[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


                                  
                         [H.A.S.C. No. 115-108]

                         DEPARTMENT OF DEFENSE

                     AVIATION SAFETY MISHAP REVIEW

                         AND OVERSIGHT PROCESS

                               __________

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON TACTICAL AIR AND LAND FORCES

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                             JUNE 13, 2018

                                     
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 

                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
33-381                    WASHINGTON : 2019                     
          
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              SUBCOMMITTEE ON TACTICAL AIR AND LAND FORCES

                   MICHAEL R. TURNER, Ohio, Chairman

FRANK A. LoBIONDO, New Jersey        NIKI TSONGAS, Massachusetts
PAUL COOK, California, Vice Chair    JAMES R. LANGEVIN, Rhode Island
SAM GRAVES, Missouri                 JIM COOPER, Tennessee
MARTHA McSALLY, Arizona              MARC A. VEASEY, Texas
STEPHEN KNIGHT, California           RUBEN GALLEGO, Arizona
TRENT KELLY, Mississippi             JACKY ROSEN, Nevada
MATT GAETZ, Florida                  SALUD O. CARBAJAL, California
DON BACON, Nebraska                  ANTHONY G. BROWN, Maryland
JIM BANKS, Indiana                   TOM O'HALLERAN, Arizona
WALTER B. JONES, North Carolina      THOMAS R. SUOZZI, New York
ROB BISHOP, Utah                     JIMMY PANETTA, California
ROBERT J. WITTMAN, Virginia
MO BROOKS, Alabama
                John Sullivan, Professional Staff Member
                  Doug Bush, Professional Staff Member
                          Neve Schadler, Clerk
                           
                           
                           C O N T E N T S

                              ----------                              
                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Tsongas, Hon. Niki, a Representative from Massachusetts, Ranking 
  Member, Subcommittee on Tactical Air and Land Forces...........     3
Turner, Hon. Michael R., a Representative from Ohio, Chairman, 
  Subcommittee on Tactical Air and Land Forces...................     1

                               WITNESSES

Francis, BG David J., USA, Commanding General, U.S. Army Combat 
  Readiness Center and Director of Army Safety...................     4
Leavitt, RADM Mark, USN, Commander, Naval Safety Center..........     5
Rauch, Maj Gen John T., Jr., USAF, Air Force Chief of Safety, 
  Commander, Air Force Safety Center.............................     6

                               
                               APPENDIX

Prepared Statements:

    Francis, BG David J..........................................    39
    Leavitt, RADM Mark...........................................    48
    Rauch, Maj Gen John T., Jr...................................    66
    Turner, Hon. Michael R.......................................    37

Documents Submitted for the Record:

    Charts of Navy and Marine Corps Aviation Mishaps by Active 
      and Reserve Component and Mishap Class.....................    83

Witness Responses to Questions Asked During the Hearing:

    Mr. Panetta..................................................    95

Questions Submitted by Members Post Hearing:

    Ms. Gonzalez-Colon...........................................   107
    Ms. Rosen....................................................   105
    Mr. Turner...................................................    99
   
   
   DEPARTMENT OF DEFENSE AVIATION SAFETY MISHAP REVIEW AND OVERSIGHT 
                                PROCESS

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
              Subcommittee on Tactical Air and Land Forces,
                          Washington, DC, Wednesday, June 13, 2018.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
Room 2212, Rayburn House Office Building, Hon. Michael R. 
Turner (chairman of the subcommittee) presiding.

 OPENING STATEMENT OF HON. MICHAEL R. TURNER, A REPRESENTATIVE 
  FROM OHIO, CHAIRMAN, SUBCOMMITTEE ON TACTICAL AIR AND LAND 
                             FORCES

    Mr. Turner. The hearing will come to order. The 
subcommittee meets today to receive testimony on the Department 
of Defense [DOD] aviation safety mishap review and oversight 
process.
    I would like to welcome our distinguished panel of 
witnesses. We have Brigadier General David J. Francis, 
Commanding General of the Army Combat Readiness Center and 
Director of the Army Safety; Rear Admiral Mark Leavitt, 
Commander of the Naval Safety Center; and Major General John T. 
Rauch, Jr., Air Force Chief of Safety and Commander of the Air 
Force Safety Center.
    I want to thank all of you for attending today, and we look 
forward to your testimony.
    This hearing continues the subcommittee's ongoing oversight 
of the aviation modernization and readiness. As I have stated 
before, we are experiencing a crisis in military readiness 
brought on by years of continuous combat operations and 
continued deferred modernization, lack of training hours, and 
aging equipment.
    The alarming number of aviation accidents just in the past 
3 months reveals how deep the damage goes and the magnitude of 
the task of repairing and rebuilding our capabilities.
    According to a recent Military Times investigation, 
aviation mishaps rose nearly 40 percent from fiscal years [FY] 
2013 to 2017 and nearly doubled for some aircraft.
    Just this past weekend an F-15 aircraft assigned to Kadena 
Air Base in Okinawa crashed while performing routine training 
maneuvers. Fortunately, the pilot survived. I believe this is 
the sixth Air Force-related aircraft accident in the last 12 
months.
    Most concerning is that more U.S. military service members 
have died in aircraft mishaps over the past year than have died 
while serving in Afghanistan. One of those service members was 
a constituent of mine. Gunnery Sergeant Derik Holley was a 33-
year-old enlisted Marine, and he was killed while conducting 
training missions in a CH-53E helicopter, a helicopter that had 
been in service since the 1970s.
    Given this alarming trend, the hearing today will examine 
how the military services conduct investigations post accident 
or mishap. We need to be assured the military services are 
adequately identifying the source and cause fast enough for us 
to be able to remedy them.
    We specifically want to better understand the process used 
by the Department and the military services to answer these 
three fundamental questions regarding mishaps: What happened? 
Why did this happen? And what changes and recommendations are 
being taken to prevent this from happening again?
    The witnesses today are responsible for conducting 
investigations of service mishaps, identifying mishap causes 
and problems, and recommending mitigation actions. We have 
asked them to walk us through the steps that they use to 
determine the root causes of aviation mishaps, as well as how 
they communicate the results of these investigations to their 
senior leadership for action.
    It is my understanding that military accident investigation 
processes include a thorough review of the mishap aircraft, 
circumstances of the incident and personnel involved. 
Investigations of an automobile accident might use a similar 
process, but if repeated accidents are occurring at the same 
intersection, it seems most reasonable to examine the 
intersection itself for changes that need to be made, such as 
signage, lighting, lane markings, and the number and adequacy 
of the lanes in question in the intersection.
    So I expect today that the witnesses will elaborate on how 
the military service safety centers collect and report mishap 
data to the Office of the Secretary of Defense [OSD] as 
required by current policy, to include data on the underlying 
factors that cause the mishaps.
    For example, I would like to know whether the safety 
centers include information on human factors that contributed 
to mishap, which according to DOD represent the leading cause 
of DOD mishaps.
    The hearing will also provide an opportunity to understand 
how lessons learned or recommendations from the outcomes of 
these investigations are informing changes to requirements for 
aircraft modernization in a timely manner.
    Additionally, the hearing should help members make a 
determination as to whether potential changes and reforms are 
needed in the overarching governance structure for the safety 
enterprise.
    Before I close, I also want to briefly touch on the issue 
of aging equipment and the undetermined causes and effects that 
may be evident pre-mishap, and with an awareness that some of 
those are identified in mishaps actually avoided.
    I have had recent discussions with the Secretary of the Air 
Force. This particular issue is a major concern of not only the 
Air Force, but also the Department as well. Our subcommittee 
will be taking a closer look at this issue also, in that there 
are circumstances with aging equipment where we are identifying 
vulnerabilities that are being addressed that avoid mishaps, 
but nonetheless should be brought to the attention of this 
committee so we look at the overall enterprise of reviewing 
these equipments and how we fund and look at modernization and 
maintenance.
    In closing, I am deeply concerned by the recent increase in 
these mishaps. While I am traveling to military bases, and 
spoken to pilots and maintainers, I have been more concerned 
also about morale and how this affects the military services 
and whether or not the military services are being too slow to 
respond. We have to do whatever it takes to ensure that our 
aircraft are safe and that pilots are getting the training that 
they need. And before we begin with our witness opening 
statements, I would like to then turn to my good friend Ranking 
Member Tsongas for her comments.
    [The prepared statement of Mr. Turner can be found in the 
Appendix on page 37.]

     STATEMENT OF HON. NIKI TSONGAS, A REPRESENTATIVE FROM 
MASSACHUSETTS, RANKING MEMBER, SUBCOMMITTEE ON TACTICAL AIR AND 
                          LAND FORCES

    Ms. Tsongas. Thank you, Mr. Chairman. And good morning.
    I would like to thank our witnesses for being here today to 
provide us with information on how each of the military 
services handles aviation mishap investigations and more 
broadly, aviation safety programs--or aviation safety programs.
    The past 2 years and the statistics provided by the 
witnesses show that despite the best efforts of the services, 
the aviation safety community, and others, military aviation is 
an inherently risky endeavor. We ask our aviators to train for 
and conduct missions in bad weather, at night, at low 
altitudes, and under other high-risk conditions that no civil 
aviation aircrew would ever even consider attempting to operate 
under.
    However, this capability to operate at high tempo in all 
kinds of conditions while conducting complex missions is what 
differentiates U.S. military from all others. Simply put, lots 
of nations have advanced aircraft, but only the United States 
has a capability to put it all together and use airpower to 
achieve remarkably effective airpower in all kinds of 
operations.
    So I think it is important to keep in mind that having the 
most capable and powerful military in the world comes at a 
price, one that is all too real for our pilots and their 
families.
    Realistic and complex training is required to achieve the 
kind of airpower only the United States can provide. However, 
this realistic training is sometimes also dangerous, as we have 
been reminded of recently.
    While we would all like there to be zero accidents, it is 
important to remember there this is no, quote, ``free lunch,'' 
unquote, and no zero-risk way to train for war. We are 
fortunate that we have a military full of people willing to 
take these risks to protect us.
    Based on the testimony we received, it is clear that all 
the services take aviation safety seriously and have a strong 
cadre of professionals dedicated to this challenge. However, 
there is always room for improvement.
    In today's hearing, I would like to hear how we can do even 
better and where Congress might be able to help. With that, Mr. 
Chairman, I look forward to hearing from our witnesses and I 
yield back.
    Mr. Turner. Thank you. I ask unanimous consent that 
nonsubcommittee members be allowed to participate in today's 
hearing after all subcommittee members have an opportunity to 
ask questions. Is there objection? Without objection, 
nonsubcommittee members will be recognized at the appropriate 
time for 5 minutes.
    And, also without objection, all witnesses' prepared 
statements will be included in the hearing record.
    General Francis, please begin.

STATEMENT OF BG DAVID J. FRANCIS, USA, COMMANDING GENERAL, U.S. 
    ARMY COMBAT READINESS CENTER AND DIRECTOR OF ARMY SAFETY

    General Francis. Chairman Turner, Ranking Member Tsongas, 
and distinguished members of this committee, thank you for the 
opportunity to appear before you today to talk about aviation 
safety and for your continued commitment to our aviation 
forces.
    It is an honor to represent the Army leadership, the 
soldiers and civilians, and, most importantly, the men and 
women of Army Aviation who are deployed throughout the world, 
supporting our Nation today.
    The United States Army maintains the world's most 
modernized and well-trained aviation force of its kind, 
providing an asymmetric advantage to the joint force. Aviation 
is an inherently dangerous business and we continue to make 
strides to reduce mishaps.
    Army Aviation Class A mishap rates have steadily declined 
over the course of the last 35 years, with noticeable anomalies 
associated with major combat deployments. In FY 2007, during 
the surge in Iraq, the Army's manned Class A mishap rate was 
2.39 per 100,000 flying hours.
    In the 10 years that followed, that rate fell to a point--
to a low of 0.87 during FY 2016, with a 10-year average of 
1.33. FY 2017 ended with a Class A manned mishap rate of 0.99, 
and the current rate for FY 2018 is 0.93.
    The mishap rates from FY 2016 to 2018 year-to-date 
constitute the lowest 3-year period for Class A aviation 
mishaps in the last 35 years. Despite this improvement, the 
Army can--remains committed to aggressively driving our mishap 
rates down further.
    Commanders across the Army are committed to conducting 
rigorous training in the most demanding environments to ensure 
we are ready to conduct large-scale combat operations in the 
most demanding conditions.
    The Army Combat Readiness Center mishap investigation and 
analysis capability is also crucial to meeting this goal. The 
Combat Readiness Center maintains a cadre of expertly trained 
accident investigators ready to deploy on a moment's notice, 
anywhere in the world.
    They are tasked with determining the root cause of our most 
severe mishaps and reporting lessons learned for Army-wide 
distribution, all with the aim of future mishap prevention.
    These teams follow a very deliberate and methodical process 
to answer three fundamental questions: what happened, why it 
happened, and what we are going to do about it. The follow-on 
collective analysis of these mishaps is also crucial to 
determining strategies to prevent future mishaps.
    The Army's efforts to reduce aviation mishaps is an ongoing 
process. We must train to the highest standards in the most 
demanding conditions to meet future threats, while 
systematically drawing from and disseminating lessons learned.
    We must remain aware of and mitigate inherent aviation 
risks, but--aviation risks, but must avoid becoming risk-
averse, or we will pay the price in our next conflict.
    Mr. Chairman, Ranking Member Tsongas, thank you again for 
your continued support of Army soldiers, civilians, and 
families, and I look forward to your questions.
    [The prepared statement of General Francis can be found in 
the Appendix on page 39.]
    Mr. Turner. Admiral Leavitt.

 STATEMENT OF RADM MARK LEAVITT, USN, COMMANDER, NAVAL SAFETY 
                             CENTER

    Admiral Leavitt. Chairman Turner, Ranking Member Tsongas, 
distinguished members of the subcommittee, I am grateful for 
the opportunity to appear before you today.
    The aviation mishap investigation review and oversight 
process is an important topic. Any loss of aircraft, aircrew, 
or maintainers negatively affects the lethality and resilience 
of our Navy-Marine Corps team. Our goal is to have zero 
preventable mishaps, but, for those that do occur, we 
rigorously investigate and learn from them to help prevent them 
from happening again.
    You have heard in previous testimony that physiological 
episodes are the number one safety priority in the Naval 
Aviation community. I wholeheartedly agree. This is a 
challenging issue, but there are many developments taking place 
to make our aircrew safer.
    Reporting is up because awareness is up. As we thoroughly 
investigate every single suspected physiological episode, we do 
that so we can continue to understand them, improve 
technological advances and human factors modification already 
in progress.
    In addition to our work on physiological episodes, it is 
important to know that we have detailed procedures in place to 
immediately investigate all aviation mishaps, even those that 
don't make the headlines.
    After investigating mishaps, hazard reports, and near-miss 
reports, we immediately disseminate those lessons learned from 
each one to the respective community of interest. Furthermore, 
high-velocity learning is central to the fleet safety culture. 
As such, we reaffirm at every opportunity the importance of and 
requirement for units sharing these lessons learned and risk 
mitigation techniques with others.
    To enhance the important work that we do responding to and 
investigating mishaps, the Naval Safety Center is undergoing 
some major internal organizational improvements. These 
initiatives align with Secretary Mattis' vision of innovation 
and delivering performance at the speed of relevance.
    Based on the findings in the Comprehensive Review and the 
Strategic Readiness Review, we are working with fleet and type 
commanders to aggregate manning, training, and other data 
sources so we can conduct complex modeling and analytics.
    This will allow us to provide a holistic picture about the 
overall health and risk level of units. Such analysis will 
provide preventative solutions that naval leaders can use to 
make decisions that reduce unnecessary exposure to risk.
    Getting this right is a vital interest to our Navy-Marine 
Corps team. Our people are our greatest asset, and keeping them 
safe is our responsibility. We owe them nothing less.
    I look forward to answering your questions. Thank you.
    [The prepared statement of Admiral Leavitt can be found in 
the Appendix on page 48.]
    Mr. Turner. General Rauch.

