Aviation Accident Investigation Template Exhibit 9-3 Page 7
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10Chapter 9—Aviation Investigations
EXHIBIT 9–3
(continued)
Preliminary Factual Section
• Flight and duty limitations.
B. Who reviews these documents on the unit? What is
• Contracting.
done about problems identified? Determine timeliness
• Airport guides.
of submission including review.
• Minimum altitudes.
C. Were other unit incident reports reviewed and dis-
• Safety briefings.
cussed by the individuals involved in the accident? Is
• Other.
a file available?
B. Identify and discuss special mission procedures as
D. Are other unit reports or safety alerts available and
they are related to the accident.
used?
29. Training and Qualifications
33. Mission risk factors.
A. The purpose of this section is to evaluate the training
A. Determine whether a risk analysis has been performed
and qualifications of personnel including supervisors
and by whom. Is it current and applicable to the
involved or directly associated with the accident.
accident mission? Who was involved; management,
B. Identify and discuss specific violations of established
pilot, crew, incident commander?
policy.
B. Determine whether risk determination is a consider-
ation in mission planning. How frequent? Supervision
30. Records management.
and oversight?
A. Identify and discuss whether directives, operational
C. Establish what part the risk analysis played in the
guides, contracts, manifest, and so forth, were readily
accident mission.
available and properly utilized by personnel associated
with the accident. Were they current?
34. Safety emphasis. The objective of this section is to
B. Other records to consider:
determine the safety emphasis at each level of the organi-
• Timesheets and overtime records.
zation as it applies to this accident.
• Dispatching logs and communications records.
A. Who provides emphasis on safety?
• Forest aviation plan, fire plan, and so forth.
B. How is it provided? Accountability?
• Daily diaries.
C. What is the frequency of briefings?
• Other ICS forms, and so forth.
D. When was the last safety briefing held?
E. Do the district ranger, fire management officer, forest
31. Accident prevention opportunities.
fire staff, forest aviation officer, and others participate?
A. Attitudes and performance
• Discuss attitudes of personnel involved in the
accident and their peers concerning:
—Use of PPE.
Findings
—Records management.
—Training guide and handbook compliance.
35. Develop findings from supporting data. Findings are the
—Pilot and contractor performance.
conclusions of the accident investigation team based on the
—Past operational practices.
facts, weight of evidence, professional knowledge, and good
—Weather, terrain, and fire behavior predictions.
judgment. Each finding should, where possible, be supported
—Safety practices and standard orders.
by two or more facts from the investigation.
—Management oversight.
A. Divide the listing of findings into sections by subject
matter. For example:
32. Incident reports. The purpose of this section is to
• People
determine whether 5700–14s, SAFECOMs, safety
—Pilot
documents, and other operational information is routinely
—Personnel
completed and submitted. Establish the following:
—Management
A. History of submission by the unit/individual. Deter-
• Equipment
mine whether any are related to the accident being
—Aircraft
investigated. If relevant include a listing of reports and
—Fuel Truck
actions taken to correct at the field and Forest level.
(Continued)
Exhibit 9–3—Aviation accident investigation template.
99
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