Army Regulation 638-2: DA PAM 385-40 Army Accident Investigation and Reporting

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<p>Army Regulation 638-2: DA PAM 385-40 Army Accident Investigation and Reporting</p>

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Tuesday, January 11, 1994
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Returned to military control The status of a person whose casualty status of duty status—whereabouts unknown or missing has been changed due to the person's return or recovery by U.S. military authority. Also called RMC. See also casualty status; duty status— whereabouts unknown; missing. (Joint Pub 1-02) Selected Reserve Those units and individuals within the Ready Reserve designated by their respective Services and approved by the Joint Chiefs of Staff as so essential to initial wartime missions that they have priority over all other Reserves. All Selected Reservists are in an active status. The Selected Reserve also includes persons performing initial active duty for training. See also Ready Reserve. (Joint Pub 1-02) Seriously wounded A stretcher case. See also Wounded. (Joint Pub 1-02) Service representative Any individual, either military or DA civilian, duly appointed to represent the Department of the Army, for an assigned mission. Within the Casualty and memorial Affairs are, an individual, appointed to represent the Army in dealings with the next of kin of casualties. Slightly wounded A casualty that is a sitting or a walking case. See also wounded. (Joint Pub 1-02) Standby Reserve Those units and members of the Reserve Components (other than those in the Ready Reserve or Retired Reserve) who are liable for active duty only, as provided in the U.S. Code, title 10 (DOD), sections 10151,12301, and 12306. See also active duty; Ready Reserve; Reserve Components; Retired Reserve. (Joint Pub 1-02) Stopover Planned stop and delay in the onward movement of remains at a designated intermediate funeral home between point of origin and receiving funeral home. Summary court-martial A summary court-martial is comprised of one commissioned officer on active duty. Unless otherwise prescribed by the Secretary concerned, a summary court-martial shall be of the same armed force as the accused. Supporting installation Army installations located within a CAC area of responsibility, but not an integral part of the CAC organization. Supporting installations provide local resources to the CAC. Temporary cemetery A cemetery for the purpose of: a. The initial burial of the remains if the circumstances permit or b. The reburial of remains exhumed from an emergency burial. (Joint Pub 1-02) Temporary interment A site for the purpose of: a. The interment of the remains if the circumstances permit or b. The reburial of remains exhumed from an emergency interment. (This term and its definition modify the existing term "temporary cemetery," and its definition is approved for inclusion in the next edition of Joint Pub 1-02.) Tentative identification See Belived to Be. Terrorism The unlawful use or threatened use of force or violence against individuals or property to coerce or intimidate governments or societies, often to achieve political, religious, or ideological objectives. A victim of a terrorist act directed against the United States or its allies is a hostile casualty. Testator A person who dies with a valid will. 141 AR 638-2 • 22 December 2000 DODDOA 022297 Training period An authorized and scheduled regular inactive duty training period. A training period must be at least two hours for retirement point credit and four hours for pay. Previously used interchangeably with other common terms such as drills, drill period, assemblies, periods of instruction, and so forth. (Joint Pub 1-02) Trench burial A method of burial resorted to when casualties are heavy whereby a trench is prepared and the individual remains are laid in it side by side, thus obviating the necessity of digging and filling in individual graves. See also burial. (Joint Pub 1-02) Trench interment A method of interment in which remains are placed head-to-toe. Used only for temporary multiple burials. (This term and its definition modify the existing term "trench burial," and its definition is approved for inclusion in the next edition of Joint Pub 1-02.) Unaccompanied baggage Suitcases, trunks, or luggage not in association or possession of the decedent. Unaccounted for An inclusive term (not a casualty status) applicable to personnel whose person or remains are not recovered or otherwise accounted for following hostile action. Commonly used when referring to personnel who are killed in action and whose bodies are not recovered. See also casualty; casualty category; casualty status; casualty type. (Joint Pub 1-02) United States civil authorities Those elected and appointed public officials and employees who constitute the governments of the 50 States, District of Columbia, Commonwealth of Puerto Rico, United States possessions and territories, and political subdivisions thereof. (Joint Pub 1-02) Very seriously ill or injured The casualty status of a person whose illness or injury is classified by medical authority to be of such severity that life is imminently endangered. Also called VSII. See also casualty status. (Joint Pub 1-02) Voluntary training Training in a non-pay status for individual Ready Reservists and active status Standby Reservists. Participation in voluntary training is for retirement points only and may be achieved by training with Selected Reserve or voluntary training units; by active duty for training; by completion of authorized military correspondence courses; by attendance at designated courses of instruction; by performing equivalent duty; by participation in special military and professional events designated by the Military Departments; or by participation in authorized Civil Defense activities. Retirees may voluntarily train with organizations to which they are properly preassigned by orders for recall to active duty in a national emergency or declaration of war. Such training shall be limited to that training made available within the resources authorized by the Secretary concerned. (Joint Pub 1-02) Will A written and signed statement, made by an individual, that provides for the disposition of their property when they die. (See also codicil and probate.) Wounded See seriously wounded; slightly wounded. See also battle casualty. (Joint Pub 1-02) Section III Special Abbreviations and Terms Abrasion Antemortem injuries resulting from friction of the skin against a firm object and causing removal of the epidermis. Accessory chemicals Chemicals used in addition to vascular (arterial) and cavity embalming fluids. Include but are not limited to hardening compounds, preservative powders, sealing agents, mold-preventive agents, and compress application agents. 142 AR 638-2 • 22 December 2000 DODDOA 022298 Acquired immunodeficiency syndrome (AIDS) Specific group of diseases or conditions that are indicative of severe immunosuppression related to infection with the human immunodeficiency virus (HIV). Persons who died with AIDS may exhibit conditions such as wasting syndrome, extrapulmonary tuberculosis, and Kaposi's sarcoma. Aerobic In the presence of free oxygen. Anaerobic In the absence of free oxygen. Antemortem Before death. Anticoagulant fluid Ingredient of embalming fluids that retards the natural postmortem tendency of blood to become more viscous or prevents adverse reactions between blood and other embalming chemicals. Arterial (vascular) fluid Concentrated, preservative, embalming chemical that is diluted with water to form the arterial solution for injection into the arterial system during vascular embalming. Its purpose is to inactivate saprophytic bacterial and render the body tissues susceptible to decomposition. Arterial solution Mixture of arterial (vascular) fluid and water used for the arterial injection. May include supplemental fluids. Aspiration Withdrawal of gas, fluids, and semi-solid from body cavities and hollow viscera by means of suction with an aspirator and a trocar. Autopsy Postmortem examination of the organs and tissues of a body to determine cause of death or pathological condition. Biohazard Biological agent or condition that constitutes a hazard to humans. Blood Human blood, human blood components, and products made from human blood. Bloodborne pathogens Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Contaminated Marked by the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. Contaminated laundry Laundry that has been soiled with blood or other potentially infectious materials or may contain sharps. Contaminated sharps Any contaminated object that can penetrate the skin including, but not limited to needles, scalpels, broken glass, and exposed ends of wires. Universal precautions An approach to infection control in which all human blood and certain human body fluids are treated as if they are contaminated with HIV, HBV, and other bloodborne pathogens. 143 AR 638-2 • 22 December 2000. DODDOA 022299 Blood discoloration Discoloration resulting from changes in blood composition, content, or location, either intravascularly or extravascularyly. Cadaveric lividity Postmortem intravascular red-blue discoloration resulting from hypostasis of blood. Cavity fluid Embalming chemical that is injected into a body cavity following aspiration in cavity embalming. Cavity fluid can also be used as the chemical in hypodermic and surface embalming. Coagulating agents Chemical and physical agents that bring about coagulation. Communicable disease Disease that may be transmitted either directly or indirectly between individuals by an infectious agent. Cosmetic fluid Embalming fluid that contains active dyes and coloring agents intended to restore a more natural skin tone through the embalming process. Coverall Plastic garment designed to cover the body from the chest down to the upper thigh. Cranial embalming Method used to embalm the contents of the cranial cavity through aspiration and injection of the cranial chamber by passage of a trocar through the cribriform plate. Cremated remains Those elements remaining after cremation of a dead human body. Creutzfeldt-Jakob disease Disease of the central nervous system with unknown etiology, assumed to be a slow virus. Because etiology is unknown, caregivers using invasive procedures use extreme caution. Decomposition Separation of compounds into simpler substances by the action of microbial and/or autolytic enzymes. Dehydration Loss of moisture from body tissue that may occur antemortem or postmortem (antemortem: febrile disease, diarrhea, or emesis; postmortem: injection of embalming solution or through absorption by the air). Desiccation Process of drying out. Desquamation (skin-slip) Sloughing off of the epidermis, wherein there is a separation of the epidermis from the underlying dermis. Discoloration Any abnormal color in or on the human body. Edema Abnormal accumulation of fluids in tissue or body cavities. Embalming Process of chemically treating the dead human body to reduce the presence and growth of microorganisms, to retard organic decomposition, and to restore and acceptable physical appearance. There are four types of embalming: Cavity embalming. Direct treatment other than vascular (arterial) embalming of the contents of the body cavities and the lumina of the hollow viscera. Usually accomplished by aspiration and then injection of chemicals using a trocar. Hypodermic embalming. Injection of embalming chemicals directly into the tissues through the use of a syringe and needle or a trocar. 144 AR 638-2 • 22 December 2000 DODDOA 022300 Surface embalming. Direct contact of body tissues with embalming chemicals. Vascular (arterial) embalming. Use of the blood vascular system of the body for temporary preservation, disinfection, and restoration. Usually accomplished through injection of embalming solutions into the arteries and drainage from the veins. Embalming analysis (case analysis) That consideration given to the dead body prior to, during, and after the embalming procedure is completed. Documentation is recommended. Environmental Protection Agency (EPA) Governmental agency with environmental protection regulatory and enforcement authority. Firming Rigidity of tissue due to chemical reaction. Fixation Act of making tissue rigid. Solidification of a compound. Formaldehyde (HCHO) Colorless, strong-smelling gas that when used in solution is a powerful preservative and disinfectant. Potential occupational carcinogen. Formaldehyde gray Gray discoloration of the body caused by the reaction of formaldehyde from the embalming process with hemoglobin to form methylhemoglobin. Hardening compound Chemical in powder form that has the ability to absorb and to disinfect. Often used in cavity treatment of autopsied cases. Hematoma A swelling or mass of clotted blood caused by a ruptured blood vessel and confined to an organ or space. Humectant Chemical that increases the ability of embalmed tissue to retain moisture. Hypodermic embalming See Embalming. Infant Child less than 1 year of age. Injection Act or instance of forcing a fluid into the vascular system or directly into tissues. Laceration Wound characterized by irregular tearing of tissue. Lesion Any change in structure produced during the course of a disease or injury. Maggot Larva of an insect, especially a flying insect. Masking agent See Perfuming Agents. Massage Manipulation of tissue in the course of preparation of the body. 145 AR 638-2 • 22 December 2000 DODDOA 022301 Modifying agents Chemicals for which there may be greatly varying demands predicated on the type of embalming, the environment, and the embalming fluid to be used. Moribund In a dying state. In the agonal period. Multiple-site (Multipoint) injection Vascular injection from two or more arteries. A minimum of two sites are prescribed in the suggested Minimum Standard for Embalming. Occupational Safety and Health Administration (OSHA) A Governmental agency with the responsibility for regulation and enforcement of safety and health matters for most U. S. employees. An individual state OSHA agency may supersede the U.S. Department of Labor OSHA regulations. One-point injection Injection and drainage from one location. Opaque cosmetic A cosmetic medium able to cover or hide skin discolorations. Palpate To examine by touch. Perfuming agents (masking agents) Chemicals found in embalming arterial formulations having the capability of displacing an unpleasant odor or of altering an unpleasant odor so that it is converted to a more pleasant one. Petechia Antemortem, pinpoint, extravascular blood discoloration visible as purplish hemmorrhages of the skin. Postmortem Period that begins after somatic death. Postmortem examination See autopsy. Postmortem stain Extravascular color change that occurs when heme, released by hemolysis of red blood cells, seeps through the vessel walls and into the body tissues. Preinjection fluid Fluid injected primarily to prepare the vascular system and body tissues for the injection of the preservative vascular (arterial) solution. This solution is injected before the preservative vascular solution is injected. Preparation room That area or facility wherein embalming, dressing, cosmetizing, or other body preparation is effected. Preservation See Temporary Preservation. Purge Postmortem evacuation of any substance from an external orifice of the body as a result of pressure. Putrefaction Decomposition of proteins by the action of enzymes from anaerobic bacteria. Restoration Treatment of the deceased in the attempt to recreate natural form and color. AR 638-2 • 22 December 2000 DODDOA 022302 Restorative fluid (humectant) Supplemental fluid, used with the regular arterial solution, whose purpose is to retain body moisture and retard dehydration. Sealing agents Agents that provide a barrier or seal against any leakage of fluid or blood. Sign of death Manifestation of death in the body. Stillborn Dead at birth. A product of conception either expelled or extracted dead. Surface discoloration Discoloration due to the deposit of matter on the skin surface. These discolorations may occur antemortem or during or after embalming of the body. Examples are adhesive tape, ink, iodine, paint, and tobacco stains. Surface embalming See Embalming. Temporary preservation Science of treating the body chemically so as to temporarily inhibit decomposition. Terminal disinfection Institution of disinfection and decontamination measures after preparation of the remains. Thanatology Study of death. Tissue gas Postmortem accumulation of gas in tissues or cavities 147 AR 638-2 • 22 December 2000 DODDOA 022303 . UNCLASSIFIED PIN 074130-000 DODDOA 022304 USAPA ELECTRONIC PUBLISHING SYSTEM OneCol FORMATTER .WIN32 Version 136 PIN: 074130-000 DATE: 01-12-01 TIME: 13:59:04 PAGES SET: 151 DATA FILE: alciata\R638-2.FIL DOCUMENT: AR 638-2 DOC STATUS: NEW PUBLICATION DODDOA 022305 Department of the ArmyPamphlet 385-40 Safety Army Accident Investigation and Reporting Headquarters Department of the Army Washington, DC 1 November 1994 Unclassified DODDOA 022306 SUMMARY of CHANGE DA PAM 385-40 Army Accident Investigation and Reporting This new Department of the Army pamphlet-- o Contains information for all accident investigation and reporting, not solely for aviation accidents. o Contains information on generic accident investigation techniques and procedures (chap 2). o Revises the DA 2397 Series aircraft accident investigation forms, with accompanying instructions (chap 3). o Adds DA Form 2397-AB-R, Abbreviated Aviation Accident Report (AAAR), with instructions (chap 3). o Includes DA Form 285, Army Accident Report, with supporting forms and detailed instructions (chap 4). o Adds DA Form 285-AB-R, Abbreviated Ground Accident Report (AGAR) with instructions (chap 4). DODDOA 022307 *Department of the Army Headquarters Department of the Army Pamphlet 385-40 Washington, DC 1 November 1994 Safety Army Accident Investigation and Reporting expanded to encompass all Army accidents, pamphlet are not official unless they are au­to include aviation, ground, explosives, nu-thenticated by the Administrative Assistant to clear, radiation, biological, and maritime. the Secretary of the Army. Users will destroy This pamphlet implements compliance proce-interim changes on their expiration date un- By Order of the Secretary of the Army: dures for Department of Defense Instructions less sooner superseded or rescinded. GORDON R. SULLIVAN 6055.7, 7730.12, and AR 385-40. General, United States Army Applicability. This regulation applies to the Suggested Improvements. Users are in- Chief of Staff Active Army, the Army National Guard, the vited to send comments and suggested im- U.S. Army Reserve, and Army appropriated provements on DA Form 2028 Official: fund employees. This pamphlet is applicable (Recommended Changes to Publications and during full mobilization. Blank Forms) directly to Army Safety Office, Proponent and exception authority. DACS-SF, Chief of Staff, 200 Army Penta- MILTON H. HAMILTON The proponent of this pamphlet is the Direc­gon, Washington, DC 20310-0200. Administrative Assistant to the tor of Army Safety, under the Office, Chief Secretary of the Army of Staff, Army. The proponent has the au-Distribution. Distribution of this publica­thority to approve exceptions to this pam­tion is made in accordance with DA Form History. This UPDATE printing publishes a phlet that are consistent with controlling law 12-09-E, block number 4496 intended for new Department of the Army pamphlet. This and regulation. Proponents may delegate this command levels A, B, C, D, and E for the publication has been reorganized to make it approval authority, in writing, to a division compatible with the Army publishing chief under their supervision within the pro-Active Army, the Army National Guard, and database. No content has been changed. ponent agency who holds the grade of colo-the U.S. Army Reserve. nel or the civilian equivalent. Summary. This pamphlet on accident inves­ tigation and reporting for the Army has been Interim changes. Interim changes to this Accident investigation techniques for Electromagnetic Contents (Listed by paragraph and page number) Environmental Effects (E3) • 2-7, page 13 Chapter 1 Analysis • 2-8, page 13 Accident investigation kit contents • 2-9, page 15 Introduction, page 1 Purpose • 1-1, page 1 References • 1-2, page 1 Chapter 3 Explanation of abbreviations and terms • 1-3, page 1 Aviation Accident Reporting, page 17 Introduction • 3-1, page 17 Methodology • 1-4, page 1 DA Form 2397-R Series, Technical Report of U.S. Army Aircraft Concept • 1-5, page 1 Safeguarding accident information • 1-6, page I Accident • 3-2, page 17 DA Form 2397-R, Part I, Statement of Reviewing Officials • 3-3, Use of forms and reports • 1-7, page 1 page 17 Chapter 2 DA Form 2397-1-R, Part II, Summary • 3-4, page 17 Investigation Procedures and Techniques, page 2 DA Form 2397-2-R, Part III, Findings and Recommendations • 3-5, page 17 DA Form 2397-3-R, Part IV, Narrative • 3-6, page 18 Section 1 DA Form 2397-4-R, Part V, Summary of Witness Interview Procedures, page 2 • 3-7, page 18 Organization and planning • 2-1, page 2 DA Form 2397-5-R, Part VI, Wreckage Distribution • 3-8,Preliminary accident site procedures • 2-2, page 4 page 18 DA Form 2397-6-R, part VII, In-Flight or Terrain Impact & Section II Crash Damage Data • 3-9, page 18 Techniques, page 6 DA Form 2397-7-R, Part VIII, Maintenance and Material DataWitness interview techniques • 2-3, page 6 • 3-10, page 19 Human factors • 2-4, page 8 DA Form 2397-8-R, Part IX, Personal Data • 3-11, page 19Materiel factors • 2-5, page 9 DA Form 2397-9-R, Part X, Injury/Occupational Illness DataEnvironmental factors • 2-6, page 13 • 3-12, page 19 This pamphlet supersedes DA Pam 385-95,20 May 1991. i DA PAM 385-40 • 1 November 1994. Unclassified DODDOA 022308 Contents-Continued DA Form 2397-10-R, Part XI, Personnel Protective Escape/ Survival/Rescue Data • 3-13, page 19 DA Form 2397-11-R, Part XII, Weather/Environmental Data • 3-14, page 19 DA Form 2397-12-R, Part XIII, Fire Data • 3-15, page /9 DA Forms 2397-13-R, Index A, and 14-R, Index B • 3-16, page 19 Substantiating Data • 3-17, page 19 Miscellaneous • 3-18, page 20 Assembly of the accident folder • 3-19, page 20 DA Form 2397-AB-R, Abbreviated Aviation Accident Report (AAAR) • 3-20, page 21 Chapter 4 Ground Accident Reporting, page 77 Introduction • 4-1, page 77 DA Form 285, U.S. Army Accident Report • 4-2, page 77 Findings and recommendations • 4-3, page 77 Narrative of investigation • 4-4, page 78 DA Form 285-W, U.S. Army Accident Report Summary of Witness Interview • 4-5, page 80 Accident folder • 4-6, page 81 DA Forms 285-A-R and 285-B-R • 4-7, page 81 DA Form 285-0-R, U.S. Army Accident Report Statement of Reviewing Officials • 4-8, page 82 Miscellaneous • 4-9, page 82 DA Form 285-AB-R, Abbreviated Ground Accident Report (AGAR) • 4-10, page 82 Appendixes A. References, page 112 B. Explanations, Examples, and Key Words, page 113 C. Crash Survival Charts and Figures, page 118 D. Basic Examples of Fractures and Damaging Stresses, page 126 E. Medical, page 133 F. Accident/Incident Event Codes Associated With Aircraft Accidents, page 135 G. Accident Investigation Guidelines, page 139 Table List Table 3-1: Aviation accident reporting requirements, page 21 Table 3-2: Event Codes associated with aircraft accidents, page 67 Table 3-3: Ownership of Damaged Property, page 68 Table 3-4: Phase of Operation, page 68 Table 3-5: Duty Position Codes, page 68 Table 3-6: Accident Case Number, page 69 Table 3-7: Accident Errors/Failures/Effects/System Inadequacy(ies) /Recommendations, page 69 Table 3-8: Pay Grade Codes, page 70 Table 3-9: Personnel service codes, page 70 Table 3-10: Injury Terms and Codes, page 70 Table 3-11: Equipment Information Codes, page 72 Table 3-12: Survival Equipment/Components, page 73 Table 3-13: Method of Evacuation/Escape, page 74 Table 3-14: Location in aircraft, page 74 Table 3-15: Exit Attempted, page 74 Table 3-16: Exit Used, page 74 Table 3-17: Aircraft Attitude at Time of Escape, page 74 Table 3-18: Cockpit/Cabin Condition, page 75 Table 3-19: Escape Difficulties, page 75 Table 3-20: Survival Problems, page 75 Table 3-21: Means Used to Locate Individual, page 75 Table 3-22: Rescue Equipment Used, page 76 Table 3-23: Factors That Helped Rescue, page 76 Table 3-24: Factors That Complicated Rescue, page 76 Table 3-25: Individual's Physical Condition, page 77 Table 4-1: Accident notification and reporting requirements and suspense's 3, page 82 Table 4-2: Army Branches, page 110 Table 4-3: Types of Accident Locations, page 110 Table 4-4: Pay grade/Rank Codes, page 111 Table B-1: Aviation-Specific Mistakes/Errors, page 114 Table B-2: Ground Specific Mistakes/Errors, page 115 Table B-3: Materiel Failures/Malfunctions, page 116 Table B-4: Environmental Conditions, page 116 Table 3-5: System Inadequacies/Readiness Shortcomings/Root Causes, page 117 Table B-6: Recommendations/Remedial Measures/ Countermeasures, page 119 Table F-1: Accident/Incident Event Codes, page /35 Table F-2: Materiel Factor Events, page 138 Figure List Figure 1-1: 3W approach to the investigation, analysis, and prevention of accidents, page 2 Figure 2-1: Determining system inadequacy(ies) responsible for human error, page 16 Figure 2-2: Sequence of Events. Method to place each factor in its proper perspective in relation to other events, page 17 Figure 3-1: Sample of a completed DA Form 2397-R, Part I, Statement of Reviewing Officials, page 22 Figure 3-2: Sample of a completed DA Form 2397-1-R, Part II, Summary, page 24 Figure 3-2: Sample of a completed DA Form 2397-1-R, Part II, Summary-Continued, page 25 Figure 3-3: Sample of a completed DA Form 2397-2-R, Part III-Findings and Recommendations, page 27 Figure 3-3: Sample of a completed DA Form 2397-2-R, Part III-Findings and Recommendations-Continued, page 28 Figure 3-4: Sample of a completed DA Form 2397-3-R, Part IV-Narrative, page 31 Figure 3-4: Sample of a completed DA Form 2397-3-R, Part TV-Narrative, page 32 Figure 3-5: Sample of a completed DA Form 2397-4-R, Part V-Summary of Witness Interview, page 36 Figure 3-5: Sample of a completed DA Form 2397-4-R, Part V-Summary of Witness Interview-Continued, page 37 Figure 3-6: Sample of a completed DA Form 2397-5-R, Part VI-Wreckage Distribution, page 39 Figure 3-7: Sample of a completed DA Form 2397-6-R, Part VH-In-Flight or Terrain Impact & Crash Damage Data, page 41 Figure 3-7: Sample of a completed DA Form 2397-6-R, Part VII-In-Flight or Terrain Impact & Crash Damage Data&-Continued, page 42 Figure 3-8: Flight path and impact angle, page 45 Figure 3-9: Sample of a completed DA Form 2397-7-R, Part VIII, Maintenance and Materiel Data, page 46 Figure 3-10: Sample of a completed DA Form 2397-8-R, Part IX-Personal Data, page 48 Figure 3-10: Sample of a completed DA Form 2397-8-R, Part IX-Personal Data-Continued, page 49 Figure 3-11: Sample of a completed DA Form 2397-9-R, Part X-Injury/Occupational Illness Data, page 52 Figure 3-12: Sample of a completed DA Form 2397-10-R, Part XI-Personnel Protective Escape/Survival/Rescue Data, page 54 Figure 3-13: Sample of a completed DA Form 2397-11-R, Part XII-Weather/Environmental Data, page 57 Figure 3-14: Sample of a completed DA Form 2397-12-R, Part XIII-Fire Data, page 59 ii. DA PAM 385-40 • 1 November 1994 DODDOA 022309 Contents—Continued Figure 3-15: Sample of a completed DA Form 2397-13-R, Index A, page 61 Figure 3-16: Sample of a completed DA Form 2397-14-R, Index B, page 62 Figure 3-17: Sample aviation accident folder layout, page 63 Figure 3-18: Sample of a completed DA Form 2397-AB-R, Abbreviated Aviation Accident Report (AAAR), page 64 Figure 3-18: Sample of a completed DA Form 2397-AB-R, Abbreviated Aviation Accident Report (AAAR)—Continued, page 65 Figure 4-1: Sample of a completed DA Form 285, page 83 Figure 4-1: Sample of a completed DA Form 285—Continued, page 84 Figure 4-1: Sample of a completed DA Form 285—Continued, page 85 Figure 4-1: Sample of a completed DA Form 285—Continued, page 86 Figure 4-1: Sample of a completed DA Form 285—Continued, page 87 Figure 4-1: Sample of a completed DA Form 285—Continued, page 88 Figure 4-1: Sample of a completed DA Form 285—Continued, page 89 Figure 4-1: Sample of a completed DA Form 285—Continued, page 90 Figure 4-1: Sample of a completed DA Form 285—Continued, page 91 Figure 4-2: Sample of a completed DA Form 285-W, page 96 Figure 4-2: Sample of a completed DA Form 285-W—Continued, page 97 Figure 4-3: Sample of a completed DA Form 285-A-R, Index A, page 99 Figure 4-4: Sample of a completed DA Form 285-B-R, Index B, page 100 Figure 4-5: DA Form 285-0-R, U.S. Army Accident Report, Statement of Reviewing Officials, page 102 Figure 4-6: Sample of a completed DA Form 285-AB-R, page 104 Figure 4-6: Sample of a completed DA Form 285-AB-R-Continued, page 105 Figure 4-7: Sample ground accident folder layout, page 109 Figure C-I: Relationship of velocity of impact and declarative distance to force, page 119 Figure C-2: Aircraft Design* Load Factors and Landing Sink Rates, page 120 Figure C-3: Army servicemember during typical crash impacts. The values shown are for no serious injury, page 120 Figure C-4: Lap Belt-Only Extremity Strike Envelope—Top View, page 121 Figure C-5: Lap belt-only extremity strike envelope—side view, page 122 Figure C-6: Lap belt-only extremity strike envelope—front view, page 123 Figure C-7: Full-restraint extremity strike envelope—top view, page 124 Figure C-8: Full-restraint extremity strike envelope—side view, page 125 Figure C-9: Full-restraint extremity strike envelope—front view, page 126 Figure D-1: Metal fatigue, page 126 Figure D-2: Fatigue fractures, page 127 Figure D-3: Propagation of fatigue crack and ductile-type failure of instantaneous zone, page 127 Figure D-4: Fatigue failure, no stress and high stress concentration, page 128 Figure D-5: Fatigue failure under torsion loading, page 128 Figure D-6: Torsion load failure, page 128 Figure D-7: Bending load failure, page 128 Figure D-8: Deformation and fracture due to tension and compression, page 130 Figure D-9: Failure characteristics of ductile mental due to tension load, page 130 Figure D-10: Failure characteristics of brittle metal due to tension load, page 131 Figure D-11: Static tension failure, page 132 Figure D-12: Pure shear failure, page 133 Figure D-13: Compression buckles and tension shear failure due to shear loads, page 133 Glossary Index . DA PAM 385-40 • 1 November 1994 iii DODDOA 022310 RESERVED DA PAM 385-40 • 1 November 1994 iv. DODDOA 022311 Chapter 1 Introduction 1-1. Purpose This pamphlet provides implementing instructions for the investiga-tion and reporting of Army accidents, as directed by AR 385-40. 1-2. References Required and related publications and prescribed and referenced forms are listed in appendix A. 1-3. Explanation of abbreviations and terms Abbreviations and special terms used in this pamphlet are explained in the glossary. Special terms imperative to the understanding of this pamphlet are listed in section III of the glossary. 1 4. Methodology - Accidents resulting in the damage or destruction of Army resources or personnel injury/death impair the combat readiness of the United States Army. Initiation of the accident investigation will be accord­ing to AR 385-40, paragraph 1-9. Selected Class A and B accidents will be investigated by the U.S. Army Safety Center (USASC) under the following guidelines: a. Accidents should be investigated to the degree necessary to identify the immediate mistake(s)/error(s)/failure(s), and system in­adequacy(ies) which may have caused, or contributed to, the acci­dent being investigated. The techniques and procedures contained in this pamphlet will be used as a guide according to AR 385-40. Appropriate forms (DA Form 2397 Series/DA Form 2397—AB—R/ DA Form 285/DA Form 285—AB—R) will be used for reporting the results of accident investigations. b. Recommendations will be provided that will remedy the causes and minimize the chances for similar recurrences. If the Army accident investigation reveals unsafe conditions or practices affecting an item of equipment or technical publication, the safety of an entire model or series of an Army item of equipment may be involved. The appropriate commander should be notified immediate­ly; and the program/product manager (PM) as well as USASC contacted telephonically. The PM is responsible for analyzing the defect or deficiency and issuing safety messages deemed appropriate. 1 5. Concept - Accidents are caused by adverse interactions of man, machine and environment. Investigation and assessment of these elements should reveal human, materiel, and/or environmental factors that caused or contributed to the accident. These factors can usually be attributed to one or more system inadequacy. These deficiencies are usually attributable to leader, standard, training, individual, or support fail­ure. Although an accident investigation occurs "after the fact," its primary focus must be on identifying what happened and why it happened. Once this has been accomplished, the appropriate activi­ty(s) responsible for correcting each identified system inadequacy can be notified. This procedure is called the "3W" approach to information collection, analysis and remedial measures (fig 1-1). The procedures used throughout this pamphlet are designed to assist the investigator in answering the following three basic questions: a. What happened (mistake/error). Identify key factors (human, materiel, environmental) which caused or contributed to the acci­dent. In the case of injuries, explain how they happened. b. Why it happen (system inadequacy(ies)/root causes(s)). Iden­tify the system inadequacy that permitted the accident to occur. Explain how and under what conditions those errors/failures occurred. c. What to do about it (recommendations). Identify the recom­mended actions and identify the proponent activity or lowest level of command that is most responsible for correcting the deficiency. 