STATEMENT OF MAJ GEN JOHN T. RAUCH, JR., USAF, AIR FORCE CHIEF 
         OF SAFETY, COMMANDER, AIR FORCE SAFETY CENTER

    General Rauch. Chairman Turner, Ranking Member Tsongas, and 
distinguished members of the subcommittee, thank you for the 
opportunity to provide an update on the United States Air Force 
aviation safety program.
    I would like to let you know that safety is a top priority 
for the Air Force in everything we do, especially in aviation. 
We understand flying operations carry inherent risk, but we 
strive to eliminate or mitigate these risks to the greatest 
extent possible. We owe this commitment to our airmen and to 
the Nation.
    Our view is that one mishap is one too many, and the focus 
of our safety programs is mishap prevention. We have numerous 
efforts in place to identify and mitigate hazards well before a 
mishap occurs. However, when we do have a mishap, we strive to 
learn everything we can to prevent similar occurrences in the 
future.
    It is important to stress that we thoroughly investigate 
mishaps, identify root causes in order to formulate 
recommendations. Indeed, these recommendations are the legacy 
of a mishap investigation.
    We actively manage and track these mishap recommendations 
into closure. We have had success with this approach over the 
years, and our long-term aviation mishap rates have generally 
declined, but we never lose sight of the need to make 
adjustments to ensure we stay on top of any emerging hazards or 
trends.
    I also want to highlight that working together with the 
Office of the Secretary of Defense and the other services is an 
important part of what we do. Our safety centers and leaders 
constantly share information to ensure synergy and 
collaboration.
    In the end, we want to share effective safety programs 
across the entire Department to safeguard our people, protect 
resources, and preserve combat capability.
    Thank you and I look forward to your questions.
    [The prepared statement of General Rauch can be found in 
the Appendix on page 66.]
    Mr. Turner. Gentlemen, thank you for your comments. I mean, 
we certainly all understand that you are committed. We 
understand that mishap rates might not reflect casualty rates.
    Everybody can open the newspaper and look at the news 
stories that are occurring--that we have an unbelievable amount 
of risk that our service members are currently undertaking as a 
result of these mishaps.
    We understand what you must do, but this hearing is about 
are you? So I guess the first thing I would like to ask is, 
give us an example of something that you are learning.
    Tell us something that--you all outlined the process that 
we expected that you would be undertaking, but give us an 
example of something that we are learning as a result of the 
processes that you have been undertaking.
    General Rauch, I will begin with you.
    General Rauch. Thank you, sir. One example of one within 
the last year is we had a mishap with an engine, and one--Class 
A--and, once they tore into the root cause, they noticed that 
there was a defect with the actual blades in the engine.
    So went back, discovered that it was a manufacturing 
process and then, real quickly, time-critically, went across 
the fleet, ended up inspecting 15,000 different fan blades as 
of a couple weeks ago, noticing that 163 of these were bad and 
removed them from the system.
    That is the way we do it with technology. Now of course 
that creates a demand on the maintainers or whoever's doing 
that inspection--has to do with aircraft availability and that 
sort of thing. We also do the same thing whether it is an 
operational requirement or something about the way the aircraft 
itself is maintained.
    Mr. Turner. Admiral.
    Admiral Leavitt. Chairman, I will use the example of a T-45 
and the physiological episodes that we were incurring with that 
airplane. Initially, gathering the data took a little bit of 
time.
    We established the Physiological Episode Action Team, led 
by a flag officer, instituted a three-part form that allowed us 
to collect data. And as we dug down into specifically T-45, 
what we learned--that it was a gaseous oxygen problem that was 
getting different volumes to the crews in the front and the 
back.
    Working with NAVAIR [Naval Air Systems Command], NASA 
[National Aeronautics and Space Administration], and some other 
entities, we discovered that there were some design issues with 
the piping in the system and some other things. So we increased 
the idle--power of the engine when it sits at idle to keep the 
volume of air going through the OBOGS [On-Board Oxygen 
Generation System] generation system up.
    And we are in the process of designing an alternate oxygen 
supply system that will--is out for a request for--excuse me--
to be installed in the airplane, it looks like, down the road, 
in the next fiscal year.
    Mr. Turner. General Francis.
    General Francis. Mr. Chairman, thank you for the question.
    I think the biggest thing that the Army has learned over 
the course of the last year is that an in-depth study of our 
lesser accidents, in other words Class C mishaps, has provided 
to be very revealing.
    What we often realize is that it is a matter of inches or 
seconds that make the difference between a Class C or a Class 
A, which is a more severe mishap and oftentimes with 
fatalities.
    Our study of that has brought us to the production of what 
we call the near-miss brief, where we take a Class C mishap 
and, using our flight data recorders, we can recreate the 
flight and have a conversation about what might have been 
different that would have made that catastrophic and what 
procedures and processes and training can we implement to 
prevent those from happening in the future.
    We are currently conducting that brief across all Army 
Aviation--Active, Guard, and Reserve. And it is being very well 
received in the field, and we think it is going to make a big 
difference. Thanks.
    Mr. Turner. So, when we look at these incidences, the 
commonality is that things are falling out of the sky. But, 
when you look at the instances themselves, are you finding 
commonality?
    What types of things, as you are looking at these mishaps, 
are evident and that we need to be aware of as we look at what 
we are advancing for the committee's oversight?
    General Francis.
    General Francis. Thank you, Mr. Chairman.
    The U.S. Army--our causal factors have remained relatively 
constant, and that is that human factors generally count for 
between about 76 percent and 80 percent of our mishaps; 
material causes, between about 15 percent and 19 percent of our 
mishaps.
    So what that allows us to do is go in and further refine 
what those human factors are. And that is a--that is an across 
the DOD--effort to do right now--and then really go after those 
primary human causal factors, specifically as relate to 
training, that we can get after to prevent future mishaps.
    Mr. Turner. Admiral.
    Admiral Leavitt. Thank you, Mr. Chairman. Our data is very 
similar, with the percentage of both human factors and material 
failures, and then there's another 5 percent that is yet to be 
determined due to ongoing investigations.
    We are doing the same thing when it comes to human factors. 
The human factors coding allows us to do exactly the same thing 
that the Army is doing and get after those specific traits that 
we need to either change publications for, train--change 
tactics and procedures for, or do some training adjustments as 
we move forward. Thank you, sir.
    General Rauch. Thank you, Chairman. Our numbers for us are 
about 75 percent to 80 percent, as well, that are human 
factors. And doing some more things, as the other services--and 
one of the things we are trying to do is get access to, 
potentially, other data from other sources that aren't in sort 
of normal safety chains, as well, to see if there's some 
correlations between those things, as well as the human factors 
that we are seeing.
    But, so far as the human factor identification, as well as 
the same rates as it relates to the systems, sir.
    Mr. Turner. General Rauch, I understand the Chief of Staff 
of the Air Force has directed all wing commanders to conduct an 
operational safety review. And part of the review requires a 
review of the backlog of mishap safety investigation 
recommendations which have not been closed.
    Could give us an update on the status and how that process 
works? And then the same question for the others, after you 
finish. Once you come up with recommendations, what is the 
oversight process for determining that recommendations are 
implemented? And what happens when there's a backlog, as, 
apparently, the Air Force is experiencing.
    General Rauch. Thank you, Chairman. If I could take the 
second question first. So we get recommendations that come in 
from mishaps, average, just under about 100 a month. And so 
there will be individual OPRs [Offices of Primary 
Responsibility] that are identified and responsible for those.
    And so, whether it is across the different major commands 
[MAJCOMs]--you can imagine, if they are material ones, a lot of 
those belong to Air Force Materiel Command; policy and 
oversight at the major command levels would belong to the 
operating levels; and then some things would be on the Air 
Staff that is general policy.
    And that kind of accounts for most of the recommendations 
that aren't local in nature that a wing commander would take 
care of and it is isolated to themselves, because we try and 
figure it out--broad spectrum, obviously, internal things to--a 
wing could take care of.
    That process runs yearly. The different MAJCOMs have a 
different way of handling it. We, internally at the Safety 
Center, once a week are pulling down what those numbers look 
like, what the timeline is that people are actually reviewing 
them.
    And if you dig into one of those recommendations, it might 
be a significant material solution to something that takes 
years to field. And so that mishap recommendation will stay 
open, and we will track those through. And so that is one of 
the things we spend time on.
    Other ones will be overcome by events, and the other part 
is safety investigation boards are not restricted from what 
they recommend, and so they can really stretch beyond, 
potentially, what is currently available, and that will be out 
there and it will be something that comes to fruition.
    An example of that might be the auto-ground collision 
avoidance system that was out there for a while, and it has 
been implemented on the F-16s, now, coming--we will bring it 
forward on the F-35s as well as on the F-22, a different 
system. But, anyway, so that sort of thing might be a 
recommendation; it might come from that, and it takes many 
years to implement.
    If we go back to the operational safety review, which was 
the first part of the question, sir, you are exactly right that 
in May the chief directed that they actually have a standdown 
across all the wings, that we do an operational pause; that we 
take time to look at seven different categories he asked them 
to do.
    He empowered the local commanders to clearly talk about the 
different issues that they are interested in and asked for that 
feedback. The intent was not to have the Air Force as a whole 
and the major commands fix the local problems or to highlight 
the local problems, but to give them a chance--an opportunity 
to talk about the risk that is out there and highlight those 
things that upper levels can--can take care of.
    The interim feedback we are getting is exactly that, when 
the wings got together--the Active Duties have been complete. 
The Guard and Reserve have been given to the 25th of June to 
make sure that they can fit within the schedules that they have 
on the weekends and Guard weekends and that sort of thing, the 
drill periods.
    So we are getting interim feedback back, and it talks about 
some of the things that are going on, both local, MAJCOM, and 
Air Force level that they are--they will go after and tackle.
    Some success stories are buried in there of things that 
they have been able to do, and some other concerns that have to 
do with aging aircraft, manning levels, experience levels, and 
that sort of thing. But it is still interim and we are--and it 
is still coming in.
    And so I am not sure what all we will hear from that. We 
will bind that together. Look to see what sort of actions that 
are things that we can take care of at the half level, sort of 
policy issues. And it might be larger, broader things that will 
drive an initiative that will have to do, sir.
    Mr. Turner. Thank you. Admiral.
    Admiral Leavitt. Mr. Chairman, every mishap investigation, 
when they determine causal factors, has recommendations that go 
along with those causal factors. And the recommendations, 
either from a hazard report or a safety investigation report, 
become either mishap recommendations or hazard recommendations.
    Of the majority of them, 65 percent of those are aligned to 
NAVAIR, because many of it is engineering or parts issues going 
forward. That list is maintained by the Naval Safety Center, 
and then it is kept up to date on a weekly basis through the 
aircraft controlling custodians--that would be Commander Naval 
Air Forces Pacific, Commander Naval Air Forces Atlantic, 
Assistant Commandant for the Marine Corps for Aviation, and 
things along those lines.
    Right now, in the last 90 days, there were 140 MISRECs 
[mishap recommendation responses] or HAZRECs [hazard report 
recommendation responses] closed, and there were also 74 added 
in the 90 days. So it is an ongoing effort to stay in front of 
those things, as General Rauch alluded to. Sometimes, there are 
long-term design issues or parts that have to be bought. Again, 
the mishap boards are not constrained in the Navy and Marine 
Corps, as well, from putting things out there that future 
technology may be able to solve, so some of them do stay open 
for long periods of time.
    Mr. Turner. General Francis.
    General Francis. Mr. Chairman, the U.S. Army Combat 
Readiness Center maintains what we call the recommendation 
tracking system, and that is where we take all the 
recommendations that come from mishap investigations, and we 
assign those recommendations to the appropriate agency in the 
Army to deal with that particular subject.
    On a weekly basis, the general officer leadership from 
across what we call our aviation enterprise, those that are 
responsible for training, doctrine, for sustainment, for 
acquisition, special operations, and dealing with the Army 
staff, we meet weekly and discuss the most important of these 
things.
    As you know, depending on the urgency of the 
recommendation, we will determine the speed at which we resolve 
that recommendation. Some of them might be fairly simple to do. 
Others might be more complex, involving a materiel solution or 
a revisement of training or documentation, training 
publications, et cetera, that might cause us to go a little bit 
longer.
    But we do, in fact, track those and make sure that they 
have the right leadership emphasis across the Army Aviation's 
leadership on a weekly basis.
    Mr. Turner. Ms. Tsongas.
    Ms. Tsongas. Thank you.
    In reading the materials leading up to the hearing, I see 
that the mishap notification and reporting process is governed 
by each service's internal regulations, which outline 
responsibilities, timelines, reporting, and safety 
investigation requirements for each type of mishap. I would 
like to ask more about the mishap boards that clearly have such 
responsibility that each service assembles to respond to these 
incidents.
    So are there standing boards or teams that respond to major 
mishaps? Or are the boards assembled on an ad hoc basis, 
depending on the type of aircraft, the circumstances 
surrounding the incident, and other--other factors that may be 
taken into account? And I will start with you, General Rauch.
    General Rauch. Thank you, ma'am. So, to start at the back, 
we do not have standing boards, so you are exactly right. We 
have board presidents that are previously trained ahead of time 
and throughout the organization.
    And so, when a mishap happens at a location, they'll stand 
up an interim safety board that will preserve the evidence and 
take care of things while the major command that is responsible 
to be the convening authority will assemble the board.
    That board will have that board president that is trained 
to do that. We will have an investigation officer that has been 
trained to do investigations. Both of these may or may not have 
done investigations in the past.
    We will have a pilot member, depending upon whatever 
airplane it is that is involved. We will have a medical 
professional, and then whatever else the team really needs to 
kind of round out that board. And then, as time goes, if they 
need more help, we will get them access to that help.
    Meanwhile, there will be a person from the Air Force Safety 
Center that is responsible to integrate with that team and get 
them the support they need, and on some of the boards, they are 
actually a member of the board. It really depends on the makeup 
and the mishap that occurred.
    Ms. Tsongas. The board presidents are drawn from where?
    General Rauch. They are normally drawn from the MAJCOM in 
which the accident occurred. So, if it is Air Combat Command 
and they have a mishap, then they will be the ones that will 
normally draw a colonel from somewhere across that group, 
unless there's fatalities, in which case it will be at least a 
one-star that will be chosen to be the board president.
    So what we end up doing is training a lot of board 
presidents every year to be prepared in case something happens.
    Ms. Tsongas. So you train them in anticipation that there 
will be incidents?
    General Rauch. Yes.
    Ms. Tsongas. And is there a standard protocol for that 
training?
    General Rauch. Yes, ma'am. It is actually--the training is 
run by the Safety Center for the board presidents' course, and 
we do it in Albuquerque, but we also do it on the road, 
sometimes--just send a couple instructors on the road.
    And they will actually do the instruction for both the 
safety investigation board and the accident investigation 
board; they get the same sort of training together. And so we 
do that for the group commanders and wing commanders, but then 
we also do that for other people that will--that may be 
selected, ma'am.
    Ms. Tsongas. Admiral.
    Admiral Leavitt. Thank you, ma'am. In the Navy-Marine Corps 
case, we can have either standing boards, or boards that are 
appointed by the controlling custodian when a mishap occurs. 
The controlling custodian is the convening authority.
    Membership, at a minimum, includes a senior member--either 
a naval aviator or a naval flight officer. If it is a Class 
Alpha, it is an O-5 or above, preferably outside the reporting 
chain when it comes to the mishap. All other mishaps, the 
senior member has to be a senior to the pilot and commander or 
mission commander of the aircraft that was involved.
    There's an aviation safety officer, who is professionally 
trained in aviation safety at our School of Aviation Safety 
down in Pensacola, Florida. There's a flight surgeon to do--to 
deal with aeromedical issues. There's a maintenance 
representative, and an operations representative.
    Other--just like the Air Force, other specialties as 
required, and we do rely on technical support from the outside, 
from original manufacturers and NAVAIR. But it is important to 
note that those people are not directly members of the board. 
They are advisers to the board.
    Ms. Tsongas. Do you have a similar training program for 
those that might be tasked with leading the effort?
    Admiral Leavitt. With leading the effort? No, ma'am. We 
have aviation safety officers who--who are the--the aviation 
