’s capabilities.
including physiological episodes. The JSC
shall have a program element to conduct 5.4 The Department of Defense, with input
further research into determining and from each of the safety centers, update
mitigating unexplained physiological and modify the Force Protection key
episodes. performance parameters (KPP) to better
incorporate Aviation Human Systems
5.2 Program offices address human physiology Safety.
concerns and analyze physiological effects
throughout the aircraft testing phases for 5.5 That the Force Protection Functional
T-7, B-21, Future Vertical Lift, and other Capability Board include representative
next-generation platforms early in the capabilities such as ground and other
initial aircraft and cockpit design and with aircraft collision avoidance; cockpit voice
any materiel modification of the aircraft. and flight data recording; biometric
sensing for aircrew; and a spatial
5.3 The Department of Defense and the disorientation recovery system used for
Services develop physiological standards instrument meteorological conditions
for each airframe to use in screening and and brownout.

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An Air Force aircraft maintenance

craftsman with the 435th
Contingency Response Squadron
conducts “hot pit” refueling for
an F-16 Fighting Falcon assigned
to the 510th Fighter Squadron,
Aviano Air Base, Italy, during an
exercise at Graf Ignatievo Air Base,
Bulgaria. (U.S. Air Force photo by
SrA Savannah L. Waters.)
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SUSTAINING THE MACHINE

A cross the spectrum of site visits, interviews, and

town halls, the Commission observed and heard
problems relating to aircraft parts, depot work, facilities,
powers that be don’t understand the positioning of parts
strategically around the globe,” that commander told
the Commission. “I need it fixed today.” He called this
and fleet transitions. lack of supply chain visibility a “systemic subversion of
Among these several issues, obtaining parts—on time established business rules.” By contrast, in the modern
and functional—was a constant complaint. Notably, at commercial and retail markets, customers around the
one Navy installation, when noncommissioned officers world are able to order, track, and quickly receive aviation
(NCOs) were asked about parts, the Sailors replied with parts through a variety of suppliers.
laughter. Simply put, the current supply systems are not Second, the Commission heard many complaints
meeting the needs of unit-level maintainers and are a that spare parts in their existing stock often do not work.
significant cause of non-operational aircraft. In one instance, a maintenance squadron pulled the
During its study, the Commission saw and heard of same component from the supply shelf three times before
worrisome shortcuts taken by maintenance crews trying getting one that was serviceable. The Commission also
to meet their mission. In seeking to deliver mission heard numerous complaints that components repaired by
capable aircraft, maintainers stated they often resort to contractors failed to perform when needed.
cannibalizing parts from other aircraft, using shortcuts, and Finally, in some cases, and especially with legacy
fielding aircraft with numerous deferred repairs. Although aircraft, the necessary parts simply do not exist. As
cannibalization is not a new practice, maintainers from all aircraft are extended beyond their planned service life,
Services told the Commission this has been an increasing parts that were designed to last the originally planned
practice over the past several years. While no maintainer life of the aircraft begin to fail. In many cases, the
told the Commission that they were knowingly putting industrial base to produce these parts is insufficient or
unsafe aircraft in the air, they acknowledged the danger of non-existent, especially when planned retirement dates
compounding risks on top of each other. are extended, and second- and third-tier vendors have
moved on to other products. For example, when the Air
Force set the retirement date of the A-10 Thunderbolt,
Aviation Supply System
small and mid-size companies producing parts for that
The DoD aviation supply system is large, complex, and aircraft began retooling for other projects. When the
confusing. The Commission heard from hundreds of retirement was postponed, the supply system was no
Servicemembers about the daily problems they face in longer in place. A Marine Corps CH-53E commander
getting parts to keep aircraft flyable. The complaints told the Commission that the supply system was
about spare parts came in three forms: (1) parts cannot be not designed to support an aircraft so far beyond its
obtained in a timely manner; (2) parts do not work; and published planned retirement date.
(3) parts do not exist.
First, for a military that operates around the globe
and must maintain combat readiness, parts need to AIRCRAFT AVAILABILITY
be available in a timely manner. For example, as the
Commission heard during a visit at one Air Force base, Aircraft availability is the percentage of a fleet in
when an actuator failed on a deployed aircraft in the mission-capable condition and not in a depot-
Pacific, the only replacement parts were in two locations possessed or unit-possessed nonreportable (UPNR)
on the other side of the world. The maintenance group status. UPNR status includes aircraft in the unit
commander was forced to have an actuator taken off of awaiting completion of planned or unplanned
a working plane at his home base in the United States maintenance or that require engineering dispositions.
and flown to the aircraft so it could be fixed. “The

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In sum, the lack of a functioning supply system a decreasing number of aircraft scheduled for repair.
that delivers working parts in a timely manner has a According to the GAO, “depot maintenance delays,
significant negative impact on aircraft availability and among other challenges, limit the Navy, Air Force, and
readiness. The Commission visited commercial aviation Marine Corps’ ability to keep aviation units ready by
entities with supply systems that use inventory tracking reducing the number of aircraft that are available to
and robust delivery systems to get parts delivered squadrons for conducting full spectrum training.”
anywhere in the world the next day. For commercial The GAO report’s conclusion matched what the
enterprises, responsive customer service is essential to Commission heard on its visits. For example, in one
the business’s bottom line. For the military Services, the roundtable, maintenance group personnel described
lack of parts creates aircraft availability issues that hinder fixing up aircraft delivered from other wings, saying it
pilots from getting their required flight hours. takes about two months to get those planes up to their
standards. “Is there a base where you hate to get an
airplane from?” the Commission asked. “The depot,”
Overcoming Supply Deficiencies
someone replied, followed by general consensus.
When parts are not available, maintainers routinely Most troubling, Navy and Air Force units described
resort to aircraft cannibalization, stripping parts from finding foreign objects in aircraft—tools in engines,
one aircraft to make other aircraft operational. “We are gloves in fuel tanks, old wiring still in place. “We get
cannibalizing multiple times a day,” a Marine senior interesting stuff coming out of depots,” said a maintainer
NCO told the Commission. Further emphasizing the with a Navy helicopter wing. “We had a stuck control,
prevalence of cannibalization, or “canning,” across all took apart the floor, and found bolts in there.” One
military fleets, the Commission saw a sign prominently Air Force major command representative told the
displayed in one unit that said, “Supply can’t…so we Commission that “jets are coming out of the depot in
CAN [cannibalize].” worse shape than when they started.”
Cannibalization impacts aircraft availability and
maintenance efficiency. Instead of simply replacing the FINDING
part, maintenance crews must remove the part from one
aircraft and install it on another aircraft. This increased The aircraft sustainment system, from the supply of
workload further exacerbates readiness problems. Each parts to depot maintenance, is not providing aviation
step also incurs some risk that the aircraft or part will be units with the quality products and timely services they
damaged. need to sustain operations. Accordingly, aviation units
Additionally, when replacements for expired parts are often resorting to cannibalization of other aircraft.
are not available from any source, maintainers must turn
to engineers to determine whether the part’s life can
be extended. As a senior Air Force maintainer told the
Commission, when parts would not be available for over
Facilities
a year, “we’re going to the engineers to get a work-around.
That’s why we’ve been able to fly aircraft well past their At Naval Air Station Oceana, Virginia, the Commission
service life.” When engineers make the decision to extend entered a hangar by passing under steel letters that were
the service life, aircrew are forced to accept the additional falling off the wall above the hanger’s doors. Broken
risk. As one maintainer noted, “We could negate those doors forced Sailors to use aircraft tugs to pull the
risks by having a more robust supply system, and then massive doors open and closed, one time accidently
the engineers don’t need to do the workarounds.” hitting an F/A-18 and causing substantial damage.
Commissioners stepped around buckled drain gratings
marked in yellow as a warning to keep aircraft away. The
Depot Maintenance
fire suppresion system was inoperable, and only two of
A 2019 Government Accountability Office report found eight bays had working power for aircraft maintenance.
ongoing problems at military depots and rated five of The Commission found similarly unsatisfactory
seven aviation depot facilities as poor performers. From conditions at numerous installations across the Services.
fiscal years 2008–2018, the Navy’s on-time performance As a Navy senior executive told the Commission, “I’ve
rating fell by nearly a third, even as the number of aircraft toured two naval aviation depot maintenance facilities;
scheduled for repair declined. The Air Force similarly both are maintaining fifth-generation fighters with advance
experienced decreased on-time performance despite avionics in pre-first generation—I’m talking World War

38
 Chapter 6: Sustaining the Machine

II—aviation maintenance facilities.” The GAO specifically already divesting its KC-10s even though the first KC-46
noted that more than one-third of the Navy’s aviation is not scheduled to arrive at the base until the first quarter
depot square footage was built in the 1940s. The GAO of fiscal year 2022. One commander said, “We may lose
added that outdated facilities have “electrical systems KC-10s before we get KC-46s.” The Commission also
built for different weapon systems, historical preservation received feedback that the Air Force is having trouble
requirements, and suboptimal layouts. It can be difficult with failing parts and filling KC-10 flight engineer
for a depot to maintain complex, modern weapon systems, positions. Overall, as reported to the Commission, the
such as the F/A-18, with facilities that were designed for attempt to prepare for the new tanker’s arrival while
less complex systems.” stretching the life of its predecessors is straining resources.
Poor facilities and a lack of equipment delay CH-53K and CH-53E: In response to continued
maintenance. When only two of eight hanger bays delays with the CH-53K and the need for continued
can be used to power an aircraft during maintenance, mission capacity, the Marine Corps began the RESET
maintainers must spend hours moving aircraft from one program to reinvigorate the CH-53E legacy aircraft.
bay to the next. A Marine aircraft wing commander Personnel at the unit level, who are both sustaining
estimated his maintainers put in 1,000 miles of towing aircraft and receiving those returning from RESET,
per year, “and we tell them not to have a tow accident.” expressed concerns to the Commission. For example, a
squadron leader at Marine Corps Air Station New River
said that, even after RESET, a lot of his aircraft “don’t
Aircraft Transition Issues
work. We fly an aircraft that would get antique plates
Once a Service announces it is replacing a legacy aircraft from any DMV.” Said a Marine at Marine Corps Base
with a new platform, the old aircraft’s support system Kaneohe Bay, “We have issues with the damper and the
shuts down. As the transition begins, personnel are rotor blades. There’s also some stuff with the hydraulics.
reassigned to the new platform, legacy facilities are The Echo is going to be around until 2030. Is the Kilo
neglected, and parts availability dwindles. Then, delays going to fix all of it?”
in aquiring the new platform extend the life of the old
platform for years. By their nature, aircraft transitions are FINDING
fraught with unpredictability, a process the Commission
sees repeated over and over again.   Deteriorating maintenance facilities and significant
F-35 Lightning II and Legacy Aircraft: According issues with transitioning from legacy platforms to
to feedback from line units, the F-35 program is perhaps new aircraft are contributing to delays in aviation
the best example of DoD’s pursuit of new technology maintenance and limiting operational availability of
via an erroneous acquisition and planning construct. aircraft.
As an F-35 maintenance squadron commander told the
Commission, “The bean counters got it wrong. They
said the F-35 is going to be easier to maintain, they
will need less maintenance. These aircraft take a lot
more man hours than previously thought, but they’ve
already appropriated smaller staffing.” The Services are RECOMMENDATION
devoting critical resources to the F-35 program while
simultaneously being forced to extend the service lives of The Department of Defense and Services
legacy aircraft. This creates a case of haves and have-nots must improve their planning, contracting,
as limited resources are used to support multiple aircraft and program management processes to
simultaneously. The Commission received numerous ensure timely availability of spare parts,
complaints regarding the F-35’s impact on the AV-8B, improve maintenance efficiency, increase
A-10, and F-16. For example, one commander said his mission capable rates, and better sustain the
F-35 squadrons have 85 Marines just in avionics, while investment made in aircraft. The Services
his Harrier squadrons have 85 Marines total. should improve sustainment management
KC-46 Pegasus and Legacy Aircraft: The systems, particularly for legacy aircraft
Commission received similar feedback regarding the and service life extensions, to provide the
delayed transition to the KC-46 tanker. For example, necessary visibility on expiring parts and
one unit reported drawing down its KC-135 operations production upgrades.
before the first KC-46s were delivered. Another unit is

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A pilot assigned to Helicopter Sea Combat
Squadron 26 performs preflight checks on an
MH-60S Seahawk helicopter aboard the Wasp-
class amphibious assault ship USS Kearsarge.
(U.S. Navy photo by Mass Communication
Specialist 2nd Class Michael R. Sanchez.)

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Chapter 7:

THE NEED FOR CONSISTENT

AND PREDICTABLE FUNDING
O n nearly every site visit, the Commission heard
about funding problems: not necessarily that there
was not enough funding, but that it was erratic and came
Congress tasked the Commission specifically “to
make an assessment of causes contributing to delays in
aviation maintenance and limiting aircraft availability; to
in waves. “I can always use more money,” said a senior Air make an assessment of the causes contributing to military
Force leader, “but the thing I really need is predictability: aviation mishaps; and to make recommendations on the
budget for five years, [and] get it on October 1.” modifications, if any, of safety, training, maintenance,
In May 2019, as a direct result of funding being personnel, or other policies related to military aviation
suddenly withdrawn for other priorites, a Marine Aircraft safety.” In the Commission’s assessment, unpredictable
Wing Commander issued an order for aviation units to funding compromises maintenance operations, degrades
minimize ordering new parts through the end of the fiscal the quality of training, and is a significant cause of
year. Therefore, rather than order new $5 filters, Marine unavailable aircraft. In the aggregate, inconsistent
maintainers cleaned old ones by flushing them backwards funding increases safety risks.
before reinstalling them on the aircraft. “Nobody wants
to not make the mission,” a Marine Corps junior aviation FINDING
officer told the Commission.
As Secretary of Defense James Mattis said two years Consistent, reliable, and timely funding is key to
ago, “Let me be clear: As hard as the last 16 years of war sustaining military and aviation readiness and safety.
have been on our military, no enemy in the field has done
as much to harm the readiness of the U.S. military than
the combined impact of the Budget Control Act’s defense
spending caps, worsened by operating for 10 of the last
Continuing Resolutions
11 years under continuing resolutions of varied and
unpredictable duration.” The primary source of unpredictable funding is
The Commission’s primary concern is not the Congress’s perennial use of continuing resolutions (CRs).
amount of money currently allocated to military aviation, The budget has been increasingly subjected to CRs,
but the predictability and reliability of funding. The particularly in the years since the 2011 Budget Control
problems with erratic funding ripple through all levels Act. In fact, the Department of Defense has started 13 of
of military aviation. Units cannot adequately plan for the past 18 fiscal years under a CR (see Figure 7-1). As
exercises and training. Pilots have reduced flight hours at CRs have become more common, their average duration
various points throughout the year, interfering with their has also increased. In fact, from 2002 through 2009, CRs
ability to maintain currency and proficiency. Maintainers lasted an average of 33.6 days; from 2010 through 2018,
cannot buy parts, resulting in cannibalization or CRs averaged 103 days; and the four longest CRs (2011,
inappropriate maintenance. When funding is restored, it 2013, 2017, and 2018) averaged 190.5 days, creating
is most often too late to be spent optimally. uncertainty for longer than six months in each of those
The inconsistency and unpredictability of funding years.
increases costs and decreases readiness. This forces the The issue of unpredictable funding repeatedly
Services to defer new contracts for maintenance and parts. came up during site visits. “We don’t plan exercises and
In one of several examples, the Commission learned of [mission-related travel] because you don’t know if you
brand-new aircraft, freshly delivered from the assembly will have funding,” an Air Force squadron commander
line, being cannibalized for parts in order to make told the Commission. “I can’t plan my budget and
several other aircraft operational. “This is no way to run make the purchases [needed] and can’t get them the
a railroad,” a Marine Aircraft Wing commander told the [equipment] they need to do safe flight operations.”
Commission. A Navy mid-grade officer told the Commission that

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Figure 7-1:
Days Under a Continuing Resolution: Department of Defense, Fiscal Years 2002–2019

NUMBER OF DAYS

4th Quarter

3rd Quarter

2nd Quarter

1st Quarter
FY2002

FY2003

FY2004

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010

FY2011

FY2012

FY2013

FY2014

FY2015

FY2016

FY2017

FY2018

FY2019
funding predictability “is a big issue for everyone. We Vulnerability of Military Aviation
don’t know how to plan against the unpredictability.” The Commission understands that problems related
For example, a contractor who supports the Navy by to inconsistent funding are not unique to DoD.
providing “adversaries” for air combat maneuver training However, military aviation and operational safety suffer
said his company is told to stand down at the beginning disproportionate impacts from inconsistent funding in
of almost every fiscal year. Then, months later, the three ways.
company is told to ramp back up, a practice consistent First, military flying is an extremely perishable skill.
with workarounds caused by continuing resolutions. The multitude of complex tasks require frequent training.
This issue is not limited to active duty units or Pilots who do not consistently practice demanding
personnel. One Air Force Reserve unit commander missions such as low-level flight, flying with night vision
told the Commission, “I redo the annual budget twice goggles, air-to-air refueling, or certain combat profiles
a quarter.” Reserve component aviation professionals will lose their currency in these skills quickly. Regaining
described the yo-yo effects of preparing months for a currency requires several flights with an instructor pilot,
deployment that suddenly drops off the schedule at the costing more than it would have cost to maintain the skill
last minute due to cancelled funding. “Reservists need in the first place.
predictability for their family and civilian job,” said an Second, aviation maintenance has minimal surge
Air Force Reserve aviator. capacity. When funding is delayed, aircraft remain
grounded waiting for spare parts. When funding is
FINDING restored and the pilots are flying more to regain currency
and proficiency, the maintenance system struggles to
Continuing resolutions are disruptive, compromise catch up on deferred maintenance while keeping pace
safety, and place lives at risk. with the higher level of flying. Delayed funding, no
matter how much, cannot make up for lost time.

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Finally, the high cost of military aviation makes it aviation professionals who brought it up frequently in
an attractive “bill payer” during unexpected funding town halls and roundtables. Analysis of prior CRs is
shortfalls. While the DoD budget is large, many costs complicated by the lack of readily available data. This
are fixed. A continuing resolution keeps funding flat, and issue must be analyzed in a targeted and focused manner.
when fixed costs such as salaries or health care increase, Therefore, while the Commission believes that Congress
that money often comes out of the military aviation first must resource the Department and military aviation
budget. in a consistent and predictable manner, the Commission
also sees the need for a comprehensive, data-driven report
FINDING of any future CR’s impact on military aviation.

