Army Pamphlet 385-40

18 March 2015

UNCLASSIFIED

Safety

Army Accident Investigations and Reporting



SUMMARY of CHANGE

DA PAM 385-40
Army Accident Investigations and Reporting

This major revision, dated 18 March 2015-—

* Changes Armed Forces Institute of Pathology to Armed Forces Medical Examiner System (para 2-1 c (4)(d)).

* Adds additional definitions (glossary).



Chapter 1
Introduction

1-1. Purpose

This pamphlet provides implementation instructions for the investigation and reporting of Army accidents and incidents, as directed by AR 385-10 .

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 .

1-4. Methodology

a. Accidents should be investigated to the degree necessary to identify the immediate mistake(s)/error(s)/failures(s), and system inadequacy(ies) which may have caused, or contributed to, the accident being investigated. The techniques and procedures contained in this pamphlet and AR 385-10 will be used in preparation of all accident reports. Appropriate forms ( DA Form 2397 Series, (Technical Report of U.S. Army Aircraft Accident), DA Form 2397-AB (Abbreviated Aviation Accident Report (AAAR)), DA Form 2397-U (Unmanned Aircraft System Accident Report (UASAR)), DA Form 285 (Technical Report of U.S. Army Ground Accident) or DA Form 285-AB (Abbreviated Ground Accident Report (AGAR) 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 U.S. Army Combat Readiness Center (USACRC) contacted telephonically.

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 be attributed to one or more system inadequacy (or sometimes referred to as "root cause"). The system inadequacies responsible for human error are categorized as leader, standards, 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(ies) responsible for correcting each identified system inadequacy can be notified. This procedure is called the "3W" approach to information collection, analysis, and corrective actions (see 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/failure). 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 happened (system inadequacy(ies)/root cause(s)). Identify the system inadequacy that permitted the accident to occur. Explain how and under what conditions those mistakes/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.



Figure 1-1. "3W" Approach to Information Collection, Analysis and Recommendations


1-6. Safeguarding Personally Identifiable Information and Accident Information

a. PII is information which can be used to distinguish or trace an individual's identity, such as his or her name; social security number (SSN); date and place of birth; mother's maiden name; and biometric records, including any other personal information which is linked or linkable to a specified individual. Individuals collecting and handling PII must ensure that any personal information contained in a report of an accident, of which they have access to and are using to conduct official business, shall protect that information so that the security and confidentiality of the information is preserved. Individuals with access to this information must not disclose any personal information contained in any report of an Army accident, except as authorized by Army or Department of Defense (DOD) regulations. Personnel willfully making such disclosure when knowing that disclosure is prohibited are subject to possible criminal penalties and/or administrative sanctions.

b. The Army will capture SSNs for only those individuals who have been injured or have had an occupational illness or those individuals who are identified as having a finding that was present and contributing to the accident or present and contributing to the severity of the injury or equipment damage. The SSN of investigation board members, subject matter experts, or organizational points of contact, witnesses, or other personnel not directly linked to the accident must not be captured on any document in Army accident reports. The SSN for those individuals who have had an occupational illness/injury or who are culpable in the accident must be included on certain forms only. The SSN is captured on the DA Forms 2397-8 (Technical Report of U.S. Army Aircraft Accident, Part IX, Personnel Data), DA Form 2397-9 (Technical Report of U.S. Army Aircraft Accident, Part X, Injury/Occupational Illness Data), (AAAR), and Unmanned Aircraft System Accident Report (UASAR) for aviation accidents and on the DA Form 285 and Abbreviated Ground Accident Report (AGAR) for ground accidents. Security of the SSN is particularly important as the accident investigation report is being assembled. Be extremely careful not to compromise the SSN on any draft document that is later discarded.

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 this pamphlet and AR 385-10 . Additional attachments, drawings, extracts, or other supportive media are encouraged 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 and of this pamphlet and apply to accidents involving military and Army civilian, contractor, and visiting civilian personnel. Reports can be submitted to USACRC through the automated reporting system, via e- mail, fax or the postal service.

1-8. Occupational Safety and Health Administration recordkeeping requirements

Occupational Safety and Health Administration (OSHA) recordkeeping requirements for military and Army civilian personnel are outlined in AR 385-10 and appendix I of this pamphlet.

1-9. Types of accidents and incidents

The various types and specific exceptions follow: When two or more types of Army vehicles, such as an Army motor vehicle (AMV) and an Army combat vehicle (ACV) are involved in an accident, the type of equipment operated by the individual deemed most responsible will determine the accident type. This process is also true for other types of accidents (for example, fire, marine, and explosives).

a. Army aircraft accident.

(1) Flight accidents. Those accidents in which intent for flight exists (as defined in the glossary), and there is reportable damage to the aircraft itself. (Explosives, chemical agent, or missile events that cause damage to an Army aircraft with intent for flight are categorized as flight accidents to avoid dual reporting.)

(2) Flight-related accidents. Those aircraft accidents in which there is intent for flight and no reportable damage to the aircraft itself, but the accident involves a fatality, injury to aircrew, ground crew, passengers, or other injury or property damage. These accidents are not to be used in the calculation of flight accident rates. For example, unintentional cutting of a hoist cable; failure or malfunction of a hoist system to include related equipment; unintentional jettisoning of cargo hook load or external stores.

(3) Aircraft ground accidents. Injury or property damage accidents involving Army aircraft in which no intent for flight exists and the engine(s) is in operation (an installed aircraft auxiliary power unit (APU) is not considered an aircraft engine). In the case of an Aerostat balloon accident there must be no intent for flight and the system must be operational. See the definitions of intent for flight and operational Aerostat balloon in the Glossary, Section II Terms, of this pamphlet.

b. Army Motor Vehicle accidents.

(1) An accident involving a motor vehicle owned by the Army may be classified as an AMV accident if the vehicle meets the following criteria:

(a) The vehicle is primarily designed for over-the-road operation.

(b) The vehicle's general purpose is the transportation of cargo or personnel (for example, passenger cars, trucks family of medium tactical vehicles (FMTVs), high-mobility multipurpose wheeled vehicle (HMMWV), ambulances, buses, motorcycles, fire trucks, and refueling vehicles).

(2) Army motor vehicle accidents involve the operation of an AMV when one or more of the following occurs:

(a) Collision with other vehicles, objects, or pedestrians.

(b) Personnel injuries or property damage due to cargo shifting in or falling from a moving vehicle.

(c) Personnel injuries occurring in moving vehicles or caused by falling from moving vehicles.

(d) Accidents occurring when a vehicle is being towed or pushed by an AMV.

(e) Other injuries and property damage as described in AR 385-10 .

(3) Accidents involving AMVs not reportable as AMV accidents. The following accidents, although reportable, are not considered AMV accidents. They are reportable under other accident types.

(a) Personnel injuries that occur while loading or unloading or mounting or dismounting a motor vehicle that is not moving.

(b) Injury/occupational illness or property damage occurring solely from repair or service work (for example, a vehicle falling off a jack or hoist, a tire explosion during inflation, or a finger cut off by a fan belt).

(c) Damage to a properly parked AMV unless it is damaged by another AMV.

(d) Cargo directly damaged by environmental factors.

(e) Damage to an AMV resulting solely from environmental factors (act of nature).

(f) Damage to an AMV being handled as a commodity and not being operated under its own power (excludes towing or pushing accidents).

(g) Damage to a moving or parked AMV caused by objects thrown or propelled into it.

(h) Damage to an AMV by fire when no AMV accident occurred (where the primary cause of the damage is the fire) when the vehicle was not in operation.

(i) Malfunction or failure of component parts, if that is the only damage.

(4) Accidents involving a privately owned vehicle/private motor vehicle (POV/PMV) and an AMV in which the AMV driver is not at fault will be reported to the local safety office. However, these accidents will not be recorded in the Army Safety Management Information System (ASMIS) unless recordable injuries are incurred by Army personnel or recordable Army damage occurs. (If recordable injuries or damage to Army equipment occur, report in accordance with AR 385-10 , chap 3.)

c. Army Combat Vehicle accidents. These accidents occur during the operation of an ACV or combat equipment, such as a tank, self-propelled weapon, armored personnel carrier, Stryker, Mine Resistant Ambush Protected (MRAP), or amphibious vehicle ashore. Additionally, injuries and property damage incurred during operation of installed ACV armament systems also qualify as an ACV accident (even if the vehicle is not in motion).

d. Other Army Vehicle accidents. Other Army Vehicle (OAV) accidents involve the operation of an Army vehicle other than those cited in paragraphs a through c , above; (for example, aircraft tugs, motorized scooters, Gators, bulldozers, forklifts, trains, and similar vehicles). These are included in AMV accident statistics.
Note. For Army train/rail and vessel accidents, additional technical information and assistance is available from the U.S. Army Transportation School (Safety Office), Defense Service Network (DSN) 826-6619, COM (757) 878-6619; vessels: DSN 827-1327, COM (757) 878-1327.

e. Army Operated Vehicle accidents. Accidents that involve vehicles that are leased, such as, General Services Administration (GSA) and government-owned, contractor-operated vehicles that are under full operational control of the Army (for example, hand receipt or like document) or vehicles rented by DA for official business, to include U.S. Army Reserve (USAR) components. These are included in AMV accident statistics.

f. Privately owned vehicle accidents. These accidents involve the operation of a motor vehicle that is privately owned by an individual that results in any injury/occupational illness to Army military personnel. This category also includes Army personnel operating a POV/PMV on official business.

g. Marine accidents. (see para 5-1 ).

h. Fire. A fire is the unintentional, destructive, and uncontrolled burning of combustible solids, liquids, or gases. Fire accidents involve —

(1) Equipment fires. Units will ensure that all fires are reported to the installation safety office. AR 420-1 requires all fires that cause damage to Army equipment to be reported through National Fire Incident Reporting System (NFIRS) by the installation fire department. In addition, the unit will submit the appropriate DA Form 285-series form on those equipment fires and explosions listed below if there is fire damage to —

(a) Wheeled vehicles or components thereof.