safety experts that have been trained at our School of Aviation 
Safety.
    Our COs [commanding officers] and wing commanders also 
attend a 2-week course down at the aviation safety school to 
give them a top-level view of what to expect if they are 
appointed senior member of a board.
    Ms. Tsongas. And, since you have both ad hoc and those that 
are created--are standing, have you compared results or 
processes between the two different approaches?
    Admiral Leavitt. Anecdotally, ma'am, I would have to say, 
from the reports that I have seen that have been done by both 
over my career in the Navy, I have seen no difference in the 
rigor that is put into those investigations.
    Ms. Tsongas. Thank you. General.
    General Francis. Thank you, ma'am. At the U.S. Army Combat 
Readiness Center, we do have four standing teams, two ground 
and two air, that consist of a board--a school-trained board 
president and recorder.
    Now, the rest of that team is built much like the other 
services, depending on the type of mishap and the expertise 
that is, in fact, required. The--what they bring to that is 
they are experts at accident investigation and the processes to 
do that.
    We do have a formal accident investigators' course that we 
do out of Fort Rucker, Alabama, that all of our investigators 
are required to go through. In addition to our standing boards, 
we do have--we do train other accident investigators throughout 
the Army, in the event that we are committed, another mishap 
occurs and we do have other trained--school-trained folks to 
conduct our mishap investigations.
    And we have the same board makeup that the other services 
have, as well, in terms of the medical and the technical and 
all the other disciplines that may be required in any 
particular mishap.
    Ms. Tsongas. And, again, have you seen the benefit of one 
versus another, the ad hoc versus the standing?
    General Francis. So the--the accident investigators that we 
have at the Combat Readiness Center--that is what they do. That 
is all they do. They are very, very good at what they do.
    The completeness of the reports is--the quality of the 
reports tends to be a little bit better, quite frankly, than 
the rest of the field. However, we do a quality control check 
on all accident reports that come up from the team--but their 
expertise in that particular area makes them better than just 
about anybody else.
    Ms. Tsongas. Thank you.
    I would like to ask a question about how you are responding 
to families as these events are happening. So I believe keeping 
face with the families of our military aviators is obviously 
critical whenever there is an accident.
    And family members do deserve to know as much as possible, 
as soon as possible, about how their loved ones were injured or 
lost in an event. So how are families integrated into the 
investigation process? And we will start with you, General.
    General Rauch. Ma'am, the purpose of the Safety 
Investigation Board--the primary purpose of that is mishap 
prevention. And there are some aspects of that that go back 
quite a ways that end up with taking safety privilege from 
privileged communications that may come from an aircrew member 
or somebody else.
    And so what the Air Force has done is, at the same time, we 
do a separate board by the individuals trained--the board 
presidents are trained, for us, the exact same way--called the 
Accident Investigation Board.
    And so, within 2 days of that standing up, they plan on 
talking--the normal routine is to go talk to the families to 
make sure they understand the process from the very beginning. 
Depending upon where the mishap occurred, there may be--the 
families may have an unusual request or something that they can 
meet there, and then they keep the family informed.
    And it is that Accident Investigation Board that is 
actually releasable to the public. And what we do is, they are 
the ones that are first advised. So, once it is signed off and 
approved, that board president offers to go brief those family 
members, let them know what was discovered, answer any 
questions before it is released to the public, because, 
obviously, we agree with you and think that they should be the 
first ones to receive that information, ma'am.
    Ms. Tsongas. So, essentially, they are first told the 
process, but it may be some time before they are actually 
informed of what happened?
    General Rauch. Yes, ma'am. It will take some time to go 
through and figure out--determine exactly what did happen, yes, 
ma'am.
    Ms. Tsongas. And does the seriousness of the accident play 
a role in what you are able to tell and when?
    General Rauch. Sometimes it is the nature of the accident, 
maybe, more than seriousness. Obviously, if you are talking 
about families of injured or deceased members, those are the 
worst type of accidents, obviously, because we have lost life 
or injured individuals.
    So a lot of those--each one is different, but a lot of 
those will have that time dynamic that there's something, 
probably, complicated that happened, and it takes a while for 
that investigation to occur, ma'am.
    Ms. Tsongas. Admiral.
    Admiral Leavitt. Yes, ma'am. Similarly, there will be 
parallel investigations that go on--the safety investigation to 
determine the causal factors and prevent reoccurrence. The 
other investigation that goes on is the JAG [Judge Advocate 
General's Corps] manual investigation, which assigns 
accountability.
    The Safety Center does not directly interface with family 
members or--of someone who is injured or involved in an 
accident. If there's a fatality, the Casualty Assistance Call 
Office, which is local to the command that had the fatality, 
will notify the family members and things along those lines.
    Before the JAG manual is released, the family does get a 
brief, and, if the family member desires a copy of the safety 
information--safety investigation report, they can generally 
contact our FOIA [Freedom of Information Act] office for 
freedom of information and obtain a redacted copy, due to some 
of the safety-privileged information that would be in the 
report that we would not want--that is important to getting to 
the bottom of the investigation, finding out the causal 
factors.
    Ms. Tsongas. But they would have to go through that FOIA 
process before they would be privy to some of those details?
    Admiral Leavitt. The specific details of the accident, 
ma'am?
    Ms. Tsongas. Yes.
    Admiral Leavitt. If it was non-safety privileged and it was 
factual, yes, they would get--they would go through the--the 
FOIA process to get that information. Yes, ma'am.
    Ms. Tsongas. General.
    General Francis. Ma'am, obviously, as with all the 
services, the Army is very, very concerned about our families, 
especially in a time of crisis, if there's a fatality and so 
forth. And the Army has multiple mechanisms to help families 
through those times that are outside of the safety arena.
    Within the safety arena, just like the other services, we 
have the safety investigation and what we call the AR, Army 
Regulation, 15-6 investigation, which is the legal 
investigation.
    At the completion of those investigations, the safety 
investigation will share all factual data with the--with the 
15-6 investigation, and that is the--the 15-6 is the one that 
would get out-briefed to the family members.
    The family members, much like the other services, can 
request the--the report that is not safety privileged through 
the FOIA process. But, other than that, the factual data would 
already have been transmitted to them through the 15-6 that we 
could share from the Safety Center.
    Ms. Tsongas. Thank you. I yield back.
    Mr. Turner. Mr. Bacon.
    Mr. Bacon. Thank you, Chairman. Appreciate it. We thank our 
three safety experts here and leaders for being here. I was 
trained to be safety officer, by the way, Ms. Tsongas, so I did 
two accident board president duties myself and briefed the 
families.
    I thought it was one of the most challenging jobs, but when 
you find a root cause and can compassionately brief a family it 
is also, I would say, rewarding and something you never forget.
    So I really appreciate what you all do, and I know 
firsthand the importance of your--your jobs. And, also, I would 
like to say, firsthand, I know the professionalism of Major 
General Rauch over here, who I have worked with on multiple 
occasions, so good to see you here.
    We had 80 fatalities last year from routine operations. We 
think some of that--can't say all of it, but some of it goes 
back to underfunding--or underresourcing our training, our 
maintenance, stretching people out too thinly in some of our 
service areas. So last year, we plused-up funding by 10 percent 
to the NDAA [National Defense Authorization Act]. This year, 
we--we held that even with inflation. And is our hope that 
through better funding of our operations and training and 
maintenance that we are going to see some improvements in our 
safety record this--you know, in the coming years.
    And that is--that is one of the motivators for us to fund 
and approve the funding of our military. One of the things that 
concern me is I was on an aircraft carrier over Christmas in 
the Persian Gulf and the skipper of the aircraft carrier said 
that the average fighter pilot got 11 hours a month training 
prior to deployment. And I know in the Air Force, there are 
some communities they are getting the same kinds of flying 
hours.
    And I think it is about one-third of what we used to do in 
the 1990s. Or I should say maybe one-third of optimal training 
before we deploy people and put them in--in combat. So I would 
like just get your-all's sense. Are you getting enough flying 
hours right now with your various crews? I know it may depend 
on what MDS [mission design series] or what type aircraft out 
there. But we would like to get your feedback.
    Are we giving enough flight hours and what is the 
relationship between routine flight flying hours and training 
versus safety? I would appreciate your--your feedback. And we 
will start left to right. Thank you.
    General Francis. Thank you, Congressman, for the question. 
Our data do not indicate a correlation between the execution of 
flight hours and--and mishaps. It--we just cannot correlate 
that data one to the other. What we can say is that our data 
does indicate that the Army Aviation has experienced the most--
biggest spike in Class A mishaps in conjunction with major 
combat operations.
    So when we went to Desert Shield/Desert Storm, Bosnia and 
Kosovo, Iraq and Afghanistan. During each one of those 
conflicts, especially during the initial stages, we experienced 
a major spike in Class A mishaps. And so where we are focused 
right now is making sure that we are doing that hard training 
that is going to be required to meet a peer or near-peer threat 
which will drive us to lower flight profiles and increase risk 
to prevent that next spike from occurring, when and if we do 
get called to the next combat engagement.
    Mr. Bacon. So what I hear you saying, if I may-- if you are 
under-training, that adds risk in the early stages of combat. 
If you--if you under-train.
    General Francis. Yes, sir.
    Mr. Bacon. And there--and so you are seeing that direct 
correlation. Thank you. Admiral.
    Admiral Leavitt. Thank you, Representative, for the 
question. Again, the Navy has not--Navy-Marine Corps team has 
not been able to draw a direct correlation between a lack of 
flight hours and increase in mishaps. What we have discovered 
through a study that was done recently was a change in OPTEMPO 
[operational tempo] from very high OPTEMPO to very low OPTEMPO 
or very low OPTEMPO to very high OPTEMPO. That is where we see 
the greatest increase of risk.
    Units that remain in low OPTEMPO and are able--they are 
able to look at that low OPTEMPO, mitigate risk ahead of time 
and same when we are in the high OPTEMPO area. We have 
discovered it is the fluctuation between the two is when we see 
the increased level of risk out there going forward.
    Mr. Bacon. General Rauch.
    General Rauch. Congressman, we--so we went--and of the 
recent ones being investigated, of course we went back to look 
at the individual pilots to see the amount of flying they would 
have had in the last 30, 60, and 90 months. What we did not see 
was a correlation between those that have had a lot or a little 
as it relates to the Class A's within recent times. Now, 
clearly those numbers--when we are fortunate--are in the small 
numbers.
    And so you end up with small number dynamics if you are 
not--if you are not careful. And so we don't think that it 
proves that there's no correlation, but at least from the 
individuals that we have had that have been in the mishaps, 
that has not been something that we can directly correlate to 
the number of mishaps we have had in--across the different 
years of cross--last couple years, we were looking to compare 
that sort of thing.
    We are tracking the number above flight--total flight hours 
we fly as a service, look at that as it relates to the rates. 
So that you can--we kind of judge years to years. Like I say, 
fatalities at different rates across the different years. We 
actually looked for last year, for us, the number was less than 
it was this year. And so we do--we do track those closely but--
but haven't got the connection between two, sir.
    Mr. Bacon. This may be a better question for the A-3 or the 
G-3 or N-3, whatever--whatever service it may be. But wouldn't 
you agree that maybe 11 hours a month would be too low? And 
that--that does induce risk, particular maybe for the pre-
combat or early stage--early phases of a combat? So maybe I 
will just come back to you. We--are we getting enough flight 
hours for safety?
    General Rauch. Congressman, I will tell you the one thing 
we are looking at that from a safety point of view is if we are 
getting inadequate flying time and if there's inadequate 
training, then there's some concern is that a hazard that we 
are now having to deal with. And then how do you mitigate that 
hazard and how to create that risk. And definitely reduced 
flying hours below a threshold that would cause that.
    We don't have a number that--on the safety community that 
we are using, but obviously as you say, the three is the one 
that is looking at that. But from our point of view, we are 
worried about the risk if you are not flying enough.
    Mr. Bacon. Okay. Either--any more comments? Maybe one 
follow up--go ahead, General. You--were you going to----
    General Francis. Certainly, sir, there's a risk if we don't 
train to standard. The aviation training strategy for the U.S. 
Army says that we shoot for 14.5 hours per crew per month. It 
would change the battalion level collective proficiency. And 
that--that is what we are going for as we transition to large-
scale combat operations. And--and the Army is working towards 
funding that, they are getting us to closer to those levels 
than we are currently.
    Mr. Bacon. Okay, thank you. Chairman, I yield back.
    Mr. Turner. Mr. Carbajal.
    Mr. Carbajal. Thank you, Mr. Chairman. In the Navy's 
testimony, I found something a bit disturbing. On page 3, there 
is a chart showing the Marine Corps Class A mishap rate over 
the past 10 years. The Army, the Air Force, and the Navy show 
roughly a flat rate of Class A events over that time period. 
But as shown in the testimony, the Marine Corps rate has more 
than doubled between 2008 and 2017. Fiscal years, should I say.
    This data appears to show that the Marine Corps has a 
serious aviation safety problem. What is going on with this 
situation when you look at the comparisons? What seem to be the 
top reasons for this problem? Is it funding? Is it--is it old 
aircraft? Is it the lack of training? What is it? And what is 
the plan to get to this issue? If you could outline maybe what 
that plan to move forward is, I would greatly appreciate it.
    Admiral Leavitt. Thank you for the question, sir. Over a 
10-year average, the Marine Corps is within normal rates with a 
couple aberrations, as we talked about. Last year was a--a 
tough year for the Marine Corps with the number of personnel 
that we had lost along the way. One of the efforts that we are 
pursuing at the Naval Safety Center right now to look across 
greater data streams instead of just mishap and hazard 
reporting data.
    We are working internal with our organization to stand up a 
knowledge management safety promotion directorate that is going 
to aggregate data that includes operational data, manning data, 
and many other things. We are hiring data scientists and some 
other folks who are working with the Army analytic group to 
come up with some complex modeling and deep-dive analytics that 
will be informed by subject matter experts who are operators of 
Navy and Marine Corps aircraft.
    And hopefully from that we can become much more predictive 
in--in discovering what could come in the future for occurring 
mishaps; getting left of the bang, as I like to put it, sir.
    Mr. Carbajal. Is there an actual plan to achieve that and 
timelines?
    Admiral Leavitt. Yes, sir, there is. It actually came out 
of the Strategic Readiness Review and the Comprehensive Review, 
although those were focused on the tragic ship mishaps last 
year. Aviation safety is taking lessons from those and we are 
funded both in 2018, 2019, and 2020 to increase our staffing 
and manning.
    We have a contract with Army Analytics Group right now, we 
just hired a data scientist contract at the Safety Center, so 
within this year--I would say by the end of this year, we will 
have that division stood up at the Safety Center, we will be 
producing results hopefully next year at some point, sir.
    Mr. Carbajal. Thank you, Admiral. Mr. Chair, I yield back.
    Mr. Turner. Mr. Panetta.
    Mr. Panetta. Thank you, Mr. Chairman. Gentlemen, good 
morning and thank you for being here. Major General Rauch, you, 
in your testimony, you submitted information and basically 
differentiated in regards to the mishap rate between manned and 
unmanned rates.
    However, Admiral Leavitt and General Francis, you did not. 
Can you provide this data or do you know now whether or not 
there are any trends between manned and unmanned mishaps that 
you can talk to right now?
    Admiral Leavitt. Sir, I will have to take that for the 
record, I don't have those stats in front of me.
    [The information referred to can be found in the Appendix 
on page 95.]
    Mr. Panetta. Affirm, thank you.
    General Francis. Sir, we will get back to you with those 
statistics as well.
    [The information referred to can be found in the Appendix 
on page 95.]
    Mr. Panetta. I appreciate that, thank you. And then in 
regards to--let's see, General Francis, you did a good job in 
your testimony pointing out the need to train in regards to 
large-scale combat operations. However, you go on to say this 
operational tempo challenges our ability to achieve collective 
level training standards above the platoon level.
    Now obviously, as you know well, the NDAA, we authorized a 
pretty big budget and if we can't train the large-scale combat 
operations under this record budget, you know, what are we 
doing wrong? What else do we need to do in your recommendation?
    General Francis. Congressman, thank you for the question. 
This would be more for the Army G-3 to answer, but the 
operational tempo can deploy units at less than that collective 
level. And so as we deploy, we actually can sometimes consume 
readiness depending on how we deploy our aviation forces.
    So it is not that our aviation forces aren't flying in 
training, but training to that battalion collective level for 
large-scale combat operations is quite a challenge for us right 
now with this operational tempo.
    Mr. Panetta. Okay, all right, thank you. Gentlemen, I look 
forward to continuing the conversation as we move along. Thank 
