[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
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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.
[all]