Accident Investigation Preparation and Preliminary Examination As a safety professional, you will be called upon to investigate accidents. This call will probably come when you least expect it; therefore, sound and thoughtful preparation is necessary to make you ready for any accident contingency.

Terminal Learning Objective Action: Determine the support items required to conduct an accident investigation Condition: Given a simulated accident site and an accident investigation kit Standard: Student must choose the appropriate tool for the task and demonstrate correct operation of the equipment Go over TLO

Risk Assessment Safety Requirements: None Risk assessment Level: Low Environmental Considerations: None; however, it is the responsibility of all Soldiers and DA civilians to protect the environment from danger. Evaluation: Group practical exercise and questions on the Accident Investigation exam.

References DA Pam 385-40, Army Accident Investigations and Reporting Aircraft Accident Investigation, Wood & Sweginnis Accident Investigator’s Handbook

Overview Preparation for an Accident Investigation Investigator Safety Accident Notification Process Accident Investigation Kit Support Items Field Investigation Equipment Briefly go over lesson topics.

Overview The 3W Process Preliminary Site Procedures continued The 3W Process Preliminary Site Procedures Preservation of the Site Qualities of An Investigator Support Plan Briefly go over lesson topics.

Prepared For Anything Standing List Be Prepared Deployment Kit Safety personnel should create a list of possible items they will need immediately at an accident site. Safety personnel must be prepared to respond to an accident at any time 24/7. Prepare a deployment kit for easy access and packed according to the standing list you have developed.

Investigator Safety Physical Fitness Immunizations Diet/Nutrition PPE Physical fitness – Maintain the best health possible at all times; never know where you may have to travel or what you will do once you get there Immunizations – Stay current on your immunizations. If you’re called to go to a particular location, you don’t want to be delayed, hindered, or put at risk because you haven’t received or maintained the proper immunizations. Diet and nutrition – During an investigation, your body and mind are often pushed to or beyond their normal limits. Ignoring your physical limitations and exhibiting poor nutrition habits (i.e. constantly eating junk food or not eating at all) can affect your performance and cause you to become a hindrance to your team and the investigation. PPE – An accident site is full of hazards; check you PPE, wear it, stay alert, and make safe choices.

Accident Notification Before you run… Gather your thoughts Implement the pre-accident plan Gather equipment Gather your thoughts – Decipher what you know about the accident. Asking questions will help you determine what you need and how to proceed. Implement the pre-accident plan – This will save a lot of time because the “way ahead” has already been established. Gather equipment - Determine what equipment will be required. Maintain two kits that are always ready to go. Prepack everything and have it in a single location. Periodically check your kits to ensure you have a complete kit and all items function correctly.

Accident Investigation Kit Primary Kit Carrying case for kit contents Camera (digital with memory media) Tape recorder, batteries, and tape Inclinometer/Abney level Tape measure (100 foot) Optic range finder/distance measuring Flashlight (w/ batteries) DA Pam 385-40, 2–9. Accident investigation kit contents a. This paragraph contains a list of items recommended for an accident investigation kit. It is neither all inclusive, nor mandatory. b. Each organization should assemble its accident investigation kit based on their mission and needs. Items listed in paragraphs (3), (4), (7), and (8) below should not be stored in kit, but obtained as needed. (1) Carrying case for kit contents. (2) Camera (recommend 35mm camera with at least a 50mm lens). (3) Film (prints and slides). ( 4 ) T a p e r e c o r d e r ( w i t h a d e q u a t e q u a n t i t y o f b l a n k t a p e s , batteries). (5) Inclinometer/Abney level. (6) Tape measure, 100 foot (steel recommended). (7) Optic range finder/distance measuring (batteries if needed). (8) Flashlight (batteries). DA Pam 385-40, Para. 2-9