(b) Tracked vehicles or components thereof.

(c) Aircraft (ground) (excludes those reported on the DA Form 2397-series or DA Form 2397-AB.)

(d) Ammunition/explosive fires (production, use, and storage).

(e) Missiles, to include subsystems.

(f) Tents.

(g) Space heaters.

(h) Generators.

(i) Other equipment (masks, weapons, and so forth).

(2) Facility fires. Army Fire and Emergency Services organizations will report all fire department responses using the NFIRS as required by Department of Defense Instruction ( DODI ) 6055.06 and AR 420-1 . Although all explosion and aircraft impact losses are reported whenever a fire department responds, they are not considered fire losses unless an ensuing fire causes injuries/facilities/ materiel losses. Fire accidents involving Army-owned or -leased fixed facilities will be reported through NFIRS except where the fire was willfully and maliciously ignited (arson) ( AR 385-10 ). A DA Form 285 will not be submitted for fires listed below unless those fire accidents result in medical treatment beyond first aid or greater injury, occupational illness, or damage to equipment as described in (1) above.

(a) Family quarters (rent free, mobile home, leased).

(b) Bachelor enlisted quarters, bachelor officer quarters, barracks.

(c) Industrial buildings.

(d) Public assembly buildings and areas.

(e) Grass, forests, and ranges.

(f) Warehouse and storage buildings.

(g) Administrative offices.

(h) Schools.

(i) Health care and day care facilities.

(j) Vacant structures.

(k) Aircraft hangars.

(l) USAR centers (leased or government-owned).

(m) Area maintenance support activities (leased or government-owned).

i. Chemical agent events. (see para 5-2 ).

j. Explosives accidents. (see para 5-3 ).

k. Ionizing and nonionizing radiation accidents and incidents. (see para 5-4 ).

l. Nuclear accidents. (see para 5-5 ).

m. Personnel injury-other. These accidents involve injury/occupational illness to Army personnel, Army direct contractors, contractors and subcontractors contractually required to report accidents, and non-Army personnel as a result of Army operations not covered by any other accident type and injury to off-duty military personnel not covered by any other accident type.

n. Property damage-other accidents. These accidents involve property damage not covered by any other accident type.

o. Commercial carrier/transportation accidents. These accidents involve the operation of a commercial motor vehicle, plane, helicopter, train, or vessel (including those under contract to the Army) which transport Army personnel and result in —

(1) Any injury beyond first aid to Army military personnel, on or off duty.

(2) Injury/occupational illness to Army civilian personnel while performing duties in a work-compensable status.

p. Biological mishaps. (see para 5-6 ).

q. Fratricide or friendly fire. Fratricide and friendly fire accidents are special situations that must be reported promptly and thoroughly investigated.

(1) These accidents will be reported and investigated as an accident under the provisions of AR 385-10 .

(2) These accidents must also be reported and investigated as a legal accident investigation under the provisions of AR 15-6 and AR 385-10 .

r. Visiting public. ( AR 385-10 , para 3-5).

1-10. Accident costs

a. Army accident costs are based on the severity of injury, occupational illness, or property damage (Army and non- Army) resulting from Army operations. For accident reporting purposes, the logistical disposition of damaged property/ equipment (whether or not it is repaired or replaced) will not negate the requirement to report the accident.

(1) Injury and illness costs. These costs are used solely to provide total accident cost since cost is generally proportional to severity of injury/occupational illness. They are not used for determining accident classifications (see AR 385-10 ). Actual time lost may not be known at the time the accident report is submitted. If it is not known, an official estimate of days away from work, made by a competent medical authority, will be used in computing the cost. The cost data in table 1-1 is used to compute the cost of injuries and occupational illnesses to Army personnel for safety/accident reporting purposes only.

(a) The figures include the cost of pay while away from work, medical treatment, hospitalization, dependent survival, unused training costs, gratuities, compensation, disability retirement, and burial.

(b) The figures do not include indirect costs associated with the accident such as wages lost to employees not injured (production loss), cost of hiring and training new employees, cost of investigating the accident, public liability costs, and costs to lease equipment if available.

(2) Damage costs. Costs of damage to Army property and equipment will be computed using criteria in the Army Master Data File (AMDF), to include such things as actual cost of new or used parts or materials and labor cost at the standard rate of 41 dollars per hour, unless the actual labor cost rate is available within the reporting time limits. When Army property, other than aircraft, is damaged to the extent it cannot be repaired, or the cost of repair exceeds the cost specified in Federal logistics Record(FED LOG) or the property book, the accident cost will be the property cost listed in FED LOG or the property book, plus any additional equipment not included in the original property cost. When damaged equipment or facilities will not be repaired or replaced, the cost reported will be the acquisition cost AMDF, plus the estimated cost to clean up the site. For destroyed equipment, the estimated scrap value or residual value of the parts may not be used to reduce the accident classification.

b. Costs peculiar to aircraft accidents include —

(1) Destroyed, missing, or abandoned aircraft cost. The cost of destroyed, missing, or abandoned Army aircraft is to be computed per aircraft replacement cost figures obtained from Technical Bulletin(TB) 43-0002-3, tables 3-1 and 3-2 . The cost of aircraft repair will be updated if the depot's estimated cost of damage (ECOD) is significantly different (10 percent or non-repairable) from the initial or reported ECOD. Include the cost of all modifications. Unmanned Aircraft System (UAS) cost to repair or replace will be computed by the appropriate Field Support Representative and obtained from the system program management office until such a time as UAS are included in TB 43-0002-3.

(2) Army parts cost. The cost will include —

(a) For destroyed parts or components, the cost of replacement per current AMDF, this can be found in technical supply or direct support units. Unit turn-in credits will not be used to reduce the accident classification.

(b) The cost to repair damaged parts.

(3) Direct man-hour costs. Direct man-hours include —

(a) The cumulative (estimated) man-hours required to remove, repair, and replace damaged aircraft assemblies, subassemblies, or components.

(b) Man-hours required to restore the aircraft to serviceable condition if economically repairable.

(c) Man-hours expended in removing and replacing undamaged aircraft components in order to remove, repair, or replace damaged components.

(d) Man-hours required to remove and replace a part that is not economically repairable.

(e) Man-hours expended to determine damage amount.

(4) Man-hours not included in aircraft accident cost. The cost will include —

(a) Depot and contract overhaul man-hours.

(b) Time used in setting up equipment preparatory to actual repair of the aircraft.

(c) Man-hours used in removing, replacing, and inspecting undamaged parts and components solely to satisfy technical manual inspection requirements.

(d) Indirect man-hours such as investigating, travel, test flights, and maintenance operational checks.

(e) Maintenance facility overhead cost.

(5) Replacement of damaged components. Removing a damaged component and replacing it with a new component to decrease the number of man-hours and costs for purposes of accident classification is prohibited. If another like component is available, it may be installed so that the aircraft will be available for flight. However, the total best available estimated man-hour costs to remove, replace, and repair the damaged component will be included for accident classification.

(6) Cost computation of aircraft engine. When an aircraft engine is damaged as a result of the accident sequence to the extent that it must be returned to a depot, the cost of such damage or inspection will be computed at 17 percent of the engine cost. Depreciation and/ or turn-in credits will not be used when calculating damage costs to determine accident classification.

(7) Cost computation of helicopter main or tail rotor blades and fixed wing propeller blades. Costs will be computed based on the following criteria:

(a) Destroyed blades are to be calculated at the full unit cost per the AMDF. Depreciation and/ or turn-in credits will not be used when calculating damage costs to determine accident classification.

(b) Blades that are to be repaired locally will be the actual cost of damage (ACOD), if known, or the ECOD, if the ACOD is not known prior to the submission of the report. Early submission to reduce the blade cost is prohibited.

(c) Blades sent to depot or contract rebuild facilities for repair or rebuild will be the ACOD, repair facility established cost, or 44 percent of the AMDF cost of the blade with no depreciation allowed. For example, if a repairable blade is returned to depot for repair and the AMDF cost of the blade is 100,000 dollars; the cost of the blade for classification and reporting would be 44,000 dollars. Depreciation and/ or turn-in credits will not be used when calculating damage costs to determine accident classification.
Note. 44 percent AMDF cost does not apply when a tip cap is the only damage.

(8) Aircraft structural damage. When available, the actual cost of aircraft structural damage should be cited. When actual cost cannot be determined and the structural damage is repairable, use the following calculations:

(a) For minor structural damage not requiring realignment (jigging), use 3 percent of the aircraft replacement cost in TB 43-0002-3. (UAS cost will be calculated using the current established cost at the time of the accident.)

