AIR FORCE AF P MAC 127-4-1978 GUIDE FOR INVESTIGATION OF MAC AIRCRAFT MISHAPS《MAC航空器失事调查指南》.pdf

1、3535787 02b0724 718 Z;-o%-;ZO DEPARTMENT OF THE AIR FORCE Headquarters Military Airlift Command Scott Air Force Base. Illinois 62225 MAC PAMPHLET 127-4 1 November 1978 Safety GUIDE FOR INVESTIGATION OF MAC AIRCRAFT MISHAPS Provides guidance for conducting MAC aircraft mishap investigations and the p

2、ublishing of formal reports of Class A. B. and C mishaps . It explains the individual duties of board members and how to prepare the various sections of the report . Guidance for mishap board training also is provided . Each member of an investigation board should have a personal copy of this pamphl

3、et during an investigation . This publication is affected by the Privacy Act of 1974 under 10 U.S.C. 8012 . Page Chapter 1 . General Information 1-1 Chapter 2 . Investigations , . 2-1 Chapter 3 . Immediate Actions 3-1 Chapter 4 . Board President , . 4-1 Chapter 5 . Operations (Pilot) Member 5-1 Chap

4、ter 6 . Maintenance Member . 6-1 Chapter 7 . Medical Member . 7-1 Chapter 8 . Investigating Officer 8-1 Chapter 9 . Board Recorder . 9-1 Chapter 10 . Support Personnel 10-1 Chapter 11 . The Report . 11-1 Chapter 12 . Aircraft DOD Class C Mishap and Engine Shutdown Investigations and Reports . , 12-1

5、 Chapter 13 . Mishap Board Training , 13-1 Attachments 1 . General Checklist for Mishap Investigations . , . , . a1-1 3 . Initial Mishap Investigation Board Training Outline . A3-1 2 . AFISC Quality Control Checklist . , . , , A2-1 Figures 2-1 Board Organization . 2-2 2-2 Group Board Organization 2-

6、3 8-1 How to Get Technical Assistance 8-5 11-1 Report Cover . 11-3 11-2 Index Tabs - Parta I. II 11-4 11-3 Transmittal Letter Format for Formal Reports 11-6 11-4 Transmittal Letter Format for Findings Not Directly Related to Mishap 11-7 12-1 Investigation Sequence 12-4 Forms Implemented AF 74 Commun

7、ication Status Notice/Request . 711 USAF Mishap Report . 711gA Life Sciences Report of An Individual Involved In An AF Accident/Incident- Section A. Aircraft Accident/Incident 711h USAF Mishap Report and Checklist 846 Flight Management/Training/Evaluation Records 847 Recommendation for Change of Pub

8、lication . 781 Aerospace Vehicle Flight Data Document DD 175-1 Flight Weather Briefing . 365F Weight and Balance Form F . 1801 DOD International Flight Plan . Paragraph Page 12-4f( 1) 12-2 5-5 5-2 3-6b( 13)(e) 4-8a 3-6b(13)(f)Note 4-5d(3) 3-6b( 9)( d) 3-6b( 1) 3-6b( 3) 3-6b( 1) Supersedes MACR 127.2

9、. 15 August 1974 . (See signature page for summary of changes.) No . of Printed Pages: 60 OPR IGFF (Maj Lewis) Approved by: Colonel John R . Moulton Distribution: F 3-1 4-1 3-1 4-3 3-1 3-1 3-1 3-1 1490 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-

10、1 ii D 3535789 0260725 b54 MACP 127-4 1 November 1978 Paragraph Page . MAC 21 Aircrew Qualification Training Record 3-6 b( 9Xc) 3-1 69 Mission Following Folder 3-6b(4) 3-2 151 Control and Follow-Up Closeout Action 12-7 12-3 97 USAF Aircraft AccidenVIncident Report Worksheet 12-2 12-1 I 541 MAC Fligh

11、t Safety Mishap Data Card 12-6 12-2 I . I . 1491 O Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-3515789 026072b 590 m MACP 127-4 1 November 1978 1-1 a c o . o Chapter 1 GENERAL INFORMATION 1-1. INTRODUCTION: a. This pamphlet provides guidance for

12、MAC aircraft mishap investigators. b. The Air Force publications which explain the requirements for aircraft mishap investigations are AFRs 127-4, 127-11, and AFM 127-1. The information provided in this publication aids the investigator by describing techniques, individual board member duties, and p