Accident Investigation Kit continued Primary Kit Magnetic compass (lensatic) Small magnifying glass Pocket/universal multi-tool, with case Steel ruler (1 foot) with large index Screwdrivers (flat tip and cross tip) Pliers and crescent wrench (8 inch) DA Pam 385-40, 2–9. Accident investigation kit contents a. This paragraph contains a list of items recommended for an accident investigation kit. It is neither all inclusive, nor mandatory. b. Each organization should assemble its accident investigation kit based on their mission and needs. Items listed in paragraphs (3), (4), (7), and (8) below should not be stored in kit, but obtained as needed. (9) Magnetic compass (lensatic). (10) Small magnifying glass. (11) Pocket/universal multi–tool, with case. (12) Steel ruler (1 foot) with large index. (13) Screwdrivers (flat tip and cross tip). (14) Pliers and crescent wrench (8 inch). DA Pam 385-40, Para. 2-9, b (9)-(14)

Investigation Kit References DA Pam 385-40 Appropriate report forms: AAAR -- DA Form 2397 series AGAR -- DA Form 285 series Additional references Technical manuals Field Manuals Training Circulars Local regulations and SOPs 2–9. Accident investigation kit contents a. This paragraph contains a list of items recommended for an accident investigation kit. It is neither all inclusive, nor mandatory. b. Each organization should assemble its accident investigation kit based on their mission and needs. Items listed in paragraphs (3), (4), (7), and (8) below should not be stored in kit, but obtained as needed. (15) AR & DA Pam 385–40. (16) A p p r o p r i a t e f o r m s ( D A 2 8 5 , D A 2 3 9 7 s e r i e s , A G A R , AAAR, and so forth). (17) Additional references (TMs, FMs, and local regs/SOPs). DA Pam 385-40 –– DA Pam 385-40, Paragraph 2–9 is your primary reference for accident investigation. Appropriate Reporting Forms –– Aviation accidents are reported using forms in the DA Form 2397 series; whereas, ground accidents are reported using forms in the DA Form 285 series. Additional references –– For additional information, you may also want to include TMs, FMs, training circulars, local regulations, and SOPs in your kit. DA Pam 385-40, Para. 2-9, b (15) - (17)

Support Items Plastic bags Batteries Camelback Office supplies Power bar and/or snacks First aid kit Hat, sun glasses, sun screen, bug repellant Batteries Office supplies Clip board/ notebook Templates Poncho These items are very beneficial but often overlooked when determining important items to pack in an accident investigation kit or deployment kit..

Cases Durable, Weatherproof, Portable or Wheeled These are some of the types of cases you want to consider for carrying the contents of your accident investigation kit. The main thing to remember is you want a case that is durable, weatherproof, and either portable or wheeled. Durable, Weatherproof, Portable or Wheeled

Angles and Azimuths Abney Inclinometer Suunto Tandem Lensatic Compass The Abney Inclinometer is an optical device for measuring elevation angles above a horizontal line. In an Abney clinometer, the object sighted and the level bubble can be seen simultaneously. This instrument enables the surveyor to rotate the horizontal bubble vial through ±60 degrees to measure inclination. The arc is divided to single degrees and reading by vernier to 1 arcminutes. Gradients are adjusted with a wheel attached to the spirit level while correcting the position of the bubble A Lensatic Compass is very useful device because it has numbers which are useful in identifying the directions of target objects. Suunto Tandum is Liquid-filled precision compass and clinometer for surveyors, cartographers, and others (investigators) Ideal for accurately measuring directional indications, heights, vertical angles, and slopes Offers scales in both degrees (0 +/- 90 degrees) and percent (0 +/- 150 percent) A protractor is an instrument for measuring angles, typically in the form of a flat semicircle marked with degrees along the curved edge Lensatic Compass Protractor

Tools Screwdriver Inspection Mirror Multi-tool ViseGrips Magnifier Magnifier – To enlarge evidence such a fibers, etc. Inspection Mirror – To see into cramped areas or inaccessible areas that may pose potential hazards   Multi-tool – Contains several mechanical (often unconsidered) items that may be beneficial during an investigation Flashlights – To increase visibility during an investigation; to see items during night-time investigations (NOTE: always carry an extra flashlight with fresh batteries) ViseGrips Magnifier Flashlights Adjustable Wrench

Measuring Retractable Rule Metal Ruler 100 Foot Rule 100 foot Rule – Effective for measuring the distance of debris around a piece of equipment Metal Ruler 100 Foot Rule