(b) For major structural damage (for example, extensive damage to fuselage or damage requiring structural realign- ment), use 6 percent of the aircraft replacement cost cited in TB 43-0002-3. (UAS cost will be calculated using the current established cost at the time of the accident.)

(c) For structural damage deemed unrepairable, use the actual cost of the fuselage when available or 40 percent of the replacement cost for the aircraft, as cited in TB 43-0002-3, tables 3-1 or 3-2 or. (UAS cost will be calculated using the current established cost at the time of the accident.)

(d) Percentile calculations include man-hours, transportation, and inspection.

(9) Cost computation of other aircraft components. When a major aircraft component (as defined in the appropriate maintenance technical manual (TM)) is damaged to the extent that it must be returned to depot for overhaul or inspection, the reported cost for repair will be computed at 15 percent of the component's cost. Depreciation and/ or turn-in credits will not be used when calculating damage costs to determine accident classification.

(10) Unmanned Aircraft System damage costs. Cost to repair or replace damaged UAS components or parts will be computed by the appropriate FSR and obtained from the systems program management office until such a time as UAS national stock numbers (NSNs)/part numbers are included in the AMDF. Reduction in UAS damage by applying the provisions of paragraphs b(6), b, (7) and b(9), above are not authorized.

(11) Damage not included in aircraft accident costs.

(a) Fair wear and tear (FWT).

(b) When a malfunction or failure of a component part results in damage to another component, the FWT exception does not apply.

(c) Damage to helicopters incurred solely from flying debris during operations in confined areas and unimproved landing sites is considered FWT.

(d) Discovery of cracks, breaks, wrinkles, or ruptures during required periodic or scheduled inspections is consid- ered FWT. They will be reported per DA Pam 738-751.

(e) Damage to an aircraft as a direct result of action by an enemy force or terrorist group (considered "combat loss").

(f) Intentional in-flight controlled jettison or release of mission/activity/event essential, aircraft equipment/stores that is not essential to flight. For example, canopies, doors, drag chutes, hatches, life rafts, auxiliary fuel tanks, missiles, drones, rockets, non-nuclear munitions, and externally carried equipment. Intentional emergency jettison of cargo (internal or external) when aircraft control is essential. (There must be no injury or reportable damage to the aircraft or other property. Also, intentional controlled jettison of missiles, drones, or non-nuclear munitions must not have resulted from their malfunction.)

(g) Planned destruction of Army experimental or prototype aircraft during authorized testing or combat training.

(h) Authorized intentional destruction of Army property or equipment.

(i) Foreign object damage to aircraft, air-breathing missiles, or drone engines discovered during scheduled engine disassembly.

(j) The costs of any further Army property damage resulting from rescue or salvage .

Table 1-1. Cost Standards Table
Mishap Injury Cost Standards Table for use in FY15 (using FY14 CPI)
No Lost Time per Injury Days Away from Work per Day Day Hospitalized per Day Permanent Partial Disability Injury Permanent Total Disability Injury Fatality
Flying, Sub, Medical Officers 1,300 1 2,400 1 8,500 1 2,200,000 2 2,900,000 2 8,700,000 4
Other Officers 1,300 1 2,400 1 8,500 1 365,000 2 1,100,000 2 8,700,000 4
Enlisted Personnel/Cadets 1,300 1 2,400 1 8,500 1 363,000 2 1,100,000 2 8,700,000 4
Civilian Employees 1,300 1 2,400 1 8,500 1 750,000 3 1,100,000 3 8,700,000 4

Legend:
How to use this table:
A. This table should be used to determine mishap costs based on the injury sustained by each individual involved in the mishap. The injury costs do not determine accident class.
B. Identify the severity of injury sustained for each individual.
C. For fatal, permanent total disability, partial disability injuries, or those injuries that do not result in lost time, apply the associated cost listed in the table one time for each individual injured. No lost time injuries include needle sticks, loss of consciousness, and treatment beyond first aid.
D. Injuries resulting in first aid treatment are valued at $0.
E. For lost time cases, multiply the number of days away from work beyond the day of the accident by the cost listed under Per Days Away from Work. For injuries that result in hospitalization, multiply the number of days hospitalized by the value listed under Per Day Hospitalized and add it to the Days Away from Work Injury Cost ((# of Days hospitalized * Costs) + Days Away from Work Injury Cost).
F. Injuries that result in restricted duty or temporary reassignment apply the cost list under No Lost Time one time. Example: An individual loses consciousness at work and is returned to work on restricted duty for one day or more, the total cost of the injury is $1300.
G. To determine total injury cost for the mishap, add (sum) the injury costs for each individual.
Example: An individual is injured on the job and is hospitalized for one day, is then told to rest at home for two days, and is then put on restricted duty for three days after returning to work. The costs would be (1*8500) + (2*2400) + (1*1300) = $14600 cost of the injury.
By the end of the fiscal year, USACRC/SC will update all costs for the next FY in this table with the inflation factor based on Consumer Price Index (CPI) formula (using the average CPI from September of previous year to August of current year) to calculate inflation rate and will then post the updated chart on the USACRC internet homepage. The chart posted on the USACRC homepage will take precedence over any other injury cost table.

Notes:
1. Direct medical costs with a 1 to 1 indirect cost multiplier included. (Profiles, restricted duty, job transfers are included in No Lost Time cases.
2. Permanent Partial disability costs of military personnel include: training costs + likely medical interventions (cost of average hospital stay) + base pay for hospital stay + partial disability payments over 30-year period. Permanent total disability costs of military personnel determined based on inclusion of: training cost + likely medical interventions (cost of average hospital stay) + base pay for hospital stay + total disability payments over 30-year period.
3. Direct wage and medical costs from FECA data.
1,2,3 Values updated from FY 2014 Updated cost per injury type estimate table in 2013 dollars using the average CPI from Sep 2013-A ug 2014.
4. Value of Statistical Life based on OSHA value of $7.4M in 2006 dollars using the average CPI from Sep 2013-A ug 2014 to update.

1-11. Personnel classifications

The following personnel classifications are used in reporting Army accidents:

a. Active Army personnel.

b. Army civilian personnel.

c. Army contract personnel.

d. Army direct contractor personnel.

e. Nonappropriated funds (NAF) employees.

f. Other U.S. military personnel. This includes members of other DOD components on full-time duty in active military service.

g. Reserve Officer Training Corps (ROTC).

h. Military dependents. Army Family members.

i. Army National Guard personnel.

j. U.S. Army Reserve personnel.

k. Direct hire foreign nationals.

l. Foreign nationals, indirect hire.

m. Foreign nationals, Korean Augmentation to the U.S. Army (KATUSA) (Korean nationals assigned to the U.S. Army in a military status).

n. Foreign military personnel assigned to Army units.

o. Public. This category includes all persons not specifically covered above.

1-12. Special notification and reporting requirements

Accident notification, investigation, and reporting requirements for marine, chemical agent, explosives, ionizing and nonionizing radiation, nuclear weapons, reactor accidents, and biological mishaps are contained in chapter 5 of this pamphlet.



Figure 1-2. Ground Accident Reporting (Peacetime)





Figure 1-3. Aviation Accident Reporting (Peacetime)





Figure 1-4. Combat Accident Reporting


Chapter 2
Investigation 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 techniques and procedures described here apply to all accident investigations. 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 385-10 (see fig 2-1 ). Board members will give priority to the accident investigation and reporting duties to ensure prompt completion of the accident report.

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 final 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 1-Organization and preliminary examination. During this phase, the board president organizes the board for the investigation 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 he or she is 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. 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 actions of all personnel who influenced the operation which resulted in the accident. Paragraph 2-4 of this chapter is devoted to human factors investigation. The sources of human factors information may include, but are not limited to —

(1) Personnel involved, witnesses, supervisors, peers, and personnel from operations, training, and maintenance.

(2) Individual records, to include training, qualification, personnel, and/or medical records.

(3) Data for the evaluation of the command influence, such as unit policy for risk management, hazard analysis, accident prevention plans, mission/activity/event briefings, crew rest/sleep (both long and short term), utilization of personnel, and driver selection/training.

(4) Data for evaluation of the structure/system/equipment crashworthiness, personnel restraint systems, and personal protective clothing and equipment as related to injury/occupational illness causation or prevention.

(5) Data for the evaluation and reporting of problems encountered in egress, survival, and rescue.

(b) Materiel factors. The materiel factors portion is primarily concerned with gathering data necessary to evaluate the performance and design of the vehicle, ground support equipment, land/or other materiel. Some sources for this information are the equipment historical, modification and inspection records, operator's manuals, manufacturer's specifications, fluid analysis, teardown analysis (TDA), wreckage distribution, photographs, and the failed part(s). The board president is encouraged to engage a system safety engineer from the command safety office(s) to gather data necessary to evaluate the performance and design of the materiel involved in the accident. Also, excellent sources of materiel information include equipment project managers (PM), manufacturers, equipment operators, and maintenance personnel. Data concerning how environmental conditions have affected vehicle/system/equipment performance must be acquired and evaluated. Paragraph 2-5 of this chapter is devoted to materiel factors investigation.