1 6. Safeguarding accident information - All accident data/information will be safeguarded according to AR 385-40, paragraph 1-10. Limited use is the designation for all aircraft accidents and other accidents involving selected complex weapon systems, equipment, or military unique items/operations (for example, guided missiles, rockets, strategic defense system compo­nents, armored vehicles, and so forth). All other reports not desig­nated as "Limited Use" are labeled "General Use Accident Reports." 1-7. Use of forms and reports The report of an Army accident investigation, citing findings and recommendations, will be completed using the appropriate forms prescribed in AR 385-40. Additional attachments, drawings, ex­tracts, or other supportive media are permitted if the investigation board president determines they are needed to support the findings, recommendations, and analysis. Detailed instructions for preparation and completion of these forms are contained in chapters 3 and 4 of this pamphlet. 1 DA PAM 385-40 • 1 November 1994. DODDOA 022312 "3W" Approach to Information Collection, Analysis and Recommendations • ; , .. -.-.- - --I; -•3 - • • .•.•.;•..1.-.At.. 7 .4_-4-.• 1 •.-.„ • 7:- tsivt •.• 1.1. -a • FIXES • REWEDiAL A4EASURES • COUNTERMEASURES Figure 1-1. 3W approach to the investigation, analysis, and prevention of accidents Chapter 2Investigation Procedures and Techniques Section I Procedures 2-1. Organization and planning a. Introduction. The successful accomplishment of an accident investigation will depend upon how well it is planned, organized, and conducted. The investigating officer/board president is responsi­ble for organizing and directing the efforts toward a thorough and comprehensive investigation. The board will be established accord­ing to AR 385-40, paragraph 4-2. b. Investigation plan. The investigation plan is a systematic pro­cedure that will ensure continuity of effort from the preliminary examination of the accident site to the submission of the fmal report. The plan is divided into four phases; organization and pre­liminary examination, data collection, analysis of the data, and com­pleting the technical report. (1) Phase I—Organization and preliminary examination. This phase provides the opportunity for the board president to organize the board for the investigation. This should be accomplished in a board meeting before departing for the accident scene. This meeting should ensure that every board member understands the areas of the investigation for which they are responsible, the initial tasks to be accomplished and the data elements to be collected to complete the report. The board should also be briefed by the unit/installation safety director/officer on the status of preliminary actions. Once the board arrives at the accident site, members of the board should make a preliminary examination of the accident site to get a "mental picture" of the physical layout as an early step in their individual tasks. However, caution must be used to ensure the site, to include ground scars/marks, is not disturbed. This orientation will usually require less than 30 minutes. If the board cannot arrive at the scene with adequate daylight remaining, the preliminary examination should be delayed until the following morning. (2) Phase 2—Data collection. Human, materiel, and environmen­tal factors are interrelated as each influence the performance of man and machine. Divide data collection into the following areas: (a) Human factors. Human factors are primarily concerned with gathering data necessary to evaluate the job performance of all personnel who influenced the operation which resulted in the acci­dent. The sources of this information may include, but are not limited to: personnel involved, witnesses, supervisors, peers, and personnel from operations, training and maintenance; individual re­cords, to include training, qualification, personnel, and/or medical records; data for the evaluation of the command influence, such as unit policy for risk management, mission briefings, crew rest/sleep (both long and short term), utilization of personnel, and driver selection/ training; data for evaluation of the structure/system/equip­ment crashworthiness, personnel restraint systems, and personal pro­tective clothing and equipment as related to injury causation or prevention; and data for the evaluation and reporting of problems encountered in egress, survival, and rescue. Environmental data must also be collected for evaluation of its impact or influence on the performance of the involved individuals. (b) Materiel factors. Materiel factors is primarily concerned with gathering data necessary to evaluate the performance of the vehicle, buildings, ground support equipment, land/or other support materiel. Some sources for this information are the equipment historical, modification and inspection records, fluid analysis, teardown analy­sis, wreckage distribution, photographs and the failed part. Also, equipment project managers (PM), manufacture, equipment opera­tors, and maintenance personnel are excellent sources of materiel data. Also, data concerning how environmental conditions have af­fected vehicle/system/equipment performance must be acquired. (c) Environmental factors. Collection of environmental evidence is simultaneous and inclusive with the human and materiel factors evidence collection. Paragraph 2-6 of this chapter is devoted to environmental factors investigation. (3) Phase 3—Analysis of data. The analysis function is an ongo­ing process throughout the data collection phase. Conclusions de­rived from the analysis will be the basis for developing findings and 2 DA PAM 385-40 • 1 November 1994 DODDOA 022313 recommendations. The analysis should be thorough and should fo­cus on determining why the accident occurred. This should drive the analytical effort throughout the investigation so that findings and recommendations can be developed that have the best potential for preventing similar accidents. Paragraph 2-8 of this chapter ad­dresses accident data analysis in greater detail. (4) Phase 4—Completing the technical report. In this phase, the board must ensure that all relevant evidence gathered is carefully recorded. It is not unusual for some of the evidence to be contradic­tory. Contradictory evidence will be discussed and resolved to the extent possible in the analysis. c. Duties. Accident investigation boards will be established ac­cording to AR 385-40. In some cases, the board will consist of one individual. That individual is responsible for all aspects of the inves­tigation and report processing. When more than one individual is appointed to an investigation board, a board president and recorder will be designated. Other technical advisors, equipment operators, support personnel, and so forth, necessary to conduct the investiga­tion will be made available to the board, regardless of its composition. (1) Board president. The duties of the president of an accident investigation board include, but are not limited to, the following: (a) Managing the investigation according to AR 385-40. (b) Convening the board at the earliest possible time after notifi­cation that an accident is to be investigated. (c) Organizing the board and assigning areas of investigative responsibility to each member. (d) Taking control of the accident site upon arrival and after the area is declared safe for entry by rescue, explosive ordnance dis­posal (EOD), chemical, and firefighting personnel. (e) Verifying that adequate guards are on site to ensure the pres­ervation and protection of evidence, to include site, equipment, separated parts, impact scars, and so forth, resulting from the accident. 6) Coordinating for all required investigating equipment neces­sary to conduct the investigation. (g) Dispatching members of the board to perform their duties. (h) Evaluating the need for and request additional technical as­sistance as required. N Ensuring all available pertinent data is gathered before closing the field portion of the investigation. (1) After coordination with the collateral board, authorizing re­covery of the wreckage from the accident site when the field exami­nation is complete; and releasing wreckage/equipment for disposition to the owning organization when the investigation is completed. (k) Conducting frequent meetings of the board to ascertain prog­ress, exchange information, and adjust assignments as necessary. (1) Ensuring accident information is released only to appropriate authorities; such as, appropriate command, staff safety personnel concerned and USASC personnel. (m) Advising appropriate safety officer/public affairs officer to contact local legal advisors in cases involving potential claims against the U.S. Government for personal injury or property damage. (n) Ensuring data is correctly analyzed and conclusions are sup­ported by evidence. (o) Ensuring suitable recommendations are made and that a thor­ough and accurate report is completed and submitted according to AR 385-40 and this publication. (p) If applicable, coordinating with the local CID handling the case. (q) Writing the history of flight/event, findings, recommenda­tions, and analysis for the technical report. (2) Recorder. When possible, the recorder should be a safety trained individual. Physicians will not be assigned this duty. The duties of the recorder are listed below. (a) Receiving and administratively processing information gathered by the members of the board. (b) Monitoring report processing requirements and stages of completion. (c) Assigning tasks and monitoring work of supporting clerical personnel. (d) Ensuring all necessary substantiating data are collected and posted to the technical report. (e) Assembling the final technical report. (/) Performing other duties as assigned by the board president. (g) Completing/helping with preparation of the human, materiel, and/or environmental narrative of the technical report. (3) Maintenance officer. When possible, a maintenance specialist should be assigned to the board. The duties of the maintenance member(s) are as follows: (a) Evaluating all maintenance forms/records to determine the pre—accident status of the equipment. (b) Determining if equipment failed and could have contributed to or caused the accident. (c) Researching equipment records for adequacy of inspections and correction of discrepancies; and determining if discrepancies existed that may have caused or contributed to the accident. (d) Supervising preparation and shipment of items selected for teardown/analysis. (e) Monitoring equipment recovery if accomplished before com­pletion of the investigation. (/) Reviewing the unit's maintenance procedures and record discrepancies. (g) Completing all maintenance/materiel factor requirements for the technical report. (11) Preparing or helping with the preparation of accident scene diagram(s). (i) Performing other duties as assigned by the board president. 0) Writing the materiel factors narrative for the technical report. (4) Medical Officer. The duties of the medical officer board member are listed below. (a) Helping in the medical, physiological, and psychological as­pects of the human factors portion of the investigation. AR 40-21, AR 40-2, and appropriate chapters of this pamphlet govern the investigation and reporting of these factors. (b) Helping with and conducting the accident survival, emer­gency egress, and survival/rescue portions of the human factors investigations according to paragraph 2-4 of this pamphlet. (c) Ensuring the board is advised of medical/human factors re­lated to the cause(s) of the accident, the reason therefore, and rec­ommendations for corrective action. (d) In case of off—post accidents or where local coroners/medical examiners are involved, promptly recovering the remains for au­topsy (if applicable), specimen collection, records, and so forth. (e) Investigating and reporting data concerning personnel injuries. () Collecting and evaluating life support equipment (LSE), and personal protective clothing and equipment (PCE). (g) Helping with or completing human factors narrative for the technical report. (h) Determining the medical qualification/status of the personnel involved and rescue personnel. (i) Performing other duties as assigned by the board president. (5) Other board members. Other board members should consist of individuals who have considerable knowledge and expertise in the required fields; for example, instructor pilot, master/senior/ equipment operator, and so forth. The duties of other board mem­bers are as assigned by the board president. Other duties are, but not limited to, the following: (a) Examining and recording all factors involving operations of the equipment, to include assignment of personnel, mission plan­ning, and the history of events from mission assignment to the time the accident occurred. (b) Investigating and recording the status of personnel/individual training, experience, operating regulation, instructions, and unit di­rectives. Recommending and preparing changes to ARs and TMs, if required. (c) Investigating the activities of all personnel who were victims, had an influence on the mission, or played a role in the accident. 3 DA PAM 385-40 • 1 November 1994 DODDOA 022314 (d) Preparing a sketch of the accident site. (e) Conducting and summarizing witness interviews as necessary for inclusion in the technical accident report. (I) Completing/helping with the writing requirements of the tech­nical report. d. Support plan. (1) Commanders assigned responsibility for the conduct or sup­port of accident investigations will ensure that a local safety profes­sional is available from the local safety office to assist the accident investigation board. The duties of the safety representative are as follows: (a) Providing the local investigation board with an accident in­vestigation kit (see para 2-9 for a 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, forwarding correspondence, and so forth. (e) Providing regulatory documents and directives pertaining to accident investigation and reporting. (/) Providing necessary interpretation of local regulations and directives. (g) Helping the president of the board in obtaining administrative support; for example, work space, typist, drafting, and so forth. (h) Providing initial classification for the accident such as, Class A, B, and so forth. (2) Commanders assigned responsibility for the conduct or sup­port of an accident investigation will ensure that the following assistance is provided to the president of the investigation board, if needed. (a) Engineer. Surveying and mapping the debris pattern, prepara­tion of required sketches, and so forth. (b) Local TA SC/PA activity. Photographic assistance and communication. (c) Public Affairs Officer (PAO). Handling press representatives and public information releases. (d) Hospital commander. Treatment and examination of person­nel, identification of fatalities, facilities and support for conducting autopsies, lab support, and other medical support as necessary; for example, the preparation and shipment of body fluid samples and specimens to the Armed Forces Institute of Pathology (AFIP) for analysis. (e) Provost Marshal. Providing guards, traffic control, and site security. (f) Weather officer. Obtaining complete weather information for the time and location of the accident. (g) Maintenance support facility commander. Recovery of wreck­age, disassembly and removal of components, and preparation for shipment of items selected for teardown analysis. Also, preparation of estimated cost of damage (ECOD) to help in classifying the accident. (See para 2-2e.) (h) Transportation officer. Assistance in transportation to and from the accident site and expeditious shipment of components selected for teardown analysis. e. Additional technical assistance. The board president should ascertain what additional specialized technical assistance may be necessary. Aside from the normal assignments of technical assist­ance, the more complex accident may require professional skills to help in the data collection and analysis. The board president has the authority to call for technical assistance from all agencies available to the local commander. Experts may include metallurgists, powerplant engineers, fuel and oil analysts, and others as the cir­cumstances dictate. If assistance is needed that is outside the local commander's span of control, assistance should be requested through the USASC; such as, manufacturer's representative. f Collateral investigations interface. (1) Collateral investigations are used to make a record of the facts for use in litigation, claims, and other administrative and disci­plinary actions, whereas the safety investigation (hereinafter referred to as the accident investigation) is conducted solely for accident prevention purposes. Collateral investigations are conducted in­dependently and apart from the accident investigation; they are appointed and conducted by local commands as required by DODI 6055.7 and AR 385-40, and use guidance contained in AR 15-6 and AR 27-20. Safety personnel will not conduct, review, or store collateral investigations. (2) Accident and criminal investigations take priority over collat­eral investigations for purposes of access to evidence, witnesses, and the accident scene; however, a spirit of cooperation is also required to ensure that the collateral board will have equal access to the evidence. (3) The accident investigation board may only provide the collat­eral investigator with copies of common source, factual information; for example, technical data, maintenance records, photographs, maps, diagrams, lists of witness names, and so forth. The content of witness statements may not be provided; nor may the accident board provide its findings, analysis and recommendations to the collateral investigator. Additionally, while transcripts of relevant portions of intra—cockpit voice recordings may be included in the accident report and probably released, this information may be released within the military for accident prevention purposes. The accident board will also allow the collateral board a reasonable amount of time to perform an accident scene investigation before disturbing the evidence by movement, disassembly, and so forth. If this cannot be accomplished due to the urgency of the situation, then the accident board must ensure that the scene is documented with photographs and a wreckage distribution (accident site) diagram, which will be made available to the collateral board. If the accident board removes components for analysis, the collateral board should be so advised. g. Criminal investigation interface. Contact with the local crimi­nal investigation division (CID) office should be made as soon as practical. Determine if the CID has assumed criminal investigative authority over the accident scene, initiated an investigation, removed any evidence, or completed/terminated its investigation of the acci­dent site. The CID should determine as quickly as possible if a crime has been committed. If evidence indicates that the accident was the result of criminal intent (other than negligence, dereliction of duty, or disobedience of an order), the criminal investigation takes priority over all other investigations, and the accident investi­gation will be discontinued. Once criminal activity is determined not to be a factor, the CID will release control of the investigation to the accident investigation board. During the period where criminal in­tent is being determined, both investigations may proceed. Both the CID and the accident investigation board will cooperate with one another in order to ensure that each is able to effectively perform its mission. Information gained in the CID investigation can be re­leased to, and used by, the accident investigation board. CID will, for example, provide the accident investigation board with copies of their report, to include witness statements, photographs, and so for­th. However, the accident investigation board may release only those factual, non—privileged portions of its report to CID. h. Minority report. The official accident report will be the one signed by the board president. The board should make every effort to resolve differences in opinion. However, if differences cannot be resolved, the disagreeing board member(s) will submit a minority report. In this report, it is not necessary to repeat evidence presented in the accident report. As a minimum, the minority report will include an analysis paragraph explaining the disagreement and a signature block of the minority member(s). 2-2. Preliminary accident site procedures a. Overview. This paragraph outlines actions that normally occur according to the unit pre—accident plan. Since several of these ac­tions may have to be accomplished prior to the arrival of the investi­gation board at the accident site, the unit/installation safety officer must ensure they are accomplished. The safety officer will be the officer in charge of the accident site as soon as EOD, chemical, DA PAM 385-40 • 1 November 1994 DODDOA 022315 firefighting, and rescue personnel and military police/CID/civilian police have completed their duties and the fire chief has declared the area safe for entry. When the board president arrives, he will take charge of the accident site for the remainder of the investigation. b. Actions to be taken. (1) The first priority at every accident site is the safety of vic­tims/personnel involved. These personnel include, but are not lim­ited to, the occupants of the vehicle, fire and rescue personnel, security personnel, witnesses, bystanders, and the investigators. All injured personnel must be transported to a medical facility for exam­ination and, if necessary, treatment of injuries. Caution is advisable since some injuries may not be immediately apparent due to the stressful nature of the situation. Key personnel involved in the accident must have certain medical tests administered to make alco­hol, carbon monoxide, and drug determinations according to AR 385-40, paragraph 4-4 a(3). Specimens taken must be sent to the Aimed Forces Institute of Pathology (AFIP) for analyses and evalu­ation. When the victims are obviously deceased, the bodies should not be removed before being photographed and examined by the medical officer if he is reasonably available (can be on site within 2 hours), except to protect from further damage. If the accident oc­curred off the military reservation, the local coroner/medical exam­iner has jurisdiction on removal of the bodies. Therefore, his permission is required before the military removes the bodies. If the coroner performs an autopsy, the board president must request that a military forensic pathologist be present during the autopsy. (2) Immediate steps must be taken to prevent injury to personnel from fire, ammunition cook—off, hazardous materiel, burnt carbon fibre exposure (present for fires involving composite materials), and other potential hazards present at the accident site. The most effec­tive means of providing security in these cases is to rope off the area and place guards around the scene at a distance sufficient to ensure protection for personnel. In cases where the hazard is an explosive device, an EOD unit should be alerted. Also, since com­posite materials (burnt or fragmented) are present in most modern aircraft, tactical wheel and track vehicles, and equipment, safety personnel must evaluate all accidents (both aviation and ground) for the presence of composite materials to prevent unnecessary expo­sure or endangerment of rescue, firefighting, and investigative per­sonnel. Safety measures and procedures for handling accidents involving composite materials should be included in all pre—accident plans and incorporated in local crash rescue and firefighting train­ing. Literature for establishing a composite materiel SOP, can be obtained by contacting USASC at DSN 558-2660, or (205) 255-2660. Even after the scene has been declared safe for entry by the fire chief, fire and other hazards will usually continue to exist and all personnel entering the area must be so advised. c. Preservation of accident site. (I) As soon as the accident scene is declared safe for entry, the next task is to ensure the wreckage and other physical evidence are safeguarded from bystanders and sightseers. This includes military and civilian personnel who have no official business at the scene, according to AR 385-40, paragraph 4-5. The local safety represent­ative must ensure that guards remain on duty to keep unauthorized personnel outside the roped—off area. An entry point will be estab­lished where authorized personnel (personnel essential to the preser­vation of life, property, and evidence) can present their identification for entry clearance. Authorized personnel entering the immediate accident site area before the arrival of the board will be escorted by the safety officer. Limited access is essential to protect physical evidence such as ground scars, vegetation, and so forth, which is easily destroyed. (2) When the evidence must be removed (clear a highway) before the investigation by the board, the local safety representative must ensure the original accident scene is documented. This includes preparation of an accurate wreckage distribution diagram along with a photographic record of the accident scene. Every effort must be made to preserve the evidence when it must be moved or disturbed. A record of any subsequent damage to the equipment during rescue or recovery must be maintained. d. Preservation of evidence. (1) The local safety representative must identify as many wit­nesses (by name, address and telephone number) to the accident as possible. Witnesses must be asked not to discuss the accident with other witnesses and informed that they could be contacted for an interview by the accident investigation board. If it appears that a witness may not be available for an interview by the board, the safety representative should conduct the interview for the board. He/ she should also take as many written statements as possible and deliver them to the board president upon his arrival. He/she also needs to find out if any of the witnesses has video or photographic evidence that may be useful to the board. If such evidence exists, he/she should acquire a copy of it for the board. (2) Records pertaining to the accident equipment and its crew/ personnel must be gathered and secured. These records include the logbook, historical records, and the DA Forms 2408-13-1 (Aircraft Inspection and Maintenance Record) 6—month file. Individual/crew­member records, to include personnel (field 201 file), medical, den­tal and training records. Documents pertaining to the mission must also be gathered. The closest weather reporting facility should be notified of the accident with a request for a weather observation for the time of the accident. e. Classification of the accident. The local safety officer has responsibility for initially classifying the accident according to AR 385-40, paragraph 2-2. To help the safety representative in ac­complishing this task, the supporting maintenance facility will pro­vide the safety officer with an estimate of the costs of damage (ECOD) and repair. The supporting medical activity will provide the safety officer with an assessment of the degree of injuries according to AR 385-40, if applicable. The accident classification is necessary to determine the required notifications of the accident according to AR 385-40 and local command procedures. Manhour costs in AR 385-40, flat rate manuals, or equivalent (number of manhours to repair/replace), and Army Master Data File (parts costs) are neces­sary references for estimating accident costs. In cases where the accident costs could fall into multiple classifications, the higher class should be used since subsequent upgrading may increase in­vestigation requirements. f Press relations. If the PAO is not available, the local safety representative may have to handle press relations at the accident scene. The safety officer should be aware of the following: (I) No attempt should be made to tell a reporter what they should write in a story or to restrict them from interviewing civilian wit­nesses. Military personnel should be cautioned against making state­ments, expressing opinions, or giving out information concerning the accident. A few moments of calm conversation with the reporter can usually prevent a great deal of misunderstanding. (2) In most cases, news reporters will understand the truth of the statement that the accident investigation has just begun and that it is impossible to make statements with incomplete information. With­out giving the appearance of trying to conceal anything or pass the reporter's questions off lightly, the safety officer should advise him that the post or local PAO will have a statement as soon as the exact events leading up to the accident are known. The safety officer and accident investigation boards are not authorized to issue news re­leases, but it usually will help press relations at an accident scene if they do not quote regulations as the reason why they cannot fill reporters in completely on the accident details. (3) In many instances, the news reporters are able to provide a great deal more information than they receive. Sometimes reporters are among the first persons to arrive at the accident site and they may have talked to several witnesses before the rescue party arrives. This fact may not be apparent from their conversations, which probably will consist primarily of questions. In most cases, the reporters will be happy to pass their information along and give the investigator further assistance if they understand the value of their efforts to the safety program. If the news agency is asked to provide photos or film clips, be advised that a fee will usually be involved, so arrangements for financing should be made before making this 5 DA PAM 385-40 • 1 November 1994 DODDOA 022316 kind of request for assistance. The same caution applies to other nonmilitary agencies; such as, police, fire departments, and so forth. (4) When an accident occurs on nonmilitary property, media per­sonnel should be allowed complete freedom in taking photographs, after being requested not to disturb physical evidence consistent with procedures. If classified material is involved, the photographer should be advised of such. If necessary, the photographer may further be advised that the photographing of classified material may constitute a violation of Federal law. Any such classified material should be either covered or removed before photographs are taken. Although no restriction is placed on the photographer, a tactful request will usually prevent the use of gruesome photos. Media personnel should also be advised that the notification of next of kin may not have been accomplished. Section II Techniques 2-3. Witness interview techniques a. Introduction. (1) Purpose. In all accidents, witnesses will be advised that the sole purpose of the investigation is accident prevention. This means that, within the Department of Defense (DOD), their statement may not be used as evidence or to obtain evidence in connection with any legal, disciplinary or adverse administrative action. Their state­ments cannot be used by the Army against them or anyone else. (2) Interview. The witness interview is an extremely important part of the investigation. Witnesses may provide clues that can help identify materiel failures/malfunctions, environmental conditions, and/or human errors. In the case of human error, the interview may provide the only evidence available to identify the error(s) and its cause(s). To obtain this type of information, the interviewer must be skilled in interview techniques. (3) Statement. A witness statement should not be a verbatim or edited transcript of all that was stated. Summarization's of the wit­ness's testimony should be used, but these should not exclude any information that helps in explaining why the accident occurred. These summarization's should be written in the third person ("the witness said,""they saw," and so forth), and not in the first person ("I saw," "I observed," and so forth.). The testimony of a witness will not be made under oath. The accident investigation board must obtain complete and candid information regarding circumstances surrounding the accident to determine the actual cause factors. (4) Promises of Confidentiality—Limited Use Reports. Witnesses in a Limited Use investigation may be given a promise of confiden­tiality per AR 385-40, paragraph 1-7 a. This promises that their statement will not be released outside the Department of Defense, either to members of the public, the press, state or local govern­ments, or other Federal agencies. Such confidential witness state­ments are also protected from public release under the Freedom of Information Act (FOIA). In addition, the U.S. Army promises to oppose in court any attempt to get a legal order to release their statement, and to use the Army's best efforts to appeal any court order to release their statement. (5) Specific Procedures Governing Advice to Witnesses and Promises of Confidentiality. In both Limited Use and General Use investigations, it is important that witnesses understand the restric­tions on the use of their interviews within DOD, as well as the releasability of their interviews to the public (under the FOIA). This is especially true in Limited Use investigations when a promise of confidentiality has been given to a witness. In Limited Use investi­gations, a promise of confidentiality will routinely be offered to the following categories of witnesses: (a) Accident aircraft and vehicle crew members (pilot, mainte­nance test pilot, crew chief, drivers, tank commanders, and so forth). (b) Technical inspectors and maintenance personnel. (c) When a witness gave the interview under enhanced recall/ hypnosis, the interview will automatically be treated and designated as confidential, whether or not the witness falls under one of these particular categories. Other witnesses questioned in Limited Use investigations may be offered confidentiality at the discretion of the investigator. Specific forms and procedural guidelines for their com­pletion are at paragraphs 3-7 and 4-5. b. Locating witnesses. (1) Since witness information is based on recall and perception, it is advisable to interview all available witnesses. Witness statements may prove to be as valuable as physical evidence. Both types of evidence must be considered together in determining cause factors, as one may complement or clarify the other. (2) Witnesses must be located and interviewed as soon as possi­ble. Evaluation of their statements may tell the investigator what particular area of the investigation should be emphasized, thus re­ducing the time it will take to determine the causes of the accident. (3) It is reasonable to assume that spectators and sightseers, who are at the scene when the investigator arrives, heard or saw some­thing that attracted their attention to the accident and brought them to the scene. Talking to these people immediately may give the investigator information regarding the directions, actions, and sounds of the accident. Note. Children should not be discounted as a potential source of information. (4) In many cases, especially with aviation accidents, efforts to locate witnesses should not be confined to the actual scene of the accident. It may happen that a person many miles from the accident site has some relevant information to give. Evidence of smoke, fire, unusual maneuvers, erratic engine operation, structural failure, and loss of control may be obtained from observers along the route who were not necessarily witnesses to the actual accident. Other person­nel, for example, crews of other vehicles/aircraft in the vicinity at the time of the accident, may be particularly helpful in establishing actual weather conditions. The operators of other vehicles may also be helpful in relating transmitted messages of vital importance. (5) Statements taken from witnesses located immediately after the accident, before they have time to compare stories with other witnesses, are the most reliable. Get a statement, regardless of how brief, from all witnesses as soon as they can be located. Witnesses can always be visited again at a later time, if additional information or clarification of their statements is needed. However, the human mind has a tendency to fill gaps in recollection with logic and the longer a witness has to reconsider the events, the more he or she will subconsciously tend to do this. (6) Local police and news media personnel can often be helpful in locating witnesses. These people, particularly reporters, are inter­ested in interviewing witnesses, and it is quite possible that they will have found some witnesses having valuable information before the investigator arrives. c. The witness. It is very important that the interviewer(s) estab­lish a good rapport and gain the confidence of witnesses. It is not unusual to have to re–interview key personnel as more information becomes available from other sources or when the board begins analyzing data. Most witnesses can be placed in one of the follow­ing categories: (1) Individual personally involved. Generally, these are the indi­viduals actually involved in the accident (for example, pilot, copilot, driver, paratrooper, diver). However, other individuals having knowledge related to the cause of the accident must also be consid­ered. For example, the spouse of the pilot involved in an accident could be interviewed for information. Note. Interviews conducted to ascertain sensitive information should be con­ducted by the board president. (2) Supervisory and support personnel. This category includes those personnel whose job performance could affect the outcome of the mission or the performance of personnel. It is also important to gain the confidence of these witnesses since questions relating to their performance will be asked. (3) Eyewitnesses. This category includes not only persons who actually saw or heard things associated with the accident but also persons who saw or heard anything relevant to the subject matter of the investigation. The important point here is to try to separate what was actually seen or heard from what the witnesses may think they saw or heard. 