you, I yield back.
    Mr. Turner. Mr. Brooks.
    Mr. Brooks. Thank you, Mr. Chairman. I am trying to get a 
feel for military versus commercial, and it is like comparing 
apples and oranges with substantial differences between the 
two, obviously.
    Let me get some background and then I am going to ask some 
questions, and I have gone through your submitted testimonies 
in writing, and commercial airliners typically look at fatal 
accidents per 1 million flights, while the military data that 
you have given us is on a basis of 100,000 flight hours.
    If we were to assume, and I recognize that this makes the 
military numbers look better, because most commercial flights 
are longer than an hour, but if we were to assume 1 hour per 
commercial flight and transform your numbers, which are on 
100,000 basis, to a million basis, then this is generally 
speaking what we get.
    With commercial airliners, they are averaging about 0.25 
fatal accidents per million flights versus the Army's roughly 
0.99, if I understood your testimony correctly, per 100,000 
flight hours, multiplied times 10 gives us 9.9.
    So the military is having fatality rates that are much 
higher than what we see in the commercial sector, and the Air 
Force numbers, if I understand the difference between the Air 
Force and Army, is the Air Force has a fatality rate that is a 
little bit--or Class A mishap rate--that is a little bit higher 
than the Army's.
    So that is kind of a background, and looking at some of the 
factors as I understand them, but if you are aware of other 
factors please illuminate, you have got the types of aircraft 
and you have got the argument that military aircraft are much 
more complex and they are operated by fewer individuals, hence 
there's smaller room for error. You have got with military 
aircraft, you are almost continually testing the limits of 
those aircraft in order to be combat ready where you would be 
expected to do the same thing. That, of course, is not what 
commercial pilots do.
    Perhaps there is a difference in experience of pilots 
where, by way of example, a lot of military pilots when they 
retire, they become commercial airline pilots. That is their 
second career, so they have already got all that military 
experience built in and then they add onto it.
    And then you have got the maintenance issue, and I don't 
know how often or how much maintenance work is done by the 
military versus commercial, and there may be other factors, but 
those are four that come to mind.
    So with all this as a backdrop, which factors do you 
believe are most responsible for the Class A mishaps in your 
various services, and then second, what can we do to help?
    Mr. Turner. Just a note. I appreciate that the gentlemen's 
questions were not to them with respect to a comparison of 
commercial versus military, but I do want to note that they 
were not asked to prepare any data or information with respect 
to commercial versus military.
    But your questions seem to be pretty much targeted toward 
just their--their current role, so I appreciate that.
    General Rauch. Congressman, thanks for the question, as the 
broad overlay, we--we do spend time with the civilian aviation 
community, some of the type of flying we do is close to that, 
the actual flying itself.
    And so we pay attention to the safety forums that they have 
and are on some of those boards so that we can learn some of 
the things they do if industry drives forward with some sort of 
a safety program data gathering or some sort of analysis we try 
and learn from that and bring it on as quick as we can.
    From the Air Force's point of view, you talked about the 
different missions set, and that is exactly the case for us. It 
is--it is all the way from helicopters to fighters to cargo to 
ISR [intelligence, surveillance, and reconnaissance] and 
everything in between. So a completely different set of 
missions that are required. So while the airline is traveling 
from point A to point B, we often have some mission that is 
going on in between.
    We also have aircraft that are significantly older than the 
normal commercial fleet, which drives increased maintenance, as 
you addressed, and those are probably the two of the largest 
features for us.
    Mr. Brooks. So one thing that we can do to help would be to 
buy new aircraft.
    General Rauch. The environment that we live in with--with 
aging aircraft and the engineering that is required to sustain 
those aircraft and the more time, we are certainly setting up 
hazards there that have to mitigated if not, sir.
    Mr. Brooks. Admiral Leavitt or General Francis?
    Admiral Leavitt. Sir, thanks for the question, I would 
offer along the lines of what General Rauch said. I think the 
mission in and of itself is much more inherently risky as we go 
forward, and being able to consistently train and do things 
along those lines would be helpful to be able to keep our 
training.
    As you know, the Navy uses tiered readiness, as we get 
ready to deploy, the OFRP cycle, the optimized fleet readiness 
cycle, is a 36-month cycle for our carrier strike groups. We 
spent some of that time in the maintenance basic phase, then we 
get into the advanced phase, and then we deploy and sustain 
afterwards. And it is that training ramp along the way that 
gets people up to speed so they can be certified to deploy.
    General Francis. Thank you for the question, sir.
    Sir, we--I am very proud of what we ask our Army aviators 
to do. We ask these young aviators to operate in adverse 
weather, in unimproved conditions, they are not landing on 
runways.
    Our Army aviators are landing in the dirt, in dust, in 
various challenging environments. They are up against an enemy 
force. They are working in coordination with the ground force. 
So the complexity of what military--especially Army Aviation 
does, in conjunction with a ground force, compared to a 
civilian airline, is really apples and oranges. And so it goes 
back to training.
    You asked, you know, what--what are the causal factors. I 
think we have already talked about that the--76 percent or so 
of our mishaps are human factors related; about 19 percent are 
materiel related and so going after that biggest part of that, 
which is training, particularly for large-scale combat 
operations, is our primary focus.
    Mr. Brooks. So, as I understand it, the two main things: 
new aircraft, more money for more time for training. Thank you.
    Thank you, Mr. Chairman.
    Mr. Turner. Mr. O'Halleran.
    Mr. O'Halleran. Thank you, Mr. Chairman. Thank you for 
being here today. I would like to go back to the Air Force 
issue first, Mr.--General, and identify--it seems that there's 
three different kinds of boards.
    And does everybody talk to one another about maybe which 
one is more adept at making sure that we get to an answer 
sometime before, you know, to some of the major issues, two, 
three, four, whatever amount of years it is?
    Because--and what happens in that intervening period to 
make sure that the issue is resolved for the safety of the 
pilots in that intervening period? So right to left, please.
    General Rauch. Congressman, thank you. Yes. So, first off, 
we do--we are underneath the OSD umbrella of what needs to be 
investigated. Our mishap investigation boards are pretty 
similar. The training or background and where we pull them from 
is slightly different, with the exception of if we have a 
standing board.
    What--to not consume time, there were some details that we 
left out. For us, for example, when a board goes to 
investigate, they are tasked with coming to resolution in 30 
days. So that time pressure is there for them to find out 
what's happened within 30 days. Then there's some time after 
that for them to actually get to the convening authority and 
brief it and have it accepted.
    In that 30 days at the very beginning, if they find some 
time-critical safety item that needs to be fixed, whether it is 
identifying a problem with a part that they discover, a way an 
aircraft's maintained, a way it is operated--pretty much the 
spectrum--there is ways within the service to go out and get 
that to the fleet immediately, because we don't want that type 
of aircraft or, maybe, the entire Air Force to be operating 
with that same hazard. Once something gets identified, if it is 
a time-critical item, it will go out that way.
    Mr. O'Halleran. Admiral.
    Admiral Leavitt. Yes, sir, thank you. Very similar 
procedures to what the Air Force does when it comes to their 
boards--because we are an expeditionary force, and a lot of 
times, it would be very hard to get somebody out to the ship or 
out to an austere Marine Corps expeditionary facility, that is 
why we draw internally from our--from our own folks to comprise 
the board.
    Additionally, once the board meets, they, as well, have 30 
days to get the information out. And then, from there, it goes 
through the endorsing chain. I call them information off-ramps, 
but, along the way, there's off-ramps to get the information 
out to the fleet via hazard reports or near-miss reports or 
things along those lines--to get the information back out to 
the fleet well before the investigation report itself is done.
    I hope that answers your question, sir.
    Mr. O'Halleran. Thank you.
    General Francis. Thank you for the question, sir. The Army, 
as we said, has standing investigation boards that are really--
we are packed and ready to deploy at a moment's notice. So 
getting to the scene and beginning investigation is not 
generally an issue for us, even in remote places. We can get 
there pretty quickly.
    At any time in our investigation we determine there is an 
issue that affects the entire fleet of aircraft or the Army or 
other users, potentially other services or even other 
countries, we do not wait for the completion of an 
investigation to get after that problem.
    We immediately convene a panel with all of the correct 
technical experts to make sure that we are addressing the 
issue, be it materiel, training, whatever the case may be, and 
getting after it immediately.
    Then we have communication mechanisms that gets that word 
out to every aviation unit and aircraft user across the force, 
with foreign cases and with our joint services, as well, very, 
very rapidly, if there's a safety of flight. And that is 
generated by our airworthiness authority.
    Mr. O'Halleran. And I--this would be for anybody. But how 
do we close this window, the two, three, four--we have pilots 
up there. If we find the part that is wrong, then we can fix 
it. But, in some cases, obviously, it takes investigation.
    And it take--how do we close that window so the safety of 
the pilots and the aircraft itself is at a level that is 
reliable for those pilots to get into within a year or within 
the shortest amount of time possible?
    General Rauch. Congressman, if I understand the question 
correctly, there's really two ways we go after that. One is 
flying aircraft that are already airworthy. We are looking to 
maybe extend the timeline of it. So there's a lot of 
engineering and nondestructive inspection and that sort of 
thing that goes on to try and identify that flaw or hazard to 
do something to the fleet before it ever comes up.
    And, if we--they discover something, some time-critical--
time order change will go out to make that. And if it is 
something that is very high risk, there will be decisions about 
whether they will even fly that airplane. We might end up 
standing it down.
    The same thing happens right after a mishap occurs. 
Oftentimes, operationally, you will see the commander decide to 
elect to not to fly that platform until they can get a little 
bit of a sense of what just happened.
    Obviously, there's a lot of other good reasons for that, 
too. You just had an organization that suffered some sort of 
mishap and a loss, and that you want to make sure that you have 
got everything squared away and you can look your folks in the 
face.
    Mr. O'Halleran. I yield.
    Mr. Turner. Mr. Langevin.
    Mr. Langevin. Thank you, Mr. Chairman. I want to thank our 
witnesses for your testimony today, your service to the 
country.
    So I know that, over the last 2 weeks alone, the Air Force 
has halted flights of F-15s in Japan and stood down B-1 
operations worldwide. These are just the most recent in a long 
line of reports about aviation issues across the services.
    And while, thankfully, we did not lose pilots in these 
recent incidents, Congress is deadly serious about ensuring the 
safety of our service members. So that is why I applaud this 
and support Ranking Member Smith's initiative for an 
independent aviation commission to take an objective and 
apolitical look at--at the root causes of these mishaps and 
work to identify actionable steps that the Department can take.
    So my question is, how will these types of initiatives help 
us to turn lessons learned into best practices and, at the same 
time, with increased speed, agility, and competence?
    Admiral Leavitt. Sir, thank you for the question. One thing 
I will add about your lessons-learned piece and things along 
those lines--the three of us here, as well as the Coast Guard, 
participate in what is called the Joint Service Safety Council.
    And we meet biannually to discuss things in person, but our 
staffs and action officers exchange data, lessons learned, and 
best practices for common problems and issues, as well as 
common airframe types, when we discover something between them. 
So there's a joint effort between us and the Coast Guard, as 
well, to address the lessons learned and make them best 
practices across the services.
    Mr. Langevin. Okay. Thank you. And--and I am really curious 
as to how we balance what seems to be a very bureaucratic 
accident review process with the need to maintain readiness.
    For example, a board is going through the investigation 
process and identifies a problem. Since one point does not make 
a line and two points don't make a trend, how do they determine 
if it is a systemic problem where an action item needs to be 
disseminated to everyone, or if it was just a unique 
combination of factors that was specific to that incident?
    General Rauch. Thank you, Congressman. The boards are 
actually tasked to do just that--to dig into it, to find out, 
you know, what exactly, specifically happened in this time. And 
so the recommendations will come from there.
    And you are exactly right that, sometimes, if you see more 
than one recommendation coming from a place, they have got 
access to past investigations for us off of our databases and 
that sort of thing to help to identify that very early on.
    If they identify that there's a problem with just--the 
mechanical piece on just one jet, they will go to the--the 
actual sustainment center or organization for that and see if 
that is a systemic piece or part to it.
    But you are exactly right. For each individual mishap, they 
are tasked with finding the purpose and the root cause of that 
individual mishap. It is the analysis that happens afterwards 
that--you are exactly right--you are going to see what other 
things that could be related to--that is a little bit more 
difficult.
    Mr. Langevin. And, if it is found to be systemic, how 
quickly is that the disseminated across the services?
    General Rauch. If it is systemic about a part on an 
airplane or something like that----
    Mr. Langevin. Right.
    General Rauch. It is that day, we are talking. You know, 
we--we have a mishap of a--of a T-38, we--in this case, we end 
up calling NASA right away, just to let them know, before we 
even know anything that happened with it, to give them the 
heads-up so we can establish that communication. And we do the 
same thing with the sister services, as it relates to that.
    Mr. Langevin. Okay, thank you. And my understanding is 
that, once an investigation is complete, the board produces a 
report accepting or rejecting potential causal factors, after 
which the report's endorser--usually a flag or a general 
officer--can generally agree or disagree with the report.
    How often is there disagreement between the board and the 
endorser? And what are the most common reasons for the 
disagreement?
    General Francis. Thank you for the question, Congressman. 
Since I have been in this job, there has not been a 
disagreement between the legal investigation and the safety 
investigation. It has occurred in the past, and--and sometimes 
that is simply because the safety board may have access to some 
information that the legal investigation did not have, or there 
may be just a difference of opinion on the causal factors, if 
it is unable to be determined.
    So we did--I don't see that as a big issue. I have not seen 
it, in particular, in the Army.
    Mr. Langevin. And my last question that I have here is, 
while we have--we have increasingly moved to on unmanned 
systems and are actively working towards autonomous assistance 
in multiple domains, unmanned and autonomous systems can 
analyze information faster than humans and can operate under 
physical conditions that humans could--could not.
    Artificial intelligence has beaten our pilots in multiple 
flight simulator trials. With aviation mishaps on the rise, do 
you feel that this is going to hasten acquisition and 
utilization of these unmanned and autonomous systems? And do 
you feel that they are going to--we will--they will see an 
increased role in the future of combat aviation?
    General Rauch. Congressman, thanks for that question. As we 
have started to look through the human factors pieces of what 
might be coming next, it really is what may be the human 
factors that are involved with something that is closer to 
semiautonomous in the system. And so you let part of the 
airplane do some level of work for you.
    We already have that in the most rudimentary of algorithms 
that run, or whatever else. But, as it gets smarter and 
smarter, how do you bring that on and how do we make sure that 
the human factors--that it either doesn't overwhelm the 
aircrew, or that it does exactly what they want in the 
conditions they want?
    So the first part is probably going to be, how do we 
interact with something that is semiautonomous, that is doing 
some of the work for us? That next step is one of the ones that 
is of interest and folks looking at, as we look at the 
artificial intelligence and that sort of thing. But automating 
the system is another realm, sir.
    Mr. Langevin. Thank you very much. And my time has expired, 
but I appreciate your testimony today and I yield back.
    Mr. Turner. Mr. Gallego.
    Mr. Gallego. Thank you, Mr. Chair. I would like to have a 
couple of questions. What--number one, what specific platforms 
are of most concern to--for future incidents or mishaps? Any 
ones in particular that we should particularly be looking at? 
Let's start with----
    General Francis. Are you--did you say patterns?
    Mr. Gallego. No, I apologize. Platforms.
    General Francis. Platforms. In the Army, our--we do not 
have a specific platform that indicates to us that there's a 
particular problem. We have various sizes of fleets for 
Apaches, Chinooks, and Black Hawks, but none of them are 
indicating to us that we have a--one problem in one particular 
area.
    Mr. Gallego. Okay. Admiral.
    Admiral Leavitt. Yes, sir, thank you for the question.
    What we discovered through some studies, both--two 
independent studies that were done independently of each other, 
assisted with contractors for the Marine Corps and the Navy--
and we discovered that there are Class C aviation ground 
mishaps, primarily maintenance evolutions, towing of airplanes, 
dropping things on airplanes, and things along those lines.
    Within the Navy and Marine Corps, the two highest-density 
communities are our MH-60 Sea Hawk fleet and our FA-18 fleet--
is where we have seen the most number of mishaps. In the Marine 