13、laces all information needed (when combined with Air Force publications) in one location for easy reference. c. Mishap investigation boards work more efficiently if board members understand each others duties. Board members are well qualified in their own area of expertise but often waste valuable t

14、ime in determining how to conduct an investigation. This pamphlet includes procedures to save time and explains the sequence of events which leads to a complete report. To use this pamphlet correctly, each board member must decide which portion applies to that member. However, nothing in this pamphl

15、et keeps the investigator from using different methods or changing the sequence of the investigtion to fit the situation. d. The board membership and actions are designed to deal with specific mishaps. Mishap boards may have as few as five members, but may be larger. Some large, complex mishaps may

16、have a board made up of several small groups of board members who report to the voting board members. This makes control of the board easier for the board president. Regardless of size, a mishap board has the same goals and is managed in the same way. e. The diagrams and figures in this pamphlet con

17、tain detailed information to aid board members in their investigation. 1-2. DISTRIBUTION. The safety offices at each MAC AF, wing, group and ARRS maintain enough copies of this pamphlet to meet their needs. Squadrons, detachments, and operating locations not located with their parent units are to ke

18、ep a copy as a guide for responding to aircraft mishaps. The safety office on each base and at the MAC AFs and ARRS Headquarters should control distribution and insure board members receive a copy of this pamphlet to use during investigations. 1-3. INVESTIGATION PHASES. The mishap investigation can

19、be divided into seven phases: preparation; notification; interim board; arrival; investigation; writing and publication. a. Preparation Phase. The time between board member selection and their actual use. If possible, selectees should attend one of the formal USAF mishap investigation courses. In ad

20、dition, they should study the regulations that describe board actions and attend local mishap board training sessions. b. Notification Phase. When an aircraft mishap occurs, individuals are selected to serve on a board. This phase cannot be planned because the specific mishap circumstances vary. One

21、 problem is transportation to the mishap scene. This may be a staff car or worldwide airlift, depending on the mishap location. The board member must prepare for travel and a long TDY. c. Interim Board Phase. MAC wings are tasked to identify and train personnel to serve on mishap investigation board

22、s; most wings assign primary and alternate members. Smaller units may have only one or two trained people. Regardless of size, the interim board plays an important role in the first few hours after a misha They must be ready to assume control of the _11E mis ap scene when the initial response force

23、(fire fighters, tc.) and on-scene commander relinquishes control. The interim board continues working until the headquarters board is contacted and transported to the scene. Timeliness during this phase is important and is possible only when interim board members know their duties. Occasional practi

24、ce of actions required by board members can be of great aid to increase this capability. They make sure evidence is not lost, and fluid samples, tower and RAPCON voice tapes, aircraft and crew records are secured. (See attachment 1 for checklist.) They must insure such evidence is safe and available

25、 to the investigation board when it arrives. The interim board must also do everything possible to help the investigation board get organized and started once they arrive. d. Arrivai Phase. The time immediately after the board arrives at the mishap location. Board members should resist the desire to

26、 rush to the mishap scene. It is more important at this time to plan the board members actions in order to reduce duplication of effort. A plan of attack is needed to get as much done as quickly as possible. The time spent insuring board members know and are assigned proper duties helps develop a go

27、od investigation and report. e. Investigation Phase. The board spends most of its time in this phase. Evidence is gathered, sorted, and evaluated. Detailed instructions and ideas on how to accomplish this phase are available in AF and DOD publications. f. Writing Phase. While gathering and recording

28、 evidence is an on-going effort, there is a time in every investigation when board members must sort out their notes, memos, and evidence and compile a clearly written, well documented, and correct report. It is just as important to discard unneeded material as it is to include meaningful evidence a

29、nd a careful analysis. For example, it is not necessary todetail all of the board discussions, but it is necessary to show that apparent cause factors were considered at some time during the investigation. This is done as briefly as possible without leaving out important material. Writing the report

30、 is hard work, but if done properly and carefully, it results in a report of great value to MAC and the Air Force. 1492 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-1-2 3535789 02b0727 427 = MACP 127-4 1 November 1978 g. Publication Phase. It is n

31、atural for board 1-4. UPDATING: O members to consider their job complete when their portion of the report is written; however, this is not the case. Your report is carefully studied by many levels of command. A well constructued, neat report indicates a professional, complete job. Dont leave the pub