6. DA PAM 385-40 • 1 November 1994 DODDOA 022317 d. The interviewer. The number of investigators present during the interview is at the discretion of the board president. However, more than two or three investigators could intimidate some wit­nesses and cause others to become melodramatic. One investigator should conduct the interview and maintain eye contact with the witness. Another investigator can monitor the tape recorder and take notes on areas for further questioning. When tape recordings are to be used, the witness must first consent to the electronic recording of the statement. When the first investigator has completed their ques­tioning, they should then allow the other team member(s) to con­tinue with further questions, if necessary. Once a summarization of the witness's testimony has been prepared, preservation of the actual recording is not necessary, and may be disposed of at the discretion of the investigation board. e. Interviewing techniques. (1) Initial questioning should focus on general areas rather than relying on a prepared list of questions that can be answered by a "yes" or "no." The areas that the interviewer should plan to direct the inquiry toward will be determined by the purpose of the inter­view. Area planning has the following advantages in addition to eliminating the tendency of the person being interviewed to answer "yes" or "no": (a) It allows the witness to do most of the talking. (b) It permits the witness to elaborate on pertinent details that a planned list of questions may fail to elicit. (c) The interview is less formal and rigid. (2) The interviewer should have the person being interviewed do most of the talking. One method for keeping a witness talking without a direct question from the interviewer is the pause. The pause is best employed following an assertion by the witness. (3) The use of a tape recorder is the preferred method of record­ing witness interviews. It allows interviewer and witness to focus on the content of the interview. An alternate method is to take notes during the interview. However, this method should be used only when the witness objects to the use of a tape recorder. Although the first few minutes of a taped interview may make the person being interviewed feel "on the spot" or awkward, this is usually a transient condition and the remainder of the interview will be as candid as if unrecorded. If a tape recorder is used as the sole means of recording a witness statement, the interviewer should take a few simple pre­cautions to guarantee that the interview will be recorded with suffi­cient clarity. (a) Become familiar with, and test, the recording equipment before the interview. If the recording unit must be operated on its internal batteries, replace the batteries with fresh ones before the interview. (b) Environmental noise, such as aircraft operating nearby or windy conditions when a recording is made outdoors, may seriously impair the clarity of what is being said by the interviewer and witness. Therefore, it is preferred that interviews be conducted at locations free of this kind of distraction. (c) When several witness statements are taken via tape recorder, the interviewer will find it useful to begin each recording by taping the information required by the heading blocks of the witness state­ment. This not only allows each witness time to relax in the pres­ence of the recorder, but it will ensure the proper identification of each witness and will complement the transcribing process when it becomes necessary to summarize witness statements in the accident report. (4) If there is no tape recorder available, or if a witness seems hesitant about talking while being recorded, an alternate procedure is to take as few notes as possible during the interview, filling in the planned outline immediately after the interview. (5) Witnesses should be encouraged to speak of matters that they have personal knowledge of; in this instance, what the witness saw or heard, not what he or she may have heard other witnesses say they saw or heard. (6) Witnesses should be encouraged to tell in their own words all they know about the accident. Do not attempt to lead the witness. (7) While talking, witnesses should not be interrupted except to prevent them from going too far into irrelevant matters. (8) After the witness has finished giving a statement, questions should be asked to clarify doubtful points that may arise during the statement. Questions should not be phrased in such a manner as to suggest the answer. Get name, phone number and address for fol­low—up. Ask about eyeglass usage or hearing aid devices. Frequent­ly, if these questions are not asked at this time, they may not get answered. (9) The use of highly technical terms should be avoided when asking questions of a witness who may have no knowledge of the terms. (10) A witness should be treated with utmost courtesy at all times and any semblance of coercion avoided. (11) A witness may be able to express a statement better by sketches than words. Such sketches are acceptable as clarifications of the evidence. A scale model of the type of equipment involved in the accident is also useful as an aid in obtaining more details from a witness. (12) When a witness refers to maps or photographs, these should be identified in the summary of the statement. The points mentioned should also be cross—referenced on the map or photograph. (13) A witness may be able to give a clearer statement if inter­viewed in the same location where he observed the accident. (14) The use of enhanced recall (hypnosis) is a valuable tool, but should be approached only after consulting with proper medical personnel and obtaining consent from the person involved. f Interviewing injured witnesses. The techniques for interviewing witnesses injured and hospitalized because of their involvement in an accident are not unlike those previously discussed for uninjured personnel. There are a few special considerations, however, as follows: (1) The medical facility admitting and treating the injured survi­vors of an accident is responsible for their well—being. Therefore, interviews with injured survivors while they are in an inpatient status will be coordinated with the medical facility and attending physician(s) so as not to conflict with the injured survivor's medical needs. Utilize the board physician as an interface with the hospital/ attending physicians. (2) Timeliness in interviewing hospitalized witnesses, though de­sired, is not an overriding requirement. There are cases, however, that because of the nature and degree of injuries involved, may require subsequent evacuation of an injured key witness to another medical facility far removed from where the board is conducting its investigation. If this happens before the witness is interviewed, it may be necessary to have a board member conduct the interview(s) at the other medical facility later. If this is not feasible, then it may be possible to solicit the services of a physician stationed at or near the other medical facility to act as a proxy interviewer for the board. (3) The physician member of the board is the logical person to represent the board when it is necessary to interview hospitalized personnel because of their involvement in the accident. In this case, it may be better to prepare questions in advance. They should be tailored to obtain responses essential to the investigation. In cases where the person being interviewed is giving testimony while under the influence of medications, it is the physician member's responsi­bility to qualify the credibility of information obtained under these circumstances. Two or three short interviews with certain injured survivors may be more beneficial and have less negative effect on their emotional state than one lengthy session. Each case should be handled on the basis of its own circumstances. In any case, the well—being of the witness is paramount at all times and will govern the board's conduct of this type interview. (4) It is not unusual for an injured survivor of an accident to initially be unable to recall details of the accident that would be useful to the board. The cause of this condition is usually temporary and medically valid, and the inability of the witness to recall details should never be interpreted as a lack of cooperation. Patience and empathy on the part of the interviewer under these circumstances may eventually result in obtaining the desired information, whereas persistence and impatience may not. DA PAM 385-40 • 1 November 1994. 7 DODDOA 022318 g. Evaluating witness evidence. All witness statements should be subjected to evaluation since a witness may be honestly mistaken about actions they took or observations they made. Also, some witnesses may have a personal interest in the matter and may have a motive to intentionally distort their testimony. When the statements are numerous, complex, or contradictory, the board should evaluate each witness statement for credibility. In general, very specific in­formation about speeds or maneuvers provided by an eyewitness should be considered as approximations since even eyewitnesses with experience have difficulty with these estimates. 2-4. Human factors a. Introduction. This section provides procedure and format to perform a systematic and comprehensive investigation of human factors. For discussion purposes, the human factors assessment will be addressed within the context of the following areas: human error, accident survival, emergency egress and rescue/survival, autopsy procedures, personal protective clothing and equipment, and facili­ties/services. The objectives of the human factors investigation is to identify system inadequacy(ies) within the interactions of man, ma­chine, and environment (see fig 2-1). b. Human influence. (1) Recording accident data. Accident data recorded to date indi­cate most accidents can be ultimately traced to human errors (see para 1-3 b). When an accident investigation board lists human error(s) as causal, it does not necessarily mean the soldier/individual did something intentionally to cause the accident (as the use of the term "human error" might imply). For this reason, the human factors investigation must be broad in scope. (2) Identifying human error(s). The first step in identifying hu­man error(s) is to develop a chronology of events before, during, and when appropriate, after the accident. The need for placing events in order is to view human performance in the context that it occurred. The logical sources of information are the individuals involved in the planning, preparation, supervision, and execution of the mission. All of these individuals should be interviewed using the techniques discussed in paragraph 2-3. During these interviews, the operational expert may detect possible errors or at least suspect errors on the part of the individual being interviewed or the individ­ual who is being discussed. Some errors may not become evident until much later in the investigation when the relevant chronology has been developed. For example, investigation into the causes of materiel failures may ultimately be traced to a human error. An error by an individual may be traced to other errors committed by supervisors, instructors, and so forth. Regardless of when or how factor(s) are detected, it is important that the investigator get all the available information about those factor(s). Without this informa­tion, it will be difficult for the board to "define" the factor(s) and identify its causes(s). Recent improvements in training publications have made the process somewhat easier since most operator and mechanic tasks have been defined in technical manuals (TMs) and soldiers' manuals (SMs). These task definitions include require­ments and performance standards that will aid the investigator in identifying how the task was improperly performed. Other individu­al, supervisory, and support personnel tasks are identified in less specific terms in other publications or standard operating procedures (SOPs.) (3) Explaining human error(s). Regardless of the task involved (for example, flight planning, installing a tail rotor, changing brake pads/shoes, and so forth); the explanation of how it was improperly performed should identify the directive, standard; and the perform­ance deviated from or not complied with. The fact that an error occurred in itself has little meaning until its consequence(s) and relevance to the accident are also explained. Therefore, the defining and explanation process for human errors is not complete or mean­ingful until— (a) The duty position of the individual involved is identified. (b) The task the individual performed improperly in the context of the accident sequence is explained. (c) The human error(s) is identified. (d) The proper procedure for performing the task is identified. (e) How the human error(s) caused or contributed to the accident is identified. c. Causes of human errors. (1) Theory. The basic belief behind the investigation of human errors is that there is some reason for all human behavior. Once this reason is identified and sufficiently defined, it can be modified/ improved, thus reducing the probability of similar human errors and their consequences in the future. Therefore, the causes of human errors should be identified in terms of one or more system inadequacies. (2) Identifying system inadequacy(ies) (what allowed the mistake/ error to happen). The best way to identify system inadequacy(ies) is to work backwards from a mistake/error by asking questions aimed at "illuminating" the error. The most direct source of information is the individual who made the error. It is especially important to follow the procedure of paragraph 2-3 and not lead or intimidate this individual. The interviewer will have to use his judgment on how best to phrase the questions. The most practical approach is to establish the circumstances for the witness and allow him to recog­nize the error. If the witness acknowledges the error, the simplest method will probably be to come straight to the point and ask why he erred. Asking "why" can be extremely helpful in identifying the cause(s) of his improper task performance. On the other hand, if the witness does not recognize or acknowledge the error, it may be best for the interviewer to continue with other questions. In doing so, the interviewer lessens the possibility of making the witness defensive or uncooperative. The interviewer can continue by asking questions intended to identify possible system inadequacy(ies) which caused or allowed the error. After this indirect questioning, the interviewer can return to more direct questions about the error. This approach will usually produce the most reliable information. The human fac­tors investigator will also have information from other sources. These include individual records, unit records, and other individuals who may have knowledge about the individual or the accident. A post–accident medical examination may identify physiological fac­tors; for example, acute fatigue, alcohol, carbon monoxide, drugs, impaired vision, and so forth. d. Accident survival investigation. The purpose of the accident survival portion of the investigation is to identify preventable inju­ries and report them in a format that will help in an injury preven­tion program. To accomplish this, the types of injuries must be defined and related to the impact, design, and other conditions to determine underlying causes. This investigation normally will be performed by the medical officer. e. Emergency egress investigation. Egress associated with an ac­cident is usually in response to an emergency situation. The egress may be voluntary or involuntary. Egress is the exiting of the vehi­cle/equipment/structure by individual(s) aboard/in it. Egress is ter­minated when the individual actually exits the equipment. Information to be reported will include— (1) Where the individual was located when the initial attempt to exit the equipment occurred; such as, were there any delays in attempting the egress; for example, turn off fuel or battery. (2) Where the individual exited the equipment. Ascertain any difficulties that were encountered due to obstructions, opening the exit, or in using the exit after it was open. (3) Was assistance required? Assistance that an occupant requires in exiting the equipment could indicate a deficiency in emergency exit design or operation. (4) Human factors contributing to difficulties in the egress. In regard to egress, human factors refer to the difficulties encountered in the interaction between man, machine, and the environment effec­ting egress. (5) Egress materiel failure. Equipment and materiel used during the egress that failed to function or functioned improperly will be investigated and reported. f Survival/rescue investigation. The survival/rescue sequence of an accident includes that period of time from the onset of the accident to the time the individual has been reached by rescue personnel or has reached a facility that can provide medical care. . DA PAM 385-40 • 1 November 1994 DODDOA 022319 Throughout the investigation, it is important to examine factors that may have contributed to or inhibited the success of the survival situation. Consider methods used and time taken for actions. The methods survivors used to help in survival should be evaluated to determine if these methods were adequate or inadequate and why. The methods and equipment rescue parties used in locating, recover­ing, and rescuing survivors should be examined to determine their adequacy. g. Autopsy procedures. (1) Requirement for autopsy. A requirement that an autopsy be performed on the remains of air-crewmembers is contained in AR 40-21 and AR 385-40, paragraph 4-4 a(5). In other cases, to specifically include cases where soldiers on active duty or active duty for training die, the Commander, USASC, in consultation with the commander of the Medical Treatment Facility (MTF) nearest the scene of the accident or where the body is located, may authorize an autopsy on the remains per AR 40-2, paragraph 4-4 c(1). This authority applies to those cases where an autopsy is deemed neces­sary for safety reasons in order to determine the true cause of death. The pathologist must obtain permission to perform an autopsy from the appropriate military/civilian authority having jurisdiction over the body as it is recovered. In the above cases, investigation of a fatal accident is not complete without an autopsy, special body fluid, and tissue studies. Detailed instructions regarding collection and shipping of material for these studies can be found in appendix E. Every effort will be made by the medical investigator to obtain an autopsy report according to Army regulations. (2) The Armed Forces Institute of Pathology (AFIP). The AFIP may provide on-site assistance for fatal accidents. When Army equipment and personnel are involved, requests for such assistance may be made through the USASC. The AFIP will also provide telephonic consultation on any accident. Telephone numbers are— (COM) 202-570-3232, (DSN) 291-3232. The AFIP, Washington, DC 20306-6000, can provide the following types of assistance. (a) Collecting information that may show a correlation between pathological evidence and accident cause factors. (b) Determining causes of unexplained accidents by detailed pathological study. (c) Using pathological correlation to improve personnel and pas­senger restraint systems and equipment crash-worthiness. (d) Accumulating pathological data from a wide variety of cases. (e) Studying psychological and physiological factors that cause stress and may result in pathological changes. (3) The pathologist/physician should examine the results of the autopsy for evidence that may help to explain the cause of the accident. This information is needed to determine the exact trau­matic changes that occur, specify the causes of each, and differenti­ate whether they occurred before or after death. These determinations should not be used solely to determine the cause of death. They should also be used to establish time and cause relation­ship between preexisting disease and the accident, correlate injuries with various factors in equipment design, and determine all patho­logical evidence that might lead to an accurate analysis of the chronology of events surrounding an accident. (4) Conduct of gross autopsy. Procedures for conducting gross autopsies are contained in appendix E. h. Life support equipment and protective clothing and equipment. (1) It is the responsibility of the investigator to analyze how well LSE, or other PCE, did the job for which it was intended. If the investigator determines the equipment did not operate as designed, the investigator must further determine if the item of equipment contributed to, or caused injury. (2) All LSE and/or PCE that is in any way implicated in the cause or prevention of injury will be recorded in the accident report. Items that caused injury, failed to function as designed, or were significant in preventing injury should be shipped to the United States Army Aeromedical Research Laboratory (USAARL) for fur­ther analysis. This equipment includes, but is not limited to; hel­mets, survival vests and components, body armor, crashworthy seat system, restraint harnesses, inertial reels, seat belts, and air bags. (3) Contact USAARL concerning which items of LSE/PCE that should be shipped and the supporting documentation required (DSN 558-6893/6943/6892 (COM (205) 255-6893/6943/6892). (4) Before completion of the field investigation, the president of the investigation board will arrange for shipment of the equipment for laboratory analysis to: Commander, USAARL ATTN: Crew Injury/Life Support Equipment Branch Building 6901, P.O. Box 620577 Fort Rucker, Alabama 36362-0577 (5) Equipment items sent to USAARL for laboratory analysis will be noted in the technical report of accident investigation. For personal LSE/PCE sent, identify the wearer/user of each item. For items sent such as a survival vest, count vest and components as one item, unless a component is torn free or separated during the acci­dent sequence. Upon completion of the laboratory analysis, USAARL will dispose of unserviceable items and return serviceable items to the unit of origin or the supply system. (6) Upon request by the USASC, a copy of the completed labora­tory analysis performed under the provisions of this paragraph will be furnished for inclusion in the final report of the accident. i. Narrative reporting. Paragraphs 3-6 and 4-4 provides instruc­tions for narratively reporting the human factors investigation. 2-5. Materiel factors Note. (In this paragraph, the term "equipment" is utilized to indicate the piece of equipment involved in an accident investigation (end-item); such as, aircraft, vehicle, structure, weapon system, component, part, and so forth) a. Introduction. (1) This paragraph provides procedures for performing a system­atic and comprehensive investigation of materiel factors associated with an accident. The objectives of the materiel factors investigation are as follows: (a) To establish the equipment's condition at the time of the accident. (b) To describe the damage that occurred during the accident sequence. (c) To identify materiel failures/malfunctions that resulted in an accident (what happened). (d) To identify the system inadequacies for the materiel failures/ malfunctions (what caused it). (2) The investigation of materiel factors requires, as a minimum, the assistance of a maintenance or technically qualified individual. b. Materiel failure/malfunction. (1) Equipment, or a part thereof, is considered to have failed or malfunctioned when one of the following occurs: (a) Becomes completely inoperable. (b) Is still operable but no longer able to perform its intended function satisfactorily. (c) Has deteriorated to the point where it is unreliable or unsafe for continued use. Note. (This explanation does not apply if the equipment achieves any of these three states because the required operational situation/condition that it was employed in exceeded its design capability or operating limits.) (2) The success of the materiel factors investigation is dependent upon determining the difference between failures/malfunctions that may have caused the accident and damage caused by the accident. The procedures to be followed are generally the same for all acci­dents, regardless of damage. (3) The first step in identifying materiel failure/malfunction is to document the most obvious evidence available at the accident site by taking notes, photographs, and drawing diagrams. By the time these tasks have been completed, the human factors investigation will usually have some preliminary information from witnesses that may further indicate the most probable failures/malfunctions. These possibilities should be carefully examined. Even though the investi­gation begins by examining components that most probably failed, this examination is not complete until all major components and systems have been examined for evidence of failure/malfunction. In . 