Digital or Tape Recorder Electronics GPS Camera and “Film” Digital or Tape Recorder Digital or tape recorder – Used to record witness testimony   GPS – Used to determine accident location (?) Camera and film – Used to capture photos of the accident scene and associated evidence Range finder – Any of various optical, electronic, or acoustical instruments used to determine the distance of an object from the observer Range finder w/ binocular –Any of various optical, electronic, or acoustical instruments used to determine the distance and magnification of an object from the observer Range finder w/ compass –Any of various optical, electronic, or acoustical instruments used to determine the distance and direction of an object from the observer Range Finder w/Compass Range Finder w/Binocular Range Finder Only

Personal Survival Protection From Elements First Aid Repellant Food Protection from the elements – Accidents occur in all types of environments and during all types of weather. Constant exposure to the elements makes an investigator susceptible to illness.   Repellant – Protect from insects that may carry illnesses and diseases. Especially beneficial when working in heavily vegetated or hot, moist environments. Be sure to use a repellant with DEET for the optimal protection. First Aid –No matter how careful you are, it is always possible to be injured at an accident site. Keep a first aid kit handy to deal with injuries that may occur. Hydration –Always have a hydration system and be sure to stay hydrated while conducting an accident investigation — especially if you are in a hot environment or exerting yourself physically. Camelbacks are an excellent source for carrying water as they can hold up to 100 oz. Food – Maintain a healthy diet during accident investigations; doing so will help you keep up your strength and maintain your focus and endurance. Power bars are excellent if you need to eat quickly. Sunscreen – Protects your skin during hot weather or in hot, dry environments. Cover all body parts that will be exposed to the sun for extended periods of time. If possible, apply at least 30 minutes prior to sun exposure. Food Sunscreen Hydration

Investigator Protection Leather Gloves Rubber Gloves Respirators Tyvek suit – Protective (often disposable) suit worn to protect the body from exposure to hazards   Rubber gloves – Worn to protect the hands from hazards such as chemicals, bodily fluids, etc. Leather gloves – Worn to protect the hands from hazards such as sharp objects; also used to protect the hands while picking up wreckage or handling equipment Respirators – Mask worn to aid in breathing within a hazardous environment. Filters the incoming air and removes hazardous particulates. Particulate mask – Mask worn over nose and mouth to prevent inhalation of airborne hazards or toxic particles. (NOTE: prevents inhalation only; does not filter air) Eye protection – Plastic or non-penetrable glasses worn over the eyes to protect from hazards such as flying debris, splashes, etc.. Tyvek Eye Protection Particulate Mask

Field Kit Bag Camera Marking tape At a minimum, a field kit may include a camera (for photographing the scene) and marking tape (for securing the scene/preventing unnecessary access to the investigative area.).   

CAI Time Line (by Phase) Phase 1: Organization & Preliminary Examination Phase 2: Data Collection Phase 3: Analysis/Deliberations Phase 4: Complete Field Report Staffing D+13 D+11 D+1 D+2 D+12 Outbrief Phase 1: Organization & Preliminary Examination – Usually occurs Day 1. Investigation board is organized and tasks assigned. Conduct preliminary exam of accident.   Phase 2: Data Collection – Usually ranges Day 2-11. Secure accident and collect data from accident scene. Data divided into 3 categories (human, material, and environmental) later used to determine root cause(s). Phase 3: Analysis and Deliberations – Ongoing process that begins during the Data Collection phase; however, deliberations usually begin on or about Day 11 and last until about Day 12. During Analysis, you take all the “pieces” of evidence you/your team has collected and analyze the data to determine how the accident occurred. Conclusions derived from the analysis become the basis for your findings and recommendations (which emerge during the Deliberation phase). Phase 4: Complete Field Report – All related evidence, findings and recommendations are recorded in a field report (also referred to as a “Red Book”). The Red Book contains several components that provide more detail regarding evidence discovered during the investigation. Finally, once everything is completed, the findings and recommendations of the accident are outbriefed to the Commander. D+14 Typically, the investigation will take 14-21 days DA Pam 385-40, Para. 2-1