(c) Environmental factors. Collect environmental data to evaluate its impact and influence on the performance of the individuals involved. 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 recommendations. The analysis should be thorough and focus on determining why the accident occurred. This will drive the analytical effort throughout the investigation so that findings and recommendations can be developed, which 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 in the analysis to the greatest extent possible.

c. Duties. Accident investigation boards will be established according to AR 385-10 . When more than one individual is appointed to an investigation board, a board president, recorder, and other personnel (as required) will be designated. In some cases, the board will consist of one individual. This individual is responsible for all aspects of the investigation and report processing. As needed, technical advisors, equipment operators, support personnel, and other personnel will be made available to the board, regardless of its composition.

(1) 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 this pamphlet.

(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 or other engineering or administrative controls are in place to ensure the preservation and protection of evidence, to include site, equipment, separated parts, impact scars, resulting from the accident.

(f) 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.

(i) Ensuring all available pertinent data is gathered before closing the field portion of the investigation.

(j) After coordination with the legal accident 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.

(l) Ensuring accident information is released only to appropriate authorities, such as appropriate command, staff safety personnel concerned, and USACRC personnel.

(m) Advising appropriate safety officer/public affairs officer (PAO) to contact local legal advisors in cases involving potential claims against the U.S. Government for personal injury/occupational illness or property damage.

(n) Conducting witness interviews as necessary for inclusion in the technical accident report.

(o) Ensuring data is correctly analyzed and conclusions are supported by evidence.

(p) Ensuring suitable recommendations are made and that a thorough and accurate report is completed and submitted according to AR 385-10 and this publication.

(q) If applicable, coordinating with the local Criminal Investigation Division (CID) handling the case.

(r) Writing the history of flight/event, findings and recommendations, and analysis for the technical report.

(2) Recorder. When possible, the recorder will 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.

(f) 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.

(h) Conducting and summarizing witness interviews as necessary for inclusion in the technical accident report.

(3) Maintenance officer. A qualified maintenance officer or technician will be assigned to the board when materiel is involved. 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) Identify design deficiencies.

(d) 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.

(e) Supervising preparation and shipment of items selected for TDA.

(f) Monitoring equipment recovery if accomplished before completion of the investigation.

(g) Reviewing the unit's maintenance procedures and record discrepancies.

(h) Completing all maintenance/materiel factor requirements for the technical report.

(i) Preparing or helping with the preparation of accident scene diagram(s).

(j) Performing other duties as assigned by the board president.

(k) 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 investiga- tion. AR 40-21 , AR 40-3 , 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 chapter.

(c) Ensuring the board is advised of medical/human factors related to the cause(s) of the accident, the reason(s) therefore, and recommendations for corrective action.

(d) In case of off-post accidents where the local coroners or medical examiners have jurisdiction. Ensure coordination with the Armed Forces Medical Examiner System (AFMES) prior to the autopsy, serve as an observer during the autopsy, and assist in transfer of the remains once they are released to the Army.

(e) Investigating and reporting data concerning personnel injuries.

(f) Collecting and evaluating life support equipment (LSE), and personal protective equipment (PPE).

(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 consist of individuals who have considerable knowledge and expertise in the required field. For example, instructor pilot, system safety engineer, master/senior/equipment operator, industrial hygienist, environmental health specialist, and others as required. 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/activity/event planning, and the history of events from mission/activity/event 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, TMs, and other published guidance, if required.

(c) Investigating the activities of all personnel who were victims, had an influence on the mission/activity/event, or played a role in the accident.

(d) Preparing a sketch of the accident site.

(e) Conducting and summarizing witness interviews as necessary for inclusion in the technical accident report.

(f) Completing/helping with the writing requirements of the technical report.

d. Support plan.

(1) Safety representative. 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. Duties of the safety representative include —

(a) Providing the local investigation board with an accident investigation kit (see para 2-9 for a recommended listing of accident investigation kit contents) and/or other equipment necessary to conduct the investigation.

(b) Advising the board on technical aspects of the investigation and reporting of the accident.

(c) Helping the board in obtaining other technical assistance as required.

(d) Advising the board of administrative procedures concerning accident reports. For example, command channel review and forwarding correspondence.

(e) Providing regulatory documents and directives pertaining to accident investigation and reporting.

(f) Providing necessary interpretation of local regulations and directives.

(g) Helping the board president in obtaining administrative support. For example, work space, typist, and drafting.

(h) Providing initial classification for the accident, such as Class A and B.

(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. Provide surveying and mapping the debris pattern and preparation of required sketches. The engineer may also provide technical engineering review of the accident.

(b) Local training and audio support center/public affairs activity. Primary photographic assistance provided by the local Training and Audiovisual Support Center (TASC), or from public affairs if a TASC is not available.

(c) Public affairs officer. Handle press representatives and public information releases.

(d) Military treatment facility commander. Provide 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 AFMES for analysis.

(e) Provost marshal office. Provide guards, traffic control, and site security for the accident scene. As required, serve as liaison with local law enforcement, provide accident information from DA Form 3946 (Military Police Traffic Accident Report), traffic citation history, traffic flow information, and daily blotters.

(f) Weather officer. Obtain complete weather information for the time and location of the accident. (g) Maintenance support facility commander. Provide recovery of wreckage, disassembly and removal of components, and preparation for shipment of items selected for TDA. The maintenance support facility commander will also, provide preparation of ECOD to help in classifying the accident. (See para 2-2 e .)

(g) Transportation officer. Provide assistance in transportation to and from the accident site and expeditious shipment of components selected for TDA.

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, power plant 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, such as manufacturer's representative(s), should be requested through the USACRC.

f. Legal accident investigations interface.

(1) Legal accident 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. Legal accident investigations are conducted independently and apart from the accident investigation. They are appointed and conducted by local commands as required by DODI 6055.07 , AR 385-10 , and DA PAM 385-40 and use guidance contained in AR 15-6 and AR 27-20 . Personnel serving in designated Safety positions or serving as a member on the safety accident investigation board will not participate in the conduct or formal review of legal accident investigations.

(2) Safety accident and criminal investigations take priority over legal accident investigations for purposes of access to evidence, witnesses, and the accident scene; however, a spirit of cooperation is also required to ensure that the legal accident investigation board will have equal access to the evidence.

(3) The safety accident investigation board —

(a) May only provide the legal accident investigator with copies of common source, factual information; (for example, technical data, maintenance records, photographs (as taken), maps, diagrams, lists of witness names).

(b) Will not provide the content of witness statements, findings and recommendations, and analysis, to the legal accident investigator.

(c) May provide access to transcripts of portions of intra-cockpit voice recordings included in the safety accident report in accordance with AR 385-10 .

(d) Will also allow the legal accident board a reasonable amount of time to perform an accident scene investigation before disturbing the evidence by movement and/or disassembly. If this cannot be accomplished due to the urgency of the situation, then the safety 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 legal accident board.

(e) Advise the legal accident board if the safety accident board removed components for analysis.

g. Criminal investigation interface.

(1) Contact with the local CID office should be made as soon as practical for the following:

(a) Determine if the CID has assumed criminal investigative authority over the accident scene, initiated an investiga- tion, removed any evidence, or completed/terminated its investigation of the accident site.

(b) The CID should determine as quickly as possible if a crime has been committed.

(c) The criminal investigation will take priority over all other investigations, and the accident investigation will be discontinued if the evidence indicates that the incident was the result of a criminal act (see AR 385-10 ) for nonrecordable events) other than negligence, dereliction of duty, or disobedience of an order.

(d) Once criminal activity is determined not to be a factor, the CID will release control of the investigation to the accident investigation board.

(2) During the period where criminal intent is being determined, both investigations will proceed.

(a) 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/activity/event.

(b) 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 and photographs.

(c) 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 will make every effort to resolve differences in opinion. However, if differences cannot be resolved, the disagreeing board member(s) may 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). Attach the minority report as a continuation of the DA Form 2397-3 narrative.

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 safety accident 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, 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.

(a) All personnel involved in the accident must be transported to a medical facility for examination, and, if necessary, treatment of injuries. All personnel must be evaluated by a physician or licensed health care professional, since some injuries may not be immediately apparent due to the stressful nature of the situation.

(b) Key personnel involved in the accident must have the appropriate specimens collected in order to analyze for the presence of alcohol, carbon monoxide and drugs, according to AR 385-10 . When applicable, the chain of custody of the specimens must be ensured.

(c) Specimens taken must be sent to AFMES for analyses and evaluation.

(d) 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.

(e) 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.

(f) If the coroner or medical examiner performs an autopsy, the board president must request that a military forensic pathologist or a physician approved by the AFMES be present during the autopsy.

(2) Immediate steps must be taken to prevent injury/occupational illness to personnel from fire, ammunition cook- off, hazardous material, burnt carbon fiber 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.

(a) In cases where the hazard is an explosive device, an EOD unit will be alerted.

(b) Also, since composite materials (burnt or fragmented) are present in most modern aircraft, tactical wheeled and tracked 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 inves- tigative personnel.

(c) 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.

(d) Assistance for establishing a composite material standing operating procedure (SOP) can be obtained by contacting USACRC at DSN 558-3410/2660 or COM (334) 255-2660.

(e) 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.

(1) As soon as the accident scene is declared safe for entry, the next task is to ensure the wreckage and other physical evidence is safeguarded from bystanders and sightseers. This includes —

(a) Military and civilian personnel who have no official business at the scene, according to AR 385-10 , chapter 3 .