9 DA PAM 385-40 • 1 November 1994 DODDOA 022320 cases where preliminary evidence, for example, witness statements, indicates no failures/malfunctions occurred, the examination is still required. The purpose of the examination in this case would be to describe damage along with substantiating the lack of evidence supporting a failure/malfunction. The next step is the shipment to a teardown analysis facility of those components that the board identi­fied or suspected of having failed/malfunctioned. The teardown analysis is important since the board may not have the capability to determine how and why a component failed. The last step for the materiel factors investigation is to determine the cause of the failure/ malfunction. Assistance can be obtained from the following facilities: (a) Aircraft—Corpus Christi Army Depot (CCAD), Corpus Christi, TX 78419-6020, telephone (COM) 512-939-2326/2327, (DSN) 861-2326/2327. (b) Ground vehicles—Tank–Automotive Command (TACOM) Warren, MI 48397-5000, telephone (COM) 313-574-6194/6121, (DSN) 786-6194/6121. (c) Parachutes—Natick Labs, Natick, MA (COM) 617-651-5208, DSN 256-5208) (d) LSE/PCE—USAARL, Ft Rucker, AL 36362 (COM) 205-255-6892, (DSN) 558-6892. (e) Ammunition/Explosives—U.S. Army Technical Center for Explosives Safety (USATCES), Savana Army Depot, IL 61074, (COM) 815-273-8801, DSN 585-8801. c. Causes of materiel failure/malfunction. (1) Overview. As in the case of human error, the causes of mate­riel failure/malfunction can usually be traced to an inadequate sys­tems element. (See app D for examples of metal fatigue and load stress failures.) Once identified, corrective action can be taken to prevent the probability of similar materiel failure accidents in the future. Thus, the causes of materiel failure/malfunction will be iden­tified in terms of one or more system inadequacy(ies). A materiel system inadequacy is defined as a tangible or intangible element that did not operate as intended or designed and caused, allowed, or contributed to a materiel failure or malfunction. (2) Identifying system inadequacy(ies) (what caused it). Once the materiel factors investigation has identified or at least suspects a failure/malfunction, it must continue the search for evidence to sub­stantiate the cause of the failure. For example, could unit mainte­nance have caused a failure of this part, component, or system? To answer questions like this, the investigator must examine records and unit operating procedures. The materiel factors investigation must interface with the human factors investigation to search for errors/mistakes that may have resulted in the materiel failure. The investigator should try to gather evidence that will substantiate or eliminate each of the system elements that is within his capability to investigate. Thus, the procedure can be described as a process of elimination. If the investigation is unable to uncover evidence of a system inadequacy locally, the determination of the cause should be delayed until a thorough teardown and analysis can be completed. d. Accident scene. The investigation of the equipment and the components must begin at the scene of the accident. It is here investigators get an overview of the accident pattern, degree of damage, direction traveled, and velocity when the accident occurred. This overview will play an important part in reaching decisions concerning all aspects of the investigation. Therefore, it is necessary to carefully document the scene of the accident as outlined in the following paragraphs. (1) Reconstruction of the accident sequence. The goals of the investigator(s) include determining how and why damage, separa­tions, and injuries occurred. The best way to initiate this effort is to begin at the point of first contact with objects in the path or with the ground and follow the path to its final resting place. During this survey, the investigator(s) will observe the condition and location of the various parts of the equipment and mentally begin the process of reconstructing the sequence of events that occurred during the acci­dent. If relevant, the location of human bodies and their disem­bodied parts should also be located on the diagram. This process will not be completed until near the end of the investigation when sufficient information has been assembled to answer the questions of how and why damages and injuries occurred the way they did. Once the sequence of events has been established, the investigator(s) should then reconstruct the maneuvers or actions of the individuals or equipment, etc., just before the accident. If the accident sequence can be established back to the point where the difficulty began, the causes of the accident will be more clearly defined. The application of knowledge of the performance of the individual, or equipment, and so forth, under various sets of conditions, plus the use of basic controllability, will greatly help in making these determinations. (2) Accident site/wreckage distribution diagram. An accurate, de­tailed diagram of the accident site will help the investigator(s) develop the actual sequence of events. This work may be done by the post engineer. However, in the absence of this expertise, the materiel factors investigator should accomplish this task. A field compass, measuring tape, protractor, rule, inclinometer, and writing materials are necessary to do the job. (a) A polar diagram is a simple and effective method of diagram­ming the accident site. The top of the diagram will represent north. The main body of the wreckage (center of mass) can serve as the beginning or pole of the diagram. Choose a scale that will allow plotting of the total scene on the chart. Determine the compass heading of the equipment at its final resting place and place a semblance of the equipment on the diagram in such a position as to be able to plot the other debris from that point. Determine the direction from the equipment to the outlying items and scar marks. Measure the distance from one central point of the wreckage to these items/marks. Plot them on the diagram as to their positions relative to the main wreckage. Letters or numbers may be used on the plot so that a legend can be created to give the identification and the locations of the items in reference to the main wreckage. (b) Grid method is another technique for detailing an accident site. e. Techniques of obtaining photographs. Photographs are the best means of preserving physical evidence for study and evaluation. The local safety representative should obtain a photographer from nearest post/installation assets. It is important that photographs be of good quality and composition. Self–developing photos will provide instant results in the event other films fail to develop properly or are lost. Color prints are preferable, if available, but not mandatory. A good technique is to request proof sheets from the photo lab. This service can usually be provided in one day and will help in deter­mining if additional photos are necessary. The proof sheets can also be used to select the most representative prints to be included in the accident report. All photographs used in the report must be num­bered and captioned. Captions should explain in detail what the picture is supposed to show. Captions will include type equipment, date of the accident, and location of the accident. The direction toward which the photograph was taken may be included; for exam­ple, NE and SW. A photograph without a proper caption is confus­ing and of little value. Photographs taken at the accident scene should include the following: (1) An overall view of the accident site (wreckage) taken from a minimum of four directions. Recommend eight photographs taken at 45–degree angles. (2) A view of the ground path of the equipment from point of initial and major impact to the place where it came to rest. Impact marks are vulnerable to rain and traffic; therefore, a photographic record of this type of evidence should be accomplished promptly. (3) Aerial views of the accident scene (equipment and weather permitting). (4) Photos of objects struck by the equipment. (5) Larger portions of the equipment wreckage. (6) Detailed photographs of suspected failed parts that contrib­uted to the accident. (7) Photos of failed personal protective clothing and equipment and the agents causing the failure or injuries. (8) Photograph and measure skid marks, ground scars, and so forth. Note. (Put an object of known size along side an object whose size may be 10. DA PAM 385-40 • 1 November 1994 DODDOA 022321 distorted by the photograph; i.e. a pen or ruler next to a small piece of equipment or scar.) (9) Any other photographs deemed of interest to the investigation board. f Marking and preserving evidence. (1) Protection and identification. Parts or subassemblies sus­pected of failure/malfunction must be wrapped or boxed to prevent loss or further damage. Suspected metal failure surfaces should be coated with uncontaminated grease to prevent corrosion. Carefully tag and mark all parts so that they can be readily identified with the accident (place, date, and serial number of equipment) and their location at the accident scene. The tag should contain a brief state­ment regarding the suspected relationship of the parts to the causes of the accident. Examples of parts that may be preserved for more detailed examination are— (a) Parts suspected of failure. (b) Parts that appear to be improperly designed or contain faulty workmanship. (c) Lines, fittings, wiring, or controls not properly supported and subjected to excessive strain or vibration. (d) Ruptured plumbing or fittings. (e) Faulty wiring, electrical or radio equipment. (/) Defective engines, drive shafts, transmission, and accessories, such as carburetors, fuel controls, governors, and generators. (g) Defective hydraulic system components. Note. (Do not attempt to mate separated items together. This will destroy evidence.) (2) Disassembly. Extreme discretion must be used in disassem­bling parts or components in the field. If it is known that parts and components will be submitted for teardown and analysis, disas­sembly should be avoided as it tends to compromise the analysis by destroying or obliterating bits and shreds of evidence the value of which may be known only to the analyst. However, when detailed disassembles are made, all parts must be tagged with complete .information to include nomenclature, part number, locations, and any other significant information. Document all disassembly with photographs. Assistance in disassembly and inspection of compo­nents, parts, fuel, and oil may be obtained from the next higher echelon of maintenance or U.S. Army depots or other experts identi­fied by the USASC. g. Equipment records. (1) As a minimum, the previous 6—month historical records; such as, DA Form 2408 series, the periodic inspection records, and the other relevant records should be reviewed. Check component times and replacement schedule. Review for compliance or noncompliance with modification work order(s) (MWO). Check for compliance with safety—of—use messages, safety advisory messages, safety—of—flight messages, and technical bulletins. Review current and delayed discrepancies records. Document all deficiencies and discrepancies noted for correlation against other materiel/mainte­nance factors uncovered during the investigation. (2) Any modification or alteration of the equipment should be checked against applicable technical publications to ensure proper authorization. When alteration or modification of the equipment is suspected, a thorough investigation must be made to determine how these alterations or changes may have contributed to the accident (document with photos). Inspection should be made of structural repairs for quality of workmanship in fittings, welds, stitching, ca­bles, and so forth. This inspection will disclose whether improper materials and workmanship contributed to the accident. (3) It may be necessary to investigate possible cause factors that were not originally considered. Parts must be carefully preserved and protected. h. Reassembly of wreckage. It may be necessary to reassemble wreckage to determine accident causes or to support a theory in an accident that is difficult to evaluate. When the entire system has been reconstructed, it may afford positive proof of the accident causes. Wreckage layout should resemble the original equipment as closely as possible. This gives the investigator a better overview of separations, fire damage, and control systems. A detailed and docu­mented inspection of the wreckage layout will often lead the investi­gator to the areas or systems that played a role in the accident. The layout also helps the investigator in developing the sequence of events that occurred in the accident. i. Failed parts. Unless there is conclusive evidence that a failure occurred during the operation, it is necessary to make a detailed inspection of each suspected failed part. In many cases, failure of the primary structure was caused by faulty design (improper materi­al, incorrect assembly, previously weakened parts, and so forth). The maintenance records and operating history of the equipment must be reviewed for conditions that may have initiated or contrib­uted to the failure. Suspect failed parts that may have contributed to the accident should be selected for laboratory analysis to determine the type and mode of failure. The investigation board must then fit that evidence into the total evidence to determine whether the failure contributed to the accident. j. Special investigations. (1) Investigation involving highly technical phases of the acci­dent, as described herein, will require further study and special investigations. In many cases, this cannot be accomplished in the field, and the work must be continued by technically qualified per­sonnel at a laboratory, depot, or factory. If mechanical failure oc­curred or is suspected, adequate photographic coverage must be provided and the suspect failed parts retained for further evaluation. Sketches, history, and explanatory material must accompany the parts and should contain enough information to give a clear picture of what happened. If a control switch, handle, or knob, were used improperly because of its design, or if one control was mistakenly operated when the operator intended to use another, the location, size, shape, method, or operation of the control may prove to be an underlying cause and must be examined. Statements of operator's deficiency should include his proficiency in the equipment involved in the accident as well as others. Different equipment may have controls or instruments in reversed positions from others operated by the operator and this could contribute to the accident. Accidents that are particularly difficult may require investigative techniques beyond the examination of physical evidence. The only limit to a good investigation is the imagination of the investigator. (2) Another example is the special investigation required for Night Vision Devices (NVD). k Power plants. When power plant failure is the known or sus­pected accident cause, the investigator(s) should make every effort to obtain samples from the lubricating and fuel systems. These samples should be taken from several sources to ensure capture of any foreign substance that may be in the system. Inspect the power plant to determine if all debris caused by the failure was contained within the engine case. If not contained, every effort should be made to recover the missing pieces. All locations and impact marks should be marked and photographed. This information is needed to determine at what point in the accident sequence the power plant failed. (1) Field examination. When the power plant is examined in the field, obtain the serial number of the engine, manufacturer, type, model, and all pertinent information from maintenance and inspec­tion records. In addition— (a) Locate all engine accessories and components. (b) Check the position of primary and secondary controls to de­termine the position of the various valves controlling the flow of fuel to the engine. (c) Obtain pertinent engine operation data prior to the accident. (d) Obtain information from witnesses about engine operation such as smoke, fire, explosion, and unusual noises. (e) If fire was a factor, determine the origin/location (para 2-5 m discusses fire in detail). (f) Check the fuel system for leaks or obstructions from fuel tanks to combustion chamber. (g) Check fluid carrying lines for improper installation or signs of malfunction. (h) Check for water, corrosion, or sediment in the fuel and oil systems. 11 DA PAM 385-40 • 1 November 1994. DODDOA 022322 (i) Obtain samples of fuel, oil, and hydraulic fluid for laboratory analysis. (j) Check oil filters and pumps for foreign particles. (k) Check sources of fuel (including storage tanks, pumps, and fuel service trucks) for contamination, if necessary. (1) Check the ignition system to include switches, spark plugs/ igniters, and leads. (2) Analyze failures. A review of the maintenance and inspection forms for operating time, malfunction, and technical manual compli­ance will often provide a lead to possible engine failures. The position of engine controls and readings on engine instruments should be carefully recorded. However, these readings may be af­fected by the accident forces and are not conclusive indications of the position prior to impact. If structural parts of the engine failed, these parts must be identified with a description of the failure. Sketches and/or photographs showing the failure are important in evaluating the cause. All accessories should be inspected and bench checked if malfunction is suspected. I. Transmissions. The same investigation and analysis procedures identified in paragraph 2-5k apply. In addition, check transmission case for cracks, distortion and corrosion. If severity of impact broke the case open, check condition of gears and bearings for abnormal patterns or discontinuity; such as, gears out of mesh. m. Fires. (1) Symptoms. Fire frequently destroys or consumes clues that could readily disclose the accident cause; for example, ruptured or chafed-through fuel lines may be the origin of the fire and the cause of the accident and then subsequently be consumed by fire. Fire that is a result, rather than a cause, of an accident also hampers the investigator by the destruction or damage of evidence. If a fire occurred, determine when, where, and how the fire originated. A fire originating during movement will generally leave obvious traces, such as molten metal flow marks that will conform to the airflow pattern of the component concerned. A fire resulting from impact with the ground will often leave imprints of twigs, grass, or leaves in the soot pattern on the burned parts of the wreckage. Any folded, smoked, or blackened pieces of wreckage that when unfol­ded, show shiny metal would indicate that the burning had followed the accident. Locate parts that separated from the equipment after the accident. If these parts also show signs of burning, then the fire existed before the accident. A minor fire will frequently burn un­detected until a larger source of fuel is supplied. A large fuel-fed fire may result from a smaller fire that was started by hydraulic oil, engine oil, or other flammable material. Remember that fluid vapors can travel long distances before reaching a point of ignition. (2) Flammable fluids. All flammable fluid-carrying lines should be traced and inspected for breaks, cracks, chafing, and loose fit­tings. Identify the tubing by reference to the color code or the schematic drawings in the applicable technical manual. (3) Witness information. Witnesses are especially important in establishing certain facts about the fire. A burning piece of equip­ment immediately attracts attention and can be seen from many miles away. Normally, smoke from burning oil is blue-white in color; smoke from hydraulic fluid is white; and fuel (gasoline, jet fuel) smoke is black. However, the color and density will vary with changes of intensity of the fire. (4) Warning systems. Determine how personnel were warned that a fire was in progress and how effective extinguishing attempts were. Record a complete step-by-step description of the procedure used for extinguishing the fire and compare it with the technical manual. n. Communications/Navigation equipment. The requirement to determine the functioning capability and selected frequency of the communication/navigation equipment may vary depending upon the circumstances surrounding the accident. Normally, it is possible to determine the selected frequency/station regardless of the extent of component damage. The control/dash panel normally contains vari­ous functional select switches, volume control, digital readout chan­nels or frequency. Determine if equipment or vehicle operators, crewmembers, crash rescue personnel, or early arrivals the scene moved any of the controls or switches. Index all movable switches and volume control before any changes are made from the position found. Analyze all toggle and rotary switches to determine if they show evidence of having changed positions as the result of impact/ crash. If the indicators are missing, examine the rotary switch, determine which frequency is selected, and compare the position with a like serviceable unit. Obtain the assistance of communica­tions, avionics or electronics experts for additional assistance if necessary. o. Teardown analysis request, processing, shipment, and disposi­tion (aviation only). (1) Request—aviation. The Commander, CCAD, is the prime re­cipient and evaluator of all Army aircraft components/parts selected for teardown analysis (TDA). Commander, USASC; Commander, ATCOM; Commanders of field organizations/units; aviation safety officers; maintenance officers; and presidents of aircraft accident investigation boards are authorized to select components/parts for TDA. Requests for teardown analysis will be made in the interest of establishing aircraft or materiel deficiencies, regardless of accident/ incident classification, for use in accident prevention or to establish causes of aircraft accidents. (a) Control numbers. Before shipping any components/parts to CCAD, a QDR/EIR will be submitted on the components/parts ac­cording to the instructions in DA PAM 738-751. Authorized per­sonnel will coordinate their requests for TDA with USASC. Approved requests will receive a USASC control number which will be placed on the DA Form 2407 (Maintenance Request) and be included in the address to CCAD. (b) Data requirement. To obtain USASC control numbers, the following information will be submitted to USASC- 1. Point of contact (POC) who is knowledgeable of why the request for TDA is being made. Identify the unit the aircraft is assigned and unit address. 2. Telephone number(s), military/commercial, of the POC(s). 3. Materiel identification data for each item, to include: noun nomenclature of the component(s)/part(s), serial number(s), part number(s), national stock number(s); and when applicable the time since new (TSN), time since overhaul (TSO), number of prior over­hauls, overhaul activity and date of last overhaul. 4. ATCOM QDR/EIR control number for component(s)/part(s). 5. Accident/Incident data to include: complete aircraft serial number from which component(s)/part(s) are removed, Army mis­hap classification, mishap date, state how the defect was found, description of the required analysis, and whether or not a DA Form 2397-AB-R (Abbreviated Aviation Accident Report)/Telephonic report has been provided to USASC, or any other technical data that may be of assistance to the materiel analysis personnel. (2) Processing. The processing of the item(s) to be shipped for TDA will be accomplished by the nearest activity having a packing, crating, shipping capability. The item(s) to be shipped will be cleaned and decontaminated to the degree necessary to preclude the possibility of generating a health hazard or crop infestation. Howev­er, the cleaning process will not distort or remove evidence such as heat discoloration, abrasion, stress and torsion splinters, and corro­sion. All possible traces of foreign matter such as vegetation, hu­man/animal tissue, insects, dirt/soil, or contaminated water will be removed. This is especially required when items are shipped from outside CONUS. When contamination, loose ordnance, tools, or other foreign materiel are suspected as the cause of an accident or malfunction, photographs will be taken before cleaning and for­warded with the item(s) as evidence for study by the analyst. (3) Shipment. DA Form 2407 will accompany each component/ part. Insert the USASC control number in the first line of block 16. The description of the analysis desired will follow the USASC control number. DA Form 2410 (Component Removal and Repair Overhaul Record), when required and DA Form 2408-16 (Aircraft Component Historical Record), will accompany the item(s). Also, arrange for the most expeditious delivery/shipment of item(s) for TDA to Commander, Corpus Christi Army Depot (CCAD), ATTN: SCSCC-QLA, Corpus Christi, Texas 78419. Container(s) will be clearly, permanently, and conspicuously marked in red on a white . DA PAM 385-40 • 1 November 1994 DODDOA 022323 background and in sufficient size to allow for ease of visual identifi­cation. If container is too small, follow the QDR/EIR procedures contained in DA Pam 738-751. The marking will be as indicated below: CDR, CORPUS CHRISTI ARMY DEPOT ATTN: SCSCC—QLA ATCOM SRA 5-3723 PURPOSE CODE A CCF ACFT CRASH DAMAGED PARTS FOR TEARDOWN AND ANALYSIS SPECIAL HANDLING REQUIRED EXPEDITE DA PAM 385-40. USASC CONTROL NO. (XXXXX) (4) Disposition of TDA report. (a) CCAD/contractor/MFG will provide four copies of the final report to Cdr, ATCOM; Cdr, USASC, ATTN: CSSC—PMA (six copies if USASC conducts the accident investigation), one copy each to the applicable theater/command aviation safety officer, and four copies to the commander of the unit/activity that requested the analysis. (b) Component(s) or part(s) submitted for TDA on USASC con­trol numbers will be held until disposition instructions are issued by Cdr, USASC. p. Paragraphs 3-6 and 4-4 provides instructions for narratively reporting the materiel factors investigation. 2-6. Environmental factors a. Environmental factors are those environmental elements or conditions such as noise, illumination, space and weather conditions (for example, precipitation, temperature, humidity, pressure, wind, and lightning, and so forth) having an adverse affect on the perform­ance of the individual or equipment so that an accident results or could result. b. Assessment of environmental elements (for example, contami­nants, noise, vibration, artificial illumination, acceleration, decelera­tion, radiation, adequacy of work surface/space, and weather conditions) should be accomplished to determine their influence on human and/or materiel performance. Contaminants (fumes, chemi­cals, and so forth) can lead to respiratory problems; noise (radio static, engine, and transmission noise) can distract attention, inter­fere with effective communications and lead to fatigue; inadequate illumination can cause reduced visibility; inadequate work space (cluttered, poorly designed drivers compartment) can contribute to procedural errors or limit outside visibility. Knowledge of environ­mental elements does not eliminate them as factors influencing errors, injuries or failures. To determine if an environmental factor should be assessed as a causal factor, the central question to ask is: Did this factor adversely influence human and/or equipment per­formance; was the environmental element unknown or unavoidable at the time of the accident/injury/occupational illness? c. Environmental factors can be divided into those which could not have been avoided and those for which precautions could have been implemented to reduce or eliminate its adverse effects on personnel and/or equipment. An environmental deficiency should not be assessed as a causal factor if it was known and could have been avoided before the accident 2-7. Accident investigation techniques for Electromagnetic Environmental Effects (E3) a. Electromagnetic Environmental Effects (E3), formerly known as electromagnetic interference (EMI), is a recognized potential ac­cident cause factor and should be thoroughly evaluated during all accident investigations to determine if it could or could not have influenced the operation of the equipment involved. b. The following E3 list is recommended for use: (1) During the initial phase of the investigation, try to determine if there is any evidence of an external energy influence on the equipment or its subsystems. Consider cockpit/instrument indica­tions reported by surviving crewmembers, eyewitness reports, and other physical evidence. This is especially important where the physical evidence indicates that the equipment was out of control or malfunctioning prior to the accident. For aviation accidents, apply the current U.S. Army Aviation and Troop Command (ATCOM) criteria concerning the reporting of suspected electromagnetic inter­ference encounters. (2) If E3 can be ruled out as a causal factor during this stage, then note the actions taken to eliminate E3 as a causal factor. For class A or B aviation accidents, document this in the special investi­gation portion of the DA Form 2397-3—R (Technical Report of U.S. Army Aircraft Accident) narrative and the narrative portion of the DA Form 2397—AB—R (in this instance, E3 was considered but ruled out for the following reasons:). For ground accidents, docu­ment this in the narrative of DA Form 285/DA Form 285—AB—R (U.S. Army Abbreviated Ground Accident Report) or on a separate piece of paper. (3) If E3 cannot be eliminated early on, or there are positive indications of an external energy influence, advise the USASC im­mediately, DSN 558-3943, and request technical assistance. In addi­tion, perform the following: (a) Check for high intensity radio transmission areas (HIRTAs) in the area of the accident. Note visual flight rule (VFR) sectional or tactical maps for large towers (transmitters) in proximity to the accident site. Identify mobile transmitters operating within the area at the time of the incident. For aviation accidents, apply HIRTA standoff criteria contained in current ATCOM messages (HIRTA guidance). (b) While taking aerial photographs of the accident site, review the area surrounding the accident for large towers (transmitters) such as radio/television, telephone microwave, radar, etc. 1. All towers (transmitters) are considered a potential source and should be plotted on a diagram in relation to the accident site. 2. Contact owners of the towers (transmitters) to determine the hours of operation, nature of transmission(s) (signal power level, antenna gain, and frequency), signal beam width, and azimuth(s) of transmitter signal(s). c. For aviation accidents, gather any and all available ATC tapes, to include radar and voice, for later review. (1) If there are surviving crewmembeis, record all cockpit/instru­ment indications experienced during the accident (such as, caution/ waming/advisory light illumination, audio warning tones, degrada­tion/loss of flight controls, stiffness of pedals, and so forth). To compare cockpit/instrument indications with the data base of known type aircraft responses to E3, call ATCOM Engineering, DSN 693-1634 or COM (314) 263-1634. (2) If there are no surviving crewmembers, analysis of the above data plus any additional information gained from flight data record­ers (if so equipped) will indicate possible contribution of E3. (3) If E3 is considered a potential causal factor due to accident circumstances, teardown analysis and review of acceptance test pro­cedures for affected systems/components may be required. d. Close coordination with the USASC will be maintained throughout the E3 investigation. E3 can be eliminated as a causal factor only if accident circumstances (physical evidence, equipment maintenance history, witness statements, and so forth) indicate a suspected materiel failure or human error was the primary cause or if subsequent investigative actions described above have been completed. e. The USASC office for additional technical aspects concerning this information is Engineering Programs Section, DSN 558-3943/ 6219; the USASC office for policy aspects of this information is the Programs Division, DSN 558-2947/3367. 2-8. Analysis a. Documentation. A systematic analysis of the data collected during an accident investigation is required. The accident causes identified in the analysis will become the basis for developing find­ings and recommendations contained in the technical report of the 13 DA PAM 385-40 • 1 November 1994. DODDOA 022324 accident. Findings and recommendations cited in the technical report will have an impact on remedying system inadequacy(ies). The written analysis must fully support each finding. Therefore, the analysis shall be thorough, logical, and conclusive. b. Concept. The reasons people make errors, materiel fails, envi­ronmental conditions contribute, or injuries occur in an accident are the keys to accident prevention. The rationale behind this premise is that if the reasons (system inadequacy(ies)) can be dealt with effec­tively, then the probability of similar deficiencies causing future accidents or injuries can be reduced. c. Scope. The accident analysis function inherently requires that the accident data be examined in detail to determine how man, machine, and environment interacted. The scope of the analysis will not necessarily be limited to the field investigation of the accident and may extend beyond the tenure of the investigator/board. The contents of the report will subsequently be reviewed and analyzed by the USASC and other agencies responsible for the management of resources. d. Objectives. (1) Analysis of the data collected during the investigation permits the board to reach a consensus. The objectives are as follows: (a) Establish a chronology of events as they relate to the accident. (b) Identify human errors, materiel failures, and/or environmental conditions that caused or contributed to the accident (what happened). (c) Identify system inadequacy(ies) that caused or permitted er­rors/failures/injuries to occur or environmental factors to contribute (what caused it). (d) Determine adequacy of LSE/PCE equipment in terms of min­imizing/preventing injuries (how injuries occurred). (e) Provide corrective actions having the best potential for reme­dying the system inadequacy(ies) (what to do about it). (2) Each objective has related tasks as follows: (a) The scope of the chronology may include events that oc­curred before, during, or after the mission. The need for placing events in a chronological order is to view human error, materiel failure, environmental conditions, and injuries in the context that they occurred. (b) To identify errors/failures/environmental factors that caused or contributed to the accident, it will be necessary for the board to evaluate each event in terms of its accident cause relationship. When it is determined that an event involves an error/materiel fail­ure/environmental factor that contributed to the accident, it should be defined as follows: 1. When the error/failure/environmental condition occurred in the context of the accident sequence of events. 2. Who (duty position) erred, what (part component, system) failed, or what environmental factor contributed. 3. The task or function required of the person, part, component, or system when the accident occurred. 4. How performance of the task/function deviated from published orders, SOPs, directives, standards, or common practice, or how the materiel failure deviated from design limits, specifications, and/or performance standards. 5. The effect/results(s) of the error/failure/ environmental condition. (c) To determine adequacy of LSE/PCE equipment, the board must evaluate injuries in terms of whether they could or should have been prevented. (d) To identify system inadequacy(ies) that caused or permitted an error/failure/injury to occur. (e) To provide corrective actions having the best potential for remedying the system inadequacy(ies), the board must- 1. Specifically tailor the corrective actions to the system inadequacy(ies). 2. Identify the activities having proponency for the correction of the system inadequacy(ies). 