Corps, it has been with the MV-22 and F-18, as well.
    We don't single those--those platforms out as necessarily 
having problems. It is because we are having an increase in 
Class C mishaps, and that is the preponderance of the fleet for 
both services, sir.
    Mr. Gallego. Thanks.
    General Rauch. Thank you, Congressman. We haven't 
identified a specific fleet that is worse than the others, but 
there are hazards across the spectrum. And so, with the aging 
fleets that--some that are--that aged--we are looking at what 
it takes to sustain those and what hazards that creates.
    We are bringing new systems on. We are looking at what does 
it take to absorb and learn that new system and train to it and 
so each one has some peculiar hazards that exist that have to 
be mitigated.
    Mr. Gallego. And, holding that thought, you know, is age 
the issue here? Because--I mean it's just me, but it looks like 
what--what we see happening is, on some of the older airframes, 
like the B-52 or U-2, you rarely hear about any problems with 
that.
    And then, newer platforms, we actually do have more 
problems. Is that--is there something going on about how things 
are made or different training cycles that--that have 
evolutionized how people actually are able to take care of 
these platforms?
    General Rauch. Congressman, I think there's really two 
parts to that. There's a lot of work that is required to keep 
an aged aircraft, you know, flying, as time goes on, so a lot 
of extra maintenance that goes into it, the engineering support 
and that sort of thing.
    So there is a lot of work that goes on there. Those sort of 
things that are found ahead of time and somebody does something 
about it--doesn't necessarily hit the news cycle.
    Then, on the more modern aircraft, we do have a situation 
where, if it is a fifth-generation fighter or some others--that 
the engine components and some other things are more expensive 
to those, and especially, the first couple times you have a 
mishap, it takes a lot longer to figure out what--the cost to 
repair and replace that piece.
    And so, on some of the newer aircraft, you are also seeing 
that and that is why some of them pop up in--on our system, and 
you look at our--if you--when you dive into our mishaps for 
Class A rates, there's more that are of that system than if it 
was an older airplane--would not have risen to the same level 
of damage, so it would not have been the same sort of mishap, 
sir.
    Mr. Gallego. Okay. I yield back.
    Mr. Turner. Mr. Banks.
    Mr. Banks. Thank you, Mr. Chairman. Thanks to each of you 
for being here today.
    To begin with, I wonder if any of you have any programs in 
place that use artificial intelligence or other basic data 
analytics tools that might help detect possible issues before 
they occur. General.
    General Francis. So we do not have that. We are moving 
towards that right now. Much like the Navy with--working with 
the Army Analytics Group, we are developing what we call the 
Army Safety and Occupational Health Enterprise Information 
Management System that will incorporate that. And that--we will 
start fielding that in the beginning of 2019.
    Mr. Banks. Okay. Admiral.
    Admiral Leavitt. Yes, sir, thanks for the question. I spoke 
earlier about partnering with Army Analytics and the fleet and 
type commanders out there to obtain their data, to 
collaboratively share data, and come up with deep-dive analytic 
tools.
    Additionally, we are moving from our legacy safety 
reporting system, which is called the Web-Enabled Safety 
System, which was fielded in about 2006, and we are moving to 
what is now called RMI, Risk Management Information.
    We are actually partnering with the Air Force, using their 
AFSAS, Air Force Safety Automated System, and we are creating 
our data fields in there and we are populating that.
    Within AFSAS by itself, there will be a couple tools, 
business intelligence tools, that will be able to just mine 
data at the squadron level, ship level, individual unit level, 
to take a look at how they are doing compared to other units 
and things along those lines.
    That is kind of the--the less deep-dive stuff. And Army 
Analytics is going to be where we are going to get the big bang 
for the buck, sir.
    Mr. Banks. Okay. Sir.
    General Francis. And, as discussed, sir, that automated 
system for us that we stood up in 2007, moved to the cloud in 
2014--about 370,000 records that are in there. And so we have 
this layer of analytic tools that are there.
    But what we were also craving is access to other datas 
and--other data and then things to handle big data analytics 
and that sort of thing. And so we--although we have a level of 
analytics that are there, we definitely want to ramp that up, 
sir.
    Mr. Banks. Okay. Thanks for that. General Francis, I would 
like to commend you on the Army's lowest 3-year period of 
mishaps. In your testimony, you stated that most mishaps are 
the result of a series of events. First of all, does the Army 
investigate different mishaps depending on the initial cause, 
or is it more of a blanket approach?
    General Francis. You know, we--the Army investigates all 
mishaps. Regardless of the severity, we investigate all of 
them. And, yes, regardless of what we suspect is the underlying 
causal factor, we investigate them all. That is how we get the 
data that we do have.
    Mr. Banks. Okay. And how are mishap reviews prioritized? 
And do different causes play a part in the prioritization?
    General Francis. It is really prioritized by severity. So 
the Combat Readiness Center, we won't necessarily go out and 
use one of our centralized investigation teams to investigate a 
Class D mishap, for instance.
    We will go do the most severe Class A's, and it is usually 
associated with a fatality, when we--when we would use our 
particular team. So they are prioritized primarily on severity 
versus any other category.
    Mr. Banks. Are certain causes any more prevalent than 
others?
    General Francis. Yes, human factors comprise about 76 
percent of our current mishaps, and about 19 percent are 
material failure. So we track those, and those--that ratio has 
been pretty consistent over the 35 years that Army Aviation has 
been a branch.
    Mr. Banks. Okay. General Francis, the global security 
environment is obviously changing rapidly. As we transition 
away from counterinsurgency and strictly air-to-ground tactics 
and the larger scale operations, is the mishap review process 
shifting accordingly?
    General Francis. Yes. What we are doing is trying to go 
from being reactive to more proactive. In other words, we are 
taking a look at the--where we have suffered the most Class A 
mishaps in previous conflicts. And we have experienced those in 
conflicts like Desert Shield/Desert Storm, Bosnia and Kosovo, 
and Iraq and Afghanistan.
    So, as we sit here today, as we--as the Army prepares for 
large-scale combat operations, we are looking very hard at what 
can we do to get after the problem now, before we get launched 
into another conflict that may cause us to have that spike and 
what can we do to prevent that now.
    Mr. Banks. Okay. And my last question--as you noted [in] 
your testimony, the less severe mishaps are downgraded to 
review by local entities with, quote, ``abbreviated 
requirements.'' Does this more minor threshold of review lead 
to less effective results or recommendations?
    General Francis. No, it does not. It simply means that they 
have--they have less of a requirement to report that to higher 
levels with a formal briefing. We still get all the data from 
those mishaps to conduct analysis with.
    Mr. Banks. Okay. I want to make sure that abbreviated 
requirements doesn't necessarily lead to less thorough reviews.
    General Francis. No, it does not.
    Mr. Banks. Okay. With that, I yield back. Thank you.
    Mr. Turner. Mr. Wittman.
    Mr. Wittman. Thank you, Mr. Chairman. I would like to thank 
our witnesses for joining us today.
    I wanted to begin with Rear Admiral Leavitt and--and ask 
you this. As we look at our Navy air assets--and we know that, 
when the demand signal goes out, the first question is, you 
know, where are the aircraft carriers, how do we get them to 
the fight? Want to make sure we understand, with that, the risk 
that our naval aviators are facing.
    And I just wanted to--to get you to--to give us a 
distinction about how the different levels of investigations 
happen when we have these crashes. Is there a difference when 
there's a fatality involved? Is it something different if it 
causes, you know, an emergency landing? Is it different if it 
occurs at sea than on the land? Are--are there--are there 
different levels about how you do that evaluation?
    Do you risk-rate that? Give us some indication about what 
urgency is placed on these investigations and then the urgency 
placed on what the follow-up corrective actions would be.
    Admiral Leavitt. Congressman, thanks for the question. Like 
the other services, all accidents are investigated. If it is 
the most serious accident, either in cost of lives or damage to 
an airplane, they have the largest priority.
    Every action is invested by an accident investigation board 
and a trained aviation safety officer. There is no difference 
in the investigation process itself. The idea is to prevent 
this mishap from happening again in the future. When it comes 
to corrective actions in the endorsement chain and--and--well, 
let me go back.
    If something's identified immediately that--it is a bad 
part on an airplane or there's a training procedure out there 
that is wrong, an immediate HAZREP, hazard report, will go out 
that identifies the problem, and it goes to NAVAIR, who's our 
airworthiness authority.
    And if they determine it is an airworthiness issue, it will 
go--what is called red-stripe the fleet, which means it puts 
that entire type, make, model, series of airplanes out of 
service until they can come up with the corrective action for 
it.
    But, from there, outside of something that--that pops up 
immediately, the endorsement chain, as it goes up--if it is a 
Class A, it makes it all the way to the Naval Safety Center and 
the commander of the Naval Safety Center endorses that for CNO 
[Chief of Naval Operations].
    Bs, Cs and Ds aren't--go up the endorsement level, where 
the individual has the authority to affect the corrective 
actions for what that mishap report came out with. So it may 
just go to AIRLANT [Naval Air Force Atlantic] or Naval Air 
Forces or CNATRA [Chief of Naval Air Training] or one of those 
individuals to--to initiate the corrective action for the--for 
the issue, sir.
    Mr. Wittman. Got you. Thanks. Thanks. I am just concerned 
about, you know, making sure there's consistency, especially in 
how we respond to those.
    Brigadier General Dav--Francis--excuse me. I wanted to ask 
a question about how investigations occur in what I see as a 
bifurcated way. You know, we are already, you know, almost 
halfway through 2018. We already have 20 people dead in 2018 
mishaps.
    The thing that concerns me is, I understand the need for us 
to have safety privilege protections, but it seems like to me 
that we have a two-tiered system. One where we incentivize 
aviators to come in and give a full account of what happened in 
that and say--listen, do that, no legal ramifications.
    And then, afterwards, we have a formal investigation that 
says, by the way, be careful what you say. Don't disclose 
anything, because there are legal ramifications to that.
    How do we really get at the root of these issues, if you 
say one thing at one point in the investigation, say, we want 
your really honest opinion about what is happening, and then, 
later on, when we get to the formal process, we say, by the 
way, there are all kinds of legal ramifications to what you may 
give us?
    Give us your perspective about how somehow that serves the 
better purpose of really getting to the root of these mishaps.
    General Francis. Thank you for the question, Congressman. 
That is exactly why we have this thing called safety-privileged 
information. Okay? Those involved give witness statements and 
so forth, so that we can in fact get that unadulterated view of 
what happened for the purpose of loss prevention.
    The purpose of the other investigation is a different 
purpose, and each--anyone who is a subject of one of those 
investigations has all the legal rights associated with those 
investigations.
    So I don't necessarily see it as a bifurcated system, but 
one that preserves our ability to get after safety-privileged 
information that helps us with loss prevention.
    Mr. Wittman. But doesn't one affect the other? Doesn't one, 
where you say, hey, be honest and forthright with us and don't 
worry about it, we are going to make sure that we privilege 
that information--yet, later, they are going to be in a formal 
investigation where they know that what they say could have 
legal ramifications for them.
    I still see that, in one, you are asking them to be 
truthful; in the other, you are--essentially, the incentives 
are to be tight-lipped.
    General Francis. I haven't seen that as being a concern. 
I--we also have the ability to give safety privilege to a 
specific individual, saying that we will not, even in a FOIA 
request--I will guarantee that we will not submit your 
statement to anyone or anywhere, so that we can, in fact, get 
that information.
    So we have not experienced that--a problem with either one 
of those investigations competing with one another or causing a 
change of information.
    Mr. Wittman. Okay, very good. Thank you, Mr. Chairman, I 
yield back.
    Mr. Turner. Thank you. Ms. Tsongas, your follow-up 
question?
    Ms. Tsongas. Well, as we have been hearing today, it is 
clear that all the services have large safety organizations. 
And over time, like other parts of the military, you have come 
under budget pressures, as well. And so your funder--funding 
priorities and amounts have to change.
    So, over the past 10 years, how have resources changed in 
your service? Do you have more people? Less? What about funding 
levels? Are they adequate? And, most especially, are there any 
areas of the safety enterprise where we are taking risks where 
we shouldn't because of these constraints?
    So we will start on the right and move to the left here.
    General Rauch. Okay, ma'am. As we talk about funding 
levels, the Safety Center has funds, and, me as part of the Air 
Staff, get funded that way. And so the entire safety 
enterprise, though, is much, much larger than that, right? So 
there's safety organizations, and it is really a commanders' 
program; and so operational and maintenance accounts pay for 
some day-to-day safety things that are spread throughout the 
entire enterprise.
    And then the preventive engineering-type work that happens 
in the program offices to identify what it takes to extend the 
life of an aircraft safely is, at least from our point of view, 
something that also goes towards safety. And so it is hard to 
wrap around what all those items are.
    I can tell you that, from the account that individually 
goes to pay for the Safety Center, for example, this year is 
the best year in the last 10 years for funding for the Air 
Force. We have been able to go after more of the initiatives 
that we wanted to do inside the Safety Center.
    But, as a member of that, over the years, we have had both 
plus-ups--in the last 10 years, we have had both plus-ups and 
reductions in manning levels within the Safety Center as the 
staffs were forced to cut manpower down.
    Ms. Tsongas. So do you see an area where you are absorbing 
risk that you worry about?
    General Rauch. What I see us doing is, in a time when we 
are very, very busy responding to current mishaps--that you may 
not have the forces you would like to have to be able to do 
some of the proactive things that you are able to do, because, 
of course, the mishaps don't happen in a steady rate, 
unfortunately for, at least, the workload.
    But--so, yes, we had more manpower before, which allowed 
you to do more initiatives. But we have enough folks to do the 
things that we are doing now. So, really, it is, how much 
hazards can you mitigate? And how do you go after those 
practice things you want----
    Ms. Tsongas. So, the more hazards that you are having to 
investigate, the more--the more thinly you are stretched.
    General Rauch. Yes, ma'am.
    Ms. Tsongas. Admiral.
    Admiral Leavitt. Yes, ma'am, and I will speak strictly for 
the Naval Safety Center and not the enterprise writ large. But 
much like General Rauch said, there are things at Naval Air 
Systems Command and things like that--extending airplanes, 
doing engineering investigations, and things like that--that 
affect--are affected by funding.
    But the Naval Safety Center itself, over the last 10 years, 
has remained fairly constant and as we take new tasks in our 
knowledge-management, safety-promotion area--we are actually in 
a growth mode right now, over the next several years. We got a 
plus-up in funding in 2018, we will get one in 2019, and we are 
palming for some additional manpower to assist in our data 
analytics for 2020.
    So one issue that we have seen is our operational aviation 
safety assessments, where our teams go out and assess different 
units along the way. Sometimes, when funding gets tight, we cut 
back on the number of those that actually go out and do that.
    But we have a program in place where we can identify at-
risk squadrons and high-performing squadrons, so we try to look 
at those specifically and take the best practices from the 
high-performing squadrons and try to inculcate that into our 
at-risk squadrons and move from there.
    Ms. Tsongas. General.
    General Francis. Thank you, ma'am. So we are adequately 
funded and resourced to do the mission that we are required to 
do. Over the last 5 years, we have had a decrease in personnel 
that has--that has--we were asked to say, how can we do this 
more efficiently? Just like everybody else is challenged to do 
in tough times.
    And we--we designed the organization that we thought best 
did that. As we have now executed using that new organization, 
we have identified probably two places where we need to re-
shore up. One is our analytic capability and then the other is 
our investigation capability.
    So we do have enough teams to support our requirements 
right now in terms of accident investigation, but our analytic 
capability has gone down. So not only are we going to go back 
to the Army and compete and--for those spaces, if we compete 
well for them, but we are looking at other assets, like Army 
Analytics Group, to help us with that analysis. And we think 
that is going to be a very a strong partnership that will help 
us to do that.
    Ms. Tsongas. So, until that happens, do you feel that is an 
area where you are--you are absorbing a level of risk that 
worries you?
    General Francis. It does not worry me. We are not--we are 
not missing anything. It is taking us a little bit longer than 
we would like, right now, to get to some of the analytics.
    But, certainly, on urgent things, there's no--we are not 
seeing a risk to the force or to the Army right now--with our 
ability, right now. But we do want to expand that capability to 
look deeper into some areas.
    Ms. Tsongas. Thank you. I yield back.
    Mr. Turner. Gentlemen, thank you for your testimony. And we 
have had great participation by members of the committee. This 
is going to be the beginning of a series of hearings that we 
will be having, looking at all aspects of how this issue is 
managed.
    I am certain that we will be returning to you again and 
your expertise. But we greatly appreciate both your commitment 
to this issue and the insight that you have provided us today. 
Thank you. We will be adjourned.
    [Whereupon, at 11:26 a.m., the subcommittee was adjourned.]