(b) The local safety representative must ensure that guards remain on duty to keep unauthorized personnel outside the roped-off area and upwind of hazardous composite material.

(c) 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.

(d) 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, 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 —

(a) Ensure the original accident scene is documented.

(b) This includes preparation of an accurate wreckage distribution diagram along with a photographic record of the accident scene.

(c) Every effort must be made to preserve the evidence when it must be moved or disturbed.

(d) 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 (duty/ work) to the accident as possible.

(a) 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.

(b) If it appears that a witness may not be available for an interview by the board, the safety representative will conduct the interview for the board.

(c) He/she should take as many written statements as possible and deliver them to the board president upon his arrival.

(d) The local safety representative will determine 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 —

(a) The logbook.

(b) Historical records.

(c) The appropriate inspection and maintenance records.

(d) Individual/crew member records, to include personnel, medical, dental, and training records.

(e) Documents pertaining to the mission/activity/event must also be gathered.

(f) A weather observation for the time of the accident from the closest weather reporting facility.

e. Classification of the accident. The local safety officer has responsibility for initially classifying the accident according to AR 385-10 .

(1) To help the safety representative in accomplishing this task, the supporting maintenance facility will provide the safety officer with an ECOD (a UAS contract may require the ECOD(s) be provided by the contractor and/or manufacturer).

(2) The supporting medical activity will provide an assessment of the degree of injuries according to AR 385-10 , if applicable.

(3) The accident classification is necessary to determine the required notifications of the accident according to AR 385-10 and local command procedures.

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:

(1) 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 reporters' questions off lightly, the safety officer should advise media 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 disclose 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 kind of request for assistance. The same caution applies to other nonmilitary agencies, such as police and fire departments.

(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 photogra- pher, 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 and Procedures

2-3. Witness interviews

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 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 will not be a verbatim or edited transcript of all that was stated. Summarizations of the witness's testimony will be used, but these will not exclude any information that helps in explaining why the accident occurred. These summarizations should be written in the third person ("the witness said," "They saw,"), not in the first person ("I saw," "I observed,"). 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) Promise of confidentiality.

(a) Limited use reports. Witnesses in a Limited Use investigation may be given a promise of confidentiality per AR 385-10 . This promises that the Army will not voluntarily release their statement outside the DOD, 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). 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.

(b) General use reports. Witnesses in General Use accident investigations will not be given a promise of confiden- tiality unless approved by the Commander, USACRC. Typically, these promises are requested in cases where key witnesses choose not to provide information unless they are given the promise of confidentiality or for cases listed in AR 385-10 , chapter 3. Upon approval by the Commander, USACRC, that accident report would then be deemed Limited Use.

(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 release 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 crew members (pilot, maintenance test pilot, crew chiefs).

(b) Technical inspectors and maintenance personnel (typically for aircraft accidents).

(c) 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 paragraph 3-7 and paragraph 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(s) what particular area of the investigation should be emphasized, thus reducing the time it will take to determine the cause(s) of the accident.

(3) It is reasonable to assume that spectators and sightseers, who are at the scene when the investigator(s) 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, and 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 pertaining to the mental state of the pilot should be conducted by the board president.

(2) Supervisory and support personnel. This category includes those personnel whose job performance could have affected the outcome of the mission/activity/event 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.

d. The interviewer. The number of investigators present during the interview is at the discretion of the board president.

(1) More than two or three investigators could intimidate some witnesses.

(a) One investigator should conduct the interview and maintain eye contact with the witness.

(b) Another investigator can monitor the tape recorder and take notes on areas for further questioning.

(2) When tape recordings are to be used, the witness must first consent to the electronic recording of the statement.

(3) When the first investigator has completed his/her questioning, he/she should then allow the other team member(s) to continue with further questions, if necessary.

(4) Once a summarization of the witness's interview has been prepared, preservation of the actual recording is not necessary and will be disposed of.

e. Interviewing techniques.

(1) Planning the interview. 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." Subsequent questions should focus on key areas of interest. In addition to eliminating the tendency of the person being interviewed to answer "yes" or "no," planning has the following advantages:

(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.

(a) 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.

(b) 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.

(c) 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.

(1) 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.

(2) 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.

(3) When several witness interviews 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 summary of witness interview. 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 interviews 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 areas of interest immediately after the interview.

(4) Other considerations when conducting witness interviewing are as follows:

(a) 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.

(b) Witnesses should be encouraged to tell in their own words all they know about the accident. Do not attempt to lead the witness.

(c) While talking, witnesses should not be interrupted except to prevent them from going too far into irrelevant matters.

(d) After the witness has finished giving an interview, questions should be asked to clarify doubtful points that may arise during the interview. 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, the information may not be captured.

(e) The use of highly technical terms should be avoided when asking questions of a witness who may have no knowledge of the terms.

(f) A witness should be treated with utmost courtesy at all times and any semblance of coercion avoided.

(g) 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.

(h) When a witness refers to maps or photographs, these should be identified in the summary of the interview. The points mentioned should also be cross-referenced on the map or photograph.

(i) A witness may be able to give a clearer statement if interviewed in the same location where he observed the accident.

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 —

(a) Coordinated with the medical facility and attending physician(s) so as not to conflict with the injured survivor's medical needs.

(b) 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.

(a) In cases where the person being interviewed is under the influence of medications, it is the physician member's responsibility to qualify the credibility of information obtained under these circumstances.

(b) Two or three short interviews with certain injured survivors may be more beneficial and may minimize any negative affect on their emotional state than conducting 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.

(c) 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 persist- ence and impatience may not.

g. Evaluating witness evidence. All witness interview results 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 the information they provide. When the interviews are numerous, complex, or contradictory, the board should evaluate each witness interview for credibility. In general, very specific information about speeds or maneuvers provided by an eyewitness should be considered as approxima- tions since even eyewitnesses with experience have difficulty with these estimates.

2-4. Human factors investigation

a. Introduction. This section provides procedure and format to perform a systematic and comprehensive investiga- tion 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, PPE, 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 2-2 ).

b. Human influence.

(1) Recording accident data. Accident data recorded to date indicate most accidents can be ultimately traced to human errors. 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).

(a) The first step in identifying human error(s) is to develop a chronology of events before, during, and when appropriate, after the accident (see fig 2-3 ). 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, prepara- tion, supervision, and execution of the mission, event, task, or activity. All of these individuals should be interviewed using the techniques discussed in paragraph 2-3 .

(b) 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 and instructors. 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 cause(s).

(c) Recent improvements in training publications have made the process somewhat easier since most operator and mechanic tasks have been defined in TMs and Soldier manuals. 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 SOPs.

(3) Explaining human error(s). Regardless of the task involved (for example, flight planning, installing a tail rotor, and changing brake pads/shoes), 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) (why the mistake/error/failure occurred).

(a) The best way to identify system inadequacy(ies) is to work backward from a mistake/error by asking questions aimed at "illuminating" the error (see fig 2-1 ). 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.

(b) The most practical approach is to establish the circumstances for the witness and allow him/her 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. Asking "why" can be extremely helpful in identifying the cause(s) of his/her improper task performance.

(c) 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 to avoid 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.

(d) After this indirect questioning, the interviewer can return to more direct questions about the error. This approach will usually produce the most reliable information.

(e) 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, and impaired vision).

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. Information to be reported will include —

(1) Where the individual was located when the initial attempt to exit the equipment occurred.

(2) Any delays in attempting the egress; (for example, turn off fuel or battery).

(3) Where the individual exited the equipment. Ascertain any difficulties encountered due to obstructions, opening the exit, or in using the exit after it was open.

(4) Any assistance that an occupant required in exiting the equipment that could indicate a deficiency in emergency exit design or operation.

(5) Equipment and materiel used during the egress that failed to function or functioned improperly.

(6) Any other difficulties encountered during egress.

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 rescue personnel reached the individual or the individual reached a facility that provided medical care. Throughout the investigation, it is important to examine factors that may have contributed to or inhibited the success of the survival situation.

(1) Consider methods used and time taken for actions.

(2) The methods survivors used to help in survival should be evaluated to determine if these methods were adequate or inadequate and why.

(3) 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 crew members is contained in AR 40-21 and AR 385-10 . In other cases, to specifically include cases where Soldiers on "active duty" or "active duty for training" are fatally injured, the Commander, USACRC, 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.

(a) This authority applies to those cases where an autopsy is deemed necessary for safety reasons in order to determine the true cause of death.

(b) The pathologist must obtain permission to perform an autopsy from the appropriate military/civilian authority having jurisdiction over the body as it is recovered.

(c) 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 .

(d) Every effort will be made by the medical investigator to obtain an autopsy report according to Army regulations.

(2) Armed Forces Medical Examiner System. AFMES may provide on-site assistance for fatal accidents. When Army equipment and personnel are involved, requests for such assistance may be made through the USACRC. Telephone number - COM (302) 346-8648, DSN 285-8648. AFMES, 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.

(1) Using pathological correlation to improve personnel and passenger restraint systems, PPE, and equipment crashworthiness.

(2) Accumulating pathological data from a wide variety of cases.

(3) Studying psychological and physiological factors that cause stress and may result in pathological changes.