3. Recommend remedial measures to the activities and/or levels of command most capable of correcting the system inadequacy(ies). e. Credibility. The credibility of the findings and recommenda­tions presented in the technical report will depend largely on how completely the board analyzes the accident data. The conclusions resulting from the analysis should be fully supported by evidence whether it be direct, circumstantial, or a combination of both. A lack of evidence will make the analytical task more difficult. In this case, it may become necessary for the board to develop hypothetical explanations of what may have caused the accident. When the hypo­thetical approach is used, the hypotheses should be developed and discussed in terms of why certain explanations are or are not sup­ported by the evidence. Through deductive reasoning and a process of elimination, the most probable cause(s) can be established. f Coordination. (1) All board members will frequently meet as a group to discuss mutual progress, trade information, reduce redundancy, resolve con­flicting information, and redirect investigative efforts as appropriate. As these meetings grow in number, it will not be unusual to dis­cover that data initially considered insignificant may prove to be important and vice versa. Also, preliminary data that may appear to be a cause of the accident may prove to be an effect or result, and so forth. Therefore, board members should keep an open mind and stay flexible, receptive, and discerning throughout the investigation. Board members should not entertain preconceived ideas as to the cause of an accident. (2) A point will eventually be reached where the data collection phase is completed and there are no remaining sources of informa­tion or expected inputs. What remains are the tasks of finalizing the analysis effort and structuring the results in a format that clearly shows the interrelationships between cause related factors and the system inadequacy(ies) that caused or permitted them to occur. When these tasks are properly accomplished, the final task of developing/writing findings and recommendations is greatly simplified. g. Deliberations/analysis sessions. (1) When the investigators responsible for collecting and analyz­ing accident data have completed their tasks, the entire board should meet at a central location to collectively review the data and finalize the analysis. The facility used for the meetings should be secure and free from distractions and allow for privacy. The board president will chair the meetings and guide the proceedings. The investigator responsible for conducting the human and materiel portions of the investigation should present the factors he believes caused the acci­dent, contributed to injuries, or had other significance. In presenting this information, the events directly involving each factor should be identified. This will help to place each factor in its proper perspec­tive and relation to the other events, Factors associated with an event will usually fall into one of five categories. (a) Factor(s) that definitely contributed to the accident (present and contributing). (b) Factor(s) suspected to have contributed to the accident (sus­pected present and contributing). (c) Factor(s) that did not contribute to the accident but contrib­uted to the severity of the injuries (present and contributing to the severity of the injury or extent of property damage). (d) Factor(s) that did not contribute to the accident but caused injuries or could adversely affect the safety of continued operations if left uncorrected (present but not contributing). (e) Factor(s) that in no way contributed to the accident but iden­tify local conditions or practices that should be corrected. Although these factors do not have to be addressed in the analysis or listed in the findings and recommendations part of the technical report of the accident, they should be subsequently briefed to the lowest level commander capable of taking corrective action; for example, minor administrative errors in records keeping, inadequate procedures, and/ or lack of required SOPs, directives, and so forth. (2) The investigator should next identify each system inadequ­acy(ies) that caused or permitted the factor to become causal. Tangi­ble system inadequacy(ies) offer a better potential for corrective action than intangible. Therefore, the tangible system inadequ­acy(ies) causing or permitting causal factors should be identified if possible. If a consensus of the board members agrees with the . DA PAM 385-40 • 1 November 1994 DODDOA 022325 factors presented and their associated system inadequacy(ies), the process continues until the investigators have completed their pre­sentations. The board president should not allow unresolved issues to be debated indefinitely during deliberations. If a board consensus on an issue cannot be reached within a reasonable amount of time, the board president will decide the issue and continue with the proceedings. There are provisions for submitting a minority report as explained in paragraph 2-1. (3) It may become apparent during the deliberations that evi­dence is conflicting. In such cases, the board usually has two choices: (a) It may further question personnel involved or other witnesses. If this approach is used, it is probably best to come directly to the point; such as, inform the personnel being questioned of the conflict and ask for an explanation. (b) If the first approach does not resolve the conflict, it may be possible to rationalize why the conflict exists and then develop a hypothetical explanation. In any case, the board is responsible for resolving conflicts and must carefully weigh the evidence and de­cide what is most credible. (4) When the board has reached a consensus on each significant factor involved in the accident, a concerted effort is necessary to develop corrective actions having the best potential for remedying each system inadequacy. When a board consensus concerning reme­dies is achieved, the commands or activities having proponency for correcting the system inadequacy(ies) should be identified. When this is accomplished, the remedial measures proposed in the techni­cal report can then be directed to the activities and levels of com­mand best capable of accomplishing them. To achieve the goal of accident prevention, recommendations should not focus on specific punitive or administrative actions that might deal with the shortcom­ings of a particular individual in a specific case. Rather, the recom­mendations should address the issue on a broader level. Each recommendation will identify the actions to be taken at the appropri­ate level of command; such as, unit—level actions, higher level actions, DA—level action, or the agency/activity most appropriate to fix the system inadequacy(ies). The recommendations will be writ­ten in conjunction with the fmdings and will be included in the technical report of the accident. (5) The task of summarizing this information and transposing it into a complete and informative format remains. The final results of the total analytical effort will be summarized in the findings, recom­mendations and analysis portion of the technical report. To accom­plish this, each error/mistake, materiel failure/malfunction or environmental condition with its corresponding system inadequ­acy(ies) should contain the elements of information outlined in this paragraph. 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) Tape recorder (with adequate quantity of blank tapes, batteries). (5) Inclinometer/Abney level. (6) Tape measure, 100 foot (steel recommended). (7) Optic range finder/distance measuring (batteries if needed). (8) Flashlight (batteries). (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). (15) AR & DA Pam 385-40. (16) Appropriate forms (DA 285, DA 2397 series, AGAR, AAAR, and so forth). (17) Additional references (TMs, FMs, and local regs/SOPs). 15 DA PAM 385-40 • 1 November 1994. DODDOA 022326 Determining System Inadequacy(ies) Responsible for Human Error HUMAN ERROR Was support provided to individual to perform task: • Personnel • Equipment/materiel • Supplies • Services/facilities Do standards/ procedures exist for the task? Did individual receive training on how to perform the task? Did leadar(s) enforce standards? Did Individual know standard and wee he trained to standard? NO I SUPPORT FAILURE 4 NO Was type/capability/amount/ pw condition of support provided__ sufficient to correctly perform YES_ NO YES ¦ YES YES Pe YES the task? STANDARDS FAILURE Are they clear/practical? TRAINING FAILURE NO Was training correct, complete, and sufficient for performance to standard? LEADER FAILURE 4 NO Did leader(s): YES YES responsible Training not responsibleYES Support not _ responsible Standards/ procedures not Make on-the-spot corrections? _le-Leader not -Emphasize by-the-book ope?_ YES -Thke action when appropriate? INDIVIDUAL FAILURE *YES Did individual elect not to follow the standard (self-discipline)? [attitude, haste, overconfidence, NO self-induced fatigue] responsible Individual not responsible 4 SIHE Figure 2-1. Determining system inadequacy(les) responsible for human error 16 DA PAM 385-40 • 1 November 1994 DODDOA 022327 Sequence of Events 1.(When did errorlfallure/environmental factor/inJury occur?) a. Selection and training of personnel or design and manufacture of b. Mission assignment c. Mission planning d. Actions during mission o. Accident f. Egress, survival, rescue equipment 2. (What happened?) Human factors, materiel factors, environmental factors, Injury 3. (Why did It happen?) System Inadequacy(les)/Root cause(s) 4. (What should be done about it?) Remedies for system inadequacy(les)/Root cause(s) Figure 2-2. Sequence of Events. Method to place each factor in its proper perspective in relation to other events Chapter 3 Aviation Accident Reporting 3-1. Introduction AR 385-40 prescribes the classes of aircraft accidents that will be reported via DA Form 2397—R series and DA Form 2397—AB—R, Abbreviated Aviation Accident Report (AAAR). This chapter iden­tifies the types of substantiating data that will be appended to each report and includes instructions on how to process the data. This chapter also provides information for determining which forms of the DA Form 2397—R series are required for each report (See table 3-1). Detailed instructions are included explaining how to complete each form, including the DA Form 2397—AB—R. 3-2. DA Form 2397—R Series, Technical Report of U.S. Army Aircraft Accident a. Instruction. DA Forms 2397—R series consist of 12 technical reporting forms, a command review form, and two index forms. The forms are designed for reporting Army aircraft flight or flight—re­lated accidents. Not all forms are necessary for every technical report. See table 3-1 for general information on the requirement for submitting each form of the series. Specific instructions concerning the submission of each form are given in this chapter in the para­graph relating to that form. The DA Form 2397—R series are not available through publications supply channels. They will be repro­duced locally on 8 1/2— by 11—inch paper. A camera—ready copy of each form for reproduction purposes is at the back of this pamphlet. b. Formats. The forms contained in the DA Form 2397—R series are designed to provide three different accident report formats. The first format is narrative in content and includes DA Form 2397—R (Part I — Statement of Reviewing Officials) and DA Forms 2397-2—R (Part III — Findings and Recommendations), 3—R (Part IV — Narrative), and 4—R (Part V — Summary of Witness Interview). The second format requires graphic information on DA Form 2397-5—R (Part VI — Wreckage Distribution). The third format requires coded data on DA Form 2397-1—R (Part II — Summary), the bottom part of DA Form 2397-2—R, and DA Forms 2397-6—R (part VII — In—Flight or Terrain Impact and Crash Damage Data) through 12—R (Part XIII — Fire Data) which will be stored in the Army Safety Management Information System (ASMIS). It is essen­tial that the forms contain all information requested in the instruc­tions and that the information provided is accurate. 3-3. DA Form 2397—R, Part I, Statement of Reviewing Officials DA Form 2397—R (fig 3-1), will be submitted with the copy of the technical report forwarded through channels to the USASC. If addi-tional space is required, use letter—size paper for continuation sheets. 3-4. DA Form 2397-1 —R, Part II, Summary DA Form 2397-1—R, Part II, Summary (fig 3-2), will be completed for each aircraft accident requiring a technical report according to AR 385-40. (See tables 3-3 through 3-6 for additional informa­tion.) The purpose of the form is to summarize essential elements of information contained in other parts of the technical report. Acci­dents involving one aircraft require only one DA Form 2397-1—R. Accidents involving more than one aircraft may require additional DA Forms 2397—I—R, depending upon the circumstances. A DA Form 2397-1—R is required for each aircraft involved which meets the criteria for flight, flight related, or aircraft ground accident per AR 385-40. A DA Form 2397-1—R will be completed in its entirety for the aircraft and crew deemed most responsible for the accident. This DA Form 2397-1—R will be referred to as the "case aircraft." Additional DA Forms 2397-1—R, identifying other aircraft involved in the accident, will be completed as necessary to account for all aircraft except inactive or otherwise nonparticipating aircraft. These DA Forms 2397-1—R, however, do not require a duplication of the information entered in blocks 1 through 7 and blocks 9,20,23, and 24 of the "case aircraft" on DA Form 2397-1—R. Damaged aircraft that were inactiveMonparticipating will be costed as "other damage military." 3-5. DA Form 2397-2—R, Part III, Findings and Recommendations DA Form 2397-2—R (fig 3-3), will be completed for all aircraft accidents requiring a technical report according to AR 385-40. (See tables 3-3 through 3-6 for additional information.) If additional space is required, use letter—size paper for continuation sheets. This form is designed to provide a narrative and coded summary of accident cause factors, system inadequacies, and remedial measures. Block 1 is used to explain block 2 in terms of what happened, why . 17 DA PAM 385-40 • 1 November 1994 DODDOA 022328 it happened, and what should be done to reduce the chances of its happening again (3W approach). An abbreviated list of the codes and associated mistakes/errors, materiel malfunctions, environmental conditions, system inadequacy(ies) and remedial measures is pro­vided at table 3-7. Appendix B contains expanded descriptions and examples of the abbreviated codes. 3-6. DA Form 2397-3-R, Part IV, Narrative DA Form 2397-3-R (fig 3-4), will be completed for all aircraft accidents requiring a technical report per AR 385-40. 3-7. DA Form 2397-4-R, Part V, Summary of Witness Interview a. Instruction. DA Form 2397-4-R (fig 3-5), will be completed for all aircraft accidents requiring a technical report according to AR 385-40. As a minimum, summaries of the interviews with surviving crewmembers aboard the aircraft will be included. The form will also be used to summarize interviews and statements of command­ers, supervisors, maintenance and ground support personnel, and others who are able to contribute pertinent information concerning the accident. If additional space is required, use letter-size paper for continuation sheets. b. Procedural guidelines. The following procedural guidelines/ instructions will be followed: (1) All witnesses will be interviewed according to paragraphs 2-3 a and e, chapter 2. The investigator will emphasize to the witness that the sole purpose of the accident investigation is acci­dent prevention. The witness should be further informed that the U.S. Army seeks to isolate the causes of the accident so it may take appropriate action to avoid similar accidents. If the witness is a civilian, the investigator will avoid using Army terms and acronyms. (2) The board president or recorder will brief all witnesses con­cerning the interview. This will be done by reading to the witness the information on the back of the DA Form 2397-4-R, contained in Block 15 (see fig 3-5), the "General Witness Information Briefing." The purpose is to ensure that the witness understands the purpose of the interview, who will have access to the information, DOD restrictions on the use of the interview, and its public releasability. If a promise of confidentiality is to be offered, the interviewer will read the section, "Promise of confidentiality of­fered." This includes the specific categories of witnesses (crewmem­bers and maintenance personnel) to whom confidentiality will be routinely offered, any interview under enhanced recalUhypnosis and any other cases in which the interviewer feels it is necessary to offer a promise of confidentiality (to include situations where the inter­viewer feels that the witness is not providing complete or accurate information). This explains to the witness that the interview may be used within DOD only for accident prevention purposes. Beyond that, it explains that non-confidential interviews are publicly releasable and, to avoid that outcome, the interview must have been given under a promise of confidentiality. If a promise of confiden­tiality is not offered to the witness, the interviewer will read the section, "No promise of confidentiality offered." It explains that within the military, the interview may only be used for accident prevention purposes. It also explains the rules governing the public releasability of the interview. (3) When a promise of confidentiality is offered, the witness will complete block 16, "Availability of Promise of Confidentiality for Limited Use Report of Investigation." The witness will initial sec­tion b by indicating his/her choice, requesting or declining confiden­tiality (note the exception for interviews under enhanced recall/ hypnosis, which will automatically be deemed confidential and treated as such). (4) If the witness is willing to be interviewed or make a state­ment, it will be summarized in block 13, DA Form 2397-4-R. (5) The promise of confidentiality will be entered in block 12, DA Form 2397-4-R, and will be signed and dated by the interview­er. The promise is as follows: "The witness made this statement under a promise of confidentiality." The summarized interview will then be set forth in block 13. (6) There is no requirement to have an interview signed by the witness, and such should not be done. The interviewer does not have to sign either, except as addressed above. To approach a witness for a signature may give the indication that the statement will be used for purposes other than accident prevention. Neither is it necessary to record explanations discussed in paragraph 3-7 b on the DA Form 2397-4-R. (7) Witness statements should be summarized for inclusion in the report. The complete, verbatim account of all that was stated should not be included. A summarization is to be used, but it should not exclude any information that assists in explaining the circumstances of the accident. 3-8. DA Form 2397-5-R, Part VI, Wreckage Distribution a. Instruction. DA Form 2397-5-R (fig 3-6), will be submitted with each technical report, when needed to substantiate information that is not clarified by other data reported in the DA Form 2397-R series. A decision to not include this form should not be construed to mean diagramming of the crash scene will not be used as an investigation technique. The board may be required to furnish a copy upon request. b. Form terminology. (1) Wreckage distribution. The location of all aircraft compo­nents in their postcrash positions. The locations should be shown relative to the flight path of the aircraft. (2) Initial impact. The first contact of the aircraft with terrain or obstacles. (3) Major impact. The impact causing the most severe crash forces. (4) Secondary impact. An impact that is less severe than the major impact. Several secondary impacts may occur in an accident. 3-9. DA Form 2397-6-R, part VII, In-Flight or Terrain Impact & Crash Damage Data a. Introduction. DA Form 2397-6-R (fig 3-7), will be completed for the following (see table 3-6): (1) All technical/reports involving in-flight collisions (see defini­tions below), excluding tail rotor strike accidents. (2) All technical reports involving aircraft damage excluding the following: (a) Aircraft ground accidents. (b) Flight-related accidents with no aircraft damage. (c) Rotor blade strikes (main or tail rotor) with no additional aircraft damage. b. Flight terminology. (1) In-flight collision. The aircraft collides with an obstacle while in flight (helicopters at an altitude greater than normal taxi-hover height). (2) Terrain collision. The aircraft collides with the terrain. (3) Flight path. The profile motion of the aircraft center of grav­ity during flight relative to the horizontal, measured in degrees. (4) Terrain slope. Slope of terrain measured in degrees. (5) Aircraft attitude. The orientation of the aircraft with respect to the horizontal at the instant of impact. The attitude is measured in degrees about the pitch, roll, and yaw axes. (6) Impact angle. The angle between the flight path and the terrain. This angle is identical to the flight path angle for level terrain. For an upslope impact, the terrain slope angle is added to the flight path angle; for a downslope impact, the terrain slope is subtracted. An upslope and downslope impact is shown at figure 3-8. (7) Flammable fluid. Engine fuel, lubricating oil, hydraulic fluid, and so forth. (8) Major impact. That impact which results in the highest ac­celeration forces being transmitted to the aircraft. (9) Gravitational force (g force). A downward force resulting from gravitational deceleration action on a mass (Newton's second law, F = Ma). This is normally expressed as a one g force. (10) Impact force. A force in any direction resulting from the deceleration of an aircraft. These forces are usually expressed as multiples of the gravitational force; such as, 1g, 2g, and so forth. . DA PAM 385-40 • 1 November 1994 DODDOA 022329 Impact forces are resolved into components relative to some refer­ence such as the longitudinal and vertical axes of an aircraft. (11) Airspeed. Indicated airspeed along the flight path (knots). (12) Vertical velocity. Rate of ascent or descent in feet per min­ute (fpm). (13) Ground speed. Ratio of distance covered to time required relative to ground (knots). 3-10. DA Form 2397-7-R, Part VIII, Maintenance and Material Data DA Form 2397-7-R (fig 3-9), will be completed for each technical report, as applicable, when any of the following had a role (definite or suspected) as to the cause of the accident. If explanatory remarks are required, use block 6 and letter-size paper for continuation sheets. a. An act of omission or commission at any maintenance level (to include manufacturing defects). State the specifics in block 6, "Remarks." b. The failure or malfunction of any system, major component, or part. A separate DA Form 2397-7-R will be completed for each major component or part that failed or malfunctioned and contrib­uted to the accident, or anytime an analysis is to be performed or requested on a part. Only DA Form 2397-7-R pertaining to compo­nents or parts that contributed to the accident will be incorporated into the completed technical report of aircraft accident. When analy­sis of components/parts shows that there was no contribution to the accident, DA Form 2397-7-R pertaining to these items will be retained as work copy documents, but will not be included in the completed Technical Report of Aircraft Accident. 3-11. DA Form 2397-8-R, Part IX, Personal Data DA Form 2397-8-R (fig 3-10) will be completed for all aircraft accidents requiring a technical report per AR 385-40 (see tables 3-5, 3-6, 3-8, and 3-9). It will be submitted for- a. Each aviator who occupied a seat with access to the flight controls or an evaluator (SP, IE) occupying a jump seat. For each of these individuals, fill in blocks 1 through 4d, 5, and 8 through 17. b. Support personnel and non-rated crewmemberS whose contrib­utory role in the accident was attributed to duties such as mechanic, crew chief, POL handler, air traffic controller, technical inspector, medical officer, etc. For each of these individuals, fill in blocks la, 2a through i, 3g, 3n, 3p, 3q, 4e, 5, 7, 8, 9 (if a crewmember), and 10 through 17. c. Supervisory personnel who may have contributed to the acci­dent. For these individuals, fill in blocks la, 2a through i, 5, and 10 through 17. d. Any crewmember, when the required laboratory analysis indi­cated the presence of an unauthorized drug or substance. For each of these individuals, fill in the appropriate blocks as indicated in a and b above, to include block 8. 3-12. DA Form 2397-9-R, Part X, Injury/Occupational Illness Data DA Form 2397-9-R, (fig 3-11), will be completed for each individ­ual who was injured or sustained an occupational illness as a result of the aircraft accident. The accident investigation board shall refer­ence and comply with AR 40-21. It is mandatory that autopsies be performed on all deceased crewmembers. The protocol will not be included or attached to the accident report when the report is for­warded through the command channels for review, but will be forwarded to the Commander, U.S. Army Safety Center, ATTN: CSSC-ZM, Fort Rucker, AL 36362-5363 for inclusion into the historical copy of the report. 3-13. DA Form 2397-10-R, Part XI, Personnel Protective Escape/ Survival/Rescue Data DA Form 2397-10-R (fig 3-12) will be completed for crew mem-bers aboard an aircraft involved in an accident requiring a technical report, and for all other personnel aboard the aircraft for which the following applies (see tables 3-5, 3-6, 3-8, 3-9, and 3-11 through 3-24 for additional information: a. Protective/restraint/survival equipment played a role in the causation/prevention/reduction of an injury(s) resulting from the accident. b. Protective/restraint/survival equipment failed to function as de­signed or was required but not available or used. c. Egress/Rescue difficulties were encountered. 3-14. DA Form 2397-11-R, Part XII, Weather/ Environmental Data DA Form 2397-11-R (fig 3-13), will be completed for all aircraft accidents requiring a technical report according to AR 385-40. This form does not negate the requirement for the substantiating weather data addressed in paragraph 3-17. Weather/Environmental informa­tion submitted on DA Form 2397-1I-R is the board's best estimate of the actual environmental conditions existing when and where the accident occurred and its role in the accident, if any. The informa­tion will be gathered from available sources to include witnesses, surviving crewmembers, etc. 3-15. DA Form 2397-12-R, Part XIII, Fire Data DA Form 2397-12-R (fig 3-14), will be completed for each techni­cal report of aircraft accident in which fire occurs (table 3-6 also applies). -3-16. DA Forms 2397-13R, Index A, and 14-R, Index B DA Form 2397-13-R (fig 3-15) and DA Form 2397-14-R (fig 3-16) will be completed for all aircraft accidents requiring a techni­cal report according to AR 385-40. 3-17. Substantiating Data a. Instruction. DA Form 2397-13-R, Index A, lists the informa­tion that will be appended to the technical report as substantiating data. See figure 3-15 for an example of DA Form 2397-13-R. The information attached to the left side of the report folder will aid in completing the remainder of the 2397 series. b. Requirements. Tab items 1, 2, 4, 6, 7, and 9 of DA Form 2397-13-R will be submitted with all technical reports. Blocks 3, 5, 8, and 10 through 14 are also required if necessary to explain or substantiate other parts of the report. Additional instructions pertain­ing to applicability are contained in paragraph d below. c. Special considerations. (1) Legibility. Original copies of substantiating documentation are not required for this report. Duplicates that are completely legible and suitable for reproduction may be appended to the report. (2) Extracts. Extracts or concise quotes of regulations, tasks, per­formance standards, specifications, and other directives are preferred in lieu of whole source documents to minimize bulk. When used, extracts will include information as to where they appear in their source documents, titles and dates of the documents. (3) Highlighting key words and phrases. Substantiating data re­ferred to by other parts of the report will have key words, phrases, or passages underlined or annotated to facilitate the review of the accident report. Underlining or annotating margins will be used in lieu of felt-tipped markers for this purpose because the fluid dis­pensed by many of these devices may obliterate the legibility of subsequent copies if they are reproduced from an original marked in this manner. d. Information items at each TAB on the DA Form 2397-13-R (1) TAB 1-Investigation board orders. A copy of the original orders appointing the board and any amendments will also be appended. (2) TAB 2-Weather Data. The relationship of weather or weather services to an accident is addressed in chapter 2 of this pamphlet. If weather or weather services had no bearing on the outcome of the accident, a brief synopsis of the weather existing before, during, and immediately after the accident, authenticated by the closest weather service activity, will suffice in most cases. Oth­erwise, if weather or weather services are suspected, the information to be provided should include, but not limited to, the following: 19 DA PAM 385-40 • 1 November 1994 . DODDOA 022330 (a) A certified narrative of weather provided by forecaster, briefer, or observer. Note. Weather data importance should be in consonance with the suspicion of weather as a factor. (b) A true copy of the forecast or observation from official files; e.g., DD Form 175-1 (Flight Weather Briefing). (c) Copies of pertinent weather advisories and related forms; e.g., AWS Form 39, Military Weather Warning Advisory, and so forth. (3) TAB 3Certificate of damage/estimated cost of damage. If — total estimated cost to repair the damage does not exceed the aircraft replacement cost specified in TB 43-0002-3, submit a complete ECOD for aircraft damage. The ECOD will include an itemized list of damaged components, number and cost of man-hours, and total cost of repair. Refer to AR 385-40 and Army Master Data File for aircraft component/part accident damage cost criteria. If the aircraft is damaged to the extent it is estimated to be a total loss, a certified statement to that effect, signed by a maintenance officer, will suffice in lieu of an ECOD. For other property damage provide a descrip­tion of the property damage, and an ECOD, to include civilian property damage. (4) TAB 4—Maps and photographs. A map/sketch depicting the aircraft's flight path leading up to the accident site, preferably plot­ted on a large scale map, should be appended to the technical report if it will help to clarify the accident sequence of events. Arrows should be placed on the face of the map depicting magnetic north and the wind, with numerical values, which existed at the time of the accident. Should the section of map being used not include an obvious geographical reference and margin data such as distance scales, this type of information should be added. Also, significant events occurring along the depicted flight path should be numbered at the point they occurred and explained by footnotes. The number and types of photographs to be appended to the accident report will be determined by the accident circumstances. Additional guidance concerning photographic coverage of an accident is contained in chapter 2. (5) TAB 5—SF 368 (Deficiency reports). Include a copy of each deficiency report completed as a result of the accident. (6) TAB 6—Special technical reports and reports of laboratory analyses. Append a copy of the results of all fluid sample analyses, teardown analyses, or other laboratory analyses of aircraft related systems. (7) TAB 7—DD Form 365-4 (Weight and Balance Clearance). A DD Form 365-4 showing the conditions existing at the time of the accident will be computed by the investigation board and also ap­pended to the accident report at TAB 7. If weight and/or balance was a factor or suspected factor in the accident, also include a copy of the DD Form 365-4 used by the aircrew at the time of the accident and explain any significant differences in the analysis por­tion of the narrative. (8) TAB 8—Directives, regulations, etc. Pertinent portions of written documents relating to cause factors will be extracted, under­lined/highlighted, and appended to the accident report. (9) TAB 9—Medical Data. Toxicological reports, preferably done by the Armed Forces Institute of Pathology (AFIP), autopsy proto­cols, and/or other medical data pertinent to the accident will be appended to the accident report. Autopsy protocols and pictures of deceased personnel will not accompany the technical report through review channels. This type of information will be handled in accord­ance with paragraph 2-4 g of this pamphlet. (10) TAB 10—Flight planning data. Append a copy of the flight plan, local clearance forms, or unit's tactical flight log to the acci­dent report if relevant to the accident. (11) TAB 1I—DA Form 2408-12. A copy of the DA Form 2408-12 covering the accident flight will be appended to the techni­cal report if it has any bearing on the accident. In cases where crew rest may be an accident cause-related factor, DA Form 2408-12 information pertaining to the same crewmember for the appropriate period preceding the accident should be included. (12) TAB 12—DA Form 2408-13. Append a copy of DA Form 2408-13 to the accident report if maintenance or material deficien­cies are discovered. (13) TAB 13—DA Form 2408-14 (Uncorrected Fault Record). Append copies of DA Forms 2408-14 applicable to the accident aircraft if a material problem related to an uncorrected fault is involved. (14) TAB 14—DA Form 2408-5 (Equipment Modification Re­cord). Append copies of applicable DA Forms 2408-5 when neces­sary to substantiate maintenance errors, omissions, etc., that caused or contributed to the accident. (15) TABs 15 through 18—Additional information. Substantiating data that have a bearing on an accident and are not covered by other information items listed on DA Form 2397-13-R should be ap­pended to this part of the technical report or filed under an addi­tional tab item (tab 16); examples include, but are not limited to the following: (a) If the training proficiency/level of an individual is an issue, a copy of the training record will be included. The area of deficiency will be highlighted. (b) Copies of crewmember postaccident flight evaluations. (c) Copies of DA Form 2028 (Recommended Changes to Publi­cations and Blank Forms) when changes in publications are recommended. (d) Results of special investigations conducted by individuals/ agencies in support of the Accident Investigation Board investigation. (e) Portions of transcripts of ATC logs, tower tapes, media news accounts, fire, rescue and law enforcement reports, relevant portions of intra-cockpit voice recordings, and so forth. 