    
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                            A P P E N D I X

                             June 13, 2018
      
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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             June 13, 2018

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                   DOCUMENTS SUBMITTED FOR THE RECORD

                             June 13, 2018

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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             June 13, 2018

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            RESPONSES TO QUESTIONS SUBMITTED BY MR. PANETTA

    General Francis. Manned and unmanned mishap rates differ greatly 
for a number of reasons. Among them are the redundancies engineered 
into manned aircraft that are not always present in unmanned systems, 
the level of training provided to operators of unmanned systems versus 
manned aviation, and the relative immaturity of the unmanned aerial 
system (UAS) community in maintenance, training, and support structure. 
The Army is still experiencing the growing pains of working hard and 
fast to provide support to commanders in combat with critical 
information through UAS.
    With that, UAS mishap rates are down significantly since 2016 and 
2017. In 2016 the Army executed a holistic look at UAS and made 
numerous recommendations, across the spectrum of Doctrine, 
Organization, Training, Material, Leadership and Education, Personnel, 
Facilities, and Policy, that are taking hold now and improving 
readiness and reducing mishap rates. In FY16 the Army's MQ-1C fleet 
experienced 12 Class A mishaps, in FY17 the number was reduced to nine, 
and so far in FY18 we have experienced only three. The mishap rate per 
100,000 flying hours reduced from 10.03 in FY17 to 3.79 in FY18. We 
have similar reductions in total mishaps and rates in our smaller RQ-7B 
fleet with the Class B rate dropping from 20.73 in FY17 to 13.57 in 
FY18.
    The Army is still pursuing many of the recommendations from the 
holistic review and we expect to see continued success with readiness 
rates and reductions in mishap rates in unmanned systems.   [See page 
18.]
    Admiral Leavitt. [See chart on next page.]   [See page 18.]
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             June 13, 2018

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                   QUESTIONS SUBMITTED BY MR. TURNER

    Mr. Turner. What benefits are provided by individual service-
specific data systems needed to collect mishap data?
    General Francis. The primary benefit of each service having their 
own data system is that it allows the service to identify and collect 
data points that are useful in analysis to support their unique mishap 
prevention programs. There are basic data points common across the 
services and relevant to all, but each service has data requirements 
beyond a one-size-fits-all approach. For example, the Army collects 
more data points on ground mishaps than the Air Force because the 
preponderance of our forces and mishaps are on the ground. More data 
points allows for easier data stratification in the Army's 8000-plus 
Class A-E ground mishap reports each year. Additionally, each service 
is able to adjust and adapt their data systems to meet emerging 
requirements to address emerging trends. We support Department of 
Defense data collection efforts and are developing a new mishap 
reporting tool that will feed point for point into the DOD database 
while also maintaining service flexibility.
    Mr. Turner. What steps, if any, have the safety centers taken to 
reassess the type of data that are collected as part of the services' 
mishap investigations in light of the recent increase in aviation 
mishaps?
    General Francis. Even though Army mishap rates remain well below 
10-year averages, we have taken actions to assess and work toward not 
only identifying the right data to collect, but also ensure all 
necessary data is collected regardless of mishap level. A team of 
experts reviewed the complete data set currently in the Army Safety 
Management Information System database to ensure we go forward with 
collecting the right data while decreasing the burden on operational 
units in mishap reporting. To do so, we are developing a new reporting 
tool that will gather much of the information needed in a mishap report 
from sources of record while conducting in-progress audits to ensure 
investigators complete all required fields. We included all 
requirements from the OSD Minimum Data Elements of 2017, as well as 
elements that support service-specific analysis.
    Mr. Turner. What responsibilities do the military services' safety 
centers have for conducting analysis of the causes of mishaps and how 
does this compare with any analyses that OSD may conduct?
    General Francis. Department of Defense Instruction 6055.07 requires 
the heads of DOD components to collect, maintain, and analyze mishap 
data including human error, human factors, and human performance data 
identified in safety investigations. We continually analyze mishap data 
to discern trends, identify anomalies, and prepare prevention measures. 
One example of this analysis is that over the course of the last few 
months, we conducted an in-depth study of Class C mishaps. We know the 
difference between a Class A and Class C can be inches and seconds, and 
73 percent of Army Aviation mishaps from FY13 to YTD FY18 are Class Cs. 
Currently, Class Cs are below 10-year averages but have remained 
relatively constant over last 5 years. Army Aviation experienced 324 
Class C mishaps in the FY13 to YTD FY18 period. There were no 
discernible trends with regard to aircraft type, time of day, time of 
year, or environmental and material factors, and an assessment of the 
leading causal factors mirrors our Class A mishaps. Of the 324 Class C 
mishaps, 233 had human factors primary causes. Of those 233, 198 fell 
into categories of object strikes not including wildlife, engine 
exceedances, hard landings, and foreign object damage. Among the human 
factors cited were performance-based errors in 84 percent of mishaps, 
judgement errors in 11 percent, and possible indiscipline in 5 percent. 
While training deficiencies can be correlated with some performance 
errors, overconfidence, distraction, and confusion are more often cited 
as underlying preconditions. Poor crew coordination is also cited in 
one third of mishaps. This data is used in working with the U.S. Army 
Aviation Center of Excellence in developing both institutional training 
and requirements to the field in several forms. This project was 
briefed to the Assistant Secretary of Defense for Energy, 
Installations, and Environment and the Under Secretary of Defense for 
Personnel and Readiness. It is difficult to compare the analysis done 
at the service level with that done in OSD, as the fidelity and focus 
of our analysis is internally focused and detailed, while OSD has a 
broader view including all the services.
    Mr. Turner. What are the key training gaps that have contributed to 
aviation mishaps and what actions have the military services taken to 
address these gaps?
    General Francis. We are seeing performance-based errors in many 
Class A through C mishaps, but these are not necessarily caused by 
training shortfalls. The underlying factors for these mishaps more 
often include complacency, overconfidence, distraction, or confusion. 
We are an Army that trains to standards and when Soldiers perform to 
those standards, we don't have accidents. There are times when units 
are challenged to meet training requirements. We recently investigated 
a mishap where recent flight school graduates were assigned less than 
90 days prior to a major deployment. This situation created a 
significant individual training requirement for the unit simultaneous 
with preparing to deploy. Unfortunately, this is not an uncommon 
scenario in an aviation force that is 84 percent committed in support 
of not only combat operations, but also engagement and support 
missions.
    Mr. Turner. Learning the right lessons so we don't repeat the past 
is important--can you tell us how you take lessons you have learned 
from your safety investigations and use them to make recommendations 
that would stop future accidents from happening?
    General Francis. Mishap safety boards make recommendations across 
the spectrum of DOTMLPF-P at three levels: unit level, defined as 
battalion or below; higher level, defined as brigade, division, and 
corps or similar levels; and Army level, defined as Army Commands, Army 
Component Commands, and Direct Reporting Units. The USACRC has 
forwarded over 300 Army-level recommendations from FY13 to present. 
Mishap boards have made literally thousands of recommendations at unit 
and higher levels. Below are high level examples of how this is 
applied.
    Doctrine--Recommendations to Army Training and Doctrine Command and 
Army G3/5/7 to make adjustments to doctrine
    Organization--Recommendations to units and higher levels, as well 
as Army G3/5/7 and TRADOC to adjust organizations based on mishap 
prevention requirements
    Training--Recommendations to units to review or adjust their local 
training programs and to TRADOC to adjust training base requirements or 
those placed on the field
    Materiel--Recommendations to Army Materiel Command and acquisition 
authorities to follow up on materiel issues discovered in a mishap or 
risk decisions made during the acquisition process
    Leadership and education--Recommendations to units and TRADOC 
concerning leader competencies, training, and selection
    Personnel--Recommendations to Army G1 concerning manning
    Facilities--Recommendations to unit and higher levels concerning 
facilities on airfields, as well as recommendations to Army G4
    Policy--Recommendations to adjust local policies and standing 
operating procedures at unit and higher levels, as well as 
recommendations across the Army for policy adjustments indicated by 
investigation results
    Mr. Turner. What benefits are provided by individual service-
specific data systems needed to collect mishap data?
    Admiral Leavitt. Over time each service has developed and refined 
their service-specific system to account for service unique needs. 
Service uniqueness encompasses operating environments, mission variance 
and institutional culture and history. Individual systems account for 
these differences and provide efficiency to the users.
    Mr. Turner. What steps, if any, have the safety centers taken to 
reassess the type of data that are collected as part of the services' 
mishap investigations in light of the recent increase in aviation 
mishaps?
    Admiral Leavitt. As Admiral Leavitt testified before the HASC in 
June, the Naval Safety Center is working to get ahead of mishaps with 
preventive mishap data analysis and informed risk identification 
through strategic partnerships. These collaborative efforts include the 
Navy and Marine Corps Public Health Center, the Digital Warfare Office, 
the Center for Naval Analysis, the Naval Post-Graduate School, the Army 
Analytics Group, and other organizations. All of these organizations 
are equipped to perform in-depth studies to gain a better understanding 
of the human, materiel and other factors that lead to mishaps thereby 
mitigations can be developed to stop a mishap before it happens. The 
Naval Safety Center is also increasing its organic analytical 
capabilities by acquiring enhanced technology and additional 
specialized manpower devoted to this effort.
    The Naval Safety Center is the authoritative source for mishap data 
however, deeper analysis requires a holistic approach where data 
scientists can leverage readiness, manning, and other information to 
assess the overall health of a unit and the safety posture of the Navy 
and Marine Corps as a whole. The Naval Safety Center is working with 
the Fleet and Type Commanders to develop mutually beneficial data 
sharing agreements that will allow for improvements in risk and hazard 
identification and analysis. This ``deep dive'' analysis should 
eventually lead to the identification of risk trends that become a 
predictive and preventative tool. The Naval Safety Center has been 
tasked with expanding its analytical workforce. This includes hiring 
contracted data scientists who will assist in the development of 
sophisticated risk models using these new data streams in addition to 
growing organic capabilities and capacity. Understanding the importance 
of working jointly, the Naval Safety Center and other Navy 
organizations have partnered with the Army Analytics Group for data 
aggregation and complex data analysis.
    Mr. Turner. What responsibilities do the military services' safety 
centers have for conducting analysis of the causes of mishaps and how 
does this compare with any analyses that OSD may conduct?
    Admiral Leavitt. The Naval Safety Center has been tasked with 
expanding its analytical workforce. As Admiral Leavitt testified before 
the HASC in June, the Naval Safety Center is working to get ahead of 
mishaps with preventive mishap data analysis and informed risk 
identification through strategic partnerships. These collaborative 
efforts include the Army Analytics Group, the Navy and Marine Corps 
Public Health Center, the Digital Warfare Office, the Center for Naval 
Analysis, the Naval Post-Graduate School, and other organizations. All 
of these organizations are equipped to perform in-depth studies to gain 
a better understanding of the human, materiel and other factors that 
lead to mishaps thereby mitigations can be developed to stop a mishap 
before it happens. The Naval Safety Center is also increasing its 
organic analytical capabilities by acquiring enhanced technology and 
additional specialized manpower devoted to this effort
    The Naval Safety Center is the authoritative source for mishap data 
however, deeper analysis requires a holistic approach where data 
scientists can leverage readiness, manning, and other information to 
assess the overall health of a unit and the safety posture of the Navy 
and Marine Corps as a whole. The Naval Safety Center is working with 
the Fleet and Type Commanders to develop mutually beneficial data 
sharing agreements that will allow for improvements in risk and hazard 
identification and analysis. This in-depth analysis should eventually 
lead to the identification of risk trends that become a predictive and 
preventative tool.
    OSD primarily pulls mishap data for analysis to inform policy. 
Statistically OSD serves as a clearing house for cross-service mishap 
information but is limited in their ability to conduct in-depth 
analysis due to limited access to data and a lack of service-specific 
expertise. However, analysis of mishap data is only one side of the 
coin. The other side of the coin is safety promotion and promulgation 
of mishap and hazard report (HAZREP) lessons learned. Using mishap 
analysis to inform safety promotion closes the information loop to 
assist in mishap prevention. For example, when a hazard is discovered 
during the safety investigation or at any point in the process, a non-
privileged HAZREP is released by the mishap board to provide timely 
notification to the fleet and program managers. These HAZREPS allow the 
air worthiness authority (Naval Air Systems Command) to decide if 
groundings, inspections, or other mitigation actions are necessary 
before the continued employment of the type of aircraft or equipment 
involved is permitted. There have been several examples where a hazard 
has prompted the release of a HAZREP which resulted in an operational 
safety pause, conditional inspections, and even groundings long before 
the investigation report was released.
    Within 10 days of the release of any Aviation Class A mishap 
report, a representative from the Naval Safety Center's Aviation Safety 
Directorate develops two products for fleet use and distribution. These 
products are the Mishap Executive Summary and Safety Officer Training 
Presentation. The Mishap Executive Summary is a two to three-page 
review of the event's mishap safety investigation report and is 
designed to be routed to the endorsing chain of command to facilitate 
briefing of Class A mishaps to higher echelon leadership. The Safety 
Officer Training Presentation is distributed to same or similar 
community unit safety departments with the intent of providing a 
training tool at the squadron level.
    The Naval Safety Center continuously looks for cost-effective ways 
to create relevant lessons-learned products. One such innovation is the 
creation of sanitized mishap safety investigation reports that are 
distributed as a lessons-learned awareness product. This product is an 
abbreviated version of the original mishap investigation report with 
the elements of privileged information and PII redacted to enable the 
report to be more readily disseminated and used for fleet training. The 
sanitized report remains a ``For Official Use Only'' (FOUO) document 
and is required to be handled accordingly.
    The Naval Safety Center aviation platform subject matter experts 
also produce periodic Safety Gram messages for their community safety 
representatives. Safety Grams are sent via email and provide community 
safety trends, contain relevant and recent mishap investigation and 
hazard reports, and distribute type/model/series community lessons 
learned and best practices across all stakeholders.
    The analysis of data collected from mishap safety investigations is 
key to understanding and communicating mishap information.
    Mr. Turner. What are the key training gaps that have contributed to 
aviation mishaps and what actions have the military services taken to 
address these gaps?
    Admiral Leavitt. While there is an assumed consensus that Class A 
mishaps are on the rise across the Defense Department writ large, 
NAVSAFECEN conducted a study of all USN Class A mishaps from FY13-FY17. 
The study revealed that USN Class A mishaps per 100,00 flight hours 
have remained statistically stagnant. Moreover, an in-depth review 
revealed that none of those mishap investigations sited deficiencies or 
a gap in training as a causal factor for the mishap.
    Improving training syllabi/standards, improving NATOPS and standard 
operating procedures (SOPs) are key steps to address iterative best 
practices with regard to safety, but the study indicated there were no 
training gaps causal to the Class As. NATOPS, SOPs, or syllabi are not 
deficient. In addition, continued focus on safety via safety stand 
downs (now directed quarterly by Commander, Pacific Fleet) and 
promulgation of best practices across the fleet with regard to 
maintenance and flight operations highlight current issues and 
compliance with established procedures and flight manuals.
    Mr. Turner. Learning the right lessons so we don't repeat the past 
is important--can you tell us how you take lessons you have learned 
from your safety investigations and use them to make recommendations 
that would stop future accidents from happening?
    Admiral Leavitt. Once an investigation is complete the board will 
produce a report in which each causal factor is accepted or rejected 
and recommendations are made. Afterwards the endorsers, in turn, have 
an opportunity to concur or non-concur on every accepted and rejected 
causal factor and associated mishap recommendations. The endorsement 
chain is determined by the aircraft controlling custodian. Any endorser 
who determines that an investigation is incomplete or that the report 
is inadequate may reopen the investigation and require resubmission of 
the report, addressing specific areas of concern. Commander Naval 
Safety Center, acting as the Chief of Naval Operations' Special 
Assistant for Safety Matters, is the final endorser for all Class A 
safety investigation reports. For mishaps below Class A, the final 
endorser is the commander who can affect the closeout of the mishap 
recommendations. This process can be lengthy, as each endorser has 15 
days and extensions are often granted. However, we do not wait until 
the report is fully endorsed to disseminate important safety 
information to the fleet.
    When a hazard is discovered during the investigation or at any 
point in the process, a non-privileged hazard report (HAZREP) is 
released by the mishap board to provide timely notification to the 
fleet and program managers. These HAZREPS allow the air worthiness 
authority (Naval Air Systems Command) to decide if groundings or other 
inspections or mitigation actions are necessary before continuation of 
flight. There have been several examples where a HAZREP resulted in an 
operational safety pause, conditional inspections, and even groundings 
long before the investigation report was released.
    Within 10 days of the release of any Aviation Class A mishap 
report, a representative from the Naval Safety Center's Aviation Safety 
Directorate develops two products for fleet use and distribution: a 
Mishap Executive Summary and Safety Officer Training Presentation. The 
Mishap Executive Summary is a two or three-page review of the event's 
safety investigation report, routed up the endorsing chain of command 
to facilitate briefing of Class A mishaps to higher echelon leadership. 
The Safety Officer Training Presentation is routed down the chain of 
command to community unit safety departments with the intent of 
providing a training tool at the squadron level.
    A sanitized investigation report is a lessons learned awareness 
product the Naval Safety Center is beginning to produce. It is an 
abbreviated version of the original safety investigation report with 
elements of privileged information and PII redacted to enable the 
report to be more readily used for fleet training. The document remains 
For Official Use Only (FOUO) and is handled accordingly.
    The Naval Safety Center aviation platform subject matter experts 
also produce periodic Safety Gram messages to for their community 
command safety representatives. Safety Grams are sent via email and 
provide community safety trends, attach relevant and recent safety 
investigation and hazard reports, and distribute community lessons 
learned and best practices across all stakeholders.