The 3W Process 1. What happened? Task (human) error, material failures/malfunctions or environmental condition that contributed to the accident (Tables B-1 thru B-4, DA Pam 385-40). Avoid preconceived ideas Follow a set pattern (deliberate) Be flexible, adjust to situations “What happened” involves determining the mistake, error, or failure that was made to cause the accident. It involves identifying the key factors (human, material, or environmental) which caused or contributed to the accident. NOTE: Take the students to Tables B-1 thru B-4. Briefly walk them through a few examples – explaining to them how the chart is divided (i.e. individual errors, environmental errors, root causes, etc.) and how each error corresponds with a specific code that they will record on the form once each areas is determined Be flexible/adjust to situations – Be prepared for delays, long hours, other possible causes for information to change. DA Pam 385-40, Para. 1- 5

The 3W Process 2. Why Did It Happen? What caused it? System inadequacy (root cause) or the why the task error occurred (Table B-5, DA Pam 385-40) Leader failure Training failure Standards/Procedures failure Support failure Individual failure Leader failure – Did the leader fail to monitor the mission execution/planning, correct inappropriate behavior, take appropriate action, or emphasize correct procedure? Training failure – Was the training incorrect, incomplete, or insufficient?   Standard/procedure failure – Standard does not exist or is unclear, impractical, or inadequate Support failure – Type, amount, capability, condition of support is insufficient to correctly perform the mission Individual failure – Individual knows the standard and is trained, but elects to follow the standard NOTE: Also refer students to DA Pam 385-40, Table B-5 for examples of each type of failure and the codes associated with each type of failure. DA Pam 385-40, Para. 1- 5

The 3W Process 3. What to do about it? The corrective recommendations that will prevent this type of accident from happening again (Table B-6, DA Pam 385-40). All corrective actions recommended must be addressed to the appropriate level of command: Unit Higher Command Army level “What to do about it” involves recommending corrective actions that will prevent this type of accident from happening again. Table B-6 in DA Pam 385-40 provides possible recommendations to propose to the appropriate level of command. NOTE: Take students to Table B-6 in DA Pam 385-40 DA Pam 385-40, Para. 1- 5

Initial Organization of Board Meeting before going to the accident site Members understand: Their areas of responsibility Initial tasks to be completed Data elements required to complete the report Preliminary actions taken by unit or installation personnel DA Pam 385-40, 2-1, b(1)

Preliminary Accident Site Procedures Procedures consisting of actions that normally occur according to the unit pre-accident plan Unit/installation safety officer takes charge After EOD, chemical, fire fighting, rescue, and law enforcement have completed duties Fire Chief declares site safe for entry DA Pam 385-40, Para. 2-2

Preliminary Accident Site Procedures First priority: Safety of victims and personnel involved Occupants Fire/rescue personnel Security personnel Witnesses Bystanders Investigators DA Pam 385-40, Para. 2-2, b (1)

Preliminary Accident Site Procedures Deceased personnel Photograph and examination, if possible, before extraction Approval required by coroner or medical examiner before moving bodies if off-post If coroner performs autopsy, the board president must request a military forensic pathologist be present DA Pam 385-40, Para. 2-2, b (1) (d)

Preliminary Accident Site Procedures Securing the Scene Rope off accident site Post guards Establish entry point and pass system Ensure protective measures for Composites Bloodborne pathogens DA Pam 385-40, Para. 2-2, b(2)

Preliminary Accident Site Procedures Preservation of the Accident Site Safeguard wreckage and evidence from sightseers Preserve Ground scars Vegetation Create wreckage distribution diagram DA Pam 385-40, Para. 2-2, c.

Qualities of an Investigator An open mind Capacity for hard work Common Sense Integrity Keep the faith Perseverance Technical knowledge Tact International society of air safety investigators (ISASI) An open mind. Jumping to preconceived ideas will lead the investigator to arrive at invalid conclusions. Only after a thorough search through all the data should the final analysis be made. Capacity for hard work. The stress involved with an investigation can be great. It may include dealing with deceased soldiers and their families and will include environmental situations, human interactions, materiel research and briefings.   Common Sense. Logical thinking is one of the best assets an investigator can have. When investigating a scene, analyze the data carefully, but also utilize your common sense and think logically Integrity. You must report the facts as they are without bias or concern for outside influence. Keep the faith. Investigations are taxing and can drain you mentally and physically; however, always remember that the investigation process will result in answers and recommendations which will preserve the force. Perseverance. Review the data collected many times. Continue to look for the missing pieces of data. Technical knowledge. Review DA Pam 385-40 and seek assistance from subject matter experts. Tact. Required throughout the investigation. Required for dealing with witnesses, chain of command, board members, and conducting the out-brief.