6) Copies of DA Form 2408-18 (Equipment Inspection List) when necessary to show compliance or noncompliance with safety-of-flight messages and similar directives or publications. 318. Miscellaneous - A list may be beneficial to the local safety point of contact (POC) for actions required prior to the arrival/appointment of the accident investigation board. The guidelines in appendix G can be used to prepare this list. 3-19. Assembly of the accident folder When all required forms in the DA Forms 2397-R series have been completed and the necessary substantiating data have been collected, the recorder will assemble the information using the instructions listed below. a. Use a separate manila or similar folder to enclose the forms and substantiating data for each copy. It is suggested that the creases and edges of each folder be reinforced with tape to maintain the integrity of the folders during subsequent handling. b. File substantiating data under the appropriate tab on the left side of the accident folder and the DA Forms 2397-R series on the right. If the accident report will contain more than one DA Form 2397-R series because of a multiple aircraft event, keep each DA Form 2397-1-R and its associated forms together and file in a manner that will permit view of the "case aircraft" DA Form 2397-I-R and its associated forms first. c. Tab and index each item on the left and right sides of the folder as shown in figure 3-17. d. File the completed DA Form 2397-I3-R, Index A, on top of substantiating data on the left side of the folder and file the com­pleted DA Form 2397-14-R, Index B, on top of the DA Forms 2397-R series on the right side of the folder. The items to be included as substantiating data are addressed in paragraph 3-17 of this pamphlet. Additional items may be included as determined by the board. e. The front of the folder will be marked with the following information: 20. DA PAM 385-40 • 1 November 1994 DODDOA 022331 Technical Report of Army Class (A through D) Aircraft Acci­ dent' or "Aircraft Ground Accident" if applicable. Aircraft MTDS and Serial No. (M109A2XXXXX). Date: (mm,dd,yy of accident). Location of accident: (DA Form 285, block 11). Unit: (DA Form 285, block 3). 3-20. DA Form 2397—AB—R, Abbreviated Aviation Accident Report (AAAR) DA Form 2397-AB-R (fig 3-18) is required for all aircraft ground accidents (regardless of class), Class C, D accidents, Class E and F (turbine engine FOD) aviation incidents. (See tables 3-4 through 3-6 and tables 3-8 and 3-9 for additional information.) This report may also be used to report aviation Class A and B accident in areas of combat operations when the submission of the DA Form 2397 series is deemed not practicable by the senior tactical commander. Also, the AAAR only reduces the Class C and above reporting requirements and should not effect the quality or extent of the accident investigation. a. Investigation and submission of the DA Form 2397-AB-R will be according to AR 385-40, paragraph 2-8. b. Submit AAAR in legible hand-printed or typed copy by mail, Table 3-1 Aviation accident reporting requirements DA Form 2397 Type and DA Form FAX, courier, by message format, electronic mail, or by other timely means. Work copies on plain paper will be acceptable, but each data element must reference the respective block of the DA Form 2397-AB-R. (1) The message address is as follows: CDR USASC FT RU-CKER AL //CSSC-Z// (2) The mailing address is as follows: Commander U.S. Army Safety Center ATTN: CSSC-Z, Fort Rucker, AL 36362-5363. (3) Personal Computer (PC)-to-USASC mainframe computer procedure is as follows: To transmit data to the mainframe computer at the USASC, individuals must have an Army Safety Management Information System (ASMIS) user identification code and password. Individuals must also have a DDN TAC Access Card to be able to use the DDN system. These are available from the U.S. Army Safety Center, Information and Systems Technology Directorate, ATTN: CSSC-ITS, Fort Rucker, AL 36362-5363. c. For Class A, B and C accidents (those reported on this form), attach all additional information or forms required or deemed appro­priate; for example, witness statements/interviews, expanded narra­tives, lab/CCAD reports, other DA Form 2397 series, additional Personnel Information sections, and additional AAAR forms for involved aircraft other than the case aircraft, and so forth. Classification Telephonic AAAR -R -1-R -2-R -3-R -4-R -5-R -6-R -7-R -8-R -9-R -10-R - 11 - R - 12 - R -13-R -14-R Avn A, B X X X X X X * * * X * X X * X X Avn C X X • • Avn D, E, & F X • • Avn Combat A, B 1 # X • • • • Acft Ground A, B, & C X X • • • • Acft Ground D, E, & F X Legend for Table 3-1: as required by the circumstances X = mandatory # = if the operational situation permits I for combat or contingency operations where the submission of the DA Form 2397 series technical report Is deemed not practicable by the senior tactical commander. DA PAM 385-40 • 1 November 1994 21 DODDOA 022332 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT i RECIUMEMENTS CONTROL SYMBOL PART I - STATEMENT OF REVIEWING OFFICIALS CSOCS-309 or use of this Mini, see AR 306-40 and DA Pamphlet 365.40; the Plowmen agency ,s OCSA • 1. REVIEWING OFFICIALS COMMENTS Comment 1: Concur with the findings and recommendations of the accident investigation board. L.. Actions specified in recommendation 2a pertaining to this level of command were implemented. 2.. .4,131),(' 1.41,...e., F. Comment 2: RI.FOREMAN, MAJ, AV, Commanding Concur with the findings and recommendations of the accident investigation board. 1.. (See continuation sheet) 2 APPROVING AUTHORITY COMMENTS 1. Concur with findings and recommendations of the accident investigation board and commerts of the reviewing officials. 2. Actions recommended by the board pertaining to higher headquarters arc considered adequate..recommendations. This command has no further BRIAN D. DIRECTOR, MG, Commanding t (--, et. SVM.ire •_--____„-- ll_ k-e,c,. ;),--4-4-' 3. DEPARTMENT OF ARMY REVEW Findings and recommendations of the accident investigation Board are considered correct and appropriate. DA level recommendations have been forwarded to the appropriate agency for action. Facts and circumstances pertaining to this accident were published in the Jan 94, Vol 23, No. 2 issue of the Flightfax. . the report data is approved for inclusion into the USASC data base. HENRY P. PRESERVER, LTC, AV, XO . ,AadOrtie.-1 Date l.c Time c. AcIt Sena! No. 4V" 931001 1000 212345 DA FORM 2397R, JUL 94 - Figure 3-1. Sample of a completed DA Form 2397-R, Part I, Statement of Reviewing Officials _ DA PAM 385-40 • 1 November 1994 DODDOA 022333 Legend for Figure 3-1; Completion instructions for DA Form 2397—R, Part I, Statement of Reviewing Officials 1. Block 1. The reviewing official(s) will indicate the official's organi­zation and will: a. State concurrence or nonconcurrence with the technical report. Any nonconcurrence will be fully explained. b. Report actions taken as well as recommendations for additional action by higher headquarters or other Army commands. Attach, as enclosures to this form, copies of correspondence, forms, and other data requiring additional action. c. Define those area(s) recommended for improvement/remedial ac­tion by the investigating board that are beyond the resources available to the command and so indicate in the forwarding endorsement to the approving authority. d. Authenticate comments with signatures and appropriate signature block at the close of each reviewing official's remarks. e. Higher command reviewing official(s) will indicate the official's organization and enter the same information as a through d above as comment number 2, 3, etc. 2. Block 2. The approving authority will indicate his command and approval or disapproval of the report. Reasons for disapproval and/or additional actions directed will be reported. The approving authority will make note of those areas recommended for improvement/remedial action by the accident investigation board or reviewing officials on which action can or will be completed by the approving headquarters. If corrective action is beyond the purview or capability of the approving authority, this will be stated. For Block 2a, the approving authority's authentication will be entered. 3. Block 3. Block 3 is reserved for USASC use and will be com­pleted to show coordination/follow—up taken in response to recommen­dations requiring DA—level action. 4. Block 4. Enter the case number as shown on the DA Form 2397-1—R. 23 DA PAM 385-40 • 1 November 1994 DODDOA 022334 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT REQUIREMENTS CONTROL SYMBOL PART II -SUMMARY CSOCS-309 I. For use at this form. see AR 385-40 and DA Pamphlet 385-40; the proponent agency Is OCSA 1. a. ClasstrloatIon ( .A ij.B...Cl b. Category.go no ¦.Flight Masted] 2. TYPE EVENTS I IL 80_l b. 85_j e. 3. PERIOD OF DAY.. Dawn.133 Day . Dusk.¦ Night.14. a. On Post.. Yes .(2) No_ l b. On ginekl.. Yea.CR No 5. NEAREST MA. MSTALLATION. le. NO. OF ACFT INVOLVED.I Fort Sand . CA. 7. LOCATION.Jo. Oily:.Level Oaks. i b. stool.CA.l c• country: a. m."Mrp$: UH-60A I b-(1)cranAcnAgOV.oC.2-14 Avn Beet l(2) U1C: WABCCO.I "11111 Agt ssfid: Fort Sand.CA P.. ORDN/CNJUN OF CMD INVOLVED AND ACCOUNTABLE a. of CMDNom ' maim ( 1) u" Dcgn Involved CO C Chain of Crnd 2-14 Avn Refit Chain of Crnd 3d Avn ride Chain of Cmd Chain of Cmd 13th Ali Div XKL11. Corns MACON COCOM Involved b. (2) tic aailill WABCCO Oran Actounlable WABCAA Chain of Cmd WABCFF Chain of Cmd WDEFAA Chain of Cmd "EFGAA Chain or Cmd WCBAAA_ PAACOM ORON/Chaln to unit of CND Accerriable P) UIC 10. a. Edimaled Cud.. Total Loss 11. SURVIVABILITY 12. IN-FLT ESCAPE 13. FIRM 14. POSTCRASH MICAPE Cerner A(1) Acel Damage Coal $1,800,000 DOS. DIFFICULTIES m Vas 0 No 0 NA • Sunlisble • Pecion Baloul NI RABIN ¦ (2) Repair Writs Cost S.19,200 "°. svilri 1 200 Buviaable Not (3) Other Damao* AU $.0 Owner . . Nonaurviable Accomplished (4) Other Damage Civ $.0 Conten MI Missing GO NA 'Mir ,ivgI.lOgirgi.-37...$ 1,10 7.:X:17.103TAMITZBil3Z, (5) injury Cost 0 , 000 . (a) Total Cost This Regt $ 2.919,200 15. USABLE FUEL a. At Takeoff:.2255 s• Al Tim. or Emig:.1405 ABOARD b. Total Cost Muttipie Aoft $ ACFT: o. At Aodt or Term:.1363 d. Type Fuel:.jpg 16..GENERAL DATA Yes No 17. Flight 18. MISSION 19. INJURIES Fatal Clashinging d Mitring kilited Flan (Number) a. Flammable Fluid Spilage X a. Type (A) (13 - E) (F-C) 81 GI) Dr] VFR b. (1) high! Visual Aida Used X S a. Occupants Patilary 1 2 (2) sP•oifi Arps . FR b. Occupants Other a. Fl Data Recorder Instated X 11 Nor. b. Operations c. Non-Oceupents Mil MR. %WV d. Meld Training Exercise Invoked d. Non-Ooouposia OMR irMili ' ship X • NA a] MIRO• e moats-Up Dooley In Use X ¦ e. Toted This Alt 1 2 f. Emergency Locakit Trans/War 1 Multiple A& Event 0'biol. Installed X 20. . TERRAIN OF CRASH SITE afore gum one may app! a. Garland attractant:tics • Mountain i Decal . Roiling.m Flat b. Surface al Ctash S... Pt w- rad . is IX] Sod . Snow . Soggy . Water LI Water c. Crash Site Grads.ER Level.. Slope d. Obstacles at Crash Site ¦ Stamps.1;4 Trees.. Bldg .Wilms.. Rocks/Boulders .Ceram ¦ Met 21. FLIGHT DATA Phase of Altitude Airspeed Heading Akerait waohl Onsrgroas Fight Duration Operation KIM (carpus) Yes.No AOL MSL a. Plumed Data Hr.02 Treig.0 G VAR 1500 120 VAR 18520 X b. When Emergency 1*.01 Occurred Tr*.0 G 1000 1500 120 270 17670 X 0.Acdclent or Hr.01 Termination Tris.1 K 0 500 0 120 17628 X 22. ACCIDENT CAUSE FACTORS (Enter a D. S. or Vie appropdato Wooks Io Identify cialIntle, saves-WC or unde4ennined causes) a Personnel D. G. or U Personnel parrisirs0 D. S. or U (1) Fight Crew:.Duty.PC D (2) Mmenilsory. Duly Duty Duly Duty (8) Other. Duty (2) Ground Crew:.Dray b. Material FelureIMelfunction D Duty c. Environmenta3 23. SEQUENCE (Factual am-Mont wow* from onset of emovency Mown termination of flight. Lisa additional Moot 1 f taquiroct) (See attached sheet) 24..AYH SFEA.TY a. Nome. Rank. THOMAS M. PREVENTOR, CW3 OFFICER and Orgn Co C, 2-14 Avn Regt 12:5,77,-ke47-4 1'1 1 ,e'f7--A4CA*4 25. CASE a. Cats (YYVMOQJ b. Time o. MIt Sort& No. 28. OTHER ACFT SERIAL NO. NO. 931001 1000 9212345 DA FORM 2397-1-R, JUL 94 Figure 3-2. Sample of a completed DA Form 2397-1-R, Part II, Summary . DA PAM 385-400 1 November 1994 DODDOA 022335 DA Form 2397-1-R (Cont'd) -- 93100110009212345 23. Sequence. While in cruise flight at 1,500 feet MSL and 120 KIAS, tail rotor control was lost. Autorotation was initiated to a large, open area. At approximately 200 feet AGL, the aircraft entered a vertical descent and settled into trees approximately 40 meters short of the intended landing point. The PC sustained Figure 3-2. Sample of a completed DA Form 2397-1-R, Part II, Summary-Continued Legend for Figure 3-2; Completion instructions for DA Form 2397-1-R 1. Blocks la and lb. Check the appropriate box to indicate the appropriate classification and category for the accident. Accident clas­sifications and categories are defined in AR 385-40. Note: Accident classification is based solely on property damage or injury/Illness seventy; e.g., fatal, permanent partial disability, etc., IAW AR 385-40, not injury cost.) 2. Block 2. Refer to Table 3-2 for accident event codes. Appendix F contains explanations of events listed. Select the type event(s) that best categorize(s) the accident and enter code(s) in space(s) provided. More than one event may apply and up to three may be recorded. The event that best describes the accident should be listed first. 3. Block 3. Check the appropriate box. Dawn is that period of time between beginning moming nautical twilight (BMNT) and official sun­rise. Dusk is that period of time between official sunset and end evening nautical twilight (EENT). 4. Block 4. Check the appropriate box. Tactical landing zones under positive air traffic control; e.g., Corps instrumented airfield, Division's VFR helipad, stagefields, and support bases are considered "on post" and "on airfield° for reporting purposes. Also, aircraft accidents occur­ring on joint-use civil airports and on civilian airports with Reserve component facilities are considered "on post" and "on airfield" when there is intent to use the military facilities on that airport; i.e., visit the unit, acquire fuel, conduct training, etc. 5. Block 5. Enter name of military installation where the accident occurred or the nearest military installation. 6. Block 6. Enter the number of aircraft that were involved in the accident. Do not include damaged aircraft that were not being oper­ated at the time of the accident. Ensure that the number entered in this block corresponds with the number of DA Forms 2397-1-R sub­mitted with the technical report. Paragraph 3-4 specifies when addi­tional DA Forms 2397-1-R are required. 7. Block 7. Enter the name of the closest city and state to the accident site. Identify the country if outside the United States. 8. Block 8. Enter appropriate information for the aircraft addressed by this form. "Organization aircraft assigned" and "UIC" pertain to the organization which has the aircraft in its inventory as recorded in the property records or a hand receipt, whichever is applicable. Enter the installation's name where the aircraft was assigned. 9. Block 9. a. Block 9a. Beginning in the left column under "Organization In­volved," enter the six digit UIC and abbreviated titles of the lowest level aviation unit, and chain of command, involved in the accident up through is major command. b. Block 9b. If it is determined that an activity other than the involved unit is deemed the accountable for the accident, enter the six digit UIC and abbreviated title of that unit and chain of command up through the major command and explain in the analysis paragraph of DA Form 2397-3-R. If the Unit is the same as listed in Block 9a, leave blank. Further guidance for determining accountability is contained in AR 385-40, paragraph 1-6. 10. Block 10. a. Block 10a. If the aircraft identified in block B was damaged beyond economical repair limits, missing, or abandoned, check the box Indicating total loss. Insert the replacement cost of the aircraft obtained from TB 43-0002-3 in the space provided for the aircraft damage cost and leave the spaces for aircraft repair man-hours and cost blank. If the aircraft was repairable, enter In the spaces provided an estimated material cost of damage, number of man-hours, and a dollar amount for total man-hours to repair the aircraft based on the standard labor rate per hour specified in AR 385-40, paragraph 2-11. Estimated cost of damage and man-hours required to repair the air­craft should be obtained from the organization's support maintenance. When more than one aircraft is damaged and the other aircraft does not meet the "intent for flight" criteria contained in AR 385-40, enter the total dollar cost of damage and man-hours to repair the other aircraft or other military property in the "Other damage mil" space. Report dollar value of civilian property damage; i.e., damaged build­ings, destroyed crops, broken utility poles and lines, livestock, etc., in the space "Other damage civ" provided. Report the total dollar value of all Injuries, as recorded in Block 19, DA Forms 2397-9-R (Part X­Injury/OccupationaUllIness Data). The cost is computed using the standard injury and illness costs contained in Table 2-1, AR 385-40. Injuries or fatalities to non-DOD personnel; i.e., private citizens, are not included in accident Injury cost. Show ownership of all damage by entering one of the codes listed in Table 3-3. b. Block 10b will be completed only for accidents Involving a multi­ple aircraft event. The information will be entered only on the DA Form 2397-1-R applying to the "case aircraft" identified in block 25. The cost entered in block 10b will show the total cost of all aircraft, prop­erty damage, injury, and occupational Illness attributable to the acci­dent. 11. Block 11. Check the appropriate box. Two factors are required for an accident to be survivable. Crash forces imposed upon the inhabitable area of the aircraft must be within the limits of human tolerance (see Appendix C), and all portions of the inhabitable area must remain reasonably Intact and occupiable. If these criteria are met for at least one, but not all seat/litter positions, the accident is partially 25 DA PAM 385-40 • 1 November 1994 DODDOA 022336 survivable. If no seat positions meet the criteria, the accident is non­-survivable. Fatal injuries or occupancy of an inhabitable area is not the criteria for determining survivability of an accident. 12. Block 12. Check the appropriate box to indicate the method or attempted method of inflight escape. This block does not apply to occupants who fell out of the aircraft or were ejected/thrown out with­out a parachute. Check "NA" if the crew/aircraft is not equipped with parachutes/ejection seats. 13. Block 13. For fires beginning before initial impact or breakup of the aircraft, check "inflight" For fires beginning after the initial crash impact has begun, check "postcrash." Check both boxes if in-flight and postcrash fires occurred. Ifinflight," "postcrash," or "other" boxes checked, ensure that a DA Form 2397-12-R is completed. For the purpose of this block, movement of the aircraft under its own power is considered inflight. 14. Block 14. Check the "yes" block if any occupant had difficulty or required assistance during egress. Leave blank for non-survivable accidents with no survivors. 15. Block 15. Enter in blocks a, b, and c the total amount of fuel on board within the aircraft fuel system, in pounds, for the times indicated. Enter in block d the type fuel with which the aircraft was last serviced. 16. Block 16. Check appropriate blocks and record supporting data on appropriate forms. a. Block 16a. If "yes," enter types and quantity in block 9e of DA Form 2397-6-R. b. Block 16b. If "yes," identify the type night visual aid used in block 16b(2). If night visual aids were a factor in the accident, discuss in the findings and "special investigation" portion of the narrative (DA Form 2397-3-R). c. Block 16c. Check "yes" if a flight data recorder (FDR) was installed and explain in the narrative portion of the report. d. Block 16d. If "yes," explain and enter name of field training exercise (FTX) in "the preflight phase" of the narrative (DA Form 2397-3-R). e. Block 16e. Check "yes" only if heads up display (HUD) was in use at time of accident. f. Block 16f. If an emergency locator transmitter (ELT) was in­stalled, check "yes." Explain any malfunctions in the narrative (DA Form 2397-3-R). 17. Block 17. Check the appropriate box to indicate under what flight rules the aircraft was being operated at the time of the accident. Check "none" if the aircraft was operated without a flight plan or without being recorded on appropriate flight dispatch records. 18. Block 18. Use the mission symbols used on the DA Form 2408-12 or as specified AR 95-1. For maintenance operational che­cks enter "S." If none, enter "NA." If the mission was classified enter "Z." If the mission symbol is undetermined, enter "U." Also, check the appropriate box to indicate if the mission was a single ship or multi­-ship operation. 19. Block 19. Enter numbers of personnel in the appropriate boxes. Columns B-E combine the injuries reported in blocks lb through to of DA Forms 2397-9-R and columns F-G combine those injuries repor­ted in blocks if and lg of DA Forms 2397-9-R. Ensure the number of personnel reported as injured, agrees with the number of injured per­sonnel reported on DA Forms 2397-9-R. Block 19f, "Multiple acft event," is completed only on the DA Form 2397-1-R for the "case aircraft" when reporting accidents involving multiple aircraft. 20. Block 20. This block is used to describe the terrain at and around the crash site: a. Block 20a. "General characteristics" pertains to the dominant terrain features surrounding the accident site. More than one may apply. b. Block 20b. Refers to surface conditions on which the aircraft made its ground run and/or came to final rest. More than one type surface may apply. c. Block 20c. Pertains to the terrain grade on which the aircraft came to final rest. If "slope" is checked, specify degrees. Leave blank if not applicable. d. Block 20d. Pertains to obstacles located in the vicinity of the accident site that may have influenced the accident. More than one may apply. 21. Block 21. Flight Data. "Flight duration;" enter hours and tenths of hours; "Phase of operation" enter appropriate code(s) (maximum of three) from the list at Table 3-4."Overgross" determinations are not in reference to design gross weight, but are in reference to the conditions under which the aircraft was being operated at the time of the acci­dent. a. Block 21a. For planned data, enter the flight parameters that were used during preflight planning for that segment of the mission profile in which the emergency or accident occurred. "Variable" (var) may be used where heading, altitude and airspeed are constantly changing due to mission requirements. b. Block 21b. For emergency data, enter the actual flight parame­ters at the time of the emergency. Note: The use of the term "Emergency" in this pamphlet refers to "any occurrence/situation wherein the personnel involved sense a need to take appropriate measures to reduce the effects of the occurrence/ situation or prevent injury, property damage, or further materiel fail­ure." c. For accident or termination data, enter flight parameters at the time when the major impact/accIdent occurred or accident sequence stops if no major impact occurred (could be same as emergency data). 22. Block 22. Place a "0," "S," or "U" in the appropriate space provided If personnel, materiel, or environmental factors definitely con­tributed, are suspected to have contributed, or the role in the accident could not be determined. Identify personnel by duty codes from the list at Table 3-5. It is essential that each entry in block 22 be supported by the findings reported in blocks 1 and 2 of the DA Form 2397-2-R, the analysis portion of the DA Form 2397-3-R, and the cause rela­tionship block elements checked on DA Forms 2397-7-R (Part IX-Personal Data), 8-R, and 11-R (Part XII-Weather/Environmental Da­ ta). 23. Block 23. Enter a concise summary of the accident sequence of events from the first indication of the emergency through termination of the accident sequence. Avoid conclusions of the investigation as to cause of the accident. Continue on letter-size bond paper as neces­sary; however, do not exceed a total of 15 lines of typewritten informa­tion. 24. Block 24. The aviation safety officer (ASO) of the unit involved in the accident will normally review the completed report and sign in this block. The ASO's signature does not indicate or imply his concurrence or nonconcurrence with the report but only that he has reviewed and is aware of the contents of the report. 25. Block 26. Enter the case number. The case number is a 17-digit numerical entry consisting of a 6-digit date (Block 24a), 4-digit hour of the day (Block 24b), and the 7-digit tail number the aircraft (Block 24c) that will be placed on each form of the DA Form 2397-R series accompanying the report, as indicated in table 3-6. 26. Block 26. If the accident involves a multiple aircraft event, block 28 will be completed only on the DA Forms 2397-1-R, addressing aircraft other than the "case aircraft." Leave blank if it Is a single aircraft accident. DA PAM 385-40 • 1 November 1994 DODDOA 022337 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT REQUIREMENTS CONTROL SYSMBOL PART III - PINDINOS AND RECOMMENDATIONS CSOCS-309 Far use of this form, sac AR 38540 end DA Pamphlet 385.40, the proponent agency is ()GSA FINDINGS AND RECOMMENDATIONS forfach additional sheet, if required) FINDING 1 (Present and Contributing: Materiel Failure): While at 1,500 feet MSL and 120 ICIAS in cruise flight, the UH-60A had a failure of the input bevel gear (P/N 70357-06314-101) of the intermediate gearbox. The continuity of the tail rotor drive system was interrupted, causing a loss of effective antitorque control. The gear failed because of inadequate quality control on the part of the manufacturer. That is, the manufacturer failed to detect a machining defect which resulted in stress concentrations on the bevel gear and the shearing of three gear teeth. RECOMMENDATION 1: a. Unit-Level Action: None. b. Higher-Level Action: None. c. DA-Level Actions: (1) Program Executive Officer - Aviation take action to have the manufacturer's bevel gear machining process reviewed and appropriate action initiated, as warranted, to improve the machining process and the quality control process. (2) Commander, U.S. Army Safety Center, inform interested agencies of the facts and circumstances surrounding this accident and the lessons learned. (See continuation sheet) 2. COOED SUMMARY OF ACCIDENT FINDINGS. SYSTEM INADEQUACIES, AND RECOMIMAIDATIONS a. Personnel 15) Mialaks/F-rror SystamInadoomMm RaroadWO.Mmormfflecorrrmodmiono Code m we PC 12) Rua) 1.15 U05.2 N05.3 131 aortae of Ope -ailon K 14) ATM flak No. NA 2. 3 P01 b. Personnel (Si Mist aka/Soar Coda Ill Duty. 121 Role.0 (31 Pnaae of Operation.141 AIM Task No. 2 3 _ -.1a IT-')•.7. --)v-11--T--":P Personnel (El Mistake/Error Code lU rarty (2 1 Role • 131 Mas. of Operation.MI ATM Tata No. 3 d. Materiel (4) Falba* Coda o:sorsEM DC] s.I (2) ProassorOpeation G 13 A05 131 Fait:id Pao Number 70357-06314-101 M12 3 A • , ••••!• ¦ ,•!. - Pt -4'1 e. Environmental (3) Concitton Coda • t.1 (11 Role. 5.12) Mena of OparatInn 1 a 3. CASE NO. a. DataNWAOM b. Time o. Acft Serial No 931001 1000 9212345 DA FORM 2397-2-R, JUL 94 Figure 3-3. Sample of a completed DA Form 2397-2-R, Part Ill—Findings and Recommendations 27 DA PAM 385-40 • 1 November 1994. DODDOA 022338 DA Form 2397-2-R (Cont'd) -- 93100110009212345 FINDING 2 (Present and Contributing: Human Error - Individual Failure): During an autorotation following the loss of tail rotor thrust, the UH-60A PC failed to properly scan his instruments, That is, he allowed his airspeed to decrease below the recommended minimum for autorotation IAW paragraph 9-23, TM 55-1520-237-10, when he concentrated on his intended point of landing. As a result, the autorotation terminated in trees, 40 meters short of the intended landing area, with major damage to the aircraft and fatal injuries to the PC. The PC's improper scan was the result of his excitement after the onset of the emergency. He was focused outside the cockpit at the intended landing area to the exclusion of monitoring his airspeed. RECOMMENDATION 2: a. Unit-Level Action: Commander, Company C, 2d Aviation Battalion, inform assigned personnel of the circumstances involved in this accident and the lessons learned. b. Higher-Level Action: Commander, 2d Aviation Battalion, direct increased emphasis on emergency procedures during trainina and standardization evaluations. c. DA-Level Action: None. THE FINDING LISTED BELOW DID NOT CONTRIBUTED TO THIS ACCIDENT. HOWEVER, IF LEFT UNCORRECTED, IT COULD ADVERSELY AFFECT THE SAFETY OF AVIATION OPERATIONS. FINDING 3 (Present but not Contributing): Upon receiving the Mayday call from the aircraft, the airfield control tower was unable to notify the activities connected to the primary crash alarm system via the direct wire intercom circuit because the circuit was inoperative. As a result, . RECOMMENDATION 3: a. Unit-Level Action: None. h. Higher-Level Action: Commander, Sand AAP, take positive command action to ensure tower personnel comply with the SOP requirements to daily test the crash alarm circuitry. c. DA-Level Action: None. Figure 3-3. Sample of a completed DA Form 2397-2-R, Part Ill—Findings and Recommendations—Continued DA PAM 385-40 • 1 November 1994 28 DODDOA 022339 Legend for Figure 3-3; Completion instructions for DA Form 2397-2—R 1. Block 1. Instructions for narratively reporting findings and recom­mendations. Each cause—related finding must be substantiated by the written analysis portion of DA Form 2397-3—R. As a minimum, the following elements of information will be reported for each finding in the order stated. Findings a. An explanation of when and where the error, materiel failure, or environmental factor occurred in the context of the accident sequence of events; e.g., "during preflight," "takeoff," "while driving," "while employing," etc. b. Identification of the individual involved by duty position; or the name and part number or national stock number (NSN) of the part, component, or system that failed; or a description of the environmental factor, as appropriate. c. For human error, identification of the task or function the individ­ual was performing and an explanation of how it was performed Im­properly. Refer to appendix B for mistake/error categories. The error could be one of commission or omission; e.g., an individual performed the wrong task, incorrectly performed the correct task, or failed to perform a required task or function. In the case of a materiel failure, identify the mode of failure; e.g., corroded, burst, twisted, decayed, etc. d. Identification of the directive (i.e. ATM, SOP, FM) or common practice governing the performance of the task or function. In lieu of a written directive, the error may represent performance that is contrary to common practice. e. An explanation of the consequences of the error, materiel failure, or environmental effect. An error may directly result in damage to equipment or injury to personnel, or it may indirectly lead to the same end result. A materiel failure may have an immediate effect on equip­ment or its performance, or it may create circumstances that cause errors resulting in further damage/injury inevitable. f. Identification of the reasons (system inadequacy(ies)) the human, materiel, environmental conditions caused or contributed to the acci­dent. Refer to the list and examples of system inadequacy(ies) pro­vided in appendix B. g. A brief explanation of how each reason contributed to the error, materiel failure, or environmental factor. h. Instructions for reporting findings that did not cause or contribute to the accident, but did adversely affect the severity of the accident results. The board should report those factors that contributed to the seventy of injury or extent of damage. Personnel injuries attributable to defects in life support equipment, personnel protective clothing and equipment or crashworthiness design should also be summarized as findings in this category. Injuries sustained from failure to use provided equipment, i.e., seat belts, must be also be addressed. The findings and recommendations fitting this category will be separated from those that caused the accident and will be preceded by the following state­ment THE FINDING(S) LISTED BELOW DID NOT DIRECTLY CON-TRIBUTE TO THE CAUSAL FACTORS INVOLVED IN THIS ACCIDENT; HOWEVER, IT (THEY) DID CONTRIBUTE TO THE (SE-VERITY OF INJURIES) OR (ACCIDENT DAMAGES). i. Instructions for reporting findings that did not cause or contribute to the accident nor to the severity of injuries. The board should report errors, materiel failures, or other hazards that did not contribute to the accident but have a high potential for causing other accidents or adversely affecting the safety of aviation operations if not corrected. Reporting these deficiencies will ensure they receive the attention of commanders throughout the chain of command to include Department of the Army staff safety personnel. The findings and recommendations fitting this category will be separated from those that caused the acci­dent, those that did not cause the accident but contributed to the seventy of injuries, and will be preceded by the following statement: THE FINDING(S) LISTED BELOW DID NOT CONTRIBUTE TO THIS ACCIDENT. HOWEVER, IF LEFT UNCORRECTED, IT (THEY) COULD ADVERSELY AFFECT THE SAFETY OF AVIATION OPERA-TIONS. Recommendations. Each finding will be followed by recommenda­tions having the best potential for correcting or eliminating the reasons (system inadequacy(ies) for the error, materiel failure, or environmen­tal factor that caused or contributed to the accident. Recommenda­tions will not focus on punitive steps addressing an individual's failure in a particular case. To be effective at preventing accidents in the future, recommendations must be stated in broader terms. Refer to the list of remedial measures in appendix B. The board should not allow the recommendation to be overly influenced by existing budgetary, material, or personnel restrictions. In developing the recommenda­tions, the board should view each recommendation in terms of its potential effectiveness; i.e., design improvement of a part that has a history of recurring failure is a better solution than recommending procedures to accommodate the deficiency. Each recommendation will be directed at the unit, command, or activity having proponency for and which is best capable of implementing the actions contained in the recommendation. The actions required at unit level, higher level, and Department of the Army levels of command will be addressed by each recommendation. If one or more of these three command levels had no action requirement, a negative report is required; e.g., "Department of the Army" level actions: None. "Unit level," "Higher level," and "Department of the Army" levels of action, as used in this context, respectively refer to the unit deemed most responsible for the acci­dent: the unit's chain of command, up to and including major Army command (MACOM), and DA—level activities. In cases where a MACOM is the highest level proponent for a recommended action having Army—wide application, the MACOM will be listed in the "Department of the Army level" category. 