Continuing resolutions create a domino effect that FINDING

harms maintenance, the ability to purchase parts,
aircraft availability, and pilot proficiency. Previous research has not been able to produce
a comprehensive assessment of the impacts of
continuing resolutions on military aviation safety,
readiness, and cost effectiveness. Additional data
Assessing Costs gathering and empirical study is necessary.
Continuing resolutions often leave military aviation
with the worst of both worlds. CRs increase costs while
simultaneously reducing the readiness of pilots and
aircraft. On site visits, the Commission found inoperable
aircraft and noncurrent aircrews—exactly what one
would expect after a history of inconsistent funding. RECOMMENDATION
The Commission looked to empirical research to
better understand the issue. As the Congressional Research
Service (CRS) explained in a 2019 brief on Defense Congress and the administration must
spending under an interim CR, “Published reports on the recognize that consistent, reliable, and
effect of CRs on agency operations . . . typically do not timely funding is key to sustaining military
provide data that would permit a systematic analysis of CR aviation readiness and safety.
effects.” Instead, these reports, as with this Commission’s,
The Commission recommends:
“typically provide anecdotal assertions that such funding
measures increase costs and reduce efficiencies.” In fact, 7.1 Congress and the administration
the CRS found only one recent report that successfully ensure predictable and reliable
quantified the effects of continuing resolutions to any funding for military aviation and stop
degree. That study, conducted by RAND in 2019, using continuing resolutions to fund
intentionally limited its focus to a discrete and measurable national security, military readiness,
impact: procurement awards. The study’s authors and aviation safety.
acknowledged that “many variables can mask CRs’ effects,”
and any study must “contend with limitations in the 7.2 Congress task the Congressional
available data,” so they conducted their analysis by solely Budget Office to study and report on
focusing on one specific area. the negative impacts of continuing
The same type of targeted analysis is necessary for resolutions on military aviation
military aviation. The Commission cannot overemphasize readiness and safety.
the importance of the effects of CRs on the military

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Air Force Reserve pilots with the 709th Airlift Squadron at

Dover Air Force Base, Delaware, prepare for a mission in
the C-5M Super Galaxy during an off-station training event
at Naval Air Station Pensacola, Florida. (U.S. Air Force
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photo by Capt. Bernie Kale.)
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THE DEMAND ENVIRONMENT

T he persistent demand and Servicemembers’ can-

do ethos have resulted in a chronic state of fatigue
across military aviation. The all-volunteer force has been
“I just had a phone call…about preparing for [a new
mission], and like everyone else, nothing is coming off our
plate,” a high-ranking Pentagon official told commissioners.
flying combat missions for more than 30 years. The “The volume and frequency of our operations are
U.S. military has many diverse missions, ranging from unprecedented.” An Air Force Reserve maintainer attending
deterring American adversaries to providing disaster an enlisted roundtable told the Commission that “there’s
relief and humanitarian assistance. While the number of times I’ve felt we were performing tasks and we shouldn’t
missions has increased in each of the past three decades, do it because we don’t have the manning. But the tempo
the size of the force has decreased (see Figure 8-1). This requires we need to do it.” The other maintainers around
unsustainable imbalance negatively impacts safety. the table nodded in agreement.
Senior NCOs, the foundation of the military’s get-
it-done ethos, revealed their frustrations. “Not only do I
More Demand than Capacity
have a shortage of manpower, it’s a shortage of time,” an
“The business model is terrible,” said a Marine squadron Army combat aviation brigade first sergeant said. “Your
commander in a roundtable discussion with the maintainers are working past duty day and then working
Commission. He told of personnel shortages in his unit weekends and then 24-hour operations. It’s completely
and said, “we’re being tasked with more requirements, unchecked.” Asked about safety concerns, a senior Marine
but we have to do those with the same or a smaller Corps NCO replied, “The OPTEMPO. I do what I can
force. ‘Do more with less’: you can’t. I know the risk of to slow that down. I tell the boss we can’t do things. The
having a mishap is going to go up. This is just reality.” recipe is there for something to occur.”
The Commission heard similar comments across all four Taskings from the Services and from combatant
Services from regular and reserve components, from commands are piling up. “We need the Air Mobility
junior enlisted maintainers to senior Service leaders. Command to go to Transportation Command and say
enough,” said a squadron commander during an Air Force
town hall. “We need to ask for something to drop off the
back end when we add something else.” A general officer
DEFINING OPTEMPO AND PERSTEMPO on the staff of a major command also spoke of pressure
from combatant commands: “At some point someone
Title 10 of the U.S. Code defines OPTEMPO and needs to bring discipline to the demand signal. We don’t
PERSTEMPO as follows: have what they need.” Yet, no one feels they can say “No.”
The tempo is particularly challenging for some career
• Operating tempo means the rate at which units fields, such as flight engineers. One KC-10 squadron
of the armed forces are involved in all military commander said the unit is well below required manning,
activities, including contingency operations, in large part because so many people are leaving the
exercises, and training deployments. unit. “Most of them are getting out before retirement
date because of burnout. Deploy, deploy, deploy. TDY
• Personnel tempo means the amount of time [temporary duty away from home] 270 days a year, the rest
members of the armed forces are engaged of the time they are in the [simulators]. They are getting
in their official duties at a location or under one or two weekends a month to [be] with their families. A
circumstances that make it infeasible for a couple people just made tech sergeant, but they are never
member to spend off-duty time in the housing in going to sew it on because they’re done. Even promotion
which the member resides. doesn’t keep them in.” OPTEMPO and PERSTEMPO is
putting the health of the force at risk.

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Degrading Future Readiness

FINDING
Mission requirements are overtasking current military
personnel while at the same time undercutting the The PERSTEMPO and OPTEMPO are overstressing
training of new entrants. During combat operations, the current military aviation force structure and
military members will accept higher risk. However, compromising the readiness standards required of
during routine training and operations, military members military aviation.
view the increased risk as a failure of leadership to adjust
the planning assumptions to reflect actual conditions.
Aviators told the Commission that OPTEMPO
demands deny them adequate time for the ongoing
Chronic Fatigue and Burnout
training necessary to keep their warfighting skills current.
The latest National Defense Strategy and National Military The Commission heard of chronic fatigue and the term
Strategy projects greater global competition in the airspace burnout many times during visits to installations across the
and the need to prepare for a high-end fight with near-peer Services, in both active and reserve components.
adversaries—a radical change from operating in largely • An Army pilot: “So much is being required of IPs
uncontested airspace over the past 30 years. If units are [instructor pilots] at the unit, and we have a shortage
always responding to routine taskings, they are unable of IPs, and they are getting burned out. That’s why
to devote the necessary time and flight hours to develop our retention rates suck.”
the skills needed for future conflicts. “I can’t train to fight • A Navy leader: “Old jets make us work our people
Russia and China. I need relief from hauling crap around harder. We have to work them to death. That’s a
the [area of responsibility] so that I can actually train,” said safety issue. We burn them out.”
an Air Force commander. • A Marine Corps aviator: “My kids don’t know who
I am.” Due to deployments, exercises, and constant
long days, he said, “they don’t know when I am

Figure 8-1:
OPTEMPO

70

60

50 2,500,000

40 2,400,000
Number of Total
Active End-Strength
Operations 30 2,300,000 (Active and
Reserve)

20 2,200,000

10 2,100,000

0 2,000,000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Source: National Commission on Military Aviation Safety

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 Chapter 8: The Demand Environment

going to be home. That stuff leads to the burnout

and distraction while flying.” SKILLS DEGRADATION
“Task saturation is a problem,” said a senior Air Force The 433rd Airlift Wing is the Air Force Reserve’s only
maintainer in an F-16 wing, who kept coming back to the formal training unit providing initial and advanced
word tired. “They are tired, sleep deprived. They are tired, C-5 training. The wing’s instructor pilots (IPs) told the
and with increasing mission and lower manning levels Commission that when pilots return for advanced
and the lack of proficient NCOs to help, NCOs are tired. training after years in operational units, their skills
It is just being tired. Knowing that with task saturation have degraded compared to when they graduated
and sleep deprivation, work performance suffers. We see from initial training. “Because of OPTEMPO, their
human factors and an increase in mishaps. They don’t have experience has improved, but their flying skills are
experience and are tired. They are tired and are crying for some of the weakest we’ve seen,” one IP said, offering
help. The response is shut up and color.” several reasons:
Chronic fatigue manifests itself in retention. “It’s • they are not flying enough because of additional
not the money or their character or attitude; it’s the duties;
OPTEMPO. They are getting crushed,” said an Air Force
logistics officer who was a prior-enlisted crew chief. A • they do not have experienced instructors in the
safety officer for an Army combat aviation brigade stated: operational units to properly train them;
“Everybody wants more money, but it’s the quality of life • they are not getting opportunities to train on the
for me. I’m gone (so often), and it’s just not worth it.” A techniques they will need to fly against a near-
senior Air Force NCO told the Commission that one of peer adversary.
his staff sergeants left the Air Force to be an automobile
mechanic. “They’re burned out.”

FINDING days [doing administrative work]. Allow us to focus on

flying, putting more priority on that than other duties.”
The pervasive sense of burnout and chronic fatigue
Additional duties add to the already unsustainable
that exists throughout the military aviation enterprise
tempo, but their negative impact does not stop there.
is contributing to unsafe conditions. Aircrew and
“I would go so far as to say 90 percent of Army
maintainers cite the compounding factors of
aviation problems fall under the umbrella of conflicting
OPTEMPO, PERSTEMPO, and the resulting fatigue
requirements,” one Soldier wrote to the Commission after
and staffing shortages as the likely cause of “the
attending a town hall meeting. “Pilots and crew members
next mishap.”
cannot maintain proficiency on any single task if their
focus is elsewhere. [Increased personnel] could impact
the problem we face and would have positive impacts on
morale, retention, proficiency, and accident rates. Soldiers
Additional Duties don’t leave the Army because they can make more money
elsewhere. They leave because they are sick of dealing
A pilot with an Army combat aviation brigade told the with BS that is outside of their job description.” Aviation
Commission he hated driving into work every day. Asked professionals are overtaxed with too many wrong tasks.
why, he replied, “Flying is 5 percent of what I do; about
95 percent is administrative [duties].” Administrative
FINDING
and logistics support personnel have been cut from
units because of decreasing end-strength or budgets. The Diverting aviation professionals from their primary
burden of fulfilling those roles has shifted to aircrew and aviation duties with additional duties adds to an
maintainers as “additional duties” that add significantly to unsustainable workload. Due to personnel cuts, military
their OPTEMPO burden while taking time away from aviation units have experienced cuts in administrative
developing their professional skills. Some report that their support over the past two decades, forcing aviators
additional duties have become their full-time jobs. “We and maintainers to undertake additional administrative
signed up to be combat fighter pilots, but that’s the fifth or duties that interrupt their primary aviation tasks and
sixth most important thing we do,” said a Marine Corps contribute to fatigue and burnout.
pilot. “It’s not the lack of flying, it’s the 12- to 15-hour

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Tracking PERSTEMPO In a 2018 report, the Government Accountability

A significant shortcoming is the lack of quantitative Office concluded that DoD lacked sufficient policy
data to effectively measure PERSTEMPO and and reliable data to monitor PERSTEMPO. This
assess its impact on units and individuals. Tracking Commission concurs with the GAO’s assessment and
individual PERSTEMPO is a necessary first step toward with Congress’ recent efforts to address this issue.
understanding the health of the force. The absence The Services carefully track the hours of use for
of focused policy that produces reliable data limits aircraft and components; the Commission asserts the
DoD and Service leaders’ ability to research, analyze, same careful attention should be spent tracking the
and understand the stress on the force so that they people who fly and maintain these aircraft.
can mitigate safety risk. It also impairs efforts to fully
understand and draw definitive conclusions about the FINDING
impact of PERSTEMPO on military aviation safety and
readiness. The Services are not adequately tracking
PERSTEMPO for units and individuals and the
resulting impact on the health of the force.

RECOMMENDATIONS

Policy at all levels must reflect that aviation is a high-demand, low-density specialty with routinely insufficient
capacity to satisfy all of the demand placed on it. This has overextended the aviation force beyond sustainable
levels, resulting in chronic fatigue and burnout, which negatively impacts retention. The current high demand
is forcing the Services to shortchange safety to accomplish current missions. The Services must increase aviator
and maintainer capacity, reduce additional duties, and focus on proficiency to mitigate the risk.
The Commission recommends:

8.1 The Services ensure aviation units have 8.3 The Department of Defense and the
sufficient administrative personnel to allow Services require that proper policies,
aviators and maintainers to concentrate on practices, staffing, and all other necessary
their primary mission, sustain currency and resources are in place to ensure that
proficiency, and meet the unit’s mission the military’s high demand/low density
readiness rates. aviation units always are fully prepared
and standing ready to perform at levels
8.2 The Department of Defense and commensurate with the critical and
the Services report aviation units’ unique role they perform in securing and
personnel experience levels and member maintaining our nation’s security.
PERSTEMPO.

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An Aviation Structural Mechanic 2nd Class oversees

maintenance on an MH-60R Seahawk from the
“Battlecats” of Helicopter Maritime Strike Squadron
73 on the flight deck of the aircraft carrier USS
Nimitz. (U.S. Navy photo by Mass Communication
50 Specialist 3rd Class Elliot Schaudt.)
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Chapter 9:

MAINTAINERS AS AVIATION
PROFESSIONALS
M aintaining military aircraft requires highly trained
and skilled specialists. However, new training
methods and outdated personnel policies are interfering
Mixed Reality for Maintainers
The Services are not shortening their maintenance training
courses. However, they are relying less on traditional
with maintainers’ duties and skill development. This hands-on training and more on augmented reality (AR)
comes at a time when operational units are short on training, including computer-based learning, simulators,
experience and OPTEMPO is high. Strategic investments and virtual reality (VR) to overcome personnel shortages.
in developing well-trained maintainers will go far in Maintenance supervisors across the Services told the
increasing operational readiness and mitigating safety Commission that overreliance on computer-based
risks on the flight line. training is resulting in undertrained maintainers arriving
at operational units. They lack the basic skills needed for
FINDING immediate integration into the unit.
Even entry-level maintainers agree their training is
Military aviation requires a significant and constant inadequate. On one site visit, the Commission heard a
investment of time and resources to train and story about a recently graduated maintainer who was
develop fully capable maintenance professionals. instructed to remove a panel. The maintainer did not
know which tool to use because the computer-based
training program removed the panel with a click of the
mouse. When the maintainer actually removed the panel
Initial Training
for the first time, it landed on his foot. “VR will give
Failing to sufficiently invest in initial training programs you familiarization before you walk out and do it,” a
is a safety risk—one that aggregates over time. “This senior level chief training officer told the Commission.
seems irreversible,” said a Navy squadron commander. “The issue is, when you use VR to remove a panel by
“I have increasingly unqualified people to teach the new touching it [on a screen], you don’t realize it’s 35 pounds,
generation who are then going to be less qualified to train and you’re out there in 100 degrees—and not an air-
the next generation.” conditioned room—and you drop it on the ground.”
Interviews with entry-level trainees and maintenance Throughout the Commission’s travels, personnel
school instructors reveal that many students have little to in other units shared similar stories about VR learning.
no mechanical or maintenance experience before joining One young enlisted Air Force maintainer admitted to the
the military. These deficiencies are not addressed during Commission that he did not know how to remove a panel
initial training. “Coming out of the schoolhouse, most upon arriving at his first unit, and a junior Marine Corps
don’t know the difference between a Phillips head and a maintainer described the training this way: “I checked a
standard screwdriver,” a senior Marine Corps maintainer box that said I got on the computer, moved my person to
said. An Air Force maintenance NCO concurred. “We are this place [on the screen], pushed this button to take off a
teaching basic tools now. A lot don’t know what a ratchet panel, and I did it safely. It’s a joke.”
set is. If you ask for a ratchet set, they bring a socket.” Maintenance students typically undergo two phases
of instruction during training. The first phase is designed
FINDING to introduce the trainee to basic mechanics and tools.
Instructors told the Commission that this training
Initial training across the Services is intended to has shifted significantly from hands-on to virtually
provide maintainers with the basic skills to perform augmented training methods. The second phase turns to
primary requirements. The Commission heard grave more aircraft-specific and specialty skills training. Hands-
concerns from operational units that the skills of student on training is the teaching method of choice during
graduates are deficient.

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National Commission on Military Aviation Safety

To be effective, hands-on training must be conducted

REALITIES DEFINED on realistic equipment that mirrors the actual aircraft
the students will maintain at operational units. Across
Simulators are training devices replicating the all Services, the Commission found a need for repairing,
environment and controls of an aircraft or system upgrading, or increasing the number of mock-up trainers
(such as aerial refueling or de-icing equipment) for the and tools that students use for hands-on instruction.
purpose of creating a realistic experience operating Mock-up trainers should match the Services’ operational
that aircraft or system in a safe environment. In fleets of aircraft.
addition to providing an accurate representation of
the system’s controls, advanced simulators use high- FINDING
fidelity motion and visuals to simulate the system’s
physical and psychological sensations. There is an urgent need for repair and upgrades of
equipment at training installations. The Commission
Virtual reality is a computer system that generates repeatedly heard reports of outdated, out-of-
three-dimensional images on screens inside helmets service, or non-available trainers. Mock-up trainers
or goggles, creating visual environments the user can are not kept current with the aircraft the aviation
physically manipulate or respond to by using gloves or professionals will maintain in operational units.
devices fitted with sensors.

Augmented reality overlays real-world surroundings

with computer-generated images, ranging from textual
labels to immersive experiences. Measuring Training Efficacy
Augmented reality training tools can enhance maintenance
skills if quickly reinforced with hands-on training. In
reviewing training syllabi, the Commission found that
this phase. However, schoolhouses often substitute this augmented reality training rarely occurs in conjunction
training with virtual instruction when there is insufficient with hands-on training, primarily because of personnel
equipment. The outcome is unprepared graduates who reductions. Overreliance on augmented reality training is
are not ready for flight line operations. As a result, the having a negative impact on skill retention.
receiving unit must divert resources to conduct basic-level The training programs do not have sufficient data
training instead of actual maintenance. collection to reliably measure virtual training’s impact
The need to produce more maintainers to on trainees’ skill retention. The Commission also noted
compensate for personnel cuts in previous years has the lack of an effective feedback loop between the
prompted the recent changes to teaching methodology. operational units and the schoolhouses. Current feedback
Use of virtual training has increased in all Service training systems have little success gathering the operational
programs. Recent graduates told the Commission they units’ perspectives and effectively integrating them into
would have liked more hands-on training before arriving revisions to training programs. The feedback loop with
at their operational units. An Air Force training group the receiving units is broken.
commander said he often hears such comments. He
considers hands-on training for young people a novel, FINDING
cool experience. “Us old guys, we think that for the
young guys that VR and AR are their bailiwick,” he said. Training commands have not been applying data-
“In fact, what’s new to them is actually doing it, the driven measurements for their training methods. The
hands-on work. That’s what fires them up.” feedback loop with the receiving units is broken.

FINDING

The Services’ training organizations are relying

more on simulation and virtual reality technologies. On-the-Job Training
Operational units believe these decisions result in The impact of initial training shortfalls in the
less-skilled graduates. schoolhouse is exacerbated by current challenges facing
on-the-job training (OJT). On-the-job training has

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 Chapter 9: Maintainers as Aviation Professionals

always been integral to the education and training of of initial training differently. Rather than graduate an
aviation maintainers as they hone their skills. The Services operationally proficient maintainer ready to contribute
count on a cadre of experienced NCO maintainers at the on the first day, their goal was to produce graduates
operational units to provide that OJT. At almost every needing OJT before being ready for initial flight line
unit the Commission visited, commanders and senior duties. The Services need to align their expectations and
NCOs reported that they were overextended for mission adjust their training strategies and resources.
requirements and did not have sufficient NCOs to
provide the necessary OJT.
Experience Matters
An important factor in the effectiveness of OJT is
the ratio of trainers to trainees. The Air Force reported “More maintainers would help,” an airlift squadron leader
that its usual trainer to trainee ratio should be 1:5 or 1:6. told the Commission; “but what would really help is
In one career field, Air Force maintenance crew chief more experienced maintainers. It takes about three years
ratios are closer to 1:8 or 1:9. The Commission saw the to get good at your job, doing it every day. We’re not even
same issue in all the Services. With this higher ratio, getting to that point with our young airmen.”
supervisors cannot properly supervise and develop the Even when fully manned, many units do not have
new maintainers. “That peanut butter gets spread so thin enough skilled personnel with the requisite experience and
that people aren’t really getting any peanut butter,” an Air qualifications for certain roles. A unit may have the right
Force commander told the Commission. number of personnel yet still lack the proficiency needed to
The units are caught between competing demands: accomplish the mission. For example, a Marine Air Group
the need to meet readiness goals with aircraft safe to fly told the Commission it was manned at 103 percent, but
today, and the need to invest the time to supervise and only 60 to 70 percent met qualifications. “We don’t have
train new maintainers who will be effective tomorrow. the skills and experience,” the commander said.
“We just got a lot of junior Marines,” said a junior The problems the Commission heard during site
Marine Corps maintainer. “We are down to five people visits also appear in the personnel data. The Commission
with qualifications. We have guys doing [maintenance] requested experience-level data from the Services and
without someone supervising them. We don’t have the received information from the Army and Air Force.
people to do OJT.” Figures 9-1 and 9-2 show examples of Army
Operational units expect to receive schoolhouse maintainer experience levels in two specialties, measured
graduates who are able to support basic flight line in average months of military service by skill level. It
operations when they arrive. The Service training reveals substantial decreases in average experience across
commands told the Commission that they saw the role the board. The downward trend in experience was

Figure 9-1:
Army AH-64 Helicopter Maintainer Average Months of Service
by Skill Level and Fiscal Year

30

25

20
Skill level 40
Average
Months of 15 Skill level 30
Service
Skill level 20
10
Skill level 10

0
2012

2013

2014

2015

2016

2017

2018

53
National Commission on Military Aviation Safety

Figure 9-2:
Army Aircraft Maintenance Senior Sergeant Average Months
of Service by Skill Level and Fiscal Year

40

35

30

Average 25
Months of Skill level 60
20
Service
15 Skill level 50

10

0
2012

2013

2014

2015

2016

2017

2018

Figure 9-3:
Air Force Refuel/Bomber Aircraft Maintainer Average Years
of Service by Skill Level and Fiscal Year

16

14

12
Average 10
Years of
Skill level 3
Service 8
Skill level 5
6
Skill level 7
4

0
2012

2013

2014

2015

2016

2017

2018

54
 Chapter 9: Maintainers as Aviation Professionals

equally true for both entry-level maintainers and senior Commision they were forced to move from one platform
supervisors. The Aircraft Maintenance Senior Sergeant to another, sometimes switching between fixed wing and
specialty saw a drop in the average months of experience rotary wing. Many of these Servicemembers reported
between fiscal years 2012 and 2018, a particular cause that they often did not receive additional training
for concern. A decrease in junior maintainer experience is before their reassignment. This lack of aircraft-specific
not being offset by experienced leaders, as the experience training fostered negative habit transfer, degraded OJT
is declining across the board. instruction, and resulted in inadequate supervision. If the
Analysis of Air Force experience levels of the Refuel/ Services improve their policies and training requirements
Bomber Aircraft Maintenance specialty illustrates a when transferring or transitioning maintainers between
trend seen broadly across aviation maintenance. Figure aircraft, experienced maintainers would be better
9-3 visualizes the changes in average years of service by prepared to apply their experience appropriately.
skill level between fiscal years 2012 and 2018. It shows a
worrisome decrease in the average years of experience for FINDING
7-levels (the senior maintenance leaders) and a shocking
decrease of more than 50 percent in average years of Maintenance professionals with technical expertise
experience for 5-levels (the first-line trainers and leaders). are often assigned non-aviation duties, reducing
These steady declines in maintainer experience aircraft availability.
negatively affect readiness and safety.