Support Plan Commanders assigned responsibility for the conduct and support of accident investigations will ensure that a local safety professional is available from the local safety office to assist the accident investigation board. An investigator is not a separate entity; in order for an investigation to be successful, an investigator needs a support plan. DA Pam 385-40 states, “Commanders assigned responsibility for the conduct and support of accident investigations will ensure that a local safety professional is available from the local safety office to assist the accident investigation board” (Para. 2-1, d). Paragraph 2-1, d also outlines the primary responsibilities of everyone who is part of the support plan. The next few slides (slides 33-39) depict the responsibilities of a few of these individuals. DA Pam 385-40, Para. 2-1, d.

Support Plan The duties of the safety representative: Provide investigation kit Advise board concerning: Technical report Advice on administrative procedures Provide regulatory documents and directives Interpret local regulations Coordinate work space Duties of the safety representative include— (a) Providing the local investigation board with an accident investigation kit (see paragraph 2–9 for a recommended listing of accident investigation kit contents) and/or other equipment necessary to conduct the investigation. (b) Advising the board on technical aspects of the investigation and reporting of the accident. (c) Helping the board in obtaining other technical assistance as required. (d) Advising the board of administrative procedures concerning accident reports. For example, command channel review and forwarding correspondence. (e) Providing regulatory documents and directives pertaining to accident investigation and reporting. (f) Providing necessary interpretation of local regulations and directives. (g) Helping the board president in obtaining administrative support. For example, work space, typist, and drafting. (h) Providing initial classification for the accident, such as Class A and B. DA Pam 385-40, Para. 2-1, d.

Support Plan Engineer Local TASC/PA (Photography) PAO Commander ensures the board president receives the following support if necessary: Engineer Local TASC/PA (Photography) PAO Hospital commander Provost Marshall Weather Officer Maintenance Support Facility Commander Transportation Officer Refer the students to DA Pam 385-40 page 13 ( Support Plan) DA Pam 385-40, Para. 2-1, d.

Support Plan Assistance for assets available to local commander Additional technical assistance: Assistance for assets available to local commander Metallurgists Power plant engineers Fuel and oil analysis Other Assistance outside the local command Request through USACR/SC Refer the students to DA Pam 385-40 page 13 ( Support Plan) DA Pam 385-40, Para. 2-1, d.

Support Plan Collateral investigation interface: Record of facts for use in litigation, claims, and other administrative and disciplinary actions Accident and criminal investigations get priority Accident board Releases common source information to collateral Cannot release content of witness statements, findings, analysis, and recommendations Refer the students to DA Pam 385-40 page 14 ( Support Plan) DA Pam 385-40, Para. 2-1, f.

Support Plan Criminal investigation interface: Contact ASAP Assumed criminal investigation authority? Both CID and accident investigations proceed while determining if criminal intent exists Accident investigation board may use any CID information (report, witness statements, photos, etc.) Factual data release to CID only Refer the students to DA Pam 385-40 page 14 ( Support Plan) DA Pam 385-40, Para. 2-1, g.

Support Plan Minority Report: Official report is signed by the board president Disagreeing board members will submit minority report Minimum requirements for report Analysis paragraph explaining disagreement Signature block of minority members Once the investigation is concluded and the report is completed, the official investigation report is signed by the board president. Often, the board agrees on the report; however, on occasion, a board member may disagree with the others (and be adamant about his/her position). When this occurs, the disagreeing board members must submit a minority report. The minority report consists of an analysis paragraph explaining the disagreement. Each minority member must sign the minority report. Refer the students to DA Pam 385-40 page 14 ( Support Plan) DA Pam 385-40, Para. 2-1, h.

Investigation Plan Phase 1 Organization and Preliminary Examination Data Collection Phase 3 Analysis of the Data Phase 4 Completing the Technical Report Discuss again the four phases of the investigation plan. DA Pam 385-40, Para. 2-1

SUMMARY