2. Block 2. Enter a coded summary of the findings and recommen­dations to Include duty, role, phase of operation, mistake/errors, aircrew training manual (ATM) tasks, system inadequacy(ies). Blocks 2a, 2b, and 2c pertains to personnel error, block 2d pertains to mate­riel failure or malfunction, and block 2e pertains to environmental effects or influence. All entries in block 2 will be consistent with and supported by the findings reported in block 1. a. Block 2a(1), Duty. Enter the code for the individual's duty posi­tion at the time the mistake/error was made. Refer to Table 3-5 for codes to be used. b. Block 2a(2), Role. Check "D" for definite, or "S" for suspected to indicate the contributing role of this individual. c. Block 2a(3), Phase of Operation. Enter the code for the phase of operation that was in progress at the time the mistake/error oc­curred (may be different from emergency or accident phase of opera­tion). Refer to Table 3-4 for codes to be used. d. Block 2a(4), ATM Task. Enter the ATM task number being performed at time the mistake/error was made. Enter "NA" if no ATM Task applies. (Note: For codes to be used for mistake/errors, system inadequ­acy(ies), remedial measures, materiel failures, and environmental con­ditions, refer to Table 3-7 and/or appendix B. Also prefix remedial codes with "U" for unit, "H" for higher, and "A" for DA, to indicate the level of command, the remedial action is directed.) Note: An abbreviated list of the codes and associated mistakes/errors, materiel malfunctions, environmental conditions, system inadequ­acy(ies) and remedial measures is provided at Table 3-7. Appendix B contains expanded descriptions and examples of the abbreviated codes. e. Block 2a(5), Mistake/error. In the space provided, enter the code of the mistake/error that best categorizes the error made by this Individual. f. System Inadequacy(les). In the spaces provided, enter the nu­merical codes of the system inadequacy(ies) that caused or permitted the mistake/error to become an accident cause factor. If there are 29 DA PAM 385-40 • 1 November 1994 DODDOA 022340 more than three system inadequacy(ies) associated with the first mis­take/error, skip the second duty and mistake/error entries and continue to list the additional system inadequacy(ies) spaces. g. Remedial measures. In the spaces provided to the right of each system inadequacy(ies), enter the codes for the remedial meas­ures selected to correct that specific system inadequacy. h. Continue the entries in blocks 2a, b, and c until all personnel who made errors causing or contributing to the accident, specified in the findings of block 1 above, have been coded. If number of entries exceeds space available, use blocks 2a, b, and c of an additional DA Form 2397-2-R to continue entries. For each duty code entered in blocks 2a, b, and c, ensure that a DA Form 2397-8-R is completed for each individual. i. Block 2d, Materiel. An entry is required for all materiel failure/ malfunction(s) that caused or contributed to the accident. If more than one materiel failure was involved, use block 2d of an additional DA Form 2397-2-R to continue entries. j. Block 2d(1), Role. Check "D" for definite, or "S" for suspected to indicate the materiel role in the accident. k. Block 2d(2), Phase of Operation. Enter the code for the phase of operation that was in progress at the time of failure/malfunction. Refer to Table 3-4 for codes to be used. I. Block 2d(3), Failed Part Number. Enter the manufacturer's part number. The number should coincide with the part number listed in block 3c of DA Form 2397-7-R. m. Block 2d(4), Failure code. Enter the code that best describes the material failure category. n. System Inadequacy(les). Enter the codes of the system in­adequacy(ies) that cause or permitted the materiel failure/malfunction to become an accident cause factor. If system inadequacy(les) identi­fying improper maintenance are selected, such as system inadequa­cies 13 and 14, and the duty code of the individual(s) can be identified, a resultant finding should be written as a mistake/error and considering the failure/malfunction as a result of the mistake/error instead of a materiel failure. The mistake/error would then be recorded in block 2a, b, and/or c. o. Remedial measures Enter codes for remedies in the spaces located to the right of each system inadequacy(ies). p. Block 2e, Environmental. This block is to summarize environ­mental conditions that had an adverse affect on human or equipment performance as related to the accident. Examples include unpredicta­ble weather phenomena (wind/turbulence) resulting in airframe dam­age; unsuitable work surface/space (unavoidable ditching in ocean or having to land in trees during forced landing); bird strikes damaging aircraft; illumination (too much or too little), etc. For the environment to be considered to have caused or contributed to an accident, it must have been avoidable or unknown at the time of the accident. If the environment does not meet the criteria, a mistake/error of failure to compensate for known or suspected conditions must be considered. If more than one environmental factor was involved, use block 2e of an additional DA Form 2397-2-R to continue entries. q. Block 2e(1), Role. Check "D" for definite, or "S" suspected to indicate the environmental role in the accident. r. Block 2e(2), Phase of operation. Enter the code for the phase of operation that was in progress at the time the environmental factor caused or contributed to the accident. s. Block 2e(3), Environmental code. Enter the code for the envi­ronmental factor. t. System inadequacy(les). Enter the codes of the system in­adequacy(ies) that caused or permitted the environmental factor to become an accident cause. u. Remedial measures. Enter remedial measure codes in the spaces located to the right of each system inadequacy(ies). 3. Block 3. Enter the case number as shown on the DA Form 2397-1-R. DA PAM 385-40 • 1 November 1994 DODDOA 022341 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT .REQUIREMENTS CONTROL I PART IV NARRATIVE. SYMBOL. For U68 01 this form, see AR 385.40 end DA Pamphlet 385-40: the proponent nanny OCSA . CSOCS-309 1. NARRATIVE ACCOUNT OF INVESTIGATION (Use format shown In OA Pamphlet 385-40) 1. History of Flight. a. Preflight phase. On 29 September 1993, the unit received a service mission from 2-14 Aviation Regiment Operations. The purpose of the mission was to .. The pilot-in-command (PC), CW3 Peter M. Pilot, and pilot (P1), CW2 Ronald A. Helper, were notified at 1600, 30 September 1993. Their preflight planning .. There was not sense of urgency associated with the mission or delays before departure. b. Flight phase. The aircraft departed on the mission at 0900, 1 October 1993. It was a routine flight until 0958 when an in-flight emergency occurred. During autorotative descent, c. Postflight phase. The aircraft came to rest on its left side with the engines running . . The PI and crew chief (CE) exited through the right cargo door unassisted. The PC exhibited no signs of life .. A small grass fire started in the vicinity .. The CE used a portable fire estinguisher .. A medical evacuation (MEDEVAC) helicopter evacuated the crewmembers to Theater Army Hospital at 1030. 2. Human Factor Investigation: a. Personal Background Information. (1) CW3 Pilot, the PC, entered the U.S. Army on 18 May 1978, at Ranakui, Hawaii. He completed flight school on .. His prior duty assignments were .. He was qualified in the following aircraft:.. He graduated from the UH-60 Instructor Pilot Course .. There was no evidence of safety violations or Flight Evaluation Board actions. He had accumulated 1,280 hours in the UH-60A, of which 29 hours were flown in the last 3 months. He (2) CW2 Helper, the PI, b. Personnel Management. (1) The PC was assigned to Company C on .. He was a Flight Activity Category (FAC) 1, Aviator. He completed Readiness Level (RL) 1 training on .. He spent approximately 20% of his time working on extra duties. The PC was highly regarded by his .. The PC's sleep and dietary habits .. The PC was on duty .. The PC was physically qualified to perform the mission. During the accident sequence the PC sustained fatal injuries (2) The PI was assigned to c. Aircraft Suitability. The accident aircraft was suitable for the mission d. Communications/Air Traffic Services. Investigation revealed not a factor. (See continuation sheet) ICASEa.Dam(YtwsW0). b. Tome. mArdtSariNNo. NM.931001.1030.9212345 DA FORM-2397-3-R, JUL 94 Figure 3-4. Sample of a completed DA Form 2397-3–R, Part IV—Narrative 31 DA PAM 385-40 • 1 November 1994 DODDOA 022342 DA Form 2397-3-R (Cont'd). 93100110009212345 3. Materiel Factors Investigation. a. Aircraft Airworthiness. UH-60A 92-12345 was airworthy with the exception of the intermediate gearbox input bevel gear (P/N 70357-06314-101). The discrepancy could not be identified without disassembly of the . until after failure . b. Flight Data Recorder. Aircraft was not equipped with a flight data recorder. c. Airframe. Investigation revealed not a factor. (Continue through Fire subparagraph) 4. Analysis. After analyzing the human, materiel, command, and environmental data collected during the investigation, the Accident Investigation Board concluded the accident was caused by materiel failure and human error. The rationale for this conclusion is as follows: a. command Data. The command policies and procedures were evaluated and determined to be a present but not contributing factor in that the Sand Army Airfield primary crash alarm system was inoperative due to .. The inoperative system went undetected because . b. Environmental Factors. The environment was not a cause factor in that the conditions were known to exist. The weather was VMC as forecast and briefed . c. Materiel Factors. Materiel failure was determined to be a cause factor in this accident. When tail rotor thrust was lost in flight due to failure of the intermediate gearbox input bevel gear (P/N 70357-06314-101), the flight crew was forced to attempt an autorotative landing. The input bevel gear failed due to a manufacturer's machining defect which served as a point of stress concentration. Three gear teeth departed the bevel gear and the intermediate gearbox failed. d. Human Factors. Human error was determined to be a cause factor in this accident. While making an autorotative emergency landing approach in response to the antitorque failure following an intermediate gearbox failure, the PC failed to follow procedures prescribed in TM 55-1520-237-10. That is, he did not .. As a result .. me may have prevented the accident had he . The PC erred because of inadequate scan. That is because of his excitement of handling the emergency, he channelized his attention on reaching an open area and was unaware the airspeed was decreasing to a critical point. Figure 3-4. Sample of a completed DA Form 2397-3-9, Part IV—Narrative analysis. Additional subheadings may be added as deemed neces-Legend for Figure 3-4; sary. It is Important that the narrative address all of the chronological Completion instructions for DA Form 2397-3–R events and evidence that had a bearing on the cause of the accident and/or have the potential for adversely affecting safety of future opera­1. Block 1. Narrative account of investigation. The board will report, tions. For accidents in which the investigation board determines thatin narrative form, the facts, conditions, and circumstances as estab­human error, materiel failure/malfunction or environmental conditions lished during the investigation and present this information in four were a factor, that portion of the narrative will be completed in itssections (history of flight, human factors, materiel factors and analy­entirety, as specified In the instructions below. The history of flight,sis). The first three sections will contain factual data. The analysis personnel background, personnel management, meteorological, air­section is reserved for the board's documentation of its conclusions/ worthiness, laboratory analysis, and analysis portions will be com­opinions conceming the accident cause relationships. Chapter 2, para­pleted for all accidents. For the remaining subheadings which thegraph 2-8, explains procedures for development of formal written investigation board determines were not a factor, enter after the sub­heading Investigation revealed not a factor and proceed to the next . DA PAM 385-40 • 1 November 1994 DODDOA 022343 subheading. Opinions concerning the accident cause relationship of evidence cited throughout the narrative will be discussed only in the analysis section. Use letter—size paper for continuation sheets as re­quired. a. History of the flight. (1) The preflight phase. Report type of mission involved, its purpose, how the unit became tasked with the mission and who or what activity authorized it. Identify the crewmembers selected for the mission by duty assigned and crewmember station, and indicate when and how they were informed of the mission. Describe the actions of the crew­members in preparing for the mission to include preflight planning, weight and balance determinations, briefings, filing flight plan, inspect­ing aircraft, etc. Describe facts which may indicate whether or not a sense of urgency was associated with the mission and if there were any delays prior to flight departure. (2) The flight phase. Indicate when the aircraft departed on the mission. If the mission involved more than one routine flight segment and there were interim ground stops before the accident occurred, concisely summarize these events until addressing the flight segment involving the accident. If the flight segment involving the accident contained an in—flight emergency, give a detailed description of the onset of the emergency to include where and when it occurred, symp­toms, warnings, instrument readings, etc. Also, describe actions/reac­tions of aircraft and crewmembers between the time of the emergency and when the aircraft came to final rest at the conclusion of flight. (3) The postflight phase. Briefly describe condition of aircraft, to include whether or not engine(s) was still operating, and condition of occupants immediately after the accident. Reserve details of injuries, impact conditions, kinematics, and crash forces for the crashworthi­ness part of the narrative. Reserve details of damage to various air­craft components for the materiel factors part of the narrative. If a postcrash fire occurred, so indicate and explain how and when it was extinguished, if applicable. Briefly summarize egress of occupants from aircraft, survival, and rescue; reserve details for the part of the narrative devoted to egress, survival, and rescue. b. Human factors. For accidents resulting from causes other than human factors, the human factors part of the narrative may be sharply reduced to negative comments for the subheadings except for sub­headings addressing personnel background information, personnel management, and meteorological conditions. (1) Personnel background information. This part of the narrative is extremely important in terms of providing a complete and informative profile of the principal persons involved. It should be a joint effort of reporting on the part of the IP/SP and flight surgeon members of the board. The sources of information will include, but are not limited to, personnel, flight, and training records, friends, peers, subordinates, superiors, and the persons themselves. Background information should primarily address the experience and qualifications of the indi­vidual upon arrival at the unit to which assigned at the time of the accident. For each rated crewmember who had a contributing role in the accident, briefly summarize service background to include date of service entry, initial flight training, type of assignments, and aviation qualifications acquired prior to joining current unit. Report aviator crew­members' background to include evidence of flight safety violations, flight evaluation boards, and history of prior aviation accident involve­ment. If the latter applies, explain role in prior accident. Describe experience in mission aircraft relative to how initially qualified, total flight time to date, and amount of flight time in past 3 months. The same scope of information is usually not necessary for non—rated crewmembers and/or passengers. If it is suspected or known that a non—rated crewmember or passenger was at the controls, or was functioning as an aerial observer, or in another possible cause—related role, summarize background and qualifications. This part of the narra­tive should also address the background and qualifications of person­nel not aboard the aircraft if they played a part in causing the accident. It can involve commanders, operations personnel, ATC and weather personnel, maintenance personnel, and others if applicable. (2) Personnel management. (a) Personnel management should primarily address how the Indi­vidual was managed by the unit to which assigned at the time of the accident. Review how the unit has managed each individual involved. Begin with the date of assignment to current unit and report how the individual was tasked, trained, and otherwise managed up to the date of accident. Describe aviation qualifications and readiness to perform the mission. Indicate whether or not each aviator was qualified and current in the mission, type, design, and series (MTDS) aircraft as­signed to the mission. Explain irregularities in the individual's training folder. (b) Discuss additional duties and the percentage of time given them versus their primary duty. Report qualifications acquired since assign­ment to unit such as checkouts In additional aircraft, appointments as IP, SP, IE, PC, UT, etc. Review the procedures involved in selecting the crew for the mission. Describe timeliness of notification, corn­patability of crew with mission, and the relative flight experience of the pilots if more than one was assigned to the mission. Describe aviator crewmembers in terms of their professional reputations in unit, opin­ions of peers, subordinates, and others who have flown with them, and so forth. Describe crewmembers' sleep and dietary habits and use of alcohol and nicotine. Review unit crew rest policy. Report whether or not a crew rest policy was In effect, being monitored and complied with. If postaccident flight evaluations were administered, summarize results. Highlight weaknesses in proficiency if appropriate, especially the performance of tasks duplicating those involved in the accident. (c) Report whether or not aviator crewmembers were physically qualified to perform mission, Discuss currency of flight physical. Ex­plain waivers and other Irregularities In medical history that may be relevant. Review results of the post accident blood and urine speci­men analyses and describe Irregularities. If none, so state. If an avia­tor crewmember was receiving medication before the accident, report type, source, dosage, side effects, and possible effect on perform­ance. Summarize the findings of the post accident medical examina­tion. If an aviator crewmember sustained injuries, give a brief description of the injuries and how they occurred. If an aviator crew­member sustained fatal injuries, briefly summarize autopsy report to include cause of death. (3) Aircraft suitability. Describe suitability of the accident aircraft to perform the mission. Consider flight and navigation instrumentation in light of prevailing weather conditions, fuel consumption in relation to range, power available In relation to planned gross weight and density attitude, aircraft design limitations as found in applicable operators manual, configurations, etc. (4) Communications/air traffic services. Describe evidence relating to communications equipment (adequacy of visual and electronic sig­nals, etc.) and the communication that occurred or failed to occur among the crew, between crew and passengers, and between crew and outside services; e.g., ATC, operations, FSS, command and con­trol, pathfinders, etc. Consider language difficulties, clarity of spoken words, adequacy and precision of instruction, etc. Summarize tape recordings of communications between crewmembers and ground sta­tions, if applicable. (5) Navigation aids. Describe adequacy of navigation aids (VOR, NDB, ILS, etc.) Consider FAA or other agency publications, NOTAMs, pilot reports, etc. (6) Meteorological information. Describe weather conditions that pre­vailed throughout the mission and conditions that existed at the acci­dent site at the time of the accident. Include sky condition, visibility, winds, icing, turbulence, and any significant weather conditions. Con­sider weather observations made by trained weather observers and/or witnesses In the area. If weather was considered a contributory factor to the accident, describe the accuracy of the weather forecast re­ceived by the aircrew. If the actual weather differed significantly from the forecast, Include a discussion of the information that was available to the forecaster. (7) Ground support services. Describe evidence that relates to the role of ground support services in the accident. Consider POL person­nel, ground guides, fire guards, etc. (8) Crash survival. Report results of crash survival investigation. Discuss crashworthiness of the aircraft in terms of crash sequence, impact conditions, kinematics, and crash impact forces. Include the performance of the restraint systems and the adequacy of the aircraft 33 DA PAM 385-40 • 1 November 1994 DODDOA 022344 structure to maintain occupiable space and attenuate crash forces. Explain occupant injury relationship to crashworthiness. Explain if inju­ries occurred during or after the crash sequence. Also include the performance of personal protective clothing and equipment; e.g., hel­met, visor, clothing, survival vest components, etc. (9) Emergency egress (including ejection or bailout), survival, and rescue. Discuss details of egress, survival, and rescue investigations. Describe where individuals were located in aircraft, how and where they exited aircraft, difficulties encountered, and position of aircraft at time of egress. Describe factors that may have enhanced or inhibited the success of the survival/rescue situation. Report when and how rescue personnel were notified and how long it took rescue personnel to respond to the initial notification, arrive at accident site, and evacu­ate the survivors. Explain problems associated with delays In rescue. (10) Special investigation. Report results of any special investiga­tions that were conducted because of the accident. If, for example, during the investigation, it is found that helmet mounted display or night vision systems were a factor in the accident, the applicable agency/program manager should be notified and a determination made as to their involvement. (11) Witness investigation. Briefly indicate number of witnesses in­terviewed and identify duty position. Summarize pertinent witness ob­servations and indicate whether or not witnesses generally agreed concerning accident events. Describe major conflicts in the provided information. Resolution of inconsistencies in the information should be discussed in the analysis portion of the report. Opinions regarding witness credibility should also be reserved for the analysis section. c. Materiel factors. Report results of materiel factors investigation in the appropriate subparagraphs. Those accidents that do not involve materiel failure/malfunctions may be abbreviated to include negative reports, if applicable, for all subheadings except aircraft airworthiness and laboratory analysis. Identify and discuss damage resulting from pre—crash materiel failure/malfunctions and omit damage that resulted from crash forces exceeding design limits. References can be made to the wreckage distribution diagram, photographs, reports, records, etc. Include the following areas: (1) Aircraft airworthiness. Describe the airworthiness of the aircraft, Investigation should include, but not be limited to, maintenance re­cords, historical records, interviews with maintenance personnel, weight and balance records, conduct of preflight, etc. Identify all defi­ciencies/discrepancies that had a role in the accident. Discuss those technical publications not complied with or inadequate in any manner. (2) Flight recorders. Report Information obtained from flight data recorders, if applicable. The board's analysis of this data, however, should be included in the analysis portion of the report. (3) Airframe. Use subparagraphs to report evidence obtained in the examination of the airframe structure and landing gear components. (4) Systems. Use subparagraphs to report evidence obtained in the examination of fuel, warning, flight control, hydraulic, electrical, stabil­ity augmentation/autopilot, and other aircraft systems. Note all discrep­ancies and their effects on the operation of the aircraft. (5) Powerplant. Report the evidence obtained during examination of the engine(s). Include indications of power at impact. List all discrep­ancies noted and their effect on engine operation. (6) Rotor systems or propellers. Report the evidence obtained dur­ing the examination of rotor systems or propellers. Describe any faults noted and their condition as a result of strikes/impact. (7) Transmissions/gearboxes and drive train. Report condition and describe any faults noted and cause, if known. (8) Laboratory analysis. Report the results of aircraft fluids, compo­nents, and parts submitted for laboratory analysis. (9) Crash site information. Describe adequacy of the crash site/ airfield (heliport, helipad, PZ, LZ, etc.) to include dimensions, lighting and marking, obstructions, type and condition of surface, slopes, etc. (10) Fire. Discuss the role of fire to include when it occurred, man­ner in which the fire was detected, ignition source, combustible materi­al, location, propagation, and degree of success in extinguishing. d. Analysis. (1) The analysis paragraph should summarize the first three paragraphs of the narrative to include the opinions and conclusions of the board and must conclusively show the cause and effect relation­ship of the evidence gathered during the accident investigation. The analysis should also discuss those potential factors considered but not supported or determined not to be factors by investigation board. The analysis discusses the influence of command activity or lack thereof in the occurrence or potential prevention of accidents. Subparagraph headings in the analysis may coincide with pertinent subparagraphs in the first three sections of the narrative, with the exception of command influence, which is reserved for the analysis paragraph only. As a minimum, the analysis part of the narrative will provide the following information: (a) Identify the Human errors, materiel failures, or environmental factors involved in the accident in the context of the accident se­quence of events. The explanations, examples, and key words are contained in appendix B. (b) Discuss the results/effects of the errors/materiel failures/environ­mental factors. (c) Identify the system inadequacy(ies) that caused or permitted the errors/materiel failures/environmental factors or injuries to occur. The definitions, examples, and key words are contained in appendix B. (d) Report preventable injuries in the context of crash survivability/ egress/rescue, and explain how they occurred. (e) Discuss the command Influence in the accident sequence of events, or the prevention of potential accidents. (2) To fulfill these information requirements, the board should review all the evidence relating to the accident disclosed during the human, environment and materiel factors investigations. This may require readdressing specific paragraphs contained in the narrative and indi­cating the relationships between the facts disclosed and the errors/ failures/environmental factors that occurred. From this review, the board should consider a logical development of the various circum­stances and events that may have existed. This process of deductive reasoning should lead to the formulation of an explanation (or expla­nations) concerning what caused the accident and preventable inju­ries, if they occurred, and why they happened. The explanation(s) should be discussed and tested against the evidence gathered during the investigation. If it is necessary to develop hypotheses, it is impor­tant for the board to state why a particular hypothesis was or was not supported by the evidence. (3) To initially outline and structure the correlation of cause—related errors/materiel failures/environmental factors and associated system inadequacy(Ies), the board will find it useful to review the definitions and examples of mistakes/errors, system inadequacy(ies), and reme­dial measures at appendix B, before composing the narrative part of the analysis. When the outline has been completed, the narrative rationale and conclusions should be composed using the following examples as a guide: (a) Begin the paragraph by specifying the scope and conclusions of the Investigation. In all cases, begin the paragraph with these words: "After analyzing the human, materiel, and environmental data collected during the investigation, the board concluded the accident was caused by . . . " Complete the sentence by specifying the factor(s) (human, materiel, or environment) which caused the accident, e.g., ".. . human error—leader failure." (b) Describe when or where the error/failure/injury/environmental factor occurred in the context of the accident chronology of events; e.g., "before the mission," "during takeoff," "during an NOE decelera­tion," "while Installing a hydraulic line," "during the in—flight ejection, "'during the crash sequence," etc. (c) Identify the duty position of the person who erred, became in­jured, or the name and part number or the national stock number (NSN) of the part, component or system that failed; e.g., "the pilot"; "the mechanic"; "the fuel control, NSN 2915-00-157-2313"; "the Input bevel gear, part number 2040405009;" etc. (d) Identify the error In the context of a listed mistake/error category; e.g., "incorrectly diagnosed the emergency at hand," "failed to assign responsibilities," "failed to detect," etc. If a materiel failure is being reported, explain the type of failure; e.g., "overheated," "vibrated, "'frayed," "decayed," etc. If an Injury is being reported, explain if the individual "struck" or "was struck by" the injury—causing agent. See appendix B for explanations. DA PAM 385-40 • 1 November 1994 DODDOA 022345 (e) Cite the directive or standard the mistake/error category failed to comply with; e.g., "contrary to standard and description for task 5007, TC 1-135;" etc. In the absence of written guidance/standards for a mistake/error, evaluate the task in terms of how other equally qualified and prudent personnel would perform the same task under similar circumstances. If the error represents performance that is unaccep­table, it is contrary to common practice. (f) Describe the specifics of the error; e.g., "he failed to initially increase collective to maintain the attitude of the tail rotor," "he exces­sively torqued the nut, PN 12345;" etc. (g) Describe the consequences of the error, materiel failure, environ­mental factor, or the resulting injury; e.g., "as a result, when he applied aft cyclic to slow to a full stop, the tail rotor struck the ground, damag­ing the tail rotor blades and causing a loss of antitorque control;-as a result, the aircraft landed hard;" "as a result, the pilot sustained a compression fracture of the T12-L1 vertebrae;" etc. (h) A complete error statement could read as follows: "During an NOE deceleration, the pilot improperly responded to the emergency as described for standard 2, task No. 5007, TC 1-135. That is, he failed to initially increase collective to maintain sufficient altitude for tail rotor clearance of the terrain. As a result, when he applied aft cyclic to slow to a full stop, the tail rotor struck the ground damaging the tail rotor blades and causing a loss of effective antitorque control." (i) A complete materiel failure statement could read as follows: "Dur­ing cruise flight, a section of the input bevel gear, PN 2040405009, eroded through. As a result, the continuity of the tail rotor drive system was interrupted, causing a loss of effective antitorque control." (4) Each statement of error, materiel failure, environmental factor or injury will be followed by statements identifying the system inadequ­acy(ies) that caused or permitted the errortfailure/injury to occur or an environmental factor to become a cause. The system inadequacy(ies) statements are the most important part of the analysis. This is be­cause the system inadequacy(ies) causing or permitting an error, fail­ure, or injury to occur or an environmental factor to become a cause are more important from a remedial standpoint than the error, failure, injury, or environmental factor itself. Each system inadequacy(les) statement will contain the following information: (a) A transition phrase to tie the system inadequacy(ies) to the error/ failure/injury; i.e., "the pilot improperly responded to the emergency because," "the bevel gear eroded to a point of failure because," "the pilot sustained the back injury because," etc. (b) Identification of the system inadequacy(ies) category(les); e.g., "because of inadequate motivation/mood (attitude)," "inadequate su­pervision by the unit operations officer," "because of inadequate qual­ity control on the part of the manufacturer,Thecause of inadequate seat design," etc. (c) An explanation of how or why each system inadequacy(ies) caused or permitted the error/failure/injury/environmental factor: e.g., "During the pilot's last standardization flight evaluation, the IP told the pilot he did not perform the NOE deceleration property and needed additional dual instruction. Regardless, the pilot chose to practice the maneuver by himself before he was given additional training. The IP contributed to the error because he graded substandard performance of the maneuver satisfactory during the standardization flight evalua­tion and he did not follow up the additional training. The unit opera­tions officer contributed to the error because, after the IP recommended the additional training, he scheduled the pilot for a tactical training mission before ensuring the pilot had received the additional training;" "the manufacturer's quality control procedures failed to detect a machining defect on the surface of the gear that became the source of progressive fatigue mechanisms;" etc. (5) Once the preceding elements of information are reported for each error, failure, Injury, or environmental factor in the manner stated, the resulting conclusions (findings) can stand on their own. The exam­ple of human error used in these instructions ties three system In­adequacy(ies) to the error. There would be more or less system inadequacy(ies) depending upon the circumstances. The point to be made is that system inadequacy(les) causing or permitting an error, failure, or environmental cause must be made visible before effective corrective actions can be recommended. (6) The analysis part of the narrative does not have to be limited to explaining and concluding what caused or contributed to the accident or Injuries. The analysis may also address present but noncontributing hazards if they could adversely affect the safety of aviation operations. There are provisions for reporting non-cause-related hazards. They are contained in the Instructions for completing the DA Forms 2397-2-R. 2. Block 2. Enter the case number shown on the DA Form 2397-1-R. 35 DA PAM 385-40 • 1 November 1994 DODDOA 022346 REQUIREMENT CONTROL SYMBOL TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT PART V - SUMMARY OF WITNESS INTERVIEW CSOCS•303 For Imo of mil form, see AR 385-40 and DA Pamphlet 585.40: the proponent agency is OCSA 1. NAME OF WITNESS.Fore, 1.14. 