FINDING

Maintainer experience has decreased across military

Maintainers Want to Maintain
aviation, especially at mid-levels. Readiness and safety would improve if aviation
maintenance professionals stayed in the maintenance career
field. The current aviation maintenance force is distracted,
under-resourced, inexperienced, and therefore struggling
to maintain aircraft. Gate guard duty, motor pool duty,
Talent Management for Aviation Maintainers
and other non-aviation tasks and ancillary training distract
The Services’ investment in aviation professionals requires maintainers from their best use. The Services should focus
an effective plan to retain experienced maintainers. aviation maintainers on doing the work only they can do
“Aviation should be separated and fenced off,” said one and that will improve aircraft availability rates.
Marine aviator. “The ground guys don’t feel that way. On The Commission also explored other ways to
the ground, you can replace a [infantry] squad leader and support the professionalism, long-term development, and
train someone in two weeks. It takes 3 1/2 years to train retention of maintainers. A system of aviation proficiency
an aviation squad lead.” The Services need to manage this badges or milestone credentials would recognize a
community differently. maintainer for proficiencies. Similarly, payment for
Fully qualified aviation maintainers frequently find outside schooling, such as an A&P (Airframe and
themselves redirected to other assignments, such as drill Powerplant) license, in exchange for an additional service
instructor or recruiter. Enlisted maintainers told the commitment would foster greater professionalism and
Commission that, despite their flight line experience, pride while simultaneously increasing skills and retention.
their assignments as a drill instructor or recruiter were As aircraft have become more complex, the technical
required for promotion. However, a multiyear absence skills required to keep them operational have advanced
from maintenance duties results in lost proficiency. commensurately. Providing enlisted maintainers with
Many maintainers returning to the flight line require a promotion system that recognizes technical expertise
refresher training before they regain minimum currency would help keep personnel in uniform. There is room
to perform maintenance supervisory functions. for both technical experts and leaders in the ranks of the
Another challenge occurs when maintainers are Services’ senior NCOs. Maintainers want the opportunity
reassigned from one type aircraft to another. While the to become masters of their trade while still advancing their
foundational principles of aviation maintenance are careers. This would provide a dedicated cadre of experts to
similar, each aircraft type is its own complex machine and support new maintainer training and generate the aircraft
requires specific knowledge. Aviation maintainers told the needed to sustain readiness. Let maintainers maintain.

55
National Commission on Military Aviation Safety

RECOMMENDATIONS

Because of the significant investment in time and resources required to train and sustain fully qualified military
aviation maintainers, and a commercial marketplace competing for such high-demand talent, Congress, the
Department of Defense, and the Services must regard and manage aviation maintainers as a specialty and their
training as a career-long pursuit. The Services must develop personnel management processes and career paths
that account for the complexities of aviation and support aviation safety, readiness, and OPTEMPO. DoD and
the Services must execute the following measures to recognize achievement and enable aviation professionals to
focus on their flight line duties, sustain their skills, and promote advancement of their proficiencies.
The Commission recommends:

9.1 The Services mandate and enforce 9.3 The Services reward and incentivize the
assignments and performance evaluation professional achievements of aviation
guidance that focus aviation maintainers maintainers with recognition and
primarily on areas of performing, professional development throughout
sustaining, and advancing their their careers.
aviation professional skills, knowledge,
and experience. The Services must a. The Services should establish
discourage using aviation professionals aviation maintenance proficiency
for assignments and additional duties badges or credentials that
unrelated to their aviation-related would recognize and incentivize
warfighting fitness, skills requirements, or excellence in aviation maintainers
essential supervisory responsibilities. DoD and empower supervisors with
and the Services should reduce mandated, support from leaders at the unit
nonaviation-related ancillary training to level to keep aviation maintainers
the minimum. focused on their primary flight line
responsibilities.
9.2 The Services experiment with technical
specialty enlisted ranks for aviation b. The Services should institute a
maintenance personnel that include tuition-paid A&P (Airframe and
unique career paths to ensure that Powerplant) license option in
maintenance personnel achieve and return for an extended enlisted
are able to sustain the highest level of commitment meeting a cost/benefit
proficiency and professionalism. threshold.

9.4 The Services implement policies and

training for transitioning maintainers
among platforms that require and certify
proficiency, promote retention, and
leverage experience for both legacy and
new platforms.

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Chapter 9: Maintainers as Aviation Professionals

57
National Commission on Military Aviation Safety

A U.S. Army AH-64E Apache helicopter pilot assigned to Task

Force Tigershark, 16th Combat Aviation Brigade, 7th Infantry
Division, prepares to depart for a mission at Jalalabad Airfield,
58 Afghanistan. (Department of Defense photo.)
 En
vi
an

ro
m

nm
Hu

en
t
Machine

Chapter 10:

PROTECTING INVESTMENT
IN AIRCREWS
T he Apache AH-64D was conducting a low-level,
night training mission when a part failed, leading
to damage of the engine, main rotor head and blades, tail
just eight years earlier. While some of this time was
replaced by additional simulator hours, a pilot in 2018
would report to their operational unit with significantly
rotor head and blades, main transmission, gearbox, and less flight experience. Twenty flights were cut from the
multiple drive shafts. syllabus.
Cause of mishap: materiel failure. This reduction in training impacted operational
Notwithstanding the materiel failure, the damage to flying units. Squadron commanders and instructor pilots
the aircraft was avoidable. The training program, flight told the Commission that recent flight school graduates
manuals, and simulator did not prepare the two pilots
to properly diagnose the failure and take remedial steps.
The training and information had been removed from Figure 10-1:
qualification courses and the operators’ manual in 2010. Army AH-64D Course Changes
Present and contributing cause of mishap: training
standards.
FLIGHT SIMULATOR
PROGRAM AND YEAR
HOURS HOURS
Pilot Training
FY12 AH-64D 95.5 61.6
The process of turning men and women into proficient
FY18 AH-64D 74.5 48
military pilots requires a complementary series of
progressive training programs. Students begin with initial
pilot training where they learn basic flight skills, then
Figure 10-2:
progress to advanced training for their specific aircraft.
Navy and Marine Corps F-18 Course Changes
Pilot training continues at their operational unit with
flight qualifications, unit-level training, and exercises.
Pilot shortages have increased pressure on the PROGRAM AND YEAR
FLIGHT SIMULATOR
Services’ training commands to produce more pilots HOURS HOURS
in less time. The Commission examined an advanced FY10 Navy F-18E/F 111.9 80.3
training program for one airframe from each Service.
Figures 10-1, 10-2, and 10-3 demonstrate changes the FY19 Navy F-18E/F 108.4 87.9
Services have made in these aircraft-specific pilot training FY10 Marines F-18C/D 99.9 78.3
syllabi to move pilots through the pipeline faster.
An Apache pilot graduating from training in 2018 FY19 Marines F-18C/D 101.7 82.4
had 21 fewer flight hours and 13.6 fewer simulator hours
than a pilot who graduated in 2012. The number of
flight hours, simulator hours, and the total course length Figure 10-3:
were all shortened. The Army attributed the changes in Air Force F-16 Course Changes
the syllabus to a lack of available aircraft.
Unlike the Army, Marine and Navy pilots learning to
FLIGHT SIMULATOR
fly the F-18 did not have their flight and simulator hours PROGRAM AND YEAR
HOURS HOURS
cut. For both Services, the number of simulator hours
increased from fiscal years 2010 and 2019. FY10 F-16 84.3 52.5
Air Force pilots learning to fly the F-16 in 2018 had
FY18 F-16 56.2 68
28.1 fewer flight hours as compared to a pilot trained

59
National Commission on Military Aviation Safety

training for new pilots and aircrew. One Air Force training
BREAKS IN TRAINING unit conducting aircraft-specific training was authorized
114 instructor pilot billets, but filled only 82 despite
Many aviators described long breaks in their training, lowering the IP qualification from 500 hours to 400 hours.
either during a course because of aircraft or instructor The pressure to get people qualified is not limited
pilot shortages or between assignments because of to the schoolhouses. Instructor pilots reported feeling
backlogs. pressure to quickly advance new aviators to higher
qualifications to offset personnel shortages. “I had seven
One student reportedly took a year to complete a progression flights quickly,” a junior Army aviator told
27-week training syllabus. “You get good training, but the Commission. “The demand for aviators is so high
there were a lot of breaks,” a student pilot at a training that there’s pressure to push people into positions that
wing told the Commission. “Some of us were only their experience doesn’t support.” Said a junior Marine
flying every two weeks.” aviator, “We just need pilots so desperately” that pilots
are getting “qualifications that they don’t deserve because
Some students reported as much as a six-month gap we have to have them.” This pressure to quickly progress
between initial pilot training and advanced training. and qualify aviators is also extending to more advanced
During that time, there’s no requirement to fly. Air credentials such as instructor pilots.
Force aircrew also have to wait for an opening to
attend the Survival, Evasion, Resistance, and Escape FINDING
(SERE) school at Fairchild Air Force Base, Washington.
“When I get to my unit, it will be six months since I’ve Unit instructor pilots are conducting basic skills
flown,” said an advanced pilot training student. training to make up for deficiencies at the
schoolhouse. Operational units are not resourced to
provide basic flight training.

are not reporting to the unit adequately prepared for

their first assignment. As a result, operational units must
dedicate limited training hours to basic flying skills, Flight Hours
reducing the hours preparing for combat missions. Flight time is the lifeblood of military aviation safety
Combat capability decreased as instructors were forced and readiness. More flight hours lead to more proficient
to teach new pilots basic flight skills instead of more aircrews. Too little flight time leads to a lack of
advanced combat tactics, techniques, and procedures. “I proficiency and the experience necessary to accomplish
get guys struggling to get qualified,” said a Navy pilot and operational missions.
department head while discussing the quality of graduates Studies have shown a relationship between career
coming from a flight training program. In his view, the flight hours and increased pilot mishap causal factors.
program has the primary goal of “just get them out of A 2009 CNA study found that P-3 Orion pilots with
the door. And it’s a snowball effect. I’m doing final check low career flight hours tended to have greater numbers
rides, and I’m appalled: they’ve gotten that far without of pilot error mishaps. A second 2009 CNA study of
learning basic stuff?” Marine Corps aviators reported that junior F/A-18, AV-
8B, CH-46E, and AH-1W/UH-1N pilots had greater
FINDING numbers of pilot error mishaps than their more senior
counterparts. A 2010 CNA study described a “well-
Pilot training is intended to provide military aviation established relationship between low pilot career flight
professionals with their basic flying skills. Across the hours and higher mishap frequency.”
Services, the flying skills of pilots graduating from The Commission heard multiple comments that total
the schoolhouses are deficient. career flight hours have decreased. Across the Services,
mid-career pilots reported having as many as 200 fewer
career flight hours than previous generations.
Other CNA studies also found a relationship
The Commission heard from commanders who between more frequent pilot error mishaps and lower
were frustrated with not having the requisite number of recent hours. A 2007 study found that an operational
instructor pilots or senior personnel to provide sufficient strike fighter pilot with 10 or less flight hours in the

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 Chapter 10: Protecting Investment in Aircrews

previous 30 days was three to four times more likely than

a pilot with 16 or more hours to have an “unsafe flight FEEDBACK FROM THE FIELD
incident.” CNA’s further studies concluded that the trend
held regardless of career experience level. A Chief Warrant Officer 4 and Aviation Safety Officer
for his unit, who attended a roundtable discussion,
FINDING shared the following with the Commission.

Decreased flight hours, inexperience, and failure to One big thing that was noted is the lack of
sustain currency and proficiency are contributors to sufficiently trained pilots from flight school. As
aviation mishaps. Sustained investment in the flying we get more and more junior pilots and keep
hour program is necessary to ensure aviation safety up with the OPTEMPO of training deployments,
and readiness. field exercises, operational deployments, etc.,
these pilots end up stagnating and waiting for
long periods of time before they are available to
use on missions. Some even wait long periods
Many aviators told the Commission that they are not to start flying at all at a unit. Here alone, we
getting the flight hours they need. Servicemembers across have had an influx of junior aviators: 18 Warrant
all four Services spoke about the challenge of getting at Officer 1s and five second lieutenants. These will
least 15 flight hours per month. Army aviators say they are all take the Instructor Pilots away from their own
flying just short of 15 hours per month. Air Force airlift continuation training. This will end up burning
squadrons are not getting the flight hours for training. out the IPs as they fly non-stop RL Progressions
Navy aviators said they are not getting 11 hours per [readiness-level progressions continuation
month unless they are preparing to deploy. Although the training]. This lends itself to mistakes, cut
Marine Corps’ goal for CH-53E pilots is 15 flight hours corners, close-calls, and things of that nature,
per month, one pilot said, “We too often are in the single all of which can change the seconds and inches
digits for flight hours per pilot per month, a dangerously that separate a non-event from an accident. This
low number of flight hours to be decent at a very difficult also puts the senior guys at the back of the line
trade.” Many Marine Corps aviators said they averaged when they come in and need local training before
about five hours per month. The Commission recognizes they can get up to an operational level, further
the importance of sustained investment in the flying hour removing them from the normal consistency of
program. flying their aircraft.

Waivers Another thing we have to deal with, that runs

With fewer flight hours, pilots risk losing currency. along with the mass influx of junior pilots, is
The Commission found evidence that the Services have the lack of flight hours. When manned at or
increased their reliance on waivers to operate despite near 100 percent, some units do not have the
currency and proficiency shortcomings. The Commission required flight hours for all personnel to make
often heard that commanders are relying on waivers to their minimum required flight times, let alone
qualify instructor pilots, conduct operations, and train provide hours for the progression of junior pilots,
during deployments. An Army pilot told the Commission retraining of regressed pilots, or any contingency
that “except for the trainers and evaluators, everyone in my that may come up. If this is allowed to continue,
flight company had minimums waived.” either the minimums will have to be lowered or
Reserve Component units have relied on waivers flight hours increased. The cost for adding flight
to overcome challenges in meeting flight hour hours would be a thing that will be considered
requirements. “Last year, of our 78 pilots, 26 got over most; however, if we continue to lower the
waivers,” said a Navy Reserve aviator. “One-third of standards, we continue to get sub-par products.
our folks didn’t meet the minimum number of flying Sub-par products require more time and effort
hours.” Army and Marine Reserve Component pilots to bring to an operational level and will end up
echoed similar concerns, with a Marine telling the costing more time and money.
Commission that he had not flown at night for two
months, despite being an instructor pilot.

61
National Commission on Military Aviation Safety

The Commission noted that waivers have shown up Constrained budgets, decreased aircraft availability,
among causal factors in mishap reports, including fatal instructor pilot shortages, and reduced training range
Class A mishaps. Yet, the Commission found there was availability have led to greater simulator usage. The
no centralized tracking of waivers across the Services or Commission heard concerns from pilots in all the
Department of Defense that leaders could use to identify Services about the increased use of simulation in
and research this risk. The proliferation of waivers represents lieu of actual flying. Recognizing that simulation is a
a new normal and acceptance of degraded standards. cost-effective flight training tool, it is a supplement
The Commission found senior leaders and safety officials or enhancement, not a replacement, for actual flight
unaware to what appears to be an erosion of safety. This training. There is great value in both.
vulnerability must be addressed. Simulators cannot replicate carrier landings or
simulate G-forces, but they do provide the safest
FINDING environment for training on emergency procedures and
aircrew coordination. Achieving the proper balance
In many units, the minimum flight hour requirements between actual flight and simulator training is crucial for
for currency are not being met, leading to flight both safety and readiness.
waivers that are increasing risks and impacting the For simulators to be effective, they must mirror
safety culture of military aviation. the specifications of the aircraft they simulate. In many
cases, units lack simulators with the same configurations
and flight characteristics as the actual aircraft. Several
units reported that contracts limit simulator availability
and do not provide the engineering support necessary
The Right Training Medium
to keep their simulators operating and up to date. This
For years, aviation has used simulators to supplement real results in “negative training,” pilots practicing skills
flight training and experience in a safe, nonthreatening contrary to how they would employ them in actual
environment. Modern simulators are effective mediums flight.
for teaching core skills, enhancing mission techniques, The units with the worst simulator support are those
practicing emergency procedures, and providing flying legacy aircraft, such as the F-16, AV-8B, KC-135,
orientation to specialized operational skills. Simulator and T-38. These aircraft receive inadequate funding
hours cost considerably less than actual flight hours, as as resources are invested in new aircraft. Nonetheless,
Figure 10-4 shows. history shows that these older aircraft will remain mission
essential and in the operational inventory for years. The
KC-135, for example, continues carrying the bulk of
refueling missions as the KC-46 encounters delays in
Figure 10-4: becoming fully operational. In anticipation of a faster
Examples of Cost Comparison of Actual Flight Hours transition to the KC-46, the Air Force removed the KC-
to Simulators, Fiscal Year 2019 135 simulator at McConnell Air Force Base, Kansas, in
2017. Those KC-135 aircrews must now travel to other
COST OF COST OF
air bases to get simulator time. The 509th Bomb Wing
AIRCRAFT at Whiteman Air Force Base, Missouri, operates T-38As,
FLYING HOUR1 SIMULATOR HOUR2
but has no T-38A simulator.
F-16 $14,000–$16,000 $900 The Federal Aviation Administration, which oversees
F/A-18 civilian simulator certification, requires regular software
$11,000–$22,000 $875 updates so that training facilities and flight simulators
(A-F)
continue to meet strict standards of performance and
AH-64 $5,000–$7,000 $300 operations.
KC-135 $13,000 $650
FINDING
C-130 $5,000–$14,000 $650

C-17 $15,000 $650 Simulators are an essential tool for training military
aviation professionals. Installations have outdated
F-35 $17,000–$23,000 $340–$600 and out-of-service simulators.

Source: 1Office of the Secretary of Defense Comptroller; 2Aircraft Program Offices

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 Chapter 10: Protecting Investment in Aircrews

Retaining Experience Notably, these cost estimates only cover initial

Retaining experienced personnel, especially seasoned training and not the subsequent years of continuous
instructors and supervisors, is imperative to sustaining investment as aircrew hone their skills and accumulate
the training pipelines for aircrew. A 2019 report from experience.
the Department of Defense to the Congressional Armed In other words, increasing aircrew experience by
Services committees warned that flooding units with increasing retention saves money and improves safety
untrained pilots would have a cascading effect, when and readiness. To maximize efficiency, safety, and
too few experienced pilots are available to train the new readiness, the Services must have the flexibility to adjust
aircrews: “[A]bsorption models show a typical fighter retention incentives. Because it costs millions of dollars
squadron should be comprised of 55 percent experienced to train a replacement pilot, the Services must be able to
pilots. As that percentage decreases, it lengthens the offer competitive compensation. Granting the Services
time it takes for junior pilots to gain the experience they standing authority to increase their annual aviation
need to be fully mission capable, as inexperienced pilots retention bonuses up to $100,000 would allow the
require experienced pilots to lead them in training.” Services to respond to retention challenges in a dynamic
The report states that increasing pilot production to environment. See 37 U.S.C. § 334.
mitigate a pilot shortage results in units “saturated with
Improving Career Management
inexperienced pilots.”
Accordingly, the Commission sees an urgent need to Many aviators told the Commission that assignments to
invest in retaining experienced military pilots. Demand nonaviation billets diminished their aviation proficiency
from the airlines for military pilots will continue in just as they were gaining experience.
the future. Notwithstanding the current pandemic, the Most pilots have fairly structured career paths and
Services need to be prepared for when that demand important developmental experiences that must be met
resumes. along the way. These assignments are designed to create
A decrease in retention affects not only readiness well-rounded officers, but they can also be a detour on
and safety, it also ineffectively utilizes resources. As the road to making good aviators. “We spend a lot of
many mid-level aviators leave the Services looking for time training pilots,” said a Navy senior NCO crew
greater stability, higher pay, or improved quality of life, chief. “We get them good at flying and then they go fly
an increased workload will fall on the less experienced a desk. Their next assignment is coming back to fly and
personnel left behind. they aren’t good.” The degradation in proficiency during
A 2019 Report to Congress on Initiatives for the time away from the cockpit diminishes the Services’
Mitigating Military Pilot Shortfalls explained that return on investment.
“replacing an experienced pilot at the end of his or her Similarly, aircrews believe the current promotion and
initial obligated service commitment (10–12 years of evaluation systems do not sufficiently take into account
service) will take a minimum of 6–8 years of training and their aviation skills. “We are told from day one in flight
experience and millions of dollars for every pilot lost.” A school, when you get to the fleet, they tell you that your
2019 RAND study estimated the total costs of training ground job is what gets you promoted,” said a Marine
a basic qualified Air Force pilot is expensive. The study aviator.
concluded, The overall failure to address problems with pilot
The cost of training a basic qualified training and experience results in an aggregation of risks
fighter pilot ranges from $5.6 million for over time: a cohort of aviators who have inadaquate
an F-16 pilot to $10.9 million for an F-22 training and lack the skills and experience they will need
pilot. Bomber pilot training cost is also high, as they advance through their careers. The Commission
ranging from $7.3 million for a B-1 pilot learned of students who completed a rushed initial
to $9.7 million for a B-52 pilot. Costs for training program, who were pushed through their
training transport pilots and mobility pilots follow-on training by less-experienced instructors, and
are somewhat lower, but still considerable, then became instructors and leaders themselves. They
ranging from $1.1 million for a C-17 pilot to are at higher risk of making costly mistakes and lack the
$2.5 million for a C-130J pilot. Training cost experience to train the next generation. Without action,
per pilot for command, control, intelligence, military aviators will not be exposed to what “right”
surveillance, and reconnaissance operations looks like. Inexperience will become institutionalized and
(e.g., the RC-135) is about $5.5 million. jeopardize the safety of a future generation of aviators.