               MISHAP RECOMMENDATIONS AND LESSONS LEARNED

    The primary purpose of the aviation mishap review and oversight 
process is to prevent recurrence. Recommendations from mishap 
investigations, hazard reports, and lessons learned must be 
communicated and implemented.
    After a mishap investigation is finalized, every causal factor is 
required to have at least one recommendation. Each agency is 
responsible for its assigned recommendation(s) or action items unless 
relieved by higher authority. Mishap recommendations vary, but common 
examples include changes to publications and procedures and technical 
equipment modifications. The Naval Safety Center tracks all open mishap 
recommendations and hazard recommendations assigned a risk assessment 
code of 1 or 2 (the two most serious categories based on probability 
and severity). The Naval Safety Center has also established a lessons 
learned program office with the sole focus of developing products aimed 
at various fleet audiences for education and training in order to get 
ahead of mishap recurrence by increasing the awareness of hazards and 
mitigation strategies. A typical lessons learned product is a two-page 
document capturing the highlights of the event and the key strategies 
to mitigate the risks in the future. The format and content, however, 
is tailored to fit the specific audience and requirement. The Lessons 
Learned division monitors and reviews incoming mishap and hazard 
reports to identify events as candidates for a Lesson Learned product. 
The division then closely coordinates with subject matter experts 
within specific communities in order to generate Lessons Learned from 
selected mishap reports and hazard reports that would be effective 
training aids in order to avoid repeat events. Generally, a Lesson 
Learned is warranted if the event(s) indicate a trend or if the causes 
of the event could be mitigated in the future by educating the fleet. A 
recent example includes a lesson learned product about maintainers in 
multiple aircraft platform squadrons using the wrong engine-oil which 
led to two Class A mishaps and several HAZREPs. Sharing this 
information across communities showed that the true extent of the 
problem went beyond one squadron or even aircraft platform.
    The LL team seeks input from the fleet and joint services for both 
LL topics as well as drafted LL products. Generally, Lessons Learned 
are written by members of the LL division and SMEs from the cognizant 
safety directorates. The Lessons Learned division edits and publishes 
the smooth Lessons Learned after final vetting by the cognizant safety 
director. The process for sanitizing SIRs/SIREPs is similar.
    Writing and disseminating a Lessons Learned does not necessarily 
require waiting until the completion of a mishap investigation. Often, 
a single Hazard Report or an identified commonality between a new 
safety event and preceding HAZREPs or mishaps is enough to both trigger 
and provide necessary data to write a Lessons Learned product. When it 
best suits the end product, Lessons Learned writing will be delayed 
until completion of the investigation report and endorsement process of 
a given mishap. A sanitized SIR/SIREP would clearly be tied to the 
completion of the investigation and endorsement process.
    The Lessons Learned division focuses on a ``PUSH'' effort to 
deliver Lessons Learned products to fleet users. This is a more 
effective and rapid method than requiring fleet users to seek 
(``pull'') the information from the NSC library. The LL division 
distributes published Lessons to the fleet via email to the cognizant 
Type Commander Safety Officers/Managers, Aircraft Controlling Custodian 
Safety Officers, NSC staff SMEs, and (when applicable) the Command 
Master Chief Petty Officer network. The team is expanding this 
distribution list to include Echelon IV Safety Officers in order to 
ensure effective delivery. For long term accessibility, the team also 
publishes Lessons Learned products to the Lessons Learned page of the 
Naval Safety Center CAC enabled website and to the Navy Lessons Learned 
Information System (NLLIS) under the ``Safety Lessons Learned 
``Community of Practice.
    Mr. Turner. In previous testimony, we have heard Navy and Air Force 
officials testify that physiological episodes are the number one safety 
concern for the aviation community, and we too are concerned about the 
risk this poses to the aviators and pilots who put their lives on the 
line for this country. We know there is inherent risk to combat, but it 
seems like this is an unnecessary risk to the health of pilots and 
aircrew. Can you give us an update on what is being done, from a safety 
perspective, to solve the problem of physiological episodes?
    Admiral Leavitt. The Naval Safety Center is actively involved in 
the efforts to solve the problem of physiological episodes via the 
following three ongoing objectives:
    1: Facilitating Event Reporting
    The Naval Safety Center has developed and implemented a 
standardized reporting policy to better ascertain timely and accurate 
answers to the basic 5-Ws of each physiological event: who was 
involved, what happened, where did it occur, when did it occur, and why 
did it occur. These questions are ultimately addressed through three 
separate but complimentary evidence data sheets, managed by the Naval 
Safety Center, that provide information from (1) involved aircrew, (2) 
aircraft maintenance, and (3) aeromedical observations.
    Furthermore, as of OCT 2017, the Naval Safety Center is responsible 
for the development, training, and continued oversight of the 
Physiological Event Rapid Response Teams (PERRT), which are local, on-
site personnel that investigate the event to determine the maintenance 
and human factors involved with each event. Each PERRT is comprised of 
an aviation safety officer, an aeromedical safety officer, a flight 
surgeon, and maintenance and/or engineering representatives--ensuring 
that all aspects of the event are investigated.
    The Naval Safety Center also coordinates a validation/verification 
process for each event. This process provides a method for subject-
matter experts, including Naval Safety Center aviation and aeromedical 
analysts, PERRT members, and aircraft-specific systems experts, to 
finalize the causal factors of why the event occurred as well as 
provide safety recommendations. Lastly, an important goal of the Naval 
Safety Center is to provide the involved aircrew with direct feedback 
about the results of the investigation. Each aircrew member involved in 
a physiological event is provided with the results of the validation/
verification process.
    2: Obtaining Better Data
    The Naval Safety Center is continually revising and updating the 
evidence data sheets so that the information they obtain provides a 
more accurate representation of what is occurring during each event. 
Immediately following the reporting of an event, Naval Safety Center 
personnel maintain regular communication with PERRT members as they 
coordinate the completion and submission of evidence data sheets. Naval 
Safety Center is also responsible for training PERRT members, including 
flight surgeons and aeromedical safety officers. Ultimately, these 
efforts help obtain better data from an event.
    3: Supporting Data Analytics
    The Naval Safety Center maintains custody for all safety event 
data, including physiological events. Ongoing research efforts from 
various research entities work with the Naval Safety Center to analyze 
data from physiological events to better understand frequencies, 
trends, and other important aspects of this problem. Naval Safety 
Center is also collaborating with Navy/Marine Corps Public Health 
Center epidemiologists and data scientists on analyzing physiological 
event data. Goals of this collaboration are to develop epidemiological 
and biostatistics methodologies for analyzing datasets to help 
potentially uncover root causes of physiological events.
    Mr. Turner. What benefits are provided by individual service-
specific data systems needed to collect mishap data?
    General Rauch. The Air Force possesses a comprehensive data 
collection system, the Air Force Safety Automated System, allowing 
report submissions from safety investigations across the globe while 
also providing searchable data for analysis of trends and other 
information to aid mishap prevention efforts at all organizational 
levels. This database ensures a secure, accessible environment to 
protect safety privileged information and allow all levels of command, 
from headquarters to installations, to access safety information and 
reports for safety programs, analysis, and awareness.
    Mr. Turner. What steps, if any, have the safety centers taken to 
reassess the type of data that are collected as part of the services' 
mishap investigations in light of the recent increase in aviation 
mishaps?
    General Rauch. The Air Force is continually evaluating its safety 
processes and data collection efforts to ensure timely and accurate 
information. Recently, Air Force Safety has implemented mobile 
applications to aid in the collection of hazard reporting that may 
highlight issues prior to a mishap occurring. In addition, the Air 
Force conducted Operational Safety Reviews at all wings with flying and 
maintenance functions in mid-2018 to obtain feedback from aircrew and 
maintenance personnel across the service. This information has been 
used to inform commanders at all levels of potential hazards and other 
issues and allow actions to mitigate and address these concerns from 
the field. Also, the Air Force is participating in an Office of the 
Secretary of Defense working group that examines the types and 
standardization of collected mishap data across the Department of 
Defense.
    Mr. Turner. What responsibilities do the military services' safety 
centers have for conducting analysis of the causes of mishaps and how 
does this compare with any analyses that OSD may conduct?
    General Rauch. Per Department of Defense guidelines, the Air Force 
investigates every mishap required by policy. Air Force safety 
investigations determine the causes of each individual mishap and 
provide recommendations to prevent future occurrences. In the case of 
higher-level aviation mishaps such as Class A and B, the investigation 
is normally conducted by a board comprised of several personnel, 
including support and technical assistance from the Air Force Safety 
Center. The Air Force Safety Center also maintains oversight of the 
investigation's process, final report, and mishap recommendations. OSD, 
as well as the Air Force, may analyze aggregate causal data for trends 
or other analysis.
    Mr. Turner. What are the key training gaps that have contributed to 
aviation mishaps and what actions have the military services taken to 
address these gaps?
    General Rauch. The Air Force has not discovered a systemic training 
issue or gap that is contributory across numerous mishap events. 
Rather, an individual issue such as non-compliance with the intent of 
guidance or procedures is sometimes revealed during an investigation 
and adjustments to training to ensure awareness and prevent 
misunderstanding of procedures or technical order guidance may be an 
action in these situations.
    Mr. Turner. Learning the right lessons so we don't repeat the past 
is important--can you tell us how you take lessons you have learned 
from your safety investigations and use them to make recommendations 
that would stop future accidents from happening?
    General Rauch. Implementing the recommendations from safety 
investigations is a core aspect of mishap prevention. After a mishap, 
the safety investigation normally provides recommendations to prevent 
or mitigate the risk of future similar occurrences. All recommendations 
are input into a centralized safety database (Air Force Safety 
Automated System, or AFSAS) that allows tracking of their status. Every 
safety recommendation from an Air Force safety investigation is managed 
by the Convening Authority for the mishap, normally the Major Command 
(MAJCOM) commander for higher-level Class A and B mishaps. A formal 
structure of Hazard Review Boards, chaired by the Convening Authority, 
manages all safety recommendations until closure.
    Mr. Turner. In previous testimony, we have heard Navy and Air Force 
officials testify that physiological episodes are the number one safety 
concern for the aviation community, and we too are concerned about the 
risk this poses to the aviators and pilots who put their lives on the 
line for this country. We know there is inherent risk to combat, but it 
seems like this is an unnecessary risk to the health of pilots and 
aircrew. Can you give us an update on what is being done, from a safety 
perspective, to solve the problem of physiological episodes?
    General Rauch. The Air Force's Air Education and Training Command 
(AETC) recently conducted a Safety Investigation Board (SIB) that 
examined numerous physiological events in the T-6 training aircraft 
that provided numerous findings and recommendations to address the 
issue. In addition, the Air Force Physiological Event Action Team 
(PEAT), led by AF/A3 (with Air Force Safety participation), is 
currently examining the issue and potential mitigating actions across 
numerous platforms.
                                 ______
                                 