(c) 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 —

(1) Establish time and cause relationship between preexisting disease and the accident.

(2) Correlate injuries with various factors in equipment design.

(3) Determine all pathological evidence that might lead to an accurate analysis of the chronology of events surrounding an accident.

(3) Conduct of gross autopsy. Procedures for conducting gross autopsies are contained in appendix E .

h. Life support equipment and personal protective equipment.

(1) It is the responsibility of the investigator to analyze how well LSE, or other PPE, 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/occupational illness.

(2) All LSE and/or PPE that is in any way implicated in the cause or prevention of injury will be recorded in the accident report. Both air and ground items that caused injury, failed to function as designed, or were significant in preventing injury will be shipped to the U. S. 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 bag systems.

(3) Contact USAARL concerning which items of LSE/PPE that should be shipped and the supporting documentation required. Call telephone number - DSN 558-6960/6920, COM (334)255-6960/6920.

(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 (Crew Injury/Life Support Equipment Branch), Bldg. 6901, Andrews Avenue, Fort Rucker, AL 36362-0577.

(5) Equipment items sent to USAARL for laboratory analysis will be noted in the technical report of accident investigation.

(6) For personal LSE/PPE 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.

(7) 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.

(8) Upon request by the USACRC, 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 and provide instructions for narrative reporting the human factors investigation.



Figure 2-1. Determining System Inadequacy(ies) Responsible for Human Error





Figure 2-2. Methods to Place Each Factor in its Proper Perspective in Relation to Other Events


2-5. Materiel factors investigation

a. Introduction.
Note. In this paragraph, the term "equipment" is utilized to indicate the piece of equipment involved in an accident investigation, such as aircraft, vehicle, structure, weapon system, component, and part.

(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 inadequacy(ies) for the materiel failure(s)/malfunction(s) (why it failed).

(2) The investigation of materiel factors requires, as a minimum, the assistance of a maintenance or technically qualified individual.

b. Materiel failure(s)/malfunction(s).

(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(s)/malfunction(s) 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 failure/malfunction. These possibilities should be carefully examined.

(a) Even though the investigation begins by examining components that probably failed, this examination is not complete until all major components and systems have been examined for evidence of failure/malfunction.

(b) In cases where preliminary evidence (for example, witness statements) indicates no failure/malfunction 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.

(4) The next step is the shipment of the material to a TDA facility of those components that the board identified or suspected of having failed/malfunctioned. The TDA is important since the board may not have the capability to determine how and why a component failed.

(5) 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 by coordinating with USACRC operations at DSN 558-3410.

(a) Aircraft. - Corpus Christi Army Depot, Corpus Christi, TX 78419-6020, telephone DSN 861-2902/2903, COM (361) 961-2902/2903.

(b) Ground vehicles. - Tank-Automotive and Armaments Command, Warren, MI 48397-5000, telephone DSN 786-6194/6121, COM (313) 574-6194/6121.

(c) Parachutes. - Natick Labs, Natick, MA, telephone DSN 256-5208, COM (508) 233-5208.

(d) Life Support Equipment/Personal Protective Equipment. - U.S. Army Aeromedical Research Laboratory, Bldg 6901, Andrews Avenue, Fort Rucker, AL 36362-0577, telephone DSN 558-6960, COM 334-255-6960.

(e) Ammunition/Explosives. - U.S. Army Technical Center for Explosives Safety, 1 C Tree Road, McAlester, OK 74501-9053, telephone DSN 956-8756/8919, COM (918) 420-8756/8919.

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. Material failure system inadequacies may be characterized as Design, Manufacture, Fair Wear and Tear and Maintenance. If system inadequacy(ies) identifying improper maintenance where the Army has control are selected, such as system inadequacies codes 13 and 14, and the duty code of the individual(s) can be identified, a resultant finding must be written as a human mistake/error and consider the failure/malfunction as a result of human mistake/error instead of a materiel failure.

(2) Identifying system inadequacy(ies) (why did it happen). Once the materiel factors investigation team has identified or 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 —

(a) Examine records and unit operating procedures.

(b) The materiel factors investigation must interface with the human factors investigation to search for errors/ mistakes that may have resulted in the materiel failure.

(c) 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.

(d) 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 —

(a) 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.

(b) 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.

(c) Once the sequence of events has been established, the investigator(s) should then reconstruct the maneuvers or actions of the individuals or equipment 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 under various sets of conditions, plus the use of basic controllabili- ty, 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.

(1) The top of the diagram will represent north.

(2) The main body of the wreckage (center of mass) can serve as the beginning or pole of the diagram.

(3) Choose a scale that will allow plotting of the total scene on the chart.

(4) 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.

(5) 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.

(6) 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.

(1) The local safety representative should obtain a photographer from nearest post/installation assets.

(2) It is important that photographs be of good quality and composition. High definition digital photographs are preferred.

(3) All photographs used in the report must be numbered and captioned.

(a) Captions should explain in detail what the picture is supposed to show.

(b) Captions will include type equipment, date of the accident, and location of the accident.

(4) The direction toward which the photograph was taken may be included; (for example, NE or SW). A photograph without a proper caption is confusing and of little value.

(5) Photographs taken at the accident scene should include the following:

(a) An overall view of the accident site (wreckage) taken from a minimum of four directions. Take photographs from the four cardinal directions (N, S, E, W) and four photographs from the midpoints between (NE, SE, SW, NW).

(b) 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.

(c) Aerial views of the accident scene (equipment and weather permitting).

(d) Photos of objects struck by the equipment.

(e) Larger portions of the equipment wreckage.

(f) Detailed photographs of suspected failed parts that contributed to the accident.

(g) Photos of failed PPE and the agents causing the failure or injuries.

(h) Photograph and measure skid marks and ground scars.
Note. Put an object of known size along side an object whose size may be distorted by the photograph; (for example, a pen or ruler next to a small piece of equipment or scar).

(i) Any other photographs deemed of interest to the investigation board.

(j) When taking digital photographs, if possible, include digital copies of the photographs as well as hard copy.

f. 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 —

(1) Parts suspected of failure.

(2) Parts that appear to be improperly designed or contain faulty workmanship.

(3) Lines, fittings, wiring, or controls not properly supported and subjected to excessive strain or vibration.

(4) Ruptured plumbing or fittings.

(5) Faulty wiring, electrical, or radio equipment.

(6) Defective engines, drive shafts, transmission, and accessories such as carburetors, fuel controls, governors, and generators.

(7) Defective hydraulic system components.
Note. Do not attempt to mate separate items together. This action could destroy evidence.

g. 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 TDA, 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 (PN), 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 USACRC.

h. Equipment records.

(1) As a minimum, the previous 6-month historical records, such as DA Form 2408 series (Aircraft Operational and Maintenance Forms), the periodic inspection records, and the other relevant records, such as manufacturer recalls, should be reviewed.

(a) Check component times and replacement schedule. Review for compliance or noncompliance with modification work order(s) (MWO)(s).

(b) Check for compliance with safety-of-use messages, safety advisory messages, safety-of-flight messages, ground precautionary messages, maintenance advisory messages, and TBs.

(c) Review current and delayed discrepancies records.

(d) 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.

(a) 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).

(b) Inspection should be made of structural repairs for quality of workmanship in fittings, welds, stitching, and, cables. 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.

(4) Historical records may be electronic (downloadable data) or paper. Care must be taken to protect from loss or corruption of data when downloading files and records onto computers or electronic log books.

i. 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.

j. 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). 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.

k. Special investigations.

(1) Highly technical aspects of the accident investigation will require further study and special analysis. 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 —

(a) Adequate photographic coverage must be provided and the suspected failed parts retained for further evaluation.

(b) Sketches, history, and explanatory material must accompany the parts and should contain enough information to give a clear picture of what happened.

(c) 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 in the human factors investigation as well as the materiel factors investigation. Operator's deficiencies relative to design issues should also be included in the human factors investigation.

(d) Different equipment may have controls or instruments in reversed positions from others operated by the operator and this could contribute to the accident.

(2) For example, night vision devices require a special investigation.

l. 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 (see para 2-5 n for details).

(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.

(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.

(l) 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 TM compliance will often provide a lead to possible engine failures.

(a) 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.

(b) If structural parts of the engine failed, these parts must be identified with a description of the failure.

(c) 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.

m. Transmissions. The same investigation and analysis procedures identified in paragraph 2-5 k 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.

n. Fires.

(1) Symptoms.

(a) Fire frequently destroys or consumes clues that could readily disclose the accident cause. (For example, ruptured or chafed fuel lines may be the origin of the fire and the cause of the accident and then subsequently be consumed by fire).

(b) Fire that is a result, rather than a cause, of an accident also hampers the investigator by the destruction or damage of evidence.

(1) If a fire occurred, determine when, where, and how the fire originated.

(2) 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.

(3) 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.

(4) 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.

(5) 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.

(6) 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 TM.

(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 TM.

o. 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.

(1) The control/dash panel normally contains various functional select switches, volume control, digital readout channels, or frequency.

(a) Determine if equipment or vehicle operators, crew members, crash rescue personnel, or early arrivals at the scene moved any of the controls or switches.

(b) Index all movable switches and volume control before any changes are made from the position found.

(c) 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.

