MISHAPS

Maj Rick Ludtke, USAF, MC, FS

NGB/SGPF

USAF FY14 Aviation Mishap Reviewver6 Mar 2015

2014 was “best year for safety in the Air Force” Historical average of 10.7 aircraft

destroyed/year2014: 2

Historical average of 8.2 fatalities/year2014: 10

Costs at highest level since FY07 at $65MNote: Partially due to change in Cost Per Injury Type

Estimate (all comers @ $8.7M; previously tiered)

2014 – Safest Year for the Air Force

X7

Cited Human Factors in FY14 #1 Inattention

Most cited causal human factor in all USAF Class A-E flight mishaps (260)

Most frequently reported contributory human factor in all Class A-D flight mishaps (45)

#2 MiscommunicationTop contributory human factor in Class E

flight mishaps

Recent Changes

Change in Cost Per Injury Type EstimateAll fatalities valued @ $8.7MPreviously, fatality cost was differentiated

based on expected lifetime income (i.e., TIS, rank, age, etc.)

Human Factors (HFACS) 7.0 releasedRarely used or confusing HFACS removedHFACS remaining reorganized into

categories

Mishap Classification

Ground vs Aviation Categorized into Class based on

estimated cost and/or extent of injuries (A-E; A>E)A = worst personal or financial costE = least personal or financial cost

Investigation Timelines Safety investigation should be completed

within 30 days of mishapDeadline can be extended in the interest of

producing a thorough, complete and accurate safety report

Outbrief to LtGen Clarke will be performed 2 weeks following de-convening of board

Secretary or Assistant Secretary of Air Force wish to be present for fatality outbriefs

Various Boards Interim Safety Baord (ISB)

Convened immediately upon notification of mishapClosest AD installation to mishap responsiblePurpose is to collect and preserve evidence

Safety Investigation Board (SIB)Convened days after mishap notificationResponsibility of “gaining” MAJCOM (think

operational owner)Purpose is to prevent another mishap

Various Boards

Aviation Investigation Board (AIB)Legal boardPurpose is to determine blame