63
National Commission on Military Aviation Safety

RECOMMENDATIONS

Because of the significant investment in time and resources required to train and sustain fully qualified military
aviation personnel, and a commercial marketplace competing for such high-demand talent, Congress, the
Department of Defense, and the Services must regard and manage aircrews as a specialty and their training
as a career-long pursuit. The Services must develop personnel management processes that account for the
complexities of aviation and support aviation safety, readiness, and the demands of OPTEMPO. Congress and
the Services must execute the following measures to focus aviation professionals on their flying duties, sustain
their skills, and promote advancement of their proficiencies.
The Commission recommends:

10.1 The Services mandate and enforce 10.4 Congress grant the Services standing
assignments and performance evaluation authority to increase the aviation bonuses
guidance that focus aircrews primarily from up to $35,000 to up to $100,000
on areas of performing, sustaining, and per year to retain pilots in exchange
advancing their aviation professional for a commensurate additional service
skills, knowledge, and experience. The commitment.
Services must discourage using aircrews
for assignments and additional duties 10.5 The Services upgrade data collection to
unrelated to their aviation-related improve training programs and training
warfighting fitness, skills requirements, tool selections that better measure student
or essential supervisory responsibilities. learning. Data collection must include
DoD and the Services should reduce classroom, pilot task training, full-motion
nonaviation-related ancillary training to simulators, and flying training plus
the minimum. feedback from the field as a measure of
training efficacy.
10.2 The Services restore flight hours to
not less than fiscal year 2010 levels for 10.6 The Services link simulator sustainment
schoolhouse and operational units. to aircraft production, upgrades, and
modifications and have the same
10.3 The Services centrally track waivers, create operational flight plan as the aircraft. The
a baseline, and monitor them to identify Department of Defense and the Services
trends, assess risk, and predict potential must eliminate software and system
problems and resource shortfalls. upgrade lags that hamper simulator
training.

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Chapter 10: Protecting Investment in Aircrews

65
F/A-18 Super Hornets from Strike Fighter Squadron (VFA) 31, VFA-32, VFA-87, and
VFA-105 honor the late Sen. John McCain with a missing man formation flyover of
the U.S. Naval Academy during his burial service, Sept. 2, 2018. (U.S. Navy photo by
Mass Communication Specialist 2nd Class Nathan Burke.)
IN MEMORIAM

T he National Commission on Military Aviation Safety honors the military aviation professionals and other
servicemembers, civilians, and contractors who paid the ultimate sacrifice in U.S. military aviation mishaps
during the period of this Commission’s study. The following are the released names of those individuals as provided by the
military Departments.

Second Lieutenant David Samuel Albandoz, Puerto Rico Chief Warrant Officer 2 Stephen Travis Cantrell,
Air National Guard U.S. Army
First Lieutenant Kenneth Allen, U.S. Air Force Chief Warrant Officer 2 Alex Caraballo-Leon, U.S. Army
Mr. Ruslan Alymkulov, Civilian Captain Clayton Carpenter, U.S. Army
Master Sergeant Jean M. Audiffred-Rivera, Puerto Rico Mr. Carlos J. Carrasco, Contractor
Air National Guard Chief Warrant Officer 2 James J. Casadona, U.S. Army
First Lieutenant Kathryn M. Bailey, U.S. Army Sergeant First Class Toby A. Childers, U.S. Army
Corporal Daniel E. Baker, U.S. Marine Corps Master Sergeant Eric Circuns, Puerto Rico Air National
Corporal Daniel I. Baldassare, U.S. Marine Corps Guard
Captain Paul J. Barbour, U.S. Air Force Corporal Justin R. Clouse, U.S. Army
Lance Corporal Joshua E. Barron, U.S. Marine Corps Aircrewman Helicopter 3 Brian A. Collins, U.S. Navy

Staff Sergeant Marcus S. Bawol, U.S. Marine Corps Master Sergeant Victor J. Colon, Puerto Rico Air
National Guard
Captain Andrew Christopher Becker, U.S. Air Force
Staff Sergeant Cole Condiff, U.S. Air Force
Staff Sergeant Lance Jacob Bergeron, Louisiana Army
Chief Warrant Officer 3 Ryan Connelly, U.S. Army
National Guard
Chief Warrant Officer 3 Stephen B. Cooley, U.S. Army
Technical Sergeant Marty B. Bettelyoun, U.S. Air Force
First Lieutenant Clayton R. Cullen, U.S. Army
Staff Sergeant Steven P. Blass, U.S. Army
Captain Sara M. (Knutson) Cullen, U.S. Army
Staff Sergeant Trevor P. Blaylock, U.S. Marine Corps
Captain Brandon Lee Cyr, U.S. Air Force
Master Sergeant Mario Braña-Ortega, Puerto Rico Air
National Guard Captain Kenneth Stephen Dalga, U.S. Air Force

Captain Travis W. Brannon, U.S. Marine Corps Major Stephen Del Bagno, U.S. Air Force
Lieutenant Junior Grade Valerie C. Delaney, U.S. Navy
Staff Sergeant Dashan J. Briggs, U.S. Air Force
First Lieutenant Frederick Drew Dellecker, U.S. Air
Major James M. Brophy, U.S. Marine Corps
Force
Chief Warrant Officer 2 Kevin F. Burke, U.S. Army
Lance Corporal Matthew J. Determan, U.S. Marine
Mr. William Burnette, Contractor Corps
Sergeant Dwight W. Burns, U.S. Army Staff Sergeant Sean Samuel Devoy, U.S. Army
Major Shawn M. Campbell, U.S. Marine Corps Staff Sergeant Richard A. Dickson, U.S. Air Force

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National Commission on Military Aviation Safety

Mr. Ralph Dietz, Contractor Lance Corporal Jacob A. Hug, U.S. Marine Corps
Corporal Matthew R. Drown, U.S. Marine Corps Corporal Thomas J. Jardas, U.S. Marine Corps
Captain William H. Dubois Jr., U.S. Air Force Sergeant Ward M. Johnson IV, U.S. Marine Corps
Lieutenant Colonel Ira S. Eadie, U.S. Air Force Senior Airman Quinn Lamar Johnson-Harris, U.S. Air
Captain Sean E. Elliott, U.S. Marine Corps Force

Staff Sergeant Carl P. Enis, U.S. Air Force Lieutenant Commander Landon L. Jones, U.S. Navy
Captain Elizabeth R. Kealey, U.S. Marine Corps
Staff Sergeant Adam Erickson, U.S. Air Force
Staff Sergeant Kerry M. Kemp, U.S. Marine Corps
Senior Airman Roberto A. Espada-Gali, Puerto Rico Air
National Guard Captain Brian T. Kennedy, U.S. Marine Corps
Staff Sergeant Daniel N. Fannin, U.S. Air Force Lieutenant Colonel John M. Kincade, U.S. Air Force
Staff Sergeant Maximo A. Flores, U.S. Marine Corps Chief Warrant Officer 2 David C. Knadle, U.S. Army
Staff Sergeant Thomas C. Florich III, Louisiana Army Mr. Shane Krogen, Civilian
National Guard Master Sergeant Gregory T. Kuhse, U.S. Air Force
Staff Sergeant Liam A. Flynn, U.S. Marine Corps Captain Jeff M. Kuss, U.S. Marine Corps
Lieutenant Colonel Morris M. Fontenot Jr., Mr. Matthew LaCourse, GS-13
Massachusetts Air National Guard Staff Sergeant Jonathan E. Lewis, U.S. Marine Corps
Captain James E. Frederick, U.S. Marine Corps Chief Warrant Officer 2 Lucas M. Lowe, Texas Army
Chief Warrant Officer 2 Kirk T. Fuchigami Jr., U.S. National Guard
Army Captain Dustin R. Lukasiewicz, U.S. Marine Corps
Chief Warrant Officer 3 Taylor J. Galvin, U.S. Army Technical Sergeant Herman Mackey III, U.S. Air Force
Master Sergeant Joshua M. Gavulic, U.S. Air Force Mr. Alberto Marin, Contractor
Chief Warrant Officer 4 Stien P. Gearhart, Idaho Army Staff Sergeant Vincent P. Marketta, U.S. Army
National Guard
Mr. Kevin A. Mason, Contractor
Chief Warrant Officer 3 Jonathan S. Gibson, U.S. Navy
Technical Sergeant Dale E. Mathews, U.S. Air Force
Captain Jonathan Joseph Golden, U.S. Air Force
Chief Warrant Officer 3 Andrew L McAdams, U.S. Army
Master Sergeant Martin Gonzales, U.S. Air Force
Chief Warrant Officer 4 Jason W. McCormack, U.S.
Major Caine M. Goyette, U.S. Marine Corps Army
Captain John Francis Snavely Graziano, U.S. Air Force Staff Sergeant Jason A. McDonald, U.S. Army
Chief Warrant Officer 4 G. George Wayne Griffin Jr., Lieutenant Junior Grade William B. McIlvaine III, U.S.
Louisiana Army National Guard Navy
Chief Warrant Officer 3 James E Groves III, U.S. Army Corporal Sara A. Medina, U.S. Marine Corps
Major Lucas F. Gruenther, U.S. Air Force Staff Sergeant Abigail R. Milam, U.S. Army
Staff Sergeant Ryan David Hammond, U.S. Air Force Chief Warrant Officer 3 Dustin L. Mortenson, Texas
Lance Corporal Steven M. Hancock, U.S. Marine Corps Army National Guard
Lance Corporal Ty L. Hart, U.S. Marine Corps Captain Reid B. Nannen, U.S. Marine Corps
Chief Warrant Officer 4 Jon L. Hartway, Idaho Army Sergeant Michael L. Nelson, U.S. Army
National Guard Captain Reid Kijiro Nishizuka, U.S. Air Force
Sergeant Justin R. Helton, U.S. Army Mr. Kristopher L. Noble, Contractor
Chief Warrant Officer 2 Bryan J. Henderson, U.S. Army Chief Warrant Officer 2 Charles P. Nord, Minnesota
Lieutenant Colonel Kevin R. Herrmann, U.S. Marine Army National Guard
Corps Captain Christopher L. Norgren, U.S. Marine Corps

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 In Memoriam

Major Richard S. Norton, U.S. Marine Corps Staff Sergeant Marc A. Scialdo, U.S. Army
Technical Sergeant Timothy A. Officer Jr., U.S. Air Force Sergeant Drew M. Scobie, U.S. Army
Captain Andreas B. O’Keeffe, U.S. Air Force Sergeant Eric M. Seaman, U.S. Marine Corps
Corporal Christopher J. Orlando, U.S. Marine Corps Staff Sergeant Andrew C. Seif, U.S. Marine Corps
Senior Master Sergeant Jan A. Paravisini-Ruiz, Puerto Sergeant Dillon J. Semolina, U.S. Marine Corps
Rico Air National Guard
Sergeant Jeffrey A. Sempler, U.S. Marine Corps
Lieutenant Commander Alan A. Patterson, U.S. Navy
Specialist Zachary L. Shannon, U.S. Army
Major Phyllis J. Pelky, U.S. Air Force
Major Stanford H. Shaw III, U.S. Marine Corps
Major Carlos Perez-Serra, Puerto Rico Air National
Guard Sergeant Tyler M. Shelton, U.S. Army
Captain Ryan S. Phaneuf, U.S. Air Force Lieutenant Christopher C. Short, U.S. Navy
Captain Jordan Pierson, U.S. Air Force Chief Warrant Officer 3 Jacob M. Sims, U.S. Army
Captain Victoria A. Pinckney, U.S. Air Force Chief Warrant Officer 3 Brandon A. Smith, U.S. Army
Sergeant Kort M. Plantenberg, Minnesota Army National Sergeant First Class Jason M. Smith, U.S. Army
Guard Technical Sergeant Mark A. Smith, U.S. Air Force
Lieutenant Nathan Poloski, U.S. Marine Corps Lieutenant Sean C. Snyder, U.S. Navy
Sergeant Afton M. Ponce, U.S. Air Force Corporal Jordan L. Spears, U.S. Marine Corps
Master Sergeant William R. Posch, U.S. Air Force Captain James Michael Steel, U.S. Air Force
Master Sergeant Christopher J. Raguso, U.S. Air Force Captain Christopher S. Stover, U.S. Air Force
Chief Warrant Officer 4 Paul J. Reidy, U.S. Army Chief Warrant Officer 4 George David Strother,
Captain Jahmar F. Resilard, U.S. Marine Corps Louisiana Army National Guard
Staff Sergeant Emil Rivera-Lopez, U.S. Army Staff Sergeant Scott R. Studenmund, U.S. Army
Captain Kevin T. Roche, U.S. Marine Corps Chief Warrant Officer 3 Michael F. Tharp, U.S. Army
Chief Warrant Officer 2 James A. Rogers Jr., Minnesota Specialist Jeremy D. Tomlin, U.S. Army
Army National Guard
Private Second Class Andrew Toppen, U.S. Army
Major José R. Román-Rosado, Puerto Rico Air National
Captain Steven R. Torbert, U.S. Marine Corps
Guard
Sergeant William J. Turner, U.S. Marine Corps
Corporal William C. Ross, U.S. Marine Corps
Captain Sean M. Ruane, U.S. Air Force Lieutenant J. Wesley Van Dorn, U.S. Navy

Chief Warrant Officer 3 Matthew P. Ruffner, Captain Mark T. Voss, U.S. Air Force
Pennsylvania Army National Guard Lieutenant Colonel Paul K. Voss, U.S. Air Force
Mr. Christopher J. Ruiz, Contractor Lieutenant Charles Z. Walker, U.S. Navy
Airman First Class Kcey Elena Ruiz, U.S. Air Force Captain Mark K. Weber, U.S. Air Force
Major Taj Sareen, U.S. Marine Corps Chief Warrant Officer 2 Kevin M. Weiss, U.S. Army
Senior Airman Nathan Cole Sartain, U.S. Air Force Major Matthew M. Wiegand, U.S. Marine Corps
First Lieutenant Adam C. Satterfield, U.S. Marine Corps Second Lieutenant Travis B. Wilkie, U.S. Air Force
Master Sergeant Thomas Arthur Vaughan Saunders, U.S. Chief Warrant Officer 3 Brian Marshall Woeber, U.S.
Marine Corps Army
First Lieutenant David John Schmitz, U.S. Air Force Chief Warrant Officer 2 Jarett M. Yoder, Pennsylvania
Sergeant Adam C. Schoeller, U.S. Marine Corps Army National Guard
Lieutenant Colonel Eric Schultz, U.S. Air Force Captain Christopher T. Zanetis, U.S. Air Force

69
National Commission on Military Aviation Safety

An Air Force F-22 Raptor from the 95th Fighter Squadron,

Tyndall Air Force Base, Florida, flies over Tallinn, Estonia.
70 (U.S. Air Force photo by TSgt. Jason Robertson.)
Appendix A:

CONGRESSIONAL CHARTER
FOR THE NATIONAL
COMMISSION ON MILITARY
AVIATION SAFETY

John S. McCain National Defense Authorization Act for Fiscal Year 2019

SEC. 1087. NATIONAL COMMISSION ON MILITARY AVIATION SAFETY.

(a) ESTABLISHMENT; PURPOSE.—

(1) ESTABLISHMENT.—There is established the National Commission on Military Aviation Safety (in this section
referred to as the ‘‘Commission’’). The Commission shall be considered an independent establishment of the
Federal Government as defined by section 104 of title 5, United States Code, and a temporary organization under
section 3161 of such title.
(2) PURPOSE.—The purpose of the Commission is to examine and make recommendations with respect to certain
United States military aviation mishaps.

(b) MEMBERSHIP.—
(1) COMPOSITION.—The Commission shall be composed of eight members, of whom—
(A) four shall be appointed by the President;
(B) one shall be appointed by the Chairman of the Committee on Armed Services of the Senate;
(C) one shall be appointed by the Ranking Member of the Committee on Armed Services of the Senate;
(D) one shall be appointed by the Chairman of the Committee on Armed Services of the House of Representatives;
and
(E) one shall be appointed by the Ranking Member of the Committee on Armed Services of the House of
Representatives.
(2) APPOINTMENT DATE.—The appointments of the members of the Commission shall be made not later than
90 days after the date of the enactment of this Act.
(3) EFFECT OF LACK OF APPOINTMENT BY APPOINTMENT DATE. — If one or more appointments under
subparagraph (A) of paragraph (1) is not made by the appointment date specified in paragraph (2), the authority
to make such appointment or appointments shall expire, and the number of members of the Commission shall be

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National Commission on Military Aviation Safety

reduced by the number equal to the number of appointments so not made. If an appointment under subparagraph
(B), (C), (D), or (E) of paragraph (1) is not made by the appointment date specified in paragraph (2), the authority
to make an appointment under such subparagraph shall expire, and the number of members of the Commission
shall be reduced by the number equal to the number otherwise appointable under such subparagraph.
(4) EXPERTISE.—In making appointments under this subsection, consideration should be given to individuals with
expertise in military aviation training, aviation technology, military aviation operations, aircraft sustainment and
repair, aviation personnel policy, aerospace physiology, and reserve component policy.
(5) PERIOD OF APPOINTMENT; VACANCIES.— Members shall be appointed for the life of the Commission.
Any vacancy in the Commission shall not affect its powers but shall be filled in the same manner as the original
appointment.
(6) CHAIR AND VICE CHAIR.—The Commission shall select a Chair and Vice Chair from among its members.
The Chair may not be a Federal officer or employee.
(7) STATUS AS FEDERAL EMPLOYEES.—Notwithstanding the requirements of section 2105 of title 5, United
States Code, including the required supervision under subsection (a)(3) of such section, the members of the
Commission shall be deemed to be Federal employees.
(8) PAY FOR MEMBERS.—
(A) IN GENERAL.—Except for the Chair, each member of the Commission who is not an officer or employee
of the Federal government shall be paid at a rate equal to the daily equivalent of the annual rate of basic pay
payable for level IV of the Executive Schedule under section 5315 of title 5, United States Code, for each day
(including travel time) during which the member is engaged in the actual performance of duties vested in the
Commission. All members of the Commission who are officers or employees of the United States shall serve
without compensation in addition to that received for their services as officers or employees of the United
States.
(B) CHAIR.—The Chair of the Commission shall be paid at a rate equal to the daily equivalent of the annual rate
of basic pay payable for level III of the Executive Schedule under section 5314, of title 5, United States Code,
for each day (including travel time) during which the member is engaged in the actual performance of duties
vested in the Commission.
(C) TRAVEL EXPENSES.—The members of the Commission shall be allowed travel expenses, including per diem
in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5,
United States Code, while away from their homes or regular places of business in the performance of services
for the Commission.

(c) ADDITIONAL STAFF.—

(1) EXECUTIVE DIRECTOR.—
(A) APPOINTMENT.—The Commission shall appoint and fix the rate of basic pay for an Executive Director in
accordance with section 3161 of title 5, United States Code.
(B) LIMITATIONS.—The individual appointed to serve as Executive Director may not have served on active
duty in the Armed Forces or as a civilian employee of the Department of Defense during the one-year period
preceding the date of such appointment.
(2) COMMISSION STAFF.—The Executive Director, with the approval of the Commission, may appoint and fix
the rate of basic pay for additional personnel as staff of the Commission in accordance with section 3161 of title 5,
United States Code.
(3) DETAILEES.—Not more than half of the personnel employed by or detailed to the Commission may be on detail
from the Department of Defense and other Federal departments or agencies.

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 Appendix A: Congressional Charter for the National Commission on Military Aviation Safety

(d) MEETINGS.—
(1) IN GENERAL.—The Commission shall meet at the call of the Chair.
(2) INITIAL MEETING. — Not later than 30 days after the date on which all members of the Commission are
required to have been appointed under subsection (b)(2), the Commission shall hold its initial meeting.
(3) QUORUM.—A majority of the members of the Commission shall constitute a quorum, but a lesser number of
members may hold hearings.