(2) Obtain the assistance of communications, avionics, or electronics experts for additional assistance if necessary.

p. Tear down analysis request. TDA request, processing, shipment, and disposition —

(1) Request. The Analytical Investigation Division (AID), Corpus Christi, TX, is the prime recipient and evaluator of all Army aircraft components/parts selected for TDA. The Commander, USACRC; Commander, U.S. Army Aviation and Missile Command (AMCOM); commanders of field organizations/units; aviation safety officers; maintenance officers; and presidents of accident investigation boards are authorized to select components/parts for TDA. Requests for TDA will be made in the interest of establishing or discounting materiel deficiencies, regardless of accident/incident classification. The results of TDA are for use in accident prevention or to establish causes of accidents.

(a) Control numbers. Before shipping any components/parts to AID (Q99745), a product quality deficiency report/ equipment improvement report (PQDR/EIR) will be submitted on the components/parts according to the instructions in DA Pam 738-751. Ground EIRs are submitted in accordance with DA Pam 750-8. The Analytical Investigation Division Q99745 is the Department of Defense activity code (DODAC) for AID and should be used anytime components are shipped to that organization. Authorized personnel must coordinate their requests for TDA with Operations, USACRC, DSN 558-3410/2660, COM (334) 255-3410/2660. Approved requests will receive a USACRC control number which will be placed on the DA Form 2407 (Maintenance Request), block 3a, and must be included in the address to AID.

(b) Data requirement. To obtain USACRC control numbers, the following information will be submitted to the USACRC:

(1) Point of contact (POC), who is knowledgeable of why the request for TDA is being made. Identify the unit to which the equipment is assigned and the unit's 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), PN(s), national stock number(s) and, when applicable, the time since new, time since overhaul, number of prior overhauls, overhaul activity, and date of last overhaul.

(4) AMCOM PQDR/EIR control number for component(s)/part(s) as appropriate.

(5) Accident/Incident data, to include complete aircraft/ground vehicle serial number from which component(s)/ part(s) are removed, Army mishap classification, mishap date, how the defect was found, description of the required analysis, and whether or not a written, electronic, or telephonic report has been provided to the USACRC, or any other technical data that may be of assistance to the materiel analysis personnel.

(2) Processing.

(a) The processing of the item(s) to be shipped for TDA will be accomplished by the nearest activity having a packing, crating, and shipping capability.

(b) 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 must not distort or remove evidence such as heat discoloration, abrasion, stress and torsion splinters, and corrosion.

(c) All traces of foreign matter such as vegetation, human/animal tissue, insects, dirt/soil, or contaminated water must be removed. This is especially required when items are shipped from outside the continental United States (OCONUS).

(d) When contamination, loose ordnance, tools, or other foreign materiel are suspected as the cause of an accident or malfunction, photographs must be taken before cleaning and forwarded with the item(s) as evidence for study by the analyst.

(3) Shipment.

(a) DA Form 2407 will accompany each component/part.

(b) Insert the USACRC control number in the first line of DA Form 2407, block 3a.

(c) The description of the analysis desired will follow the USACRC control number.

(d) DA Form 2410 (Component Removal and Repair/Overhaul Record), when required, and DA Form 2408-16 , Aircraft Component Historical Record, will accompany the aviation item(s) as appropriate.

(e) Also, arrange for the most expeditious delivery/shipment of item(s) for TDA to Analytical Investigation Division (Q99745), Bldg 1880 Ocean Drive, Naval Air Station, Corpus Christi, TX 78419-5260, telephone DSN 861-2902, COM (361) 961-2902.

(f) Container(s) will be clearly, permanently, and conspicuously marked in red on a white background and in sufficient size to allow for ease of visual identification. If container is too small, follow the PQDR/EIR procedures contained in DA Pam 738-751.

(4) Disposition of TDA report.

(a) AID/contractor/manufacturer will provide four copies of the final report to Commander, AMCOM; Commander, USACRC, (CSSC-O) (six copies if USACRC conducts the accident investigation).

(b) One copy each to the applicable theater/command aviation safety officer.

(c) Four copies to the commander of the unit/activity that requested the analysis.

(d) Component(s) or part(s) submitted for TDA on USACRC control numbers will be held until disposition instructions are issued by Commander, USACRC.

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) having an adverse effect 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.

(1) Contaminants (fumes, chemicals) can lead to respiratory problems; noise (radio static, engine, and transmission noise) can distract attention, interfere with effective communications and lead to fatigue.

(2) Inadequate illumination can cause reduced visibility.

(3) Inadequate work space (cluttered, poorly designed driver compartment) can contribute to procedural errors or limit outside visibility.

(4) 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 casual factor, the central questions to ask are: did this factor adversely influence human and/or equipment performance and 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 which could have been avoided or precautions 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

a. Electromagnetic environmental effects (E3), formerly known as electromagnetic interference (EMI), is a recog- nized potential accident cause factor and should be thoroughly evaluated during all accident investigations to determine whether it influenced the operation of the equipment involved.

b. The following E3 list is recommended for use —

(1) During the initial phase of the investigation —

(a) Try to determine if there is any evidence of an external energy influence on the equipment or its subsystems.

(b) Consider cockpit/instrument indications reported by surviving crew members, 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.

(c) Apply the current AMCOM criteria concerning the reporting of suspected E 3 encounters, for aviation accidents.

(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 all accidents where E3 could have played a role but was ruled out, document "E3 was considered but ruled out for the following reasons" in the narrative or accident summary.

(3) If E3 cannot be eliminated early on, or there are positive indications of an external energy influence, advise the USACRC immediately, DSN 558-3410/2660, and request technical assistance. In addition, perform the following:

(a) Check for high-intensity radio transmission areas (HIRTAs) in the area of the accident.

(b) Note visual flight rule (VFR) sectional or tactical maps for large towers (transmitters) in proximity to the accident site.

(c) Identify mobile transmitters operating within the area at the time of the incident.

(d) For aviation accidents, apply HIRTA standoff criteria contained in current AMCOM messages (HIRTA guidance).

(e) While taking aerial photographs of the accident site, review the area surrounding the accident for large towers (transmitters) such as radio/television, telephone microwave, and radar.

(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 Air Traffic Control (ATC) tapes, to include radar and voice, for later review.

(1) If there are surviving crew members, record all cockpit/instrument indications, such as, caution/warning/advisory light illumination, audio warning tones, degradation/loss of flight controls, and stiffness of pedals, experienced during the accident. To compare cockpit/instrument indications with the data base of known type aircraft responses to E3, call Aviation and Missile Research, Development and Engineering Center, Aviation Engineering Division, telephone DSN 879-8403 or COM (256) 313-8403.

(2) If there are no surviving crew members, 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, TDA and review of acceptance test procedures for affected systems/components may be required.

d. Close coordination with the USACRC 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) indicate a suspected materiel failure or human error was the primary cause or if subsequent investigative actions described above have been completed.

e. Contact the USACRC office for additional technical aspects concerning this information at DSN 558-3410/2660, COM (334) 255-3410/2660, or the Army Safety Office for policy aspects of this information, DSN 227-1267, COM (703) 697-1267.

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 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 USACRC 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 (why did it happen).

(d) Determine adequacy of LSE/PPE in terms of minimizing/preventing injuries (how injuries occurred).

(e) Provide corrective actions (what to do about it) having the best potential for remedying the system inadequ- acy(ies) (why did it happen). Identify design deficiencies in the materiel/equipment/system. Once design deficiencies in the materiel system are eliminated (designed out) that hazard will no longer exist to Army personnel.

(2) Each objective has related tasks as follows:

(a) The scope of the chronology may include events that occurred before, during, or after the accident. 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 factors (errors/failures/environmental) that caused or contributed to the accident, it will be necessary for the board to evaluate each factor in terms of its relationship with the accident cause. When it is determined an error/materiel failure/environmental factor caused or 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/PPE, 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 or occupational illness to occur.

(e) To provide corrective actions having the best potential for remedying the system inadequacy(ies), the board must —

(1) Tailor, specifically, the corrective actions to the system inadequacy(ies).

(2) Recommend corrective actions 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. 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 inadequ- acy(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/she 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/Occupational Illness or Extent of Property Damage).

(d) Factor(s) that did not contribute to the accident but 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 are special observations. 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 record keeping, inadequate procedures, and/or lack of required SOPs, directives).

(2) The investigator(s) should next identify each system inadequacy(ies) that caused or permitted the factor to become causal.

(a) The more specific the description of the system inadequacy is, the easier it is to identify effective corrective actions.

(b) If a consensus of the board members agrees with the factors presented and their associated system inadequacy(ies), the process continues until the investigators have completed their presentations.

(c) 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 2-1h .

(3) It may become apparent during the deliberations that evidence is conflicting. In such cases, the board usually has two choices —

(a) The board 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.

(a) 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 corrective actions proposed in the technical report can then be directed to the activities and levels of command best capable of accomplishing them.

(b) 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.

(c) Each recommendation will identify the actions to be taken at the appropriate level of command, such as unit level actions, higher-level actions, or DA-level actions most appropriate to correct the system inadequacy(ies). The recommendations will be written in conjunction with the findings and will be included in the technical report of the accident.

(5) The final results of the total analytical effort will be summarized in the findings and recommendations, and analysis portion of the technical report.

2-9. Accident investigation kit

a. This paragraph contains a list of items recommended for an accident investigation kit. It is neither all inclusive nor mandatory.

