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After the Board

  • Published
  • By Mr. Mike Wahler
  • AMC/SEF
TMF Fall 2014 --  

Most mobility crew members are familiar with Air Mobility Command's (AMC's) actions immediately following an aviation mishap. The Wing Commander normally assigns a Single Investigating Officer (SIO) for the lower class mishaps (Class C, D, and E), or AMC convenes a Safety Investigation Board (SIB) for the Class A and B mishaps. Regardless of the mishap class, the actions taken by the SIB or SIO are the same. They investigate the mishap and formulate findings, causes, and recommendations.

According to Air Force Instruction (AFI) 91-204, Safety Investigations Reports, a finding is a single event or condition that is an essential step in the mishap sequence. A cause is a deficiency that, if corrected, eliminated, or avoided, would have prevented or mitigated the damage or injury. Recommendations are feasible and effective solutions to eliminate identified hazards or to mitigate the hazard's potential consequences.

So far, this article should be a review, but here comes the new information. What happens after the SIB determines and documents their findings, causes, and recommendations? In AMC, the SIB normally comes to Scott Air Force Base to brief the Convening Authority (AMC Commander or Vice Commander for Class As and the 18 AF/CC for Class Bs) on the results of the investigation. The Convening Authority has two options: accept the investigation as reported or direct the SIB to conduct additional investigation. The Convening Authority cannot change the report. He can only direct the SIB to investigate further.

Once the Convening Authority accepts the investigation, the AMC Safety staff releases the final message and coordinates it through the rest of the AMC staff (provides findings, recommendations and assigns an OPR for each). This is the staff's chance to comment on, but not change, the findings and recommendations of the final report. AMC Safety consolidates the staff's comments and forwards them to the Air Force Safety Center for incorporation into the Memorandum of Final Evaluation (MOFE). AMC Safety then publishes the SIB's recommendations to the Live Mishap Review Panel (MRP) SharePoint site and notifies the Offices of Primary Responsibility (OPR). This gives them a chance to start implementing the recommendations almost immediately after publication.

The AMC staff is now responsible for updating the status of all recommendations on the MRP SharePoint site at least twice annually. AMC Safety transfers those updates to the Air Force Safety Automated System (AFSAS) upon receipt. The recommendation's OPRs have three primary options to close out the recommendation. The first, and preferred option, is to comply with the recommendation. The second option is to comply with the intent of the recommendation. For example, the SIB may recommend adding verbiage to a specific AFI, but the OPR determined it is more appropriate to put the verbiage in a technical order (T.O.). The final option is to close the recommendation without taking any action. The OPR must conduct a risk assessment in order to pursue this option, and the AMC Vice Commander must accept the risk of not implementing the recommendation.

AFI 91-204 mandates that each Major Command (MAJCOM) establish an MRP. The purpose of the MRP is to address Class A and B hazards throughout the command. This panel must meet a minimum of once every six months. The AMC Vice Commander chairs the MRP and is the AMC authority for closing Class A and B recommendations. The approval is normally automatic if the OPR complies with the recommendation and nearly automatic if the OPR complies with the intent of the recommendation. The Vice Commander spends the most time deliberating recommendations the OPR recommends closing without implementation.

Many recommendations are easy to close quickly, such as a change to an AFI or T.O. that can be completed in less than six months. Some recommendations take much longer. For instance, a modification to an airplane may take many years. When a board recommends modifying an airplane, we cannot immediately begin the modification. The recommendation must be approved by the engineers at the Program Office and then by the manufacturer. Once they concur that the modification is prudent, then the command must secure funding. We then begin modifying the aircraft after the recommendation gets past those hurdles. It can take 10 years or more to modify an entire fleet, depending on the complexity of the modification and the size of the fleet.

Because of this variability, the command does not track a specific metric with regard to time to close mishap recommendations. However, the OPRs must document an estimated completion date. The AMC Vice Commander requires that the OPRs document realistic completion dates, and he pays close attention to those dates. He, along with the Commander, wants to minimize the time lapse from mishap board completion to recommendation closure. This is congruent with AFI 91-204's guidance stating the MRP process must identify all recommendations open for two years with rationale.

We in AMC actually exceed this requirement through our Live MRP process. In addition to briefing the Vice Commander semi-annually, we publish all open class A and B recommendations along with their status on a SharePoint site. This not only enables the OPRs to continuously update the status of their recommendations, but it also gives AMC leadership constant visibility on the status of all of these recommendations. This top-to-bottom visibility has increased our recommendation closure velocity in the first year of its existence, and we are hopeful that it will continue that improvement.

As you can see, AMC does not forget about our mishap lessons learned after the SIB makes its recommendations. There is, in fact, a robust process in place to ensure we carefully consider these recommendations and then implement them in a timely fashion. This process, although labor intensive, is imperative to the continued safety of AMC aircrews as they execute our global mission. Hopefully this "peek under the curtain" helped you understand what happens after the board.