(e) SPACE FOR COMMISSION.—Not later than 90 days after the date of the enactment of this Act, the Administrator
of General Services, in consultation with the Secretary of Defense, shall identify and make available suitable excess space
within the Federal space inventory to house the operations of the Commission. If the Administrator is not able to make
such suitable excess space available within such 90-day period, the Commission may lease space to the extent that funds
are available for such purpose.

(f ) CONTRACTING AUTHORITY.—The Commission may enter into contracts for the acquisition of administrative
supplies and equipment for use by the Commission, to the extent that funds are available for such purpose.

(g) PROCUREMENT OF TEMPORARY AND INTERMITTENT SERVICES.—The Chair of the Commission

may procure temporary and intermittent services under section 3109(b) of title 5, United States Code, at rates for
individuals which do not exceed the daily equivalent of the annual rate of basic pay prescribed for level V of the
Executive Schedule under section 5316 of such title.

(h) DUTIES.—
(1) STUDY ON MILITARY AVIATION SAFETY.— The Commission shall undertake a comprehensive study of
United States military aviation mishaps that occurred between fiscal years 2013 and 2018 in order—
(A) to assess the rates of military aviation mishaps between fiscal years 2013 and 2018 compared to historic
aviation mishap rates;
(B) to make an assessment of the underlying causes contributing to the unexplained physiological effects;
(C) to make an assessment of causes contributing to delays in aviation maintenance and limiting operational
availability of aircraft;
(D) to make an assessment of the causes contributing to military aviation mishaps; and
(E) to make recommendations on the modifications, if any, of safety, training, maintenance, personnel, or other
policies related to military aviation safety.
(2) REPORT.—Not later than March 1, 2020, the Commission shall submit to the President and the congressional
defense committees a report setting forth a detailed statement of the findings and conclusions of the Commission
as a result of the study required by paragraph (1), together with the recommendations of the Commission for such
legislative and administrative actions as the Commission considers appropriate in light of the results of the study.

(i) POWERS.—
(1) HEARINGS.—The Commission may hold such hearings, sit and act at such times and places, take such testimony,
and receive such evidence as the Commission considers advisable to carry out its duties under this subtitle.
(2) INFORMATION FROM DEPARTMENT.—The Commission may secure directly from any element of the
Department of Defense such information as the Commission considers necessary to carry out its duties under this
subtitle. Upon request of the Chair of the Commission, the head of such element shall furnish such information to
the Commission.

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National Commission on Military Aviation Safety

(j) PROTECTION OF PRIVILEGED SAFETY INFORMATION.—

(1) REQUEST OF INFORMATION.—The Commission may request privileged safety information from the
Department of Defense.
(2) TREATMENT OF INFORMATION.—Any privileged safety information provided to the Commission by the
Department of Defense shall be handled by the Commission as though the Commission were a non-Department
of Defense Federal Government agency under Enclosure 5, Section 8, of Department of Defense Instruction
6055.07, Mishap Notification, Investigation, Reporting, and Record Keeping.
(3) PROHIBITION ON USE OF INFORMATION IN PUBLIC HEARINGS.—No privileged safety information
shall be allowed in any public hearing of the Commission. The Commission may only consider privileged safety
information in camera, and no record of the proceedings of the Commission may include privileged safety
information.
(4) PROHIBITION ON PUBLICATION.—Any privileged safety information secured by the Commission from the
Department of Defense—
(A) may not be published or revealed to anyone outside the Commission;
(B) may not be retained but shall be returned to the originating Department of Defense organization; and
(C) may not be included in any Commission report.
(5) USE OF AGGREGATED DATA.—Aggregated data based on privileged safety information or information that
has been completely sanitized in accordance with Department of Defense Instruction 6055.07, such that individual
mishaps are not identifiable, may be included in the report produced by the Commission.
(6) DEFINITION OF PRIVILEGED SAFETY INFORMATION.—In this subsection, the term ‘‘privileged safety
information’’ has the meaning given it in Department of Defense Instruction 6055.07, dated June 6, 2011.

(k) TERMINATION.—The Commission shall terminate 90 days after the date on which the Commission submits the
report required under subsection (h)(2).

(l) AUTHORIZATION OF APPROPRIATIONS.—Of the amounts authorized to be appropriated for fiscal year 2019,
as identified in division D of this Act, $5,000,000 shall be available for the National Commission on Aviation Safety.

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 Appendix A: Congressional Charter for the National Commission on Military Aviation Safety

National Defense Authorization Act for Fiscal Year 2020

SEC. 1738. NATIONAL COMMISSION ON MILITARY AVIATION SAFETY.

(a) Extension of Deadline for Report.—Subsection (h)(2) of section 1087 of the John S. McCain National Defense
Authorization Act for Fiscal Year 2019 (Public Law 115-232) is amended by striking “March 1, 2020’’ and inserting
“December 1, 2020’’.

(b) Secretary of Defense Report.—Such section is further amended by adding at the end the following new subsection:
“(m) Report to Congress.—Not later than 120 days after the date of the submittal of the
report under subsection (h)(2), the Secretary of Defense, in coordination with the Secretary
of each of the military departments, shall submit to the Committees on Armed Services of
the Senate and House of Representatives a report that includes each of the following:
(1) An assessment of the findings and conclusions of the Commission.
(2) The plan of the Secretaries for implementing the recommendations of the Commission.
(3) Any other actions taken or planned by the Secretary of Defense or the Secretary of any
of the military departments to improve military aviation safety.’’

(c) Authorization of Appropriations.—In addition to any other amounts authorized to be appropriated for the National
Commission on Military Aviation Safety established under section 1087 of the John S. McCain National Defense
Authorization Act for Fiscal Year 2019 (Public Law 115-232), of the amounts authorized to be appropriated for
Operation and Maintenance, Defense-wide for fiscal year 2020, as specified in the funding table in section 4301,
$3,000,000 shall be available for the National Commission on Aviation Safety.

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National Commission on Military Aviation Safety

A-6
Appendix B:

RECOMMENDATIONS
Chapter 4: The Joint Safety Council
The Department of Defense must establish aviation safety responsibilities within the Office of the Secretary of Defense
to ensure sufficient status, experienced and highly qualified personnel, and adequate funding to be effective in preventing
injury, death, and damage. The following recommendations will create a coordinated, robust, proactive, data-driven aviation
safety program that incorporates the best aviation safety practices from all relevant sources to become effectively predictive
and preventive instead of reactive.
The Commission recommends:
4.1 Congress mandate, authorize, and fund the creation of a Joint Safety Council that reports to the Deputy
Secretary of Defense. The Joint Safety Council would support and coordinate the capability of the Services’
safety centers to identify and mitigate safety risks to reduce the number of aviation mishaps. The Joint Safety
Council must be fully funded, staffed, and charged with developing and overseeing Defense-wide safety policies
for the Secretary of Defense. It must have funding as a program element and unlimited access to the requisite
databases.

4.2 The Joint Safety Council oversee the Services’ implementation of robust Safety Management Systems that
include programs such as MFOQA (military flight operations quality assurance), LOSA (line operations safety
assessment), HUMS (health and usage monitoring system), and CVFDR (cockpit voice and image flight data
recorders) from aircraft; SOQA (simulator operational quality assurance) from simulators; in-flight physiological
data from aviators; and ASAP (aviation safety action programs) from aviators and maintainers. These programs
should be based on best practices from commercial and military enterprises.

4.3 The Joint Safety Council set the requirements for mishap investigations in each of the Services to include the
same Human Factors Analysis and Classification System (HFACS) codes for all Class A, B, and C mishaps. The
Secretary of Defense will mandate that Class C mishap investigations use DoD reporting standards and data
collection fields including HFACS codes.

4.4 That members of the Joint Safety Council will be the military Departments’ chiefs of safety, all of whom should
be the grade of O-8, and an additional representative from each of the military Services. The chair, selected
among the military Departments’ chiefs of safety every two years, would serve in a dual-hatted role as the
Department of Defense’s Director of Aviation Safety. The vice chair should be a career Senior Executive Service
position appointed by the Secretary of Defense. The vice chair’s responsibilities should be focused entirely on the
mission and activities of the Joint Safety Council. The vice chair will report to the chair.

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National Commission on Military Aviation Safety

Chapter 5: The Human/Machine Interface

With modern aviation machines placing unprecedented stress on human physiology, the Department of Defense and
the Services must adopt an aggressive, proactive approach to understanding the physiological needs of aviators and to
developing additional capabilities that improve the human-machine interface, including aircraft and cockpit design, testing,
and subsequent modifications.
The Commission recommends:
5.1 The Joint Safety Council (Commission recommendation on page 27) lead a robust review into the effects on
humans in aviation operational environments, including physiological episodes. The JSC shall have a program
element to conduct further research into determining and mitigating unexplained physiological episodes.

5.2 Program offices address human physiology concerns and analyze physiological effects throughout the aircraft
testing phases for T-7, B-21, Future Vertical Lift, and other next-generation platforms early in the initial aircraft
and cockpit design and with any materiel modification of the aircraft.

5.3 The Department of Defense and the Services develop physiological standards for each airframe to use in
screening and training to ensure that the pilot/operator is able to successfully perform at optimal levels across the
spectrum of the weapon system’s capabilities.

5.4 The Department of Defense, with input from each of the safety centers, update and modify the Force Protection
key performance parameters (KPP) to better incorporate Aviation Human Systems Safety.

5.5 That the Force Protection Functional Capability Board include representative capabilities such as ground and
other aircraft collision avoidance; cockpit voice and flight data recording; biometric sensing for aircrew; and a
spatial disorientation recovery system used for instrument meteorological conditions and brownout.

Chapter 6: Sustaining the Machine

The Department of Defense and Services must improve their planning, contracting, and program management processes to
ensure timely availability of spare parts, improve maintenance efficiency, increase mission capable rates, and better sustain
the investment made in aircraft. The Services should improve sustainment management systems, particularly for legacy
aircraft and service life extensions, to provide the necessary visibility on expiring parts and production upgrades.

Chapter 7: The Need for Consistent Predictable Funding

Congress and the administration must recognize that consistent, reliable, and timely funding is key to sustaining military
aviation readiness and safety.
The Commission recommends:
7.1 Congress and the administration ensure predictable and reliable funding for military aviation and stop using
continuing resolutions to fund national security, military readiness, and aviation safety.

7.2 Congress task the Congressional Budget Office to study and report on the negative impacts of continuing
resolutions on military aviation readiness and safety.

B-2
 Appendix B: Recommendations

Chapter 8: The Demand Environment

Policy at all levels must reflect that aviation is a high-demand, low-density specialty with routinely insufficient capacity to
satisfy all of the demand placed on it. This has overextended the aviation force beyond sustainable levels, resulting in chronic
fatigue and burnout, which negatively impacts retention. The current high demand is forcing the Services to shortchange
safety to accomplish current missions. The Services must increase aviator and maintainer capacity, reduce additional duties,
and focus on proficiency to mitigate the risk.
The Commission recommends:
8.1 The Services ensure aviation units have sufficient administrative personnel to allow aviators and maintainers to
concentrate on their primary mission, sustain currency and proficiency, and meet the unit’s mission readiness rates.

8.2 The Department of Defense and the Services report aviation unit’s personnel experience levels and member
PERSTEMPO.

8.3 The Department of Defense and the Services require that proper policies, practices, staffing, and all other
necessary resources are in place to ensure that the military’s high demand/low density aviation units always are
fully prepared and standing ready to perform at levels commensurate with the critical and unique role they
perform in securing and maintaining our nation’s security.

Chapter 9: Maintainers as Aviation Professionals

Because of the significant investment in time and resources required to train and sustain fully qualified military aviation
maintainers, and a commercial marketplace competing for such high-demand talent, Congress, the Department of Defense,
and the Services must regard and manage aviation maintainers as a specialty and their training as a career-long pursuit.
The Services must develop personnel management processes and career paths that account for the complexities of aviation
and support aviation safety, readiness, and OPTEMPO. DoD and the Services must execute the following measures to
recognize achievement and enable aviation professionals to focus on their flight line duties, sustain their skills, and promote
advancement of their proficiencies.
The Commission recommends:
9.1 The Services mandate and enforce assignments and performance evaluation guidance that focus aviation
maintainers primarily on areas of performing, sustaining, and advancing their aviation professional skills,
knowledge, and experience. The Services must discourage using aviation professionals for assignments and
additional duties unrelated to their aviation-related warfighting fitness, skills requirements, or essential
supervisory responsibilities. DoD and the Services should reduce mandated, nonaviation-related ancillary
training to the minimum.

9.2 The Services experiment with technical specialty enlisted ranks for aviation maintenance personnel that include
unique career paths to ensure that maintenance personnel achieve and are able to sustain the highest level of
proficiency and professionalism.

9.3 The Services reward and incentivize the professional achievements of aviation maintainers with recognition and
professional development throughout their careers.

a. The Services should establish aviation maintenance proficiency badges or credentials that would recognize
and incentivize excellence in aviation maintainers and empower supervisors with support from leaders at
the unit level to keep aviation maintainers focused on their primary flight line responsibilities.

b. The Services should institute a tuition-paid A&P (Airframe and Powerplant) license option in return for
an extended enlisted commitment meeting a cost/benefit threshold.

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National Commission on Military Aviation Safety

9.4 The Services implement policies and training for transitioning maintainers among platforms that require and
certify proficiency, promote retention, and leverage experience for both legacy and new platforms.

Chapter 10: Protecting Investment in Aircrews

Because of the significant investment in time and resources required to train and sustain fully qualified military aviation
personnel, and a commercial marketplace competing for such high-demand talent, Congress, the Department of Defense,
and the Services must regard and manage aircrews as a specialty and their training as a career-long pursuit. The Services
must develop personnel management processes that account for the complexities of aviation and support aviation safety,
readiness, and the demands of OPTEMPO. Congress and the Services must execute the following measures to focus
aviation professionals on their flying duties, sustain their skills, and promote advancement of their proficiencies.
The Commission recommends:
10.1 The Services mandate and enforce assignments and performance evaluation guidance that focus aircrews
primarily on areas of performing, sustaining, and advancing their aviation professional skills, knowledge, and
experience. The Services must discourage using aircrews for assignments and additional duties unrelated to their
aviation-related warfighting fitness, skills requirements, or essential supervisory responsibilities. DoD and the
Services should reduce nonaviation-related ancillary training to the minimum.

10.2 The Services restore flight hours to not less than fiscal year 2010 levels for schoolhouse and operational units.

10.3 The Services centrally track waivers, create a baseline, and monitor them to identify trends, assess risk, and
predict potential problems and resource shortfalls.

10.4 Congress grant the Services standing authority to increase the aviation bonuses from up to $35,000 to up to
$100,000 per year to retain pilots in exchange for a commensurate additional service commitment.

10.5 The Services upgrade data collection to improve training programs and training tool selections that better
measure student learning. Data collection must include classroom, pilot task training, full-motion simulators,
and flying training plus feedback from the field as a measure of training efficacy.

10.6 The Services link simulator sustainment to aircraft production, upgrades, and modifications and have the same
operational flight plan as the aircraft. The Department of Defense and the Services must eliminate software and
system upgrade lags that hamper simulator training.

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Appendix C:

COMMISSIONERS AND STAFF

Commissioners

General Richard A. Cody (USA, Retired)

Chairman, National Commission on Military Aviation Safety
General Richard Cody recently retired from L3 Technologies, which he joined in 2008 after concluding a 36-year U.S.
Army career with four years as Vice Chief of Staff of the Army.
A Master Aviator with over 5,000 hours of flight time, General Cody served in several command and staff assignments,
including Deputy Chief of Staff for Operations (G-3); Commanding General of the 101st Airborne Division (Air Assault);
Director of Operations, Readiness, and Mobilization in the Office of the Deputy Chief of Staff for Operations and Plans,
Department of the Army; Deputy Commanding General of Task Force Hawk in Tirana, Albania; Commander of the
160th Special Operations Aviation Regiment; Commander of 4th Brigade, 1st Cavalry Division; Aide-de-Camp to the
Commanding General of the Combined Field Army, Korea; and Director of Flight Concepts Division.
He is Chairman of the Board for Homes For Our Troops, which builds mortgage-free custom homes for severely
wounded war veterans.
A graduate of the Military Academy at West Point, General Cody’s professional military education includes the
Transportation Corps Officer Basic and Advanced Courses; the Aviation Maintenance Officer Course; AH-1, AH-64,
AH-64D, UH-60, and MH-60K Aircraft Qualification Courses; Command and General Staff College; and the Army War
College.

The Honorable Richard F. Healing

Vice Chairman, National Commission on Military Aviation Safety
Mr. Richard Healing is a professional engineer and internationally recognized transportation safety expert who founded Air
Safety Engineering LLC in 2015, a company that provides safety analysis and solutions in general, military, and commercial
aviation.
He served as a Board Member of the National Transportation Safety Board, holding the Safety Engineering position and
providing technical inputs on several transportation accident investigations from 2003 to 2005. As Director of Safety and
Survivability for the Department of the Navy from 1985 to 2002, he worked on aviation safety and developed initiatives to
rapidly bring state-of-the-art safety and survivability technology into the Navy and Marine Corps.
Mr. Healing retired as a captain from the U.S. Coast Guard Reserve in 1993. During his 32-year combined active and
reserve Coast Guard career, he held four commands, including a coastal patrol boat on combat missions in Vietnam from
1966 to 1967 and, prior to his retirement, the Secretary of Defense Crisis Coordination Center Joint Reserve Unit in the
Pentagon during Operations Desert Shield and Desert Storm.
Mr. Healing attended the U.S. Coast Guard Academy and graduated from Worcester Polytechnic Institute. He
graduated from the Naval War College and was a Senior Executive Fellow at Harvard University.

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National Commission on Military Aviation Safety

The Honorable Scott C. Donnelly

Commissioner, National Commission on Military Aviation Safety
Mr. Scott Donnelly is the Chairman, Chief Executive Officer, and President of Textron Inc. He has more than two decades
of business experience in innovation, manufacturing, sales and marketing, business processes, research and development,
design engineering, and industrial systems control.
Mr. Donnelly joined General Electric and spent 20 years leading the design and development of GE products in
aerospace, industrial systems, health care, and aircraft engines. He started his career in the aerospace and semiconductor
industries as a design engineer developing advanced computer architectures and devices for special-purpose processors
and systems. In 1995, he moved to GE’s Industrial Control Systems business as Manager of Technology and System
Development. He advanced through management positions across GE’s divisions, including Vice President of Global
Technology Operations for GE Medical Systems, Senior Vice President and Director of Global Research, and President and
Chief Executive Officer for GE Aviation.
Mr. Donnelly joined Textron in 2008, serving as the Chief Operating Officer prior to becoming the company’s CEO.
Mr. Donnelly has been active in many industry associations. In 2010, he served as chairman of the Aerospace Industries
Association’s board of governors.
Mr. Donnelly attended the University of Colorado and graduated with a bachelor’s degree in electrical and computer
engineering in 1984.

The Honorable Preston Geren

Commissioner, National Commission on Military Aviation Safety
Mr. Preston “Pete” Geren, who served in the U.S. Congress and at the highest levels of the Department of Defense, is
president of the Sid W. Richardson Foundation, which provides grants to educational, health, human service, and cultural
nonprofit organizations in Texas. He assumed that position in 2011.
Mr. Geren’s Department of Defense career included several senior positions from 2001 to 2009, including Special
Assistant to the Secretary of Defense, Acting Secretary of the Air Force, Under Secretary of the Army, and Secretary of the
Army. In recognition of his service, he was twice awarded the Distinguished Civilian Service Award, the Department of
Defense’s highest civilian award.
The 12th District of Texas elected Mr. Geren to four terms in the U.S. House of Representatives from 1989 to 1997.
He was also an assistant to U.S. Senator Lloyd Bentsen. As a lawyer and former business executive, he has held leadership
positions in numerous civic, educational, business, and philanthropic organizations in Texas.
He earned his Doctor of Jurisprudence at the University of Texas Law School and his Bachelor of Arts in history at the
University of Texas at Austin. He studied architecture at Georgia Tech before transferring to the University of Texas.

The Honorable Joseph W. Hagin

Commissioner, National Commission on Military Aviation Safety
Mr. Joseph Hagin was Deputy Chief of Staff for Operations for President Donald Trump from 2017 to 2018 and for
President George W. Bush from 2001 to 2008. He served in that role longer than any other member of the White House
senior staff.
Among his many duties was responsibility for White House communications, logistics, Air Force One operations, and
security for President George W. Bush and President George H.W. Bush. He oversaw the activities of 4,000 civilian and
military personnel. As Deputy Chief of Staff, Mr. Hagin traveled with the president and has interacted with world and
business leaders around the globe.
Mr. Hagin was Chief Executive Officer at Jet Support Services Inc. from 2008 to 2009 and has held senior management
positions at Chiquita Brands and Federated Department Stores. He has been chairman of SMobile International Advisory
Board since August 2008 and was chairman of SMobile Corporation from 2008 to 2010.
Mr. Hagin serves on the Board of Directors of SMobile Systems, Jet Support Services Inc., The Franklin Mint, and
Fox Factory Inc. He was a director of Fox Factory Holding Corp from 2013 to 2016. He holds a Bachelor of Arts degree in
economics from Kenyon College.