32、lication of the report to the board recorder. Every member of the board shares this responsibility. a. This pamphlet is a guide for building a mishap report. Copies may be kept in a loose-leaf binder so new information can be easily added. Safety offices may keep additional materials that explain th

33、e boards job in the same binder. b. We encourage your input to keep this guide current. 1493 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-3535789 0260728 3b3 MACP 127-4 1 November 1978 Chapter 2 INVESTIGATIONS 2-1. RESPONSIBILITIES. AFR 127-4, par

34、agraph 3-3, and MACSUP 1 establish responsibility for investigation of MAC mishaps. Most aircraft mishap boards are appointed by the MAC AF or ARRS commander. However, the individual board members usually come from wing level or below. AFR 127-4/ MACSUP 1, requires that individuals from all levelsof

35、 the Command be identified and trained for board duty. Chapter 13, this pamphlet, is a guide for mishap board member selection and training. 2-2. MISHAP CLASSES. Aircraft mishap classes are determined by the dollar cost required to repair the aircraft. If the class of a mishap is in question, that i

36、s, Class A or Class B, use the lower class for initial reporting. It is easier to upgrade a mishap than to downgrade one; however, experience has shown that the initial investigative efforts should be conducted as if the mishap is in the higher class. This initial effort may prevent the loss of impo

37、rtant evidence. Certain mishaps may be investigated by a single investigating officer instead of a board. In determining whether to use a single officer or board, the scope of the investigation is an overriding factor. Additionally, commanders should consider the following: a. Investigation by a sin

38、gle officer imposes a heavy workload on one person. b. Often the investigation of a Class C mishap requires the same amount of work as that of a Class A. c. A single investigator tends to have tunnel vision, especially when faced with report deadlines. The board, on the other hand, offers the best b

39、rainstorming environment and leads to a more complete evaluation of the facts and possible causes. d. A formal Class B mishap report can be as much of an administrative effort as a Class A. e. Many items of evidence can be lost if not collected soon after the mishap. For example, witnesses may not b

40、e available or they may forget important facts if interviews are delayed. One person may not be able to get through the initial phases of the investigation in time to prevent delays or the loss of perishable evidence. Therefore, the commander usually is required to assign assistants for the investig

41、ator or expect a report of lower quality. 2-4. INVESTIGATING OFFICER When the commander elects to appoint a single investigator, the 2-3. SINGLE INVESTIGATION OFFICER. 2-1 officer must conduct the investigation with the same thoroughness and objectivity as a board. Therefore, investigating officers

42、are selected and trained to havea good working knowledge of the regulations and the guides available to them. This level of knowledge requires advance selection of potential investigators. a. During an investigation, the investigating officer is relieved of all other duties. The investigating comman

43、der must insure the investigating officer receives the support needed to complete the investigation. Much of this support can come from the local MAC safety officer or the local interim board members, if a board is appointed. b. Investigating officers must remember that they work for the investigati

44、ng commander. The report findings and recommendations must be impartial, direct, and appropriate for they receive Command- wide attention. c. This pamphlet is oriented to mishap investigations by a board of five or more officers. The investigating officer, in effect, replaces the board and (except f

45、or required medical expertise) assumes all functions and responsibilities of a full board. With a good working knowledge of mishap investigation as conducted by a board, the investigating officer can shape the investigation to fit most situations. 2-5. INVESTIGATION BOARDS. Aircraft mishaps that res

46、ult in significant damage or loss of life usually are investigated by a formal board. There are two types of mishap board organizations. The type used depends on the complexity of the mishap. When it is evident that the investigation requires a large group of specialists, the board president may ele

47、ct to establish an investigative group organization. Normally, a basic five officer board is adequate. a. The Basic Board. The five member board discussed in AFR 127-4. It is composed of a board president, an investigating officer, an operations (pilot) member, a maintenance member, and a medical of

48、ficer. The host base normally supports the board by providing the recorder who is an officer assigned to assist with administrative details. This board can be supplemented by commanders representatives and experts in various systems or engineering disciplines. The qualifications for the basic board

49、members are in AFR 127-4 and paragraph 2-6, below. Figure 2-1 describes the basic organizational and functional relationships of the board members. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-2-2 Other Voting Members m 3515747 ozbo7zq ZTT m MACP 127-4 1 November 1978 Medical Maintenance Pilot Member Member Member Board President *Technical Advisor *Recorder *Coordinator Administration Investigating Officer I - Technical Assistanc