2. OCCUPATION/TITLE 3. GRACE 4. SSN 6. AGE Army Aviator/ HELPER, RONALD A. .Pilot W2 123-45-6789 24 B. ADDRESS (Include ZIP Cade, (If military, include organization) 7. TELEPHONE NUMBER DSN 666-2222 Co C, 2-14 Avn Regt 8. DATE OF INTERVIEW Fort Sand, CA 94111 2 October 1993 9. EXPEMENCE AND BACKGROUND 10. LOCATION AT TIME OF ACDT. Aviator.11. INTERVIEWER 7 yrq, Left scat of acdt seft . 900 hrs R/W flt time.MAJ Leader 12. Was a promise of confidentiality offered to the witnetbs?.5U YES . NO flf yes, reed b/k (Sc to the witness end complete b/k16. If no, reed b/k 151, to the witness.) Confidentiality was requested by the witness. D-0 YES . NO Of Yet. interviewer sir' and Aura wereeper Mewl THE WITNESS MADE THIS STATEMENT UNDER A PROMISE OF CONFIDENTIALITY. CeP ha.o4 ./Wf-3. &MAT RE OF INTERVIEWER. DATE 13. SUMMARY OF INTERVIEW CW3 Helper's statement ie summarized as follows; CW2 Helper and the PC preflighted the UH-60A, 9212345,'at 0730. They found no discrepancies and departed as scheduled at 0900. At approximately 0958, while in cruise flight at 1500 feet MSL and 120 knots, CW2 Helper heard a loud bang from the aft portion of the aircraft, followed by a loud grinding noise and an increase in vibration throughout the airframe. Simultaneously, the aircraft yawed about 30° to the right. The PC told CW2 Helper that he had lost antitorque control and Was going to autorotate to a cleared area to the front of the aircraft. The PC requested CW2 Helper to reduce the power control levers to "OFF" and send a Mayday call to Sand tower on a guard radio frequency. CW2 Helper complied and was acknowledged by Sand tower. The aircraft made an autorutative descent toward the cleared area, with airspeed at approximately 90 knots. As the aircraft neared 200 feet AGL, the airspeed decreased to less than 80 knots, and the rate of descent increased. CW2 Helper noticed that the PC was concentrating his attention on the cleared area, so he told the PC the airspeed was getting too low. The PC did not acknowledge, and about 2 seconds later, at a location about 40 meters short of the cleared area, the aircraft began a near vertical descent. The aircraft descended iuto the treetops with little forward airspeed and descended vertically into the trees. It continued its vertical descent to the ground and came to rest on its left side. CW2 Helper's door was blocked by the aircraft attitude, and he exited unassisted through the right cargo door along with the crewchief. The PC was extracted from the aircraft by CW2 Helper and the crewchief. CW2 Helper stated that the PC was unconscious. The PC exhibited no pulse or respiration and was bleeding from his nose and month. A grass fire had started in the vicinity of the hot exhaust pipe and was extinguished with the aircraft portable fire extinguisher. End of summary. . 14. CASE NO.. a. Date WV/MOO) b. Time c. Acts Serial No. 931001. 1000. 9212345 DA FORM 2397-4-R, JUL 94. Figure 3-5. Sample of a completed DA Form 2397-4–R, Part V—Summary of Witness Interview 36. DA PAM 385-40 • 1 November 1994 DODDOA 022347 15. GENERAL WITNESS INFORMATION BRIEFING Interviewer mut% read appropfare hweuerrona re am werwaaj a. Promise of confidentiality offered. b. No promise of confidentiality offered. (1) Thla Nock:lent Investigation board has been convened wider the provisions of AR 385-40 for the purpose of conducting a safety investigralon. (1) This accident investigation board has been convened under the provisions of AR 385-40 for the (2) This may be hut one of a number of Investigations being conducted regardkig this purpose of conducting ¦ safety investigation. accident; oolktteral or legal investigations may be ongoing as Wel. Those investigations are entirely separate from a safety investigation and ere also required to (2) This may be Just one of a number of investigations inform you of their purpose and of your legal rights. being conducted regarding this aoolden4 mesterei or legal investigations may be ongoing as wall. Those (3) This safety Investigation is being conducted for accident prevention purposes investigations ere entirely separate from a safety only. Within the military. pursuant to Army Regulation 385-40, k cannot be used for investigation and are also required to Inform you of their any other purpose, to include any future cirscripanary actions against any Incaviduals purpose and of your legal rights. Therefore, the Interview you are being asked to provide WI be used by the Army In the interest of safety and accident prevention only. (3) This safety investigation is being conducted for acddirit prevention purposes only. Within the military, (4) Noncontidential witness 'Minima maybe released to the public pursuant to a pursuant to Army Regulation 385-40,11 cannot be used Freedom of Information Act request. If you vAsh to pretest your interview from pubic for any other purpose, to include any future disciplinary release outside the military, then your interview must be pursuant to a promise of actions against any individuals. Therefore, the Interview confidentially. Conlidenttelity means that your Interview will not be released to the you are being asked to provide Wil be used by the public or outside DOD safety channels. AMY/ In the interest of safety and accident prevention only. (5) Whether your Interview is confidential or not, the chain at command wal review the final accident report, which may Include • summary of your interview. but the chain of (4) The chain of command will review the final accident command may only use the investigation report end the interviews for eatery and report, which may include a summary of your Interview, =dried prevention purposes. but the chain of command may only use the investigation report and the Interviews for safety and (6) If you ever have icnowiedge that your wanes& interview was used by the Army for accident prevention purposes. Theirderview summary anything other than accident prevention purposes (for example, disciplinary action may be released to the pubic pursuant to a Freedom of against an individual), you should consult with your local Judge Advocate Defense Information Act request. Counsel Office and request that the Command Judge Advocate, U.S. Army Safety Center, be notified at OSN 658-3260 or commercial (206) 255-3080. (5) It you aver have lotowlsrIcie that your witness Interview was used by the Army for anything other then (7) TM promise of confklentlailly is available to you ti you desire It. Do you desks if? accident prevention purposes (for example, disciplinary action against an InctMclual). you should consult with your Wei Judge Advocate Defense Counsel Office and request dist the Command Judge Advocate, U.S. Army Safety Canter, be notified at DSN 5584980 or commercial (2051255-3060. It. AVAILAshiTy OF PROUISE OF CONFIDENTIALITY FOR 'LIMITED USE' REPORT OF INVESTIGATION a. Pursuant to AR 385-40, witness Interviews may only be used within the military for purposes of accident prevention, and may not be used as evidence In connection with any administrative ordisdplinary proceeding. This protection alone does not prevent release of the interview outside of the military (to the public, newsparers, attorneys, etc.) under the Freedom of Information Act If you wish to protect your interview from release outside of the military, then your Interview must be pursuant to a promise of confidentiality. b. If you do not wish a promise of confidentiality, you may decline such below. In that case, your interview will still be used in the military only for purposes of accident prevention, but it may be released outside of the military in response to a Freedom of Information Act request. Please indicate which option you desire by initial! g one of the choices below: I request a promise of confidentiality. I understand that the results of my interview will be used with).the military only for the purposes of accident prevention, and will also be protected from public release outside of the military under the Freedom of Information Act. I decline a promise of confidentiality. I understand that the results of my interview will be used within the military only for purposes of accident prevention. I also understand that the results may be publicly released outside of the military under the Freedom of Information Act. I).. 6441 . at vatn ss((Pant)Pant() r , . Page 2 . REVERSE OF DA FOltil-2397-4 -11, JUL 94 Figure 3-5. Sample of a completed DA Form 2397-4-R, Part V—Summary of Witness Interview—Continued 37 DA PAM 3E15-40 • 1 November 1994 . DODDOA 022348 Legend for Figure 3-5; Completion instructions for DA Form 2397-4-R 1. Block 1. Self-explanatory. 2. Block 2. Enter general occupation of the witness and duty being performed at time of the accident, if applicable. Use duties listed at Table 3-5. 3. Block 3. Enter the grade of witness. Use one of the codes at Table 3-8. 4. Blocks 4, 5, and 6. Self-explanatory. 5. Block 7. List defense satellite network (DSN) number if applica­ble. 6. Block 8. Enter date(s) statement(s) was/were made. 7. Block 9. Summarize aviation experience and background; e.g., "Army aviator 10 years. Total flight hours 3,500 (RW 3,000; FW 500)." Indicate FAA ratings and approximate flight hours for nonmilitary pilot witnesses. Indicate MOS and approximate total flight hours for non­-aviator crewmembers drawing flight incentive pay. 8. Block 10. Enter location of witness at the time of the accident relative to flight path/impact of aircraft. 9. Block 11. Enter rank/grade and last name of person in charge of interview. If witness is interviewed by different persons in charge on separate occasions, list all interviewers in charge and prefix each name with "1st," "2d," "3d," etc., to designate which interview session the interviewer conducted. 10. Block 12. Check the appropriate box to indicate if the individual "Was/Was Not" offered a promise of confidentiality. Also, check the appropriate box to Indicate whether or not the witness requested a promise of confidentiality. If "Yes" was checked, the interviewer will sign and date the confidentiality statement. 11. Block 13. Complete the summary of interview block as follows: a. Multiple interviews, same witness. Prefix the summary of each interview with the date and indicate if the statement is the 1st, 2d, 3d, etc. b. Comprehensiveness. As a general rule, the interview summaries of persons occupying crew stations aboard the aircraft during the accident should be summarized in greater detail than the statements of others. This is because the crewmembers are the best source of Information pertaining to the accident chronology of events. The chro­nology for the "history of flight," DA Form 2397-3-R, will most often be obtained from the crew and should be used as a guide in determining what elements of information to Include In the interview summaries. If crew error appears to be involved in the accident, the mistake/errors and system inadequacy(les) listed in the instructions for completing the DA Form 2397-2-R are useful for determining what should be addressed in the crewmember witness summaries. c. Consolidating. When several witnesses, other than crewmembers, provide essentially the same observations, it is not necessary to pre­pare a separate DA Form 2397-4-R for each witness except for statements made with a promise of confidentiality. In cases where the summarized statements of several witnesses can be consolidated, it is appropriate to leave blocks 1 through 9 blank. In block 13, list the names of the witnesses and then summarize their collective observa­tions. d. Format. The proper format is a concise summary of information elements. An example is as follows: "This witness was occupying a passenger seat (identify location in passenger compartment) in the aircraft at the time of the accident. His account of the accident essen­tially agreed with the "history of flight" portion of DA Form 2397-3-R. Additionally, he heard a grinding noise in the area of the aircraft's transmission and felts a high frequency vibration where his boots contacted the floor of the airframe in the passenger's compartment." In cases where such is essential, limited direct quotes of a witness (to­gether with the specific questions they are in response to) may be used. This, again, should be done sparingly and only when necessary. It is Important that the statement be the investigator's summarization and not an exact verbatim transcript of what the witness said. The summary should be written in the third person ("the witness said,'"he said,°) and not the first person ("I saw," "I heard"). 12. Block 14. Enter the case number shown on DA Form 2397-1-R. 13. Block 15. Interviewer will read block 15a or 15b to each witness, depending upon the category and/or circumstances of the witness. 14. Block 16. Those witnesses which were offered a promise of confidentiality, must indicate acceptance or refusal by initialing the appropriate statement. 38. DA PAM 385-40 • 1 November 1994 DODDOA 022349 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT REQUIREMENTS CONTROL PART VI - WRECKAGE DISTRIBUTION SYMBOL For WO of this form. sae AR 385-40 and DA Pamphlet 385-40; the proponent agency Is ['GSA CSOCS-309 1. GRID: SHOW MAJOR GOUGE MARKS. DISTRIBUTION OF WRECKAGE, OBSTACLES, DIRECTION OF NORTH, WIND DIRECTION, WIND VELOCITY, POSITION OF WITNESS. ETC. Suggested Scale: V Equals 60'.Actual Seale: 1" Equals NOT TO SCALL LEGEND NAME 1. MAIN FUSELAGE 2. TREE 70 FT TALL 3. GROUND SCAR M/R BLADE L-5'. W-18", D-7" _4. M/R BLADE AND HUB_5. RIGHT COCKPIT DOOR 6. M/R BLADE PART 10'LONG 7. M/R BLADE PART 12' LONG 8 WITNESS A-INITIAL IMPACT B-MAJOR IMPACT DIST 22' 20.5' 35' 42' 61' 83' 145' DIR 120° 123° 020° 352° 047' 020° 3W' 246° N WIND 090°-10G18 )4. 8 2. CASE a. DATE (YYJAUDD) NO..931001 b. Time 1000 o. Actt Serial No. 9212345 3. OTHER AIRCRAFT SERIAL NO. DA FORM 2397-5-R, JUL 94 Figure 3-6. Sample of a completed DA Form 2397-5-R, Part VI—Wreckage Distribution 39 DA PAM 385-40 • 1 November 1994. DODDOA 022350 Legend for Figure 3-6; Completion instructions for DA Form 2397-5-R General. Orient the flight path (at instant of initial impact) along the horizontal or vertical axis of the grid and show the direction of true north, oriented to the top of the page, with an arrow. This procedure eases the task of locating the aircraft component(s) laterally and lon­gitudinally along the crash path. A suggested scale of 40 feet per inch is shown. Actual scale used is to be entered. Show wind direction with an arrow pointed in the direction of the windflow. Identify wind direc­tion in degrees and velocity in knots. 1. Block 1. Use grid to show the following information: a. Location of all aircraft major and significant components. b. Obstacles struck by aircraft in crash sequence; i.e., structure, trees, power lines, etc. c. Terrain marks made by aircraft in crash sequence; i.e., earth gouge length, width, and depth, snow or earth pushed in front of aircraft, etc. d. A profile view of the wreckage distribution, especially if the impact occurs on sloped terrain or on obstacles in the flight path. e. It necessary, use more than one form to show the profile view of the crash sequence, especially if the initial impact occurs on a tall tree or power line where a large vertical axis is needed. f. For midair collisions, construct a composite diagram (wreckage distribution of both aircraft superimposed on the same plot). g. For a widely scattered wreckage distribution, use a larger grid sheet if needed, and attach to this form. h. If the aircraft rolls over or noses over one or more times along the crash path, so indicate by use of curved arrows. i. Identify initial, major, and secondary impact points, as applicable. j. Show location of key witnesses. k. Show location of personnel thrown or ejected from the aircraft. Note: A polar diagram is another acceptable method of diagramming rotary-wing or fixed-wing accident sites. The top of the diagram can represent north. A readily identifiable portion of the wreckage e.g., fuselage, nose, wing, etc. can serve as a point of origin or pole for the diagram. Choose a scale that will allow plotting of the whole accident scene. Determine the compass heading of the aircraft at its final rest­ing place and position a semblance of the aircraft on the diagram so debris can be plotted from that point. Determine the compass heading and distance of pieces of wreckage from the main body of the wreck­age. Number the location of each piece of wreckage at the position it was found relative to the main wreckage. Define the numbers with a legend that identifies each piece of wreckage and shows its direction and distance from the main wreckage. 2. Block 2. Enter the case number as shown on the DA Form 2397-1-R, block 25. 3. Block 3. Use only for aircraft other than "case aircraft" in acci­dents involving more than one aircraft. Enter serial number of other aircraft to which the form applies. . DA PAM 385-40 • 1 November 1994 DODDOA 022351 TECHNICAL REPORT OF U.S. ARMY AIRCRAFT ACCIDENT REQUIREMENTS CONTROL PART VII - IN-FLIGHT OR TERRAIN IMPACT AND CRASH DAMAGE DATA SYMBOL For use of this form, see AR 385-40 and DA Pamphlet 385-40; the proponent agency Is OCSA CSO CS­309 1.. IN-FUCHT COLLISION KINEMATICS AT INSTANT OF IMPACT a. Airspeed Al Impact (knots) 5 b. Vertical Speed fleet per minute).700 . Up.131 Down o. Flight Path An .(degrees). 85 CI UP. ® D own d. In-Flight Attitude At Impact (1) lakoh. (2) Rol ' AnEd• l'". AVG --., Degrees._5___ lii Up. Degrees 1........*.:, 8 RLSZthi gmemmommomigg a. Obstacle identity And Collision Height Collision He/04Ahove Ground Obstacle (1) 0 Birds (2) . Aircraft (3) . Winer/Cables (4) 0 Vehicles (3) c4 Tree 68 (S) . Other 2..TERRAR4 COLLISION KINEMATICS AT INSTANT OP MAJOR IMPACT a. Ground Speed a! Impact b. Vartkza Speed ID Up.Cia Down. e. Flight Path Mate 0Up.02Down. f. Attitude at Major Imperil (1) Pitch. ti ) i. 0.pcnots) 1 ann.(FPM) 90 .(degrees) 2) Rol. r. Obstacle Strike Sequence Mire-1, 2. 3, Mc. Jo show ?aquiline of alr14) ...._ PropfRotor. -Landing Gear Rotor Mast. _Wing Tail Rotor. _Empennage Tell Boom. WSPS Windscreen ._FL1R _.LWR Nosa/Gun Tan*.-Other (Specify) g. Obeacie Conspleutty (WW1 eockleni defence torn ekes position. h. *WWI k Its amounellnys was obestrseil (1) lig Completely.(2) 0 Parriaily.(3) (',f Not Obscured h. Wks or Cable Description Type I.Dia In Inches No. Struck (1) Power Transmission 0) Telephone or TV (3) Bracing allSitlfPP3f9 (4) Othee (Specify) I. WSPS (1) Installed.Cg Yee 0 No.(2) Cut Wire 0 Yea 0 No f. Obstacle Struck Other Than Wire (demote( ki Inches) 12" d. indicate by Cheek Marks WWII TWo of The Three Preceding Parameters (a, ts, c) Are The Most Aocurale a. 0.b. on.a. In e. Impact Angle 90 .(deognsaa) (3) Yaw -:- (2).lit., Degrees.10.(mop.0 Down. Degrees.5.cv Left.0 Right. Degrees .0.. Left.. Right 3.. ROTATION AFTER MAJOR IMPACT a. OW Alta an Rotate About Any Axis Marne Above Major Impact (Nye,. complete horns S. C. and a) ag Yea.0 No..Unknown b. Roll Degrees I:12W.ORIghl.Degrees.85 4.. a. Velloal (SW 0 Up.ori ()own.O's.1 5 S. CASE a. Date (YYMMOD) b. Time No. c. Yew Degrees d. Pitch Degrees . Left.0 Right.Degrees.0 . Up.. Down Degrees.0 IMPACT FORCES RELATIVE TO AIRCRAFT AXES (SW b. Longlnalinal (We) c. Lateral (WV 0 Fore.. A3.CII. 9.-- as Left.. Right.G's.2 e. Adt Serial No. S. OTHER ACFT SERIAL NO. 931001 1000 9212345 DA FORM 2397-6-R, JUL 94 Figure 3-7. Sample of a completed DA Form 2397-6-R, Part VII—In-FlIght or Terrain Impact & Crash Damage Data 41 DA PAM 385-40 • 1 November 1994. DODDOA 022352 7..Ft/SE/AGE INWARD DEFORMATION OR COLLAPSE AND INJURY RELATIONSHIP (Check awe/ulna Pomo.) Specific Area of Deformation or Camps, Fuselage Deformation Produced/Contributed to Injury Fuselaoe Area Amount or Typo of Deformation or Collapse Cockpit Forward Cabin Area Mid Cabin Area Res, Cabin Area Cockpit Forward Cabin Are. Mid Cabin Area Rear Cabin Area (11 (21 1 3) 141 15) Plit (7. (Eli a. Roof Up to 1 Foot Mora Than 1 Foot But Lass Than a Feet X X X More Than 3 Feet Foot b. Left Side Up to 1 Foot Mora Than 1 Foot O. Right Side Up to 1 Foot More Than 1 Foot X X X d. Nose Up to 1 Foot igginqiWalfraUl iq::.,•,•-r.1.•i: !;.::.:ri:5: More Than 1 Foot 4:ir.'4,1IE • .igit.laiZ,:ii .41.4.,.1.gif• :.: at. Floor Up to 1 Foot Mona Than 1 Foot f. Floor ((our Vertical deformation Sidaward under "af'9 Forward/Rs orword 5.. LARGE COMPONENT DISPLACEMENT (Chock opproptiole boxers) Cookpit Cabin Displaced Torn Fr ee Component Penetrated/Entered Penstrittad/Entarad 111 12) 13) 14) a. Tranominian p(awarclor min) X X b. Transmission (ray) C. Rotor Slade (forward Or TAW) X X d. Rotor Mode (rest or tali) a. Landing Geer (aPecr/ loGalkm).Left X f. Other (specify) S. . POSTCRASH FLAMMABLE FLUID SPILLAGE a. Equipped With Creshworthy b. ti Se Equipped, Did • . Amount and Type Fluid 5pSlad Fuel System areskaway Valves Separate Gallons Fuel (Type) Oil (Typo) Hyd Fluid (TS?.) Other (Specify) as Designed 0 - 1 El Va•.. No [JYas.No El NA 1 - 2 0. Flammable Fkid 8piiiag• d. Auxiliary Fuel tanks Installed 2-10 MIL23699 Occurred 10 Yam.. No 10- 20 • Internal 511 External 20 E Yet . No Crash...Any.• Yes fl No 10.. SPILLAGE SOURCE Part &.Port Noma/NornencIsture b..Part Number c..National Stock No. (1) Call/Tank/Reservoir 121 Fitter (3) Fitting (4) Fluid Line Elbow, Tube AN 833-16D 4730-00-197-2920 (5) Value teo Breakaway Valve • (71 Other (Specify) (81 Other ISpecJfy) (91 Other (Speci(y) 11. REMARKSII ESSS external tanks, 2 ea.. 230 gal., installed but were empty. REVERSE OF DA FORA! 2397-8A JUL .94. Papa 2 Figure 3-7. Sample of a completed DA Form 2397-6-R, Part VII—In-Flight or Terrain Impact & Crash Damage Data&—Continued . DA PAM 385-40 • 1 November 1994 DODDOA 022353 Legend for Figure 3-7; italicCompletion instructions for DA Form 2397-6--R 1. Block 1. This block is required for in-flight collisions, such as a midair collision, wire strike, bird strike, tree strike, etc. If doubt exists as to whether this block or block 2 should be used, both blocks can be completed. For example, the aircraft may strike a structure during an approach and continue under control some distance forward and crash; thus, in-flight and terrain collisions are Involved. Near simulta­neous impacts with trees, structures, etc., and the ground require only block 2 to be completed. In other cases, such as a bird strike, in which a subsequent routine landing is made, only block 1 would be checked. If the information desired in these blocks cannot be determined, so state in the box(es) provided for the information. a. Block la. Estimate or analytically determine and enter the air­speed (knots) just before impact. b. Block lb. Estimate or analytically determine and enter the verti­cal speed (feet per minute) just before impact, and check whether "up" or "down." If zero, enter0" in space provided and do not check "up" or "down" box. c. Block 10. Enter the flight path angle (degrees) at major impact and check whether "up" or "down.' d. Block ld. Enter the pitch and roll angles (degrees) at moment of impact and check the appropriate direction. e. Block le. Check obstacle(s) struck while aircraft was in flight. For example, contact with a hangar building would be checked as "Other." Also enter collision height above the ground. f. Block lf. Check box to identify area of aircraft that sustained the strike. If aircraft sustained a strike at more than one location, check several boxes and indicate 1st, 2d, 3d, to show strike sequence. g. Block 1g. Check the appropriate box to reflect the wire/cable(s)/ obstacle conspicuousness to the pilot under the environmental condi­tions and terrain at the time of the accident. h. Block lh. Enter the outside diameter for the type cable/bundle struck. The outside diameter of the wire bundle/cable including Insula­tion is desired, not the individual wire inside the bundle or cable. Enter the number of wires struck in the impact; i.e., in a five-cable power transmission line, only three cables may be struck. i. Block 11. Check whether or not a wire strike protection system (WSPS) was installed. Also check whether or not the WSPS cut the wire. j. Block 11. Enter outside diameter of tree limb, pole, bush, etc., that was struck, if applicable. 2. Block 2. Complete this block to show terrain collision kinematics at instant of major impact. If block 1 was filled out and aircraft contin­ues under control after in-flight collision and then sustains further damage upon ground impact, complete block 2 also. If aircraft sus­tains in-flight damage such as from a bird strike and then makes a routine landing, block 2 does not have to be filled out. a. Block 2a. Estimate or analytically determine and enter the ground/horizontal velocity (knots) at the instant of the major impact. The horizontal velocity is desired. This value is not to be confused with airspeed or resultant velocity. The ground speed vector combined with the vertical speed vector can be used to determine the resultant veloc­ity as shown for sample high angle and low angle impacts. b. Block 2b. Estimate or analytically determine and enter the verti­cal speed (fee per minute) just before impact and check whether"up" or "down." The vertical speed at impact can be combined with ground speed to yield the resultant velocity as discussed above. c. Block 2c. Enter the flight path angle (degrees) just before im­pact and check whether "up" or "down." d. Block 2d. Indicate by check marks which two of the three parameters above are the most accurate. Since any two items can determine the third, it is necessary to determine which two (a or b, b and c, or a and c) the investigator feels are most accurate. Check only two boxes. e. Block 2e. Enter the impact angle (degrees). f. Block 2f. Enter the pitch, roll, and yaw attitude (degrees) of aircraft at the Instant of Impact. (1) Pitch. Enter degrees and check "up" or "down" pitch in appropri­ate box. (2) Roll. Enter degrees and check "Left" or "Right" roll in appropriate box. (3) Yaw. Enter degrees and check "Left" or "Right" yaw as appropri­ate. If nose is to left of flight path, check "Left" box; if nose is to right, check "Right" box. 3. Block 3. a. Block 3a. Check the appropriate box. b. Block 3b. Enter the roll in degrees for the appropriate direction if the aircraft rolled significantly after the major impact. A value should be entered even if the aircraft comes to rest in the original attitude after it has rotated during the crash sequence. c. Block 3c. Enter the yaw in degrees for the appropriate direction if the aircraft yawed significantly after the major impact. A value should be entered even if the aircraft comes to rest in the original attitude after it has yawed during the creash sequence. d. Block 3d. Enter the pitch in degrees from the horizontal (level) attitude if the aircraft pitched (nose up or down) after major impact, and check the appropriate box to indicate if the pitch was up or down. For example, if an aircraft rotates forward about the nose as a fulcrum; I.e., a forward pitching motion, check "down." 4. Block 4. a. Block 4a. Estimate or analytically determine and enter the verti­cal force (g's) at the aircraft center of gravity (CG). Check whether the force was "up" or "down." b. Block 4b. Estimate or analytically determine and enter the lon­gitudinal force (g's) at the aircraft CG. Check whether the force was "fore° or "aft." c. Block 4c. Estimate or analytically determine and enter the lat­eral force (g's) at the aircraft CG. Check whether the force was"left" or "right." 5. Block 5. Enter the case number as shown on the DA Form 2397-1-R. 6. Block 6. Use only for aircraft other than "case aircraft" in acci-dents involving more than one aircraft. Enter serial number of other aircraft only on each DA Form 2397-6-R that applies to other aircraft. 7. Block 7. This block shows fuselage structural deformation or col­lapse and its relation to personnel Impact injuries. The areas of fuse­lage most likely to be deformed are stated in items a through f. The location of the deformation is indicated in the four columns labeled cockpit, forward, middle and rear cabin. If the deformation or collapse caused injuries to personnel, the appropriate box of item 7 should be checked. Information in this block shall agree with the injury cause mechanism identified in DA Form 2397-9-R and the life support equipment failure modes identified in DA Form 2397-10-R (Technical Report of U.S. Army Aircraft Accident). a. Blocks 7a-e. Check column(s) 1 through 4 to show the location of deformation for each fuselage area. As a general rule, deformation of 3 inches or less is not enough to be recorded because injuries are not likely to result from such movement. If personnel injuries were caused by fuselage structural deformation, columns 5 through 8 should be checked in the appropriate box. Injuries caused by nonuse of restraint and seat failure and other injuries not related to fuselage deformation are not to be recorded here. b. Block 7f. Check box to indicate whether the floor was deformed locally under the seat structure. This type deformation may occur as a result of external rock or tree stump impact. For example, if one seat 43 DA PAM 385-40 • 1 November 1994. DODDOA 022354

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75