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 Appendix C: Commissioners and Staff

General Raymond E. Johns (USAF, Retired)

Commissioner, National Commission on Military Aviation Safety
General Ray Johns recently retired from FlightSafety International serving as Co-CEO and President of Government and
Manufacturing following a 36-year career in the U.S. Air Force. A test pilot, including chief test pilot and test program
manager for the VC-25 Air Force One, he has over 5,000 hours in more than 83 different aircraft.  
He concluded his military career as Commander of Air Mobility Command, overseeing 135,000 personnel, 1,300
aircraft, and an annual operating budget of $20 billion. Previously, he was Air Force Deputy Chief of Staff for Strategic
Plans and Programs, developing, integrating, and analyzing the Air Force’s annual $120 billion budget, the Future Years
Defense Program, and Air Force Long-Range Plan.
General Johns has served in senior strategy, planning, and fiscal policy positions at U.S. European
Command and U.S. Pacific Command. He was a White House Fellow in the Office of National Service working on the
Points of Light initiative for President George H.W. Bush.
General Johns received a Bachelor of Science degree in aeronautical engineering from the Air Force Academy and
a Master of Science degree in administration from Central Michigan University. He is a graduate of the U.S. Air Force
Test Pilot School, the Industrial College of the Armed Forces, and the John F. Kennedy School of Government at Harvard
University. 

The Honorable Dabney Kern

Commissioner, National Commission on Military Aviation Safety
Mr. Dab Kern is Senior Vice President for Corporate Homeland and National Defense at CACI International Inc. He
served 20 years in the U.S. Navy as a pilot with a space subspecialty, a career that led to several government posts.
He served as Director of the White House Military Office and Deputy Assistant to the President from 2014 to 2017,
combining nearly 3,000 personnel in over 20 commands and directorates, including the White House Communications
Agency, Presidential Airlift Group (which operates Air Force One and other associated platforms), Marine Helicopter
Squadron One (with 22 rotary platforms including the V-22 Osprey and Marine One), the White House Medical Unit,
and Camp David. He was Senior Director for Response and Recovery Policy at the National Security Council from 2009 to
2011.
He spent the last seven years of his Navy career in national security appointments in the White House and the
Department of Homeland Security, including Director of Homeland Security’s Mt. Weather Emergency Operations Center
from 2005 to 2009.
Mr. Kern studied information systems management, computer, and military science at Jacksonville University. He has
degrees in information technology management from the Naval Postgraduate School and maritime security from the Naval
War College.

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National Commission on Military Aviation Safety

National Commission on Military Aviation Safety Staff

Major General Gregory A. Feest (USAF, Retired)

Executive Director, National Commission on Military Aviation Safety
Major General Greg Feest concluded his 34-year U.S. Air Force career as Commander of the Air Force Safety Center and Air
Force Chief of Safety. He since has worked at L3 Technologies as Vice President of USAF Programs and at Lockheed Martin’s
Advanced Development Programs (Skunk Works) as Deputy Director of Operations, Business, and Strategy Development.
A command pilot with over 5,600 flying hours, more than 800 in combat operations, Major General Feest has
commanded at all levels, including an F-117A stealth fighter squadron, the 379th Air Expeditionary Wing in Southwest
Asia, and 19th Air Force, the largest numbered Air Force with over 38,000 personnel, 1,500 aircraft, and 27 bases.
With Air Education and Training Command, he served as Director of Logistics, Installations, and Mission Support and
as Deputy Director of Operations for all Air Force flying training.
He graduated from the University of Wisconsin, Madison, with a Business Administration degree in finance and
management. He has an MBA in management and a Master of Science in national security strategy from the National
War College. He attended the Systems Acquisition Management General Officer Course, the Syracuse University National
Security Management Course, and Harvard University’s John F. Kennedy School of Government.

Carvell Akuffo Research Assistant Kevin D. Mickie Human Resources

Destini Berry Operations Analyst Eric Minton Editor
Michael J. Blaine Executive Assistant Laurel Prucha Moran Graphic Designer
Corey Bradley Deputy General Charles Risio Research Analyst
Counsel
Chad Schumacher Congressional Liaison
Cody Cheek Deputy General
Counsel Ray B. Shepherd Director of Research
and Analysis
Amy Grace P. Donohue Deputy Editor
Clark D. Frederick Research Analyst Leslie H. Smith Staff Director,
Director of Operations
Jamie Hammon Finance and Budget
Administrator Marian Veld Librarian

Denise Jade Hlavaty Public Outreach Bryan G. Whitman Director of Government

Specialist and Public Engagement
Madison Ianniello Research Assistant Stefan R. Wolfe General Counsel

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Appendix D:

COMMISSION ENGAGEMENTS

Military Organizations 143rd Airlift Wing, Rhode Island Air National Guard,
Providence, Rhode Island
1/25th Aviation Regiment, Fort Wainwright, Alaska
150th Special Operations Wing, New Mexico Air
1/52nd Aviation Regiment, Fort Wainwright, Alaska National Guard, Kirtland Air Force Base, New Mexico

101st Airborne Division, Fort Campbell, Kentucky 154th Wing, Hawaii Air National Guard, Joint Base
Pearl Harbor-Hickam, Hawaii
104th Fighter Wing, Massachusetts Air National
Guard, Barnes Air National Guard Base, Westfield, 157th Air Refueling Wing, New Hampshire Air National
Massachusetts Guard, Portsmouth, New Hampshire

108th Wing, New Jersey Air National Guard, Joint Base 15th Fighter Wing, Joint Base Pearl Harbor-Hickam,
McGuire-Dix-Lakehurst, New Jersey Hawaii

110th Aviation Brigade, Fort Rucker, Alabama 160th Special Operations Aviation Regiment, Fort
Campbell, Kentucky; Joint Base Lewis-McChord,
115th Fighter Wing, Wisconsin Air National Guard, Washington
Madison, Wisconsin
16th Combat Aviation Brigade, Joint Base Lewis-
11th Air Force, Joint Base Elmendorf-Richardson, Alaska McChord, Washington

126th Airlift Wing, U.S. Air Force Reserve, Scott Air 173rd Fighter Wing, Oregon Air National Guard,
Force Base, Illinois Kingsley Field, Klamath Falls, Oregon

128th Air Refueling Wing, Wisconsin Air National 176th Wing, Alaska Air National Guard, Joint Base
Guard, Milwaukee, Wisconsin Elmendorf-Richardson, Alaska

128th Aviation Brigade, Fort Eustis, Virginia (U.S. Army 19th Air Force, Joint Base San Antonio, Texas
Aviation Maintenance Training)
1st Armored Division Combat Aviation Brigade, Fort
133rd Airlift Wing, Minnesota Air National Guard, Bliss, Texas
Minneapolis, Minnesota
1st Fighter Wing, Langley Air Force Base, Virginia
139th Air Wing Advanced Airlift Tactics Training Center,
San Antonio, Texas 20th Fighter Wing, Shaw Air Force Base, South Carolina

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National Commission on Military Aviation Safety

22nd Air Force, U.S. Air Force Reserve, Dobbins Air 433rd Airlift Wing, U.S. Air Force Reserve, Joint Base
Reserve Base, Georgia San Antonio, Texas
22nd Air Refueling Wing, McConnell Air Force Base, 436th Airlift Wing, Dover Air Force Base
Kansas
439th Airlift Wing, U.S. Air Force Reserve, Westover Air
23rd Flying Training Squadron, Fort Rucker, Alabama Reserve Base, Massachusetts
244th Expeditionary Combat Aviation Brigade, Joint 442nd Fighter Wing, U.S. Air Force Reserve, Whiteman
Base McGuire-Dix-Lakehurst, New Jersey Air Force Base Missouri
25th Combat Aviation Brigade, Wheeler Army Airfield, 446th Airlift Wing, U.S. Air Force Reserve, Joint Base
Hawaii Lewis-McChord, Washington
2nd Air Force, 81st Training Wing, Keesler Air Force 46th Aviation Support Battalion, Joint Base Lewis-
Base, Mississippi McChord, Washington
2nd Marine Air Wing, Marine Corps Air Station Cherry 477th Fighter Group, Joint Base Elmendorf-Richardson,
Point, North Carolina Alaska
2nd Operations Group, Barksdale Air Force Base, 479th Flying Training Group, Naval Air Station
Louisiana Pensacola, Florida
305th Air Mobility Wing, Joint Base McGuire-Dix- 49th Wing, Holloman Air Force Base, New Mexico
Lakehurst, New Jersey
4th Combat Aviation Brigade, Fort Carson, Colorado
306th Flying Training Group, Colorado Springs,
Colorado 4th Fighter Wing, Seymour Johnson Air Force Base,
North Carolina
309th Aerospace Maintenance and Regeneration Group,
Davis-Monthan Air Force Base, Arizona 509th Bomb Wing, Whiteman Air Force Base, Missouri

310th Fighter Squadron, Luke Air Force Base, Arizona 512th Airlift Wing, Dover Air Force Base

33rd Fighter Wing, Eglin Air Force Base, Florida 552nd Air Control Wing, Tinker Air Force Base,
Oklahoma
355th Fighter Wing, Davis-Monthan Air Force Base,
Arizona 55th Electronic Combat Group, Davis-Monthan Air
Force Base, Arizona
375th Air Mobility Wing, U.S. Air Force Reserve, Scott
Air Force Base, Illinois 56th Fighter Wing, Luke Air Force Base, Arizona

388th Fighter Wing, Hill Air Force Base, Utah 57th Wing Maintenance Group, Nellis Air Force Base,
Nevada
3rd Marine Air Wing, Marine Corps Air Station
Miramar, California 58th Special Operations Wing, Kirtland Air Force Base,
New Mexico
4/160th Special Operations Aviation Regiment, Joint
Base Lewis-McChord, Washington 62nd Airlift Wing, Joint Base Lewis-McChord,
Washington
419th Fighter Wing, U.S. Air Force Reserve, Hill Air
Force Base, Utah 645th Aeronautical Systems Group, Wright-Patterson Air
Force Base, Ohio
422nd Test and Evaluation Squadron, Nellis Air Force
Base, Nevada 711th Human Performance Wing, Wright-Patterson Air
Force Base, Ohio

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 Appendix D: Commission Engagements

80th Flying Training Wing, Sheppard Air Force Base, Air Force Life Cycle Management Center, Hill Air Force
Texas Base, Utah
82nd Training Wing, Sheppard Air Force Base, Texas Air Force Lifecycle Management Center, Wright-
Patterson Air Force Base, Ohio
916th Air Refueling Wing, Seymour Johnson Air Force
Base, North Carolina Air Force Maintenance Next, Kelly Field, Texas
931st Air Refueling Wing, U.S. Air Force Reserve, Air Force Program Executive Office Simulation, Wright-
McConnell Air Force Base, Kansas Patterson Air Force Base, Ohio
932nd Airlift Wing, U.S. Air Force Reserve, Scott Air Air Force Recruiting Service, Joint Base San Antonio,
Force Base, Illinois Texas
940th Air Refuel Wing, Beale Air Force Base, California Air Force Research Lab, Wright-Patterson Air Force Base,
Ohio
94th Airlift Wing, U.S. Air Force Reserve, Dobbins Air
Reserve Base, Georgia Air Force Reserve Command, Robins Air Force Base,
Georgia
97th Air Mobility Wing, Altus Air Force Base, Oklahoma
Air Force Safety Center, Kirtland Air Force Base, New
9th Reconnaissance Wing, Beale Air Force Base, Mexico
California
Air Force Safety School, Kirtland Air Force Base, New
Air Combat Command, Langley Air Force Base, Virginia Mexico
Air Education and Training Command, Joint Base San Air Force Sustainment Center, Tinker Air Force Base,
Antonio, Texas Oklahoma
Air Force Acquisition Safety Systems Personnel, The Air Force Warfare Center, Nellis Air Force Base, Nevada
Pentagon, Virginia
Air Force Weapons School, Nellis Air Force Base, Nevada
Air Force Agency for Modeling and Simulation, Orlando,
Florida Air Mobility Command, Scott Air Force Base, Illinois
Air Force Air National Guard, National Guard Bureau, Air National Guard Air Force Reserve Test Center, Davis-
The Pentagon, Virginia Monthan Air Force Base, Arizona
Air Force Aircrew Crisis Task Force, The Pentagon, Alaska Army National Guard, Joint Base Elmendorf-
Virginia Richardson, Alaska
Air Force Airworthiness Office, Wright-Patterson Air Army Aeromedical Research Lab, Fort Rucker, Alabama
Force Base, Ohio
Army Analytics Group Lab-Monterey, Monterey,
Air Force Central Command, Shaw Air Force Base, California
South Carolina
Army Aviation and Missile Command, Huntsville,
Air Force Directorate of Plans and Integration Force Alabama
Support Career Field Management and Readiness
Division, The Pentagon, Virginia Army Aviation Safety School, Fort Rucker, Alabama

Air Force Global Strike Command, Barksdale Air Force Army Combat Readiness Center, Fort Rucker, Alabama
Base, Louisiana
Army Directorate of Training and Doctrine, Fort Rucker,
Air Force Initial Flight Training, Pueblo, Colorado Alabama

Army Material Command, Huntsville, Alabama

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National Commission on Military Aviation Safety

Army National Guard, National Guard Bureau, The Fleet Logistics Support Squadron 53, Washington Naval
Pentagon, Virginia Air Facility, Maryland
Army Pacific, Fort Shafter, Hawaii Fleet Readiness Center East Detachment, Joint Base
McGuire-Dix-Lakehurst, New Jersey
Army Program Executive Office Aviation, Huntsville,
Alabama Fleet Readiness Center East, Marine Corps Air Station
New River, North Carolina
Army Research Office, Durham, North Carolina
Helicopter Maritime Strike Squadron 41, Naval Air
Army Training and Doctrine Command, Fort Eustis, Station North Island, California
Virginia
Helicopter Sea Combat Weapons School Atlantic, Naval
Aviator Training Next, Fort Rucker, Alabama Air Station Norfolk, Virginia
Center for Naval Aviation Technical Training Joint Staff Force Structure, Resources, and Assessment
Detachment Lakehurst, Joint Base McGuire-Dix- Directorate (J8), Functional Capability Board, The
Lakehurst, New Jersey Pentagon, Virginia
Center for Naval Aviation Technical Training Unit Marine Air Group 11, Marine Corps Air Station
Cherry Point, Marine Corps Air Station Cherry Point, Miramar, California
North Carolina
Marine Air Group 13, Marine Corps Air Station Yuma,
Center for Naval Aviation Technical Training Unit Arizona
Lemoore, Naval Air Station Lemoore, California
Marine Air Group 14, Marine Corps Air Station Cherry
Center for Naval Aviation Technical Training, Naval Air Point, North Carolina
Station Pensacola, Florida
Marine Air Group 16, Marine Corps Air Station
Coast Guard Headquarters, Washington, District of Miramar, California
Columbia
Marine Air Group 24, Marine Corps Base Kaneohe Bay,
Corpus Christi Army Depot, Naval Air Station Corpus Hawaii
Christi, Texas
Marine Air Group 29, Marine Corps Air Station New
Defense Logistics Agency, Fort Belvoir, Virginia River, North Carolina
Defense Safety Oversight Council, The Pentagon, Marine Air Group 31, Marine Corps Air Station New
Virginia River, North Carolina
Detachment 24, Air Force Pilot Training Next, Joint Base Marine Air Group 49, Joint Base McGuire-Dix-
San Antonio-Randolph, Texas Lakehurst, New Jersey
DoD Acquisition Environment, Safety, and Occupational Marine Aviation Logistics Squadron 11, Marine Corps
Health Integrated Production Team, The Pentagon, Air Station Miramar, California
Virginia
Marine Aviation Weapons and Tactics Squadron 1,
Electronic Attack Wing, Naval Air Station Whidbey Marine Corps Air Station Yuma, Arizona
Island, Washington
Marine Corps Forces Pacific, Camp H. M. Smith, Hawaii
F-35 Joint Program Office, Arlington, Virginia
Marine Wing Support Group 37, Marine Corps Air
Fleet Logistics Support Squadron 1, Washington Naval Station Miramar, California
Air Facility, Maryland
Naval Air Facility Command, Washington Naval Air
Fleet Logistics Support Squadron 30, Washington Naval Facility, Maryland
Air Facility, Maryland

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 Appendix D: Commission Engagements

Naval Air Force Reserve, San Diego, California Office of the Assistant Secretary of the Navy (Research,
Development, and Acquisition), The Pentagon, Virginia
Naval Air Forces, Naval Air Station North Island,
California Office of the Secretary of the Air Force, The Pentagon,
Virginia
Naval Air Forces Pacific, Safety Office, Naval Air Station
North Island, California Office of the Secretary of the Army, The Pentagon,
Virginia
Naval Air Systems Command, Naval Air Station Patuxent
River, Maryland Office of the Under Secretary of Defense, Acquisition
and Sustainment, The Pentagon, Virginia
Naval Air Warfare Center Training Systems Division,
Orlando, Florida Office of the Under Secretary of Defense, Personnel and
Readiness, The Pentagon, Virginia
Naval Aviation Enterprise Total Force Cross Functional
Team, Naval Air Station North Island, California Office of the Under Secretary of Defense, Research and
Engineering, The Pentagon, Virginia
Naval Aviation Safety School, Naval Air Station
Pensacola, Florida Ogden Air Logistics Complex, Ogden Air Force Base,
Utah
Naval Aviation Warfighting Development Center, Naval
Air Station Fallon, Nevada Oklahoma City Air Logistics Center, Tinker Air Force
Base, Oklahoma
Naval Epidata Center, Portsmouth, Virginia
Pacific Air Forces, Joint Base Pearl Harbor-Hickam,
Naval Postgraduate School, Monterey, California Hawaii
Naval Safety Center, Norfolk, Virginia Patrol and Reconnaissance Wing 10, Naval Air Station
Whidbey Island, Washington
Navy Aeromedical Research Unit, Wright-Patterson Air
Force Base, Ohio Patrol and Reconnaissance Wing 11, Naval Air Station
Jacksonville, Florida
Navy Physiological Episodes Action Team, Arlington
Annex, Virginia Program Executive Office Simulation, Training, and
Instrumentation, Orlando, Florida
Navy Strike Fighter Wing Atlantic, Naval Air Station
Oceana, Virginia Program Management 202, Naval Air Station Patuxent
River, Maryland
Navy Strike Fighter Wing Pacific, Naval Air Station
Lemoore, California Program Management 209, Naval Air Station Patuxent
River, Maryland
Navy Training Air Wing 4, Naval Air Station Corpus
Christi, Texas Program Management 265, Naval Air Station Patuxent
River, Maryland
Navy Training Air Wing 5, Naval Air Station Whiting
Field, Florida Program Management 275, Naval Air Station Patuxent
River, Maryland
Navy Training Air Wing 6, Naval Air Station Pensacola,
Florida Program Management 299, Naval Air Station Patuxent
River, Maryland
Office of the Assistant Secretary of Defense for
Acquisition, The Pentagon, Virginia T-7A Program Office, Wright-Patterson Air Force Base,
Ohio
Office of the Assistant Secretary of the Navy (Energy,
Installations, and Environment), The Pentagon, Virginia U.S. Army Alaska, Joint Base Elmendorf-Richardson,
Alaska

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National Commission on Military Aviation Safety

U.S. Central Command, Tampa, Florida Institute for Defense Analyses (IDA), Alexandria,
Virginia
Virtual Test and Training Center, Nellis Air Force Base,
Nevada JetBlue Airways, Queens, New York
Warner Robins Air Logistics Complex, Robins Air Force Leonardo DRS, Arlington, Virginia
Base, Georgia
Lockheed Martin, Grand Prairie, Texas
Western Army Air Training School, Arizona National
Guard, Pinal Airpark, Red Rock, Arizona RAND Corporation, Santa Monica, California

Textron Aviation Wichita Service Center, Wichita,

Civilian and Academic Organizations Kansas

Truth Data Systems, Fort Worth, Texas

Air Methods (Helicopter Emergency Medical Services),
Greenwood Village, Colorado U.S. House of Representatives Armed Services
Committee Washington, District of Columbia
Airbus, Grand Prairie, Texas
U.S. Senate Armed Services Committee, Washington,
American Airlines, Fort Worth, Texas District of Columbia
Applied Research Laboratory Head, Materials and United Airlines, Chicago, Illinois
Manufacturing Office, Penn State University, State
College, Pennsylvania
Conferences
Bell Helicopter, Fort Worth, Texas
Air Force Association Air Warfare Symposium “Multi-
Boeing Defense, St. Louis, Missouri
Domain Operations from Vision to Reality,” Orlando,
Center for Naval Analyses, Arlington, Virginia Florida