                    QUESTIONS SUBMITTED BY MS. ROSEN
    Ms. Rosen. Each of the military services' safety centers utilize 
separate, service-specific data systems that collect mishap data. In 
addition, the Office of the Secretary of Defense aggregates mishap data 
in its own Force Risk Reduction system. a. What benefits are provided 
by individual service-specific data systems needed to collect mishap 
data? b. To what extent do the safety centers collect consistent 
information as part of their mishap investigations? c. Where is there 
collection overlap and where do we differentiate the merged data 
analytics in order to amplify safety across DOD?
    General Francis. The individual services each have unique data 
requirements beyond the minimum required by OSD and face unique 
logistical and environmental challenges associated with the collection 
and reporting of safety information. Historically, the military 
departments each investigated their own mishaps and recorded their own 
data. The history of the USACRC dates back to an organization from the 
1950s called the U.S. Army Board for Aviation Accident Research. As 
early as 1972, the organization was tasked with collection of all Army 
Aviation mishap data and became the U.S. Army Safety Center in 1978 
when it was also given responsibility for ground safety. The current 
mishap database at the USACRC contains data going back to 1972, though 
much of the older data is unreliable at this point. The system we 
currently use was built on those roots and while it is Army centric, we 
do share data with the other services and OSD. The services collect 
much of the same data, though we may have a different naming convention 
or use different data points to provide the same answers. For example, 
rather than collecting a data point for ``Area of Responsibility,'' the 
Army collects the country and exact location of the mishap. I would 
note that a minimum set of data elements was developed jointly between 
OSD and the services in 2017. All will be included in our new database, 
as will data the Army uses for its own analysis. Our intent is that we 
will meet the 2017 requirement to seamlessly blend with OSD's minimum 
data elements. Each service forwards data to OSD for inclusion in the 
Force Risk Reduction (FR2) database. Again, the services collect many 
of the same basic data points, and modernization will ensure data 
provided in the future will more closely align the data each service 
collects, enabling more complex analysis at the OSD level.
    Ms. Rosen. Each of the military services' safety centers utilize 
separate, service-specific data systems that collect mishap data. In 
addition, the Office of the Secretary of Defense aggregates mishap data 
in its own Force Risk Reduction system. a. What benefits are provided 
by individual service-specific data systems needed to collect mishap 
data? b. To what extent do the safety centers collect consistent 
information as part of their mishap investigations? c. Where is there 
collection overlap and where do we differentiate the merged data 
analytics in order to amplify safety across DOD?
    Admiral Leavitt. Over time each service has developed and refined 
their service-specific system to account for service unique needs. 
Service uniqueness encompasses operating environments, mission variance 
and institutional culture and history. Individual systems account for 
these differences and provide efficiency to the users. All services are 
required to comply with a common DOD Instruction (6055.07). In 
recognition of a lack of standardization, an associated all-service 
working group developed a list of standard data elements that apply to 
all services. The current form of that group, the Safely Information 
Management Working Group, has been tasked with studying the current and 
future potential improvements to safety reporting through the Title 10 
Section 2222 and DOD mandated BPR/BEA (Business Process Reengineering/
Business Enterprise Architecture) system. This will result in future 
systems being much more standardized. Additionally, the services have 
already agreed on major initiatives in mishap prevention by 
standardizing human factors through the work of the Joint Service 
Safety Council Human Factors Working Group.
    Common data and some service unique data is transferred 
periodically to OSD for aggregation and analysis. It is possible that 
trend identification is only possible after aggregating common data 
between the services (this could be very important in the F-35 arena).
    Ms. Rosen. Each of the military services' safety centers utilize 
separate, service-specific data systems that collect mishap data. In 
addition, the Office of the Secretary of Defense aggregates mishap data 
in its own Force Risk Reduction system. a. What benefits are provided 
by individual service-specific data systems needed to collect mishap 
data? b. To what extent do the safety centers collect consistent 
information as part of their mishap investigations? c. Where is there 
collection overlap and where do we differentiate the merged data 
analytics in order to amplify safety across DOD?
    General Rauch. The USAF established a requirement for a 
comprehensive, searchable safety database and fielded the Air Force 
Safety Automated System in 2007. This system allows collection of 
pertinent mishap data from any event world-wide and enables analysis of 
trends and other information for mishap prevention efforts. AFSAS also 
allows the tracking of causal factors from mishaps and the 
implementation of recommendations from safety investigations. In 
conjunction with Office of the Secretary of Defense direction, the Air 
Force standardizes numerous data fields in our database to ensure 
identical collection across the Department of Defense. In addition, the 
Air Force has worked extensively with the US Navy recently to ensure 
consistent data collection for physiological events as well as 
migrating overall data collection to similar software tools.
    Ms. Rosen. In Nevada we're proud to be home to Nellis AFB and Naval 
Air Station Fallon, the premier training sites for our nation's fighter 
pilots. We were saddened to lose one of our Thunderbirds at Nellis, 
Major Stephen Del Bagno, earlier this spring, when his F-16 crashed 
over the Nevada Test and Training Range. Can you please provide me an 
update on what led to this tragic event?
    General Rauch. The Safety Investigation Board (SIB) and Accident 
Investigation Board (AIB) investigations are complete for this mishap. 
SIB reports contain privileged safety information and are conducted 
solely to prevent future mishaps. According to the publically 
releasable AIB report, the Mishap Pilot experienced G-induced loss of 
consciousness (G-LOC) while maneuvering during a routine aerial 
demonstration training flight. The G-LOC lead to the MP's absolute 
incapacitation and the aircraft's impact with the ground.
                                 ______
                                 
               QUESTIONS SUBMITTED BY MS. GONZALEZ-COLON
    Ms. Gonzalez-Colon. General Rauch's presentation included charts of 
the numbers and rates of the different classes of mishaps by fiscal 
year, including partial FY2018. Is there a breakdown of these rates and 
trends that separates Active vs. Reserve vs. National Guard components? 
Is there such for the other services? If so, I would ask that these 
breakdowns be submitted for this hearing record.
    General Francis. Breakdowns of Class A flight mishaps and rates by 
component are provided in the table below. For the past 10 years, the 
Army National Guard and Army Reserve have maintained mishap rates at or 
below the active forces. There are differences in the way they execute 
flying hours and their exposure to higher-risk environments, but their 
efforts in mishap prevention are to be commended along with those of 
the active force. The Army National Guard and Army Reserve are integral 
to the success of both Army Aviation and the total force.
    Ms. Gonzalez-Colon. All our forces have been operating at an 
intensified level worldwide for almost 17 years now. Both people and 
machines are being deployed more often and for longer times than what 
was customary. Even though our people and our gear are the best in the 
world, this rate of use can degrade performance and shorten the useful 
life of the hardware. Have you been able to observe an influence of 
this in the numbers, rates or types of mishaps?
    General Francis. We have not seen a recognizable mishap trend of 
any kind indicating that extensive deployments have degraded the safety 
of our aircraft or crews. The few materiel issues we have experienced 
have not been due to excessive flying hours on airframes, but failures 
of parts or systems that are routinely replaced based on time or 
condition. The most recent catastrophic materiel failures we have 
experienced could not be attributed to excessive use as the parts that 
failed are routinely inspected and replaced when necessary.
    Ms. Gonzalez-Colon. There are several aircraft systems that have 
been kept on duty for many decades and are expected to be for a few 
more (B52, KC135, C130)--is there an observed trend relating mishaps 
and aircraft age, or whether the aircraft has had the latest upgrades?
    General Francis. There are no observed trends in Army Aviation 
mishaps relating to aircraft age or lack of upgrades. During the last 
10 years, the Army has retired the UH-1 and OH-58 fleets. We 
continually put aircraft through inspections and upgrades to ensure 
continued safe operations.
    Ms. Gonzalez-Colon. There is also a concern that the Guard and 
Reserve Components may be falling behind in getting any needed upgrades 
or in replacement of equipment as priority is given to Active 
Component. Would the services' witnesses comment on this concern?
    General Francis. The Army relies on Army Guard and Reserve Aviation 
as an integral component for success and acts to modernize the total 
force based on operational requirements and within fiscal constraints. 
This will result, for instance, in the Army National Guard's Blackhawk 
fleet being fully modernized 2 years ahead of the Regular Army. To 
date, we have not seen any major mishaps that indicate issues with Army 
National Guard or Army Reserve equipment or upgrades.
    Ms. Gonzalez-Colon. General Rauch's presentation included charts of 
the numbers and rates of the different classes of mishaps by fiscal 
year, including partial FY2018. Is there a breakdown of these rates and 
trends that separates Active vs. Reserve vs. National Guard components? 
Is there such for the other services? If so, I would ask that these 
breakdowns be submitted for this hearing record.
    Admiral Leavitt. [The charts referred to can be found in the 
Appendix on pages 83-92.]
    Ms. Gonzalez-Colon. All our forces have been operating at an 
intensified level worldwide for almost 17 years now. Both people and 
machines are being deployed more often and for longer times than what 
was customary. Even though our people and our gear are the best in the 
world, this rate of use can degrade performance and shorten the useful 
life of the hardware. Have you been able to observe an influence of 
this in the numbers, rates or types of mishaps?
    Admiral Leavitt. The Naval Safety Center does not collect data 
regarding aircraft/aircrew readiness numbers. That information is 
collected in the Defense Readiness Reporting System-Navy, a classified 
information source monitored by other DOD organizations. However, USN 
Class A rates have remained relatively constant during the last 10 
years with no statistical significance to the fluctuation in the Class 
A mishap rate during the last 10 years.
    Aviation mishap rates for all classes are calculated per 100,000 
flight hours. Total USN flight hours averaged 942,000 between FY08 and 
FY12, in the years before sequestration. In the last five years, flight 
hours have averaged about 90,000 less than before sequestration; 
however, this has not had a statistically significant impact on the 
Class A mishap rate. USMC flight hours are about a third of the USN's, 
averaging 302,000 between FY08 and FY12. In the last five years, those 
averages have dropped by approximately 50,000 hours. USMC Class A rates 
are showing an increase over the last 10 years. The majority of both 
USN and USMC Class A mishaps occur during flight operations as opposed 
to flight-related or aviation ground mishaps.
    USN Class B mishaps show a more even dispersion between flight, 
flight-related, and aviation ground mishaps than USN Class A mishaps. 
USMC Class B mishaps are nearly evenly split between flight and 
aviation ground mishaps.
    Class C mishaps have continued to rise over the past 10 years for 
both the USN and USMC. The majority of these mishaps are aviation 
ground mishaps, rather than flight or flight-related mishaps, and occur 
during maintenance evolutions.
    Human factors account for nearly two-thirds of all mishap causal 
factors. The Human Factor Analysis and Classification System (HFACS) 
was implemented by the DOD in 2011 to assist mishap investigators with 
root cause analysis. Two HFACS, Fatigue and/or Task Oversaturation/
Under-saturation causal factor preconditions, could potentially 
indicate issues with high operational tempo, however out of 453 USN and 
USMC Class A-C mishaps from FY11-FY17, only 30 mishap reports cited 
these HFACS preconditions.
    Data collected by the Naval Safety Center does not show a 
correlation relating high operation tempo as a principle factor 
influencing mishap type or rates.
    Ms. Gonzalez-Colon. There are several aircraft systems that have 
been kept on duty for many decades and are expected to be for a few 
more (B52, KC135, C130)--is there an observed trend relating mishaps 
and aircraft age, or whether the aircraft has had the latest upgrades?
    Admiral Leavitt. [See graph on next page.] Comparative mishap 
analysis of legacy Naval aircraft platforms in programs to extend their 
service lives and all other Naval aircraft platforms indicates a 
correlation of extended service life and increased mishaps due to 
material failure. As figure 1 illustrates, Naval aircraft with extended 
life programs (E-2, C-2, AV-8B, F/A-18A-D, and MH/CH-53E) that 
experienced a Class A mishap as a result of a material factor are 
experiencing those mishaps at a greater rate than Naval aircraft not in 
an extended life program. The Naval Safety Center's mishap reporting 
system does not differentiate aircraft with or without the latest 
system or material upgrade and therefore cannot measure the impact of 
aircraft upgrades and mishap occurrence.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    .epsNote: The original chart was color-coded. When reading the 
chart above, the lower line at the left, beginning at zero, represents 
legacy aircraft; the higher line at the left represents all others.
    Ms. Gonzalez-Colon. There is also a concern that the Guard and 
Reserve Components may be falling behind in getting any needed upgrades 
or in replacement of equipment as priority is given to Active 
Component. Would the services' witnesses comment on this concern?
    Admiral Leavitt. [See graph on next page.] Since 2001, similar to 
the Active Component, Navy Reserve equipment has been steadily 
declining in capacity (Enclosure 1) and capability due to the constant 
demands of warfare and budgetary constraints. Navy, as a total force, 
is working to ensure the Reserve Component has capability equal to the 
Active Component, ensuring strategic depth is maintained in the Reserve 
Force. In some cases, an increase in capability of a Reserve squadron 
over that of an Active Duty squadron is necessary due to the unique 
mission requirements (e.g. HSC-85). However, independent of the budget 
landscape, recapitalization of Reserve hardware routinely falls to the 
bottom of the priority list (unfunded or not). Reserve aircraft like 
the F-5 for Adversary training, F/A-18 as strategic reserve and P-3C 
for anti-submarine warfare are almost obsolete. Congress has been 
especially helpful in providing funding for new NP-2000 propellers for 
our aging C-130T aircraft. Our C-130T aircraft are at approximately 60% 
of their life expectancy. Currently, there remains no plan to 
transition the last 2 squadrons of P-3C aircraft to the P-8A aircraft 
in the Navy Reserve. The current strike plan continues to be a 
``waterfall'' strategy that transitions legacy aircraft from the Active 
Component to the Reserve. The Navy Reserve's only rotary wing dedicated 
SOF support squadron is transitioning from the HH-60H to the MH-60S and 
are losing SOF-peculiar capabilities unique to the legacy aircraft.
    The Navy Reserve relies heavily upon Congressional Adds to keep its 
equipment on par with the Active Component and remain deployable. 
Recapitalizing Navy Reserve equipment will enable members who leave 
Active Duty to continue to serve in the Navy Reserve, using the same 
systems capability they had in the Active Component.
    NGREA is a helpful tool to ensure capability parity is maintained, 
however, platforms like manned airframes cannot be purchased with 
Service NGREA funding.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    .epsMs. Gonzalez-Colon. General Rauch's presentation included 
charts of the numbers and rates of the different classes of mishaps by 
fiscal year, including partial FY2018. Is there a breakdown of these 
rates and trends that separates Active vs. Reserve vs. National Guard 
components? Is there such for the other services? If so, I would ask 
that these breakdowns be submitted for this hearing record.
    General Rauch. Air National Guard and Air Force Reserve mishap 
occurrences were included in the overall Air Force charts provided for 
the presentation.
    The breakout of Air National Guard aviation Class A mishap events 
over the last five years is:
    FY14 = 2 Class A mishaps, rate = 0.80 mishaps per 100K flying hours
    FY15 = 2 Class A mishaps, rate = 0.67 mishaps per 100K flying hours
    FY16 = 5 Class A mishaps, rate = 1.74 mishaps per 100K flying hours
    FY17 = 2 Class A mishaps, rate = 0.72 mishaps per 100K flying hours
    FY18 = 5 Class A mishaps, rate = 1.44 mishaps per 100K flying hours
    For the Air Force Reserve, the Class A breakout is:
        FY14 = 0 Class A mishaps
        FY15 = 3 Class A mishaps
        FY16 = 1 Class A mishap
        FY17 = 0 Class A mishaps
        FY18 = 0 Class A mishaps
    Note, due to the heavy incorporation with active-duty flying hour 
programs, separate Air Force Reserve mishap rates cannot be accurately 
accomplished.
    Ms. Gonzalez-Colon. All our forces have been operating at an 
intensified level worldwide for almost 17 years now. Both people and 
machines are being deployed more often and for longer times than what 
was customary. Even though our people and our gear are the best in the 
world, this rate of use can degrade performance and shorten the useful 
life of the hardware. Have you been able to observe an influence of 
this in the numbers, rates or types of mishaps?
    General Rauch. Operational tempo is always a concern that local 
commanders and safety offices continually monitor and address. Air 
Force Safety has not ascertained any enterprise level trends directly 
correlated to decreased capability of personnel or equipment due to 
increased use or deployment. Every aircraft flown meets airworthiness 
requirements regardless of age or frequency of use and overall aviation 
mishap trends for major Class A mishaps have generally trended lower.
    Ms. Gonzalez-Colon. General Rauch, aware that it may be early in 
the investigative process for specifics, and of course respecting the 
protection of sensitive information, what can you tell us about the 
state of the investigation on the May 2 Air National Guard tragedy in 
Charleston, insofar as the steps and stages that have been gone through 
and what would be next?
    General Rauch. The Safety Investigation Board (SIB) and Accident 
Investigation Board (AIB) investigations are complete for the Puerto 
Rico Air National Guard WC-130 mishap that occurred on 02 May 2018 
immediately after departure from the Savannah/Hilton Head International 
Airport. SIB reports contain privileged safety information and are 
conducted solely to prevent future mishaps. The publically releasable 
AIB report identified multiple causes for the mishap. First, the mishap 
crew did not reject the takeoff when the number one engine failed to 
provide normal parameters. In addition, the crew did not properly 
execute appropriate after takeoff and engine shutdown checklists and 
procedures. Finally, the crew improperly applied rudder controls after 
takeoff that led to the aircraft stalling ad departing controlled 
flight.
    Ms. Gonzalez-Colon. There are several aircraft systems that have 
been kept on duty for many decades and are expected to be for a few 
more (B52, KC135, C130)--is there an observed trend relating mishaps 
and aircraft age, or whether the aircraft has had the latest upgrades?
    General Rauch. There are no trends connecting aircraft age to 
mishaps, other than the fact that newer generation aircraft, such as 
the F-22, F-35 and CV-22, are increasingly the source of more expensive 
mishaps simply due to the cost of repairs and parts of these aircraft 
and corresponding DOD mishap reporting criteria. The Air Force utilizes 
the Aviation Structural Improvement Program (ASIP) to ensure the 
desired level of structural safety, performance, durability, and 
supportability throughout the aircraft's service life. Aircraft 
upgrades provide performance enhancement and bring technological 
advances to older aircraft, but airworthiness remains independent of 
aircraft age.
    Ms. Gonzalez-Colon. There is also a concern that the Guard and 
Reserve Components may be falling behind in getting any needed upgrades 
or in replacement of equipment as priority is given to Active 
Component. Would the services' witnesses comment on this concern?
    General Rauch. From a safety perspective, there has not been an 
increase in any type of mishap with Air National Guard or Air Force 
Reserve aircraft due to lack of upgrades.

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