Congressional Research Service, Washington, District of Air Force Association Air, Space, and Cyber Conference,
Columbia National Harbor, Maryland

Dr. Mary L. Cummings, Duke University, Durham, Air National Guard Air Force Reserve Command Test
North Carolina Center Weapons and Tactics Conference, Tucson,
Arizona
Dr. Scott Shappell, Embry-Riddle Aeronautical
University, Daytona Beach, Florida Human Factors Analysis and Classification System
Educational Seminar, Las Vegas, Nevada
Dr. Thomas Morgan
Interservice / Industry Training, Simulation and
Dr. Thomas Travis, Uniformed Services University of the Education Conference, Orlando, Florida
Health Sciences, Bethesda, Maryland
Joint Service Safety Chiefs Conference, Fort Rucker,
DuPont Corporation, Wilmington, Delaware Alabama
Everett Smith, Spiegare Aviation Safety, Albuquerque, Military Flight Training Conference, San Antonio, Texas
New Mexico
National Transportation Safety Board Symposium on
Federal Aviation Administration, Office of Accident Improving the Safety of Part 135 Safety Operations,
Investigation and Prevention, Washington, District of Reston, Virginia
Columbia
Weapons and Tactics Conference, U.S. Air Force, Nellis
Helicopter Association International, Alexandria, Virginia Air Force Base, Nevada

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Appendix E:

BIBLIOGRAPHY
AcqNotes. “JCIDS Process: Key Performance Parameter (KPP).” AcqNotes: Defense Acquisitions Made Easy, October 25,
2018. http://acqnotes.com/acqnote/acquisitions/key-perfrormance-parameter.
Acquisition Law Advisory Panel. “Streamlining Defense Acquisition Laws: Report of the Acquisition Law Advisory Panel to
the United States Congress,” 1993.
Adams, Charlotte. “Military FOQA Next Step in Safety.” Aviation Today, February 1, 2006. https://www.aviationtoday.com/
2006/02/01/military-foqa-next-step-in-safety/.
Air Combat Command. “Logistics Maintenance Performance Indicator Reporting Procedures.” Air Combat Command
Instruction 21-118. Langley AFB, VA: Air Combat Command, July 2, 2018.
Air Force Research Lab. “AFRL Team Wins Laureate Award for Life Saving Aircraft Technology.” AFRL, March 28, 2019.
https://afresearchlab.com/news/afrl-team-wins-laureate-award-for-life-saving-aircraft-technology/.
Altus Air Force Base Voluntary Protection Program. “EHR/JSA Control Numbers Worksheet,” December 3, 2018.
America’s Navy. “Fact Files.” Accessed October 8, 2019. https://www.navy.mil/Resources/
Fact-Files/?Search=united+states+navy.
Anderson, Lee, Pete Doty, Manuel Griego, Ken Timko, Brian Hermann, and John Colombi. “Solutions Analysis for
Helicopter Brownout.” Conference presentation presented at the 9th SE Conference, Wright-Patterson AFB, OH,
October 2006.
Andicochea, Chad T., Matthew E. Henriques, Joel Fulkerson, Susan Jay, Howard Chen, and Travis Deaton. “Elevated
Environmental Carbon Dioxide Exposure Confounding Physiologic Events in Aviators?” Military Medicine 184,
no. 11–12 (December 1, 2019): e863–67. https://doi.org/10.1093/milmed/usz092.
Army Combat Readiness Center, Naval Safety Center, Headquarters, United States Marine Corps (Safety Division), United
States Coast Guard Health and Safety Directorate, and Air Force Safety Center. “Policy on the Collection and
Analysis of Mishap Human Factors Data.” Memorandum of Agreement. Washington, DC: U.S. Department of
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Ausink, John A., Anthony D. Rosello, Timothy Marler, Michael Vasseur, Brynn Tannehill, Dara Gold, Kelly Klima,
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———. The Impacts of Sequestration and/or a Full-Year Continuing Resolution on the Department of Defense, 113th Cong., 1st
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———. “Armed Forces Expeditionary Medal (AFEM): Approved Operations,” 2019.
———. “Armed Forces Service Medal (AFSM): Approved Operations,” 2019.
———. “Department of Defense Design Criteria Standard: Aircraft Crew Breathing Systems Using On-Board Oxygen
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CG-1/cg113/docs/pdf/DoD_HFACS7.0.pdf?ver=2017-02-23-152408-007.
———. “Department of Defense Infrastructure Capacity.” Washington, DC: U.S. Department of Defense, October 2017.
https://fas.org/man/eprint/infrastructure.pdf.
———. “Department of Defense Standard Practice System Safety.” MIL-STD-882E, May 11, 2012. https://www.dau.edu/
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dodd/500059p.pdf.

E-14
 Appendix E: Bibliography

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———. “Inherent Resolve Campaign Medal: Approved Campaign Phases,” 2019.
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U.S. Department of the Navy. “Comprehensive Review of Physiological Episodes.” U.S. Department of the Navy, June 4,
2017.

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National Commission on Military Aviation Safety

———. “Naval Aviation Safety Management System.” U.S. Department of the Navy, May 13, 2019.
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U.S. General Accounting Office, June 1988.
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historic-buildings/tacoma-union-station-tacoma-wa.
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August 2013. https://www.gao.gov/assets/660/657115.pdf.
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———. “Aviation Workforce: Current and Future Availability of Aviation Engineering and Maintenance Professionals.”
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Physicians and Dentists.” Washington, DC: U.S. Government Accountability Office, January 2020.
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———. “Defense Strategy: Revised Analytic Approach Needed to Support Force Structure Decision-Making.” Report to
the Congress of the United States. Washington, DC: U.S. Government Accountability Office, 2019.
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———. “Department of Defense: Actions Needed to Address Five Key Mission Challenges.” Washington, DC:
U.S. Government Accountability Office, June 2017. https://www.gao.gov/products/GAO-17-369.
———. “DoD Needs to Reevaluate Fighter Pilot Workforce Requirements.” Washington, DC: U.S. Government
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———. “DoD Training: DoD Has Taken Steps to Assess Common Military Training.” Washington, DC: U.S. Government
Accountability Office, May 23, 2017. https://www.gao.gov/products/GAO-17-468.

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 Appendix E: Bibliography

———. “Military Aviation Mishaps: DoD Needs to Improve Its Approach for Collecting and Analyzing Data to Manage
Risks.” Washington, DC: U.S. Government Accountability Office, August 15, 2018. https://www.gao.gov/
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———. “Military Personnel: Collecting Additional Data Could Enhance Pilot Retention Efforts.” Report to Congressional
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products/GAO-18-439.
———. “Military Personnel: DoD Needs to Reevaluate Fighter Pilot Workforce Requirements.” Report to Congressional
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products/GAO-18-113.
———. “Military Personnel: Strategy Needed to Improve Retention of Experienced Air Force Aircraft Maintainers.”
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GAO-19-160.
———. “Military Readiness: Clear Policy and Reliable Data Would Help DoD Better Manage Service Members’ Time
Away from Home.” Report to Congressional Committees. Washington, DC: U.S. Government Accountability
Office, April 25, 2018. https://www.gao.gov/products/GAO-18-253.
———. “Navy Training: Observations on the Navy’s Use of Live and Simulated Training.” Washington, DC: U.S.
Government Accountability Office, June 29, 2019. https://www.gao.gov/products/GAO-12-725R.
———. “Service Contract Approach to Aircraft Simulator Training Has Room for Improvement.” Washington, DC: U.S.
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GAO-06-830/pdf/GAOREPORTS-GAO-06-830.pdf.
———. “Weapon System Sustainment: Selected Air Force and Navy Aircraft Generally Have Not Met Availability Goals
and DoD and Navy Guidance Need to Be Clarified.” Report to Congressional Committees. Washington, DC:
U.S. Government Accountability Office, September 2018. https://www.gao.gov/assets/700/694571.pdf.
U.S. Naval Safety Center, and Naval Postgraduate School. School of Aviation Safety. “Aviation Maintenance Human Factors
Accident Analysis: HFACS-ME: Human Factors Analysis and Classification System – Maintenance Extension.”
Student Guide v3.0, n.d.
U.S. Navy. “Platforms.” In Vision, Presence, Power 2005: A Program Guide to the U.S. Navy, 46–56. U.S. Navy, 2005.
https://www.navy.mil/navydata/policy/vision/vis98/vis-p08.html.
Venable, John. “Fighter Pilots Aren’t Flying Enough to Hone the Skills of Full-Spectrum War.”
Defense On, November 21, 2016. https://www.defenseone.com/ideas/2016/11/
fighter-pilots-arent-flying-enough-hone-skills-full-spectrum-war/133328/.
Whealin, Julia M., Wayne B. Batzer, Charles A. Morgan, Howard F. Detwiler, Paula P. Schnurr, and Matthew J. Friedman.
“Cohesion, Burnout, and Past Trauma in Tri-Service Medical and Support Personnel.” Military Medicine 172, no. 3
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Republicans, November 12, 2019. https://republicans-budget.house.gov/budget-digest/
budget-digest-continuing-resolutions-and-national-defense/.

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National Commission on Military Aviation Safety

Woodie, Clay, Claire Goldie, Kevin O’Brien, Chris Aura, and Cristina Delgado-Howard. “Aviator Training Next Technical
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Wyckoff, Christopher A. “The Slippery Slope of Air Force Downsizing: A Strategy Connection.” Thesis, Air War College,
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Young, Stephanie, and J. Gilmore. “Operating Under a Continuing Resolution: A Limited Assessment of Effects on Defense
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Ziezulewicz, Geoff. “Bullet’s Bold Blueprint to Save Navy Aviation.” Navy Times, September 24, 2018.
———. “Most Navy C-130s Remain Grounded Nearly One Year after Fatal Crash.” Navy Times, April 26, 2018.

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Appendix F:

TECHNICAL APPENDIX

T his technical appendix provides more information

beyond the mishap rates and HFACS analysis within
Chapters 2 and 3.
Commission’s calculated mishap rates. This section also
presents additional information about the relationship
between fatalities and destroyed aircraft in Class A
mishaps and changes in the mishap classification criteria.
Figures F-1, F-2, F-3, and F-4 illustrate the mishap
Additional Mishap Rate Information
rates by class and by Service for the fiscal years 2013–
Chapter 2 provides the Commission’s assessment of 2018 study period (shaded in gray on the tables) and the
fiscal years 2013 through 2018 mishap rates compared comparative historical period of fiscal years 2007–2012.
against historical trends. Following are tables with the

Figure F-1:
Class A Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army A
2.47 1.54 2.01 1.84 1.18 1.61 0.90 1.56 1.45 0.93 1.03 1.31
Mishap Rate

Air Force A
1.47 1.39 1.26 0.87 0.86 1.04 1.21 0.72 1.17 0.96 1.03 1.58
Mishap Rate

Navy A
1.08 1.70 1.36 0.76 1.03 0.99 1.06 1.78 1.28 0.93 1.55 1.44
Mishap Rate

Marine Corps A
2.62 2.25 1.71 1.70 3.80 2.35 2.98 2.28 3.29 3.81 5.19 2.49
Mishap Rate

All DoD A
1.74 1.56 1.52 1.17 1.19 1.27 1.21 1.29 1.39 1.13 1.41 1.55
Mishap Rate

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.

F-1
National Commission on Military Aviation Safety

Figure F-2:
Class B Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army B
1.19 1.30 2.01 1.04 1.18 1.27 0.81 0.68 1.67 1.27 0.69 1.07
Mishap Rate

Air Force B
4.56 5.65 7.32 2.19 3.55 2.02 2.58 3.18 2.50 2.95 2.41 2.11
Mishap Rate

Navy B
3.13 3.50 3.03 1.62 1.75 2.30 2.12 1.54 2.09 2.43 3.33 3.49
Mishap Rate

Marine Corps B
2.92 2.57 6.15 3.06 1.90 3.35 2.23 2.66 2.88 2.54 3.03 3.32
Mishap Rate
All DoD B
3.26 3.77 4.84 1.81 2.38 1.97 1.96 2.11 2.24 2.42 2.25 2.27
Mishap Rate

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.

Figure F-3:
Class C Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army C Mishap
7.17 7.70 8.30 4.63 7.22 8.04 5.11 4.98 6.68 6.37 7.81 8.59
Rate

Air Force C
29.91 29.60 46.44 34.64 30.62 29.90 34.00 37.90 35.05 36.13 38.77 35.31
Mishap Rate

Navy C Mishap
10.35 7.42 10.33 8.87 10.29 9.31 11.57 12.92 15.24 19.01 21.05 19.48
Rate

Marine Corps C
5.83 9.96 11.28 12.57 9.83 9.38 14.51 16.69 19.32 22.46 26.80 25.75
Mishap Rate

All DoD C
18.07 17.41 25.63 19.32 18.24 18.16 19.79 22.00 22.86 24.40 26.66 24.85
Mishap Rate

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.

F-2
 Appendix F: Technical Appendix

Figure F-4:
Class A–C Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army A-C
10.83 10.54 12.32 7.50 9.58 10.92 6.81 7.22 9.80 8.56 9.53 10.98
Mishap Rate

Air Force A-C

35.94 36.64 55.03 37.70 35.03 32.96 37.79 41.79 38.71 40.04 42.22 38.99
Mishap Rate

Navy A-C
14.56 12.62 14.71 11.26 13.07 12.59 14.75 16.24 18.61 22.38 25.93 24.42
Mishap Rate

Marine
Corps A-C 11.37 14.78 19.14 17.33 15.54 15.08 19.73 21.62 25.48 28.81 35.02 31.56
Mishap Rate

All DoD A-C

23.07 22.73 31.98 22.30 21.82 21.40 22.96 25.39 26.49 27.94 30.32 28.66
Mishap Rate

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.

F-3
National Commission on Military Aviation Safety

Fatalities and Destroyed Aircraft The Commission compared the numbers of fatalities,
The Commission looked for a fuller understanding of destroyed aircraft, and also calculated the number of
the relationship between fatalities and destroyed aircraft fatalities per destroyed aircraft to better understand the
and how that distinguished and characterized the types relationship and how it changed over time. The Army
of Class A mishaps the Services were experiencing during and Navy decreased their ratio of fatalities per destroyed
the two comparison periods (Figure F-5). For example, aircraft during the fiscal years 2013–2018 period. The Air
higher numbers of fatalities and fewer destroyed aircraft Force saw a significant increase, the Marine Corps a slight
indicate one or more mishaps with additional personnel increase.
on board.

Figure F-5:
Fatalities and Destroyed Aircraft by Service for Fiscal Years 2007–2018

2007- 2013-
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2012 2018

Army Fatalities 39 17 9 27 15 12 8 6 14 8 10 6 119 52

Air Force Fatalities 2 13 6 9 2 9 11 10 5 16 5 19 41 66

Navy Fatalities 14 6 7 8 2 2 5 4 0 1 1 9 39 20

Marine Corps Fatalities 9 0 7 13 7 17 0 2 19 14 20 5 53 60

All DoD Fatalities 64 36 29 57 26 40 24 22 38 39 36 39 252 198

Army Destroyed Aircraft 18 10 10 16 9 10 6 9 6 4 6 5 73 36

Air Force Destroyed

14 15 8 7 8 10 14 2 7 9 7 10 62 49
Aircraft

Navy Destroyed Aircraft 8 13 5 7 5 8 4 11 6 7 4 3 46 35

Marine Corps Destroyed

8 5 3 5 6 6 6 5 5 8 10 3 33 37
Aircraft

All DoD Destroyed

48 43 26 35 28 34 30 27 24 28 27 21 214 157
Aircraft

Army Fatalities/
2.17 1.70 0.90 1.69 1.67 1.20 1.33 0.67 2.33 2.00 1.67 1.20 1.63 1.44
Destroyed Aircraft

Air Force Fatalities/

0.14 0.87 0.75 1.29 0.25 0.90 0.79 5.00 0.71 1.78 0.71 1.90 0.66 1.35
Destroyed Aircraft

Navy Fatalities/
1.75 0.46 1.40 1.14 0.40 0.25 1.25 0.36 0.00 0.14 0.00 3.00 0.85 0.54
Destroyed Aircraft

Marine Corps Fatalities/

1.13 0.00 2.33 2.60 1.17 2.83 0.00 0.40 3.80 1.75 2.10 1.67 1.61 1.65
Destroyed Aircraft

All DoD Fatalities/

1.33 0.84 1.12 1.63 0.93 1.18 0.80 0.81 1.58 1.39 1.33 1.86 1.18 1.26
Destroyed Aircraft

Source: Force Risk Reduction database.

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.

F-4
 Appendix F: Technical Appendix

Changes in Mishap Classification Criteria Figure F-6:

Starting in fiscal year 2010, DoD changed the aircraft Mishap Classification Criteria Changes per
damage criteria for classification to “account for DODI 6055.07, Mishap Notification, Investigation,
inflationary growth in the cost of military systems [since Reporting, and Record Keeping
1989] and the resulting cost for mishaps of similar
severity” (Figure F-6). The Commission, however, did POST-FY2010 MISHAP
PRE-FY2010 MISHAP
not adjust or reclassify mishaps across the years of its CLASSIFICATION CRITERIA1
CLASSIFICATION
CRITERIA2
assessment, consistent with mishap rate analyses in
academic literature. · at least $1 million in · at least $2 million
damage ; in damage ;
Class A
· death or permanent · death or permanent
Aviation
disability; disability;
Mishap
· and/or aircraft destroyed · and/or aircraft
destroyed

· total cost of reportable · more than $500,000,

property damage is but less than $2
$200,000 or more, but less million, in damages,
than $1,000,000; · three or more people
Class B · an injury and/or hospitalized;
Aviation occupational illness results · and/or permanent
Mishap in permanent partial partial disability
disability; and/or
· when three or more
personnel are inpatient
hospitalized.

· total cost of property · at least $50,000, but

damage is $20,000 less than $500,000,
or more, but less than · and/or nonfatal
Class C
$200,000; or injuries that caused
Aviation
· a nonfatal illness or loss of one or more
Mishap
disability that causes loss of days from work not
time from work or disability including the day or
at any time shift it occurred

1
Department of Defense, “Mishap Notification, Investigation, Reporting, and
Record Keeping. Incorporating Change 1, April 24, 2008”; Department of
Defense, “Mishap Notification, Investigation, Reporting, and Record Keeping.”
2
Department of Defense, “Mishap Notification, Investigation, Reporting, and
Record Keeping. Incorporating Change 1, August 31, 2018.”

F-5
National Commission on Military Aviation Safety

Additional HFACS Analysis Figure F-8:

Air Force Top 10 HFACS Applications in Class A
The Commission determined the most frequently applied Mishaps for Fiscal Years 2013–2018
Human Factors Analysis and Classification System
(HFACS) applications for each mishap class and Service
TITLE CODE TITLE CLASS A
from fiscal years 2013 through 2018 in addition to the CODE APPLICATIONS
HFACS analysis provided in Chapter 3. The top 10
No No Data 470
results are provided in the figures below.
Data
Class A AE103 Procedure Not Followed 49
Correctly
Figure F-7: PC208 Complacency 47
Army Top 10 HFACS Applications in Class A Mishaps AE201 Inadequate Real-Time Risk 46
for Fiscal Years 2013–2018 Assessment
AE206 Wrong Choice of Action 45
TITLE CODE TITLE CLASS A During an Operation
CODE APPLICATIONS
PC102 Fixation 37
PC206 Overconfidence 33
PC504 Misperception of Changing 36
PE102 Vision Restricted by 28
Environment
Meteorological Conditions
PE101 Environmental Conditions 34
PC208 Complacency 20
Affecting Vision
SI001 Supervisory/Command 19 OP003 Provided Inadequate 31
Oversight Inadequate Procedural Guidance or
PP102 Cross-Monitoring 17 Publications
Performance PP108 Failed to Effectively 29
PC504 Misperception of Changing 16 Communicate
Environment PC110 Inaccurate Expectation 25
PP106 Critical Information Not 16
Communicated
AE103 Procedure Not Followed 13
Correctly
AE105 Breakdown in Visual Scan 13
AE104 Over-Controlled/Under- 11
Controlled Aircraft/Vehicle
PC101 Not Paying Attention 11

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 Appendix F: Technical Appendix

Figure F-9: Figure F-10:

Navy Top 10 HFACS Applications in Class A Mishaps Marine Corps Top 10 HFACS Applications in Class A
for Fiscal Years 2013–2018 Mishaps for Fiscal Years 2013–2018

TITLE CODE TITLE CLASS A TITLE CODE TITLE CLASS A

CODE APPLICATIONS CODE APPLICATIONS
AE103 Procedure Not Followed Correctly 44 AE201 Inadequate Real Time Risk 21
AE201 Inadequate Real Time Risk 43 Assessment
Assessment AE103 Procedure Not Followed 17
AE104 Over-Controlled/Under-Controlled 23 Correctly
Aircraft/Vehicle AE206 Wrong Choice of Action During 8
AE206 Wrong Choice of Action During an 17 an Operation
Operation AE104 Over-Controlled/Under- 6
AE202 Failure to Prioritize Tasks 16 Controlled Aircraft/Vehicle
Adequately AE202 Failure to Prioritize Tasks 5
AE102 Checklist Not Followed Correctly 13 Adequately
AE102 Checklist Not Followed Correctly 4
AE105 Breakdown in Visual Scan 13
AE107 Rushed or Delayed a Necessary 11 AE105 Breakdown in Visual Scan 4
Action AE107 Rushed or Delayed a Necessary 3
AV002 Commits Widespread/Routine 9 Action
Violation AE205 Ignored a Caution/Warning 3
AV003 Extreme Violation/Lack of 7 AV002 Commits Widespread/Routine 2
Discipline Violation

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National Commission on Military Aviation Safety

Class B Figure F-12:

Air Force Top 10 HFACS Applications in Class B
Figure F-11: Mishaps for Fiscal Years 2013–2018
Army Top 10 HFACS Applications in Class B Mishaps
for Fiscal Years 2013–2018 TITLE CODE TITLE CLASS B
CODE APPLICATIONS

TITLE CODE TITLE CLASS B No No Data 468

CODE APPLICATIONS Data
PC206 Overconfidence 21 AE103 Procedure Not Followed 64
PE102 Vision Restricted by 13 Correctly
Meteorological Conditions PC208 Complacency 53
PC208 Complacency 12 OP003 Provided Inadequate 42
AE104 Over-Controlled/Under- 10 Procedural Guidance or
Controlled Aircraft/Vehicle Publications
PP102 Cross-Monitoring Performance 10 AE201 Inadequate Real-Time Risk 31
Assessment
AE103 Procedure Not Followed 8
PC101 Not Paying Attention 30
Correctly
PC504 Misperception of Changing 8 OP007 Purchasing or Providing Poorly 26
Environment Designed or Unsuitable
Equipment
PP106 Critical Information Not 8
Communicated PC206 Overconfidence 18
PC101 Not Paying Attention 4 PC504 Misperception of Changing 18
Environment
SI001 Supervisory/Command 4
Oversight Inadequate PC109 Technical or Procedural 17
Knowledge Not Retained after
Training
PC110 Inaccurate Expectation 17
PP108 Failed to Effectively 17
Communicate

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 Appendix F: Technical Appendix

Figure F-13: Figure F-14:

Navy Top 10 HFACS Applications in Class B Mishaps Marine Corps Top 10 HFACS Applications in Class B
for Fiscal Years 2013–2018 Mishaps for Fiscal Years 2013–2018

TITLE CODE TITLE CLASS B TITLE CODE TITLE CLASS B

CODE APPLICATIONS CODE APPLICATIONS
AE103 Procedure Not Followed 62 AE103 Procedure Not Followed 14
Correctly Correctly
AE201 Inadequate Real Time Risk 51 AE201 Inadequate Real Time Risk 6
Assessment Assessment
AE206 Wrong Choice of Action During 22 AE202 Failure to Prioritize Tasks 3
an Operation Adequately
AE107 Rushed or Delayed a 16 AE104 Over-Controlled/Under- 2
Necessary Action Controlled Aircraft/Vehicle
AE104 Over-Controlled/Under- 15 AE105 Breakdown in Visual Scan 2
Controlled Aircraft/Vehicle AE206 Wrong Choice of Action During 2
AE102 Checklist Not Followed 11 an Operation
Correctly AV001 Performs Work-Around Violation 2
AE105 Breakdown in Visual Scan 11
AE102 Checklist Not Followed 1
AE202 Failure to Prioritize Tasks 8 Correctly
Adequately AE107 Rushed or Delayed a 1
AE300 Perception Error 8 Necessary Action
AV003 Extreme Violation/Lack of 7 AE301 Error due to Misperception 1
Discipline AV003 Extreme Violation/Lack of 1
Discipline

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National Commission on Military Aviation Safety

Class C Figure F-16:

Air Force Top 10 HFACS Applications in Class C
Figure F-15: Mishaps for Fiscal Years 2013–2018
Army Top 10 HFACS Applications in Class C Mishaps
for Fiscal Years 2013–2018 TITLE CODE TITLE CLASS C
CODE APPLICATIONS

TITLE CODE TITLE CLASS C No Data No Data 2201

CODE APPLICATIONS PC101 Not Paying Attention 374
PC206 Overconfidence 97 AE201 Inadequate Real-Time Risk 371
PC208 Complacency 76 Assessment
PC101 Not Paying Attention 61 AE103 Procedure Not Followed 291
PP106 Critical Information Not 48 Correctly
Communicated AE206 Wrong Choice of Action During 259
PP102 Cross-Monitoring Performance 44 an Operation
PC208 Complacency 171
PC504 Misperception of Changing 43
Environment PC102 Fixation 143
AE103 Procedure Not Followed 42 AE107 Rushed or Delayed a 138
Correctly Necessary Action
PE102 Vision Restricted by 40 PP108 Failed to Effectively 129
Meteorological Conditions Communicate
AE105 Breakdown in Visual Scan 38 PC504 Misperception of Changing 113
AE102 Checklist Not Followed 24 Environment
Correctly AE105 Breakdown in Visual Scan 111
AE104 Over-Controlled/Under- 24
Controlled Aircraft/Vehicle

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 Appendix F: Technical Appendix

Figure F-17: Figure F-18:

Navy Top 10 HFACS Applications in Class C Mishaps Marine Corps Top 10 HFACS Applications in Class C
for Fiscal Years 2013–2018 Mishaps for Fiscal Years 2013–2018

TITLE CODE TITLE CLASS C TITLE CODE TITLE CLASS C

CODE APPLICATIONS CODE APPLICATIONS
AE103 Procedure Not Followed 285 AE103 Procedure Not Followed 78
Correctly Correctly
AE201 Inadequate Real Time Risk 225 AE201 Inadequate Real Time Risk 76
Assessment Assessment
AE206 Wrong Choice of Action During 112 AE206 Wrong Choice of Action 36
an Operation During an Operation
AE105 Breakdown in Visual Scan 81 AE102 Checklist Not Followed 27
Correctly
AE107 Rushed or Delayed a 66
Necessary Action AE107 Rushed or Delayed a 18
Necessary Action
AE202 Failure to Prioritize Tasks 61
Adequately AE202 Failure to Prioritize Tasks 15
Adequately
AE102 Checklist Not Followed 60
Correctly AV001 Performs Work-Around 15
Violation
AE104 Over-Controlled/Under- 53
Controlled Aircraft/Vehicle AE105 Breakdown in Visual Scan 13
AE101 Unintended Operation of 52 AE205 Ignored a Caution/Warning 11
Equipment
AV001 Performs Work-Around Violation 26

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National Commission on Military Aviation Safety

F-12
Appendix G:

KEY MILITARY AVIATION

SAFETY POLICY GUIDANCE
Department of Defense Directive (DoDD) 4715.1E, Memorandum of Understanding (MOU) between the
March 18, 2005, Updated December 30, 2019, Office of the Under Secretary of Defense Personnel
Environment, Safety, and Occupational Health. This and Readiness, Personnel Risk and Resiliency,
directive establishes policies on environment, safety, and and Commander, U.S. Army Combat Readiness
occupational health to sustain and improve the DoD Center; Commander, U.S. Naval Safety Center; and
mission. This directive also establishes the Defense Safety Commander, U.S. Air Force Safety Center, August 7,
Oversight Council (DSOC) and its structure. 2017, Department of Defense Safety and Occupational
Health Data Sharing. This MOU is intended to describe
Department of Defense Instruction (DoDI) 6055.07, standard practices and procedures for collecting mishap
June 6, 2011, Mishap Notification, Investigation, data. Notably, this MOU identifies 57 aviation mishap
Reporting, and Record Keeping. This instruction data elements that would be collected and shared.
provides guidance collecting, aggregating, and analyzing
military aviation mishaps. This instruction updates Department of Defense Human Factors Analysis
procedures for mishap notification, investigation, and Classification System Guidance, May 10, 2005,
reporting, and record keeping. It also establishes the DoD updated 2014. Human factors describe how human
Mishap Data Requirements Working Group. interaction with tools, tasks, working environments, and
other people influence human performance. Human
DoDI 6055.19, April 11, 2017, Aviation Hazard factors are the leading cause of DoD mishaps. The
Identification and Risk Assessment Programs. This Human Factors Analysis and Classification System
instruction establishes policy, assigns responsibilities, guidance, initiated by Interservice MOU Policy on the
and provides direction for developing and implementing Collection and Analysis of Mishap Human Factors Data and
safety management systems around military flight finalized by the DSOC Human Factors Working Group,
operations quality assurance (MFOQA), Aviation Safety explains how DoD mishap investigators and analysts
Action Program (ASAP), and line operations safety audit can use a common human error category system to
(LOSA). This instruction highlights quantitative and investigate, report, and analyze DoD mishaps. The DoD
qualitative data collection in mitigating aviation risks. HFACS model presents a systematic, multidimensional
approach to error analysis and mishap prevention. It is
designed for use by all members of an investigation board
in order to accurately capture and re-create the complex
layers of human error in context with the individual,
environment, team, and mishap or event.

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National Commission on Military Aviation Safety

Key Service Aviation Safety Directives

Army
Air Force
AR 385-10, Army Safety Program, November 27, 2013.
AFI 91-202, Air Force Mishap Prevention Program, May
25, 2017, updated March 12, 2020
AR 385–95 Army Aviation Accident Prevention,
February 24, 2010
AFI 91-204, Safety Investigations and Hazard Reporting,
April 27, 2018
AR 70–62 Airworthiness Qualification of Army Aircraft
Systems, July 7, 2000
AFI 91-207, The Air Force Traffic Safety Program, July
26, 2019
AR 385–42 Investigation of NATO Nation Aircraft or
Missile Accidents and Incidents, May 15, 1980
AFI 62-601, Air Force Airworthiness, June 11, 2010
DA PAM 385-40, Army Accident Investigations and
AFI 63-101/20-101, Integrated Life Cycle Management,
Reporting, March 18, 2015.
May 9, 2017
Marines
AFMAN 91-223, Aviation Safety Investigations and
Reports, September 14, 2018
MCO 5100.29C: Marine Corps Safety Management
System, October 19, 2020
Joint Directives
MARADMIN 202/19, Marine Corps Aviation Safety
MIL-STD-882E, Department of Defense Standard
Awareness Program, March 28, 2019
Practice for System Safety, May 11, 2012
Navy
NATO STANAG 3101, Exchange of Flight Safety
Information, November 3, 2016
OPNAVINST 3750.6S, Naval Aviation Safety
Management System, May 13, 2014.
NATO STANAG 3102, Flight Safety Cooperation in
Common Ground/Air Space, March 27, 2007
OPNAVINST 5100.19E Navy Safety and Occupational
Health Program Manual for Forces Afloat, May 30,
2007.

OPNAVINST/MCO 5102.1 D Navy and Marine Corps

Mishap and Safety Investigation, Reporting, and Record
Keeping, January 7, 2005.

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 Appendix G: Key Military Aviation Safety Policy Guidance

Safety Management Systems

MFOQA LOSA

The military operations quality assurance program Line operations safety audits were developed to analyze
involves collecting raw recorded flight data that is aircrew behavior in real time, providing the qualitative
processed to identify potential safety concerns within an data of human perspective. All LOSA programs are
aircraft or fleet of aircraft. Consistent data collection can designed to identify errors and measures for mitigating
assist an aviation group in identifying risk trends before a those errors as well as other hazards and threats. This
mishap. It can also be used for mishap investigation. proactive formal process uses trained observers collecting
safety-related data on environmental conditions,
ASAP operational complexity, and human performance on
the flight deck. It is an ideal way to identify threats and
The aviation safety action program is a voluntary, understand flight crew responses, revealing how crews
individual reporting program used to detect safety manage errors and undesired states. Notably, LOSA is
hazards in flight and maintenance operations before confidential and nonpunitive and is not a compliance
a problem causes a mishap. The Federal Aviation audit, a key to a proactive safety program.
Administration describes the focus of ASAP as
encouraging voluntary reporting of safety issues and SOQA
events that come to the attention of aircrews and
maintenance personnel. ASAP programs share aviation Simulator operational quality assurance is a
hazards information across multiple communities, often relatively new aviation data collection program using
displaying the report narrative, recommended actions, flight simulator-based data. Simulators can provide
and resolutions. opportunities for gathering data on pilot performance,
especially in abnormal conditions and emergency
procedures. Using SOQA to record all simulator data
and using artificial intelligence to sort through that data
improves aviation safety via predictive analysis. This data
can be correlated to the weapon system or associated with
a single pilot over the course of his or her flying career.

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National Commission on Military Aviation Safety

G-4
Appendix H:

JOINT SAFETY COUNCIL

PROPOSED LEGISLATION
Sec. __ _ Establishment of Joint Safety Council
Chapter 7 of Title 10 is amended by adding a new section immediately following section 183a as follows:

“Section 184 Joint Safety Council

(a) In general. There is established, within the Office of the Deputy Secretary of Defense, a Joint Safety Council (in this
section referred to as the “Council”).

(b) Composition; Appointment; Compensation.

(1) The Council shall be composed of voting members as follows:
(A) the Director of Safety for the Department of the Army, appointed by the Secretary of the Army;
(B) the Director of Safety for the Department of the Air Force, appointed by the Secretary of the Air Force;
(C) the Director of Safety for the Department of the Navy, appointed by the Secretary of the Navy;
(D) a member of the Senior Executive Service, appointed by the Deputy Secretary of Defense; and
(E) one member from each military service, appointed by the Secretary concerned.
(2) Qualifications; Removal; Replacement.
(A) The Director of Safety for each military department shall be a uniformed officer in the grade of O-8.
(B) The person appointed under paragraph (1)(D) shall be a career member of the Senior Executive Service with a
history of successfully running programs within the Department of Defense.
(C) Members of the Council serve at the will of the official who appointed them.
(D) Vacancies on the Council shall be filled in the same manner as the original appointment.
(3) Compensation. Members of the Council shall serve without compensation in addition to that received for their
services as officers or employees of the United States.

(c) Chair and Vice Chair.

(1) Chair. The Secretary of Defense, or his designee, shall select one of the uniformed members of the Council to serve
as Chair. Unless earlier removed, the Chair shall serve for a term of two years. The Chair shall serve as the Director
of Aviation Safety for the Department of Defense.
(2) Vice Chair. The Vice Chair shall be the person appointed under subsection (b)(1)(D). The Vice Chair shall report
to the Chair and shall serve as Chair in his or her absence.

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National Commission on Military Aviation Safety

(d) Staff.
(1) Permanent Staff. The Council may appoint staff in accordance with 5 U.S.C. § 3101.
(2) Detailees. The Council may accept persons on detail from within the Department of Defense and from other
Federal departments or agencies on a reimbursable or non-reimbursable basis.

(e) Contract Authority.—The Council may enter into contracts for the acquisition of administrative supplies, equipment,
and personnel services for use by the Council, to the extent that funds are available for such purposes.

(f ) Procurement of temporary and intermittent services.—The Chair may procure temporary and intermittent services under
section 3109(b) of title 5, United States Code, at rates for individuals which do not exceed the daily equivalent of the
annual rate of basic pay prescribed for level V of the Executive Schedule under section 5316 of such title.

(g) Data Collection.

(1) Under regulations issued by the Secretary of Defense, the Council shall have access to Department of Defense
databases necessary to complete its duties and responsibilities.
(2) Under regulations issued by the Secretary of Defense, the Council may enter into agreements with the Federal
Aviation Administration, the National Transportation Safety Board, and any other federal agency regarding the
sharing of aviation safety data.
(3) Except as the Secretary of Defense may choose to provide, and notwithstanding any other provision of law, data
collected by the Council under this subsection shall be privileged from disclosure or discovery to any person.

(h) Meetings.—The Council shall meet quarterly and at the call of the Chair.

(i) Duties.—The duties and responsibilities of the Council are as follows:

(1) Subject to subsection (j), be responsible for issuing, publishing, and updating regulations related to military
aviation safety, to include regulations on the reporting and investigation of aviation mishaps.
(2) Mishap Data. The Council shall –
(A) establish uniform data collection standards for aviation mishaps in the Department of Defense;
(B) review the compliance of each military service in adopting and using the uniform data collection standards
required under subparagraph (A);
(C) review aviation mishap data to assess, identify, and prioritize risk mitigation efforts in military aviation.
(3) Non-Mishap Data. The Council shall –
(A) establish standards and requirements for the collection of aircraft, simulator, airfield, and pilot data;
(B) establish requirements for each military service to collect and analyze the issuance of any waiver related to pilot
qualifications or standards.
(4) Safety Management System. The Council shall –
(A) establish, in consultation with the Federal Aviation Administration, a requirement for each military service to
implement a safety management system;
(B) review for approval each military services’ safety management system proposal;
(C) review each military services’ implementation of a safety management system.
(5) Review and assess civil aviation safety programs and practices and determine their suitability for implementation in
military aviation.

(j) Review. The decisions and recommendations of the Council are subject to review and approval by the Deputy Secretary
of Defense.

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Appendix I:

GLOSSARY AND
ACRONYM LIST
Cannibalization: The extent to which mechanics and G-suit: A garment with pressurized pouches that are
maintenance personnel remove serviceable parts, supplies, inflatable with air or fluid, worn by fighter pilots and
or equipment from one vehicle, vessel, or aircraft in astronauts to enable them to withstand high forces of
order to render a different vehicle, vessel, or aircraft acceleration
operational.
Mishap: An unplanned event or series of events that
Class A: Any mishap with a fatality, permanent total results in damage to DoD property; occupational illness
disability, or aircraft destroyed. For fiscal years 2010– to DoD personnel; injury to on- or off-duty DoD
2019, any mishap costing more than $2 million in total military personnel; injury to on-duty DoD civilian
property damage was considered a Class A. For fiscal year personnel; or damage to public or private property, or
2020, it was increased to any mishap costing more than injury or illness to non-DoD personnel, caused by DoD
$2.5 million. activities.
Class B: Any mishap with a permanent partial disability Study period: Fiscal years 2013 through 2018, the
or three or more persons hospitalized. For fiscal years Commission’s assigned period to assess military aviation
2010–2019, any mishap costing between $500,000 and mishap rates and compare them to historic rates.
$2 million in total property damage was considered a
Class B. For fiscal year 2020, it was increased to any
mishap costing between $600,000 and $2.5 million.
Class C: Any mishap with a nonfatal injury resulting in
loss of time from work beyond the day or shift when the
injury occurred. For fiscal years 2010–2019, any mishap
costing between $50,000 and $500,000 in total property
damage was considered a Class C. For fiscal year 2020,
it was increased to any mishap costing between $60,000
and $600,000.

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National Commission on Military Aviation Safety

Acronyms

AFB Air Force base IDA Institute for Defense Analyses

AI artificial intelligence IP instructor pilot
AoA analysis of alternatives J8 Joint Staff Force Structure, Resources,
and Assessment Directorate
AR augmented reality
JSC Joint Safety Council
ASAIS Aviation Safety Information Analysis
and Sharing KPP key performance parameter
ASAP aviation safety action program LOSA line operations safety assessment
Auto-GCAS Automatic Ground Collision Avoidance MCB Marine Corps base
system
MFOQA military flight operations quality
CAST Commercial Aviation Safety Team assurance
CDD capability development document MIL-STD military standard
CFIT controlled flight into terrain NAS Naval air station
CNA Center for Naval Analyses NASA National Aeronautics and Space
Administration
CO2 carbon dioxide
NAVAIR Naval Air Systems Command
CPD capability production document
NCO noncommissioned officer
CR continuing resolution
NDAA National Defense Authorization Act
CVFDR cockpit voice and image flight data
recorders O-8 eighth officer rank or grade, Major
General or Rear Admiral (upper half )
DoD Department of Defense
OBOGS onboard oxygen generation system
DODI Department of Defense Instruction
OJT on-the-job training
DOTMLPF doctrine, organization, training,
materiel, leadership and education, OPTEMPO operations tempo
personnel, facilities
PE physiological episode or event
DSOC Defense Safety Oversight Council
PEAT Physiological Episodes Action Team
FAA Federal Aviation Administration
PERSTEMPO personnel tempo
FR2 Force Risk Reduction database
PPE personal protective equipment
FRCSE Fleet Readiness Center Southeast
RAND RAND Corporation
FRCSW Fleet Readiness Center Southwest
SES Senior Executive Service
FY fiscal year
SOQA simulator operational quality assurance
GAO Government Accountability Office
TDY temporary duty
HFACS Human Factors Analysis and
UPE unexplained physiological episode or
Classification System
event
HSI human systems integration
VR virtual reality
ICD initial capabilities document

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