(1) Carrying case for kit contents.

(2) Laptop computer.

(3) Digital camera with large memory cards or sticks. Spare batteries for the camera.

(4) Digital voice recorder and batteries.

(5) Cell phone.

(6) Global positioning system.

(7) Flashlight (batteries).

(8) Magnetic compass.

(9) Inclinometer.

(10) Laser rangefinder.

(11) Tape measure, 100 foot (steel recommended).

(12) Small magnifying glass.

(13) Pocket/universal multi-tool with case.

(14) Steel ruler (1 foot) with large index.

(15) Screwdrivers (flat tip and cross tip).

(16) Pliers and crescent wrench (8 inch).

(17) Hearing and eye protection.

(18) Tyvek protective suit and high-efficiency respirator.

(19) Leather gloves.

(20) Telephone extension cord with male-to-male adapter.

(21) Power strip extension cords (2).

(22) Printer cable.

(23) Composite Materials/Bloodborne Pathogen Safety Kit.

(24) AR 385-10 (Chapter 3) and DA PAM 385-40.

(25) Appropriate forms ( DA Form 285 , DA Form 2397-series, DA Form 285-AB (Abbreviated Ground Accident Report (AGAR)), DA Form 2397-AB (Abbreviated Aviation Accident Report (AAAR)).

(26) Additional references (TMs, Field Manuals (FMs), and local regs/SOPs).

(27) Marking/survey flags.

(28) Florescent orange paint.

(29) Tarp.

b. Each organization should assemble its accident investigation kit based on their mission and needs. Items (2), (5), and (23) listed above, as well as the memory cards/sticks and batteries, should not be stored in kit, but obtained as needed.

Chapter 3
Aviation Accident Reporting

3-1. Introduction

AR 385-10 prescribes the classes of aircraft accidents that will be reported via DA Form 2397-series (Technical Report of U.S. Army Aircraft Accident), DA Form 2397-AB (AAAR), and DA Form 2397-U (UASAR). This chapter provides instruction for completing a full report of investigation and identifies the types of substantiating data that will be appended to each report, including instructions on how to process the data. This chapter also provides information for determining which forms of the DA Form 2397-series are required for each report (see fig 3-1 ). Detailed instructions are included explaining how to complete each form, including the DA Form 2397-AB and the DA Form 2397-U.

3-2. DA Form 2397-Series, Technical Report of U.S. Army Aircraft Accident

a. Instruction. The DA Form 2397-series consists of 15 technical reporting forms, a command review form, and two index forms. The forms are required for reporting Class A and B Army aircraft flight or flight-related accidents. Not all forms are necessary for every technical report. See figure 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. They can be reproduced locally on 81/2 by 11-inch paper.

b. Formats. The forms contained in the DA Form 2397-series are designed to provide three different accident report formats.

(1) The first format is narrative in content and includes DA Form 2397 , Part I, Statement of Reviewing Officials, and DA Form 2397-2 , Part III, Findings and Recommendations, DA Form 2397-3 , Part IV, Narrative, and DA Form 2397-4 , Part V, Summary of Witness Interviews.

(2) The second format requires graphic information on DA Form 2397-5, Part VI, Wreckage Distribution.

(3) The third format requires coded data on DA Form 2397-1 , Part II, Summary, the bottom page of DA Form 2397-2, Part III, Findings and Recommendations, and DA Forms 2397-6, Part VII, In-Flight or Terrain Impact and Crash Damage Data, through DA Form 2397-12, Part XIII, Fire.

(4) 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, Part I, Statement of Reviewing Officials

DA Form 2397 (see fig 3-2 ) will be submitted with the copy of the technical report forwarded through channels to the USACRC. If additional space is required, use letter-size paper for continuation sheets.

3-4. DA Form 2397-1, Part II, Summary

The DA Form 2397-1 , Part II, Summary (see fig 3-3 ) will be completed for each aircraft accident requiring a technical report. (See tables 3-2 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.

a. Accidents involving one aircraft require only one DA Form 2397-1. Accidents involving more than one aircraft may require an additional DA Form 2397-1, depending upon the circumstances.

(1) A DA Form 2397-1 is required for each aircraft involved in a flight, or flight-related accident per DA Pam 385-40.

(2) A DA Form 2397-1 will be completed in its entirety for the aircraft and crew deemed most responsible for the accident. This DA Form 2397-1 will be referred to as the "case aircraft."

(3) Additional DA Forms 2397-1 identifying other aircraft involved in the accident will be completed as necessary to account for all aircraft, except inactive aircraft. These DA Form 2397-1; however, do not require a duplication of the information entered in blocks 1 through 7 and blocks 20, 23, and 24 of the "case aircraft" on DA Form 2397-1.

b. Damaged aircraft that were inactive (engines(s) not in operation) will be costed as "other damage military."

3-5. DA Form 2397-2, Part III, Findings and Recommendations

a. DA Form 2397-2 (see fig 3-4 ) will be completed for all aircraft accidents requiring a technical report. (See tables 3-3 through 3-7 for additional information.) If additional space is required, use letter-size paper for continuation sheets.

(1) This form is designed to provide a narrative and coded summary of accident cause factors, system inadequacies, and corrective actions.

(2) Block 1 is used to explain block 2 in terms of what happened, why it happened, and what should be done to reduce the chances of it happening again ("3W" approach).

b. An abbreviated list of the codes and associated mistakes/errors, materiel malfunctions, environmental conditions, system inadequacy(ies) and corrective actions is provided at table 3-7 . Appendix B contains expanded descriptions and examples of the abbreviated codes.

3-6. DA Form 2397-3, Part IV, Narrative

DA Form 2397-3 (see fig 3-5 ) will be completed for all aircraft accidents requiring a technical report. The narrative includes the history of events, human factors, materiel factors, and analysis of the investigation.

3-7. DA Form 2397-4, Part V, Summary of Witness Interview

a. Instruction. DA Form 2397-4 (see fig 3-6 ) will be completed for all aircraft accidents requiring a technical report. As a minimum, summaries of the interviews with surviving crew members 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 procedural guidelines/instructions are as follows:

(1) All witnesses will be interviewed according to chapter 2 , paragraph 2-3. The investigator will emphasize to the witness that the sole purpose of the accident investigation is for accident prevention. The witness should be further informed that the U.S. Army seeks to isolate the cause(s) of the accident so it may take appropriate actions 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.

(a) This will be done by reading to the witness the information on the back (page 2) of the DA Form 2397-4, contained in block 15 (see fig 3-6 ), 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. A promise of confidentiality cannot be offered unless the criteria are met as outlined in AR 385-10 . Limited Use safety accident investigation reports are required for flight and flight-related accidents. Witnesses may be given the option of making their statements under a promise of confidentiality (see AR 385-10 ).

(b) 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 (crew members and maintenance personnel) to whom confidentiality will be routinely offered, and any other case 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 nonconfidential interviews are publicly releasable and, to avoid that outcome, the interview must have been given under a promise of confidentiality.

(c) 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 15, "Availability of Promise of Confidentiality for Limited Use Report of Investigation." The witness will initial section 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 on DA Form 2397-4 in block 12.

(5) The promise of confidentiality will be entered on DA Form 2397-4 , block 11, and will be signed and dated by the interviewer. The promise is as follows: "The witness made this statement under a promise of confidentiality."

(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 .

(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, Part VI, Wreckage Distribution

a. Instruction. DA Form 2397-5 (see fig 3-7 ) 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-series. A decision to not include this from 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 post-crash positions. The locations should be shown relative to the flight path of the aircraft with the azimuth and distance from a given reference point.

(2) Initial impact. The first contact of the aircraft with terrain or obstacles.

(3) Secondary impact. An impact that is less severe than the major impact. Several secondary impacts may occur in an accident.

(4) Major impact. The impact causing the most severe crash forces.

3-9. DA Form 2397-6, Part VII, In-Flight or Terrain Impact and Crash Damage Data

a. Introduction. DA Form 2397-6 (see fig 3-8 ) 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 and 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 (CG) 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 in figure 3-8 .

(7) Flammable fluid. Engine fuel, lubricating oil, and hydraulic fluid.

(8) Major impact. The impact causing the most severe crash forces.

(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 1 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 G-force such as, 1G, 2Gs. 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, Part VIII, Maintenance and Materiel Data

DA Form 2397-7 (see 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.

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 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.

c. Only DA Form 2397-7 pertaining to components or parts that contributed to the accident, or anytime an analysis is to be performed or requested on a part.

d. When analysis of components/parts shows that there was no contribution to the accident, DA Form 2397-7 pertaining to these items will be retained as work copy documents, but will not be included in the completed Technical Report of U.S. Army Aircraft Accident.

e. If explanatory remarks are required, use block 6 and letter-size paper for continuation sheets.

3-11. DA Form 2397-8, Part IX, Personal Data

DA Form 2397-8 (see fig 3-10 ) will be completed for all aircraft accidents requiring a technical report (see tables 3-5 , 3-6 , 3-8 , and 3-9 ). It will be submitted for —

a. Each rated crew member. Fill in block 1 through 4d, and 6 through 17.

b. Each nonrated crew member and noncrew member performing nonrated crewmember duties. Fill in blocks 1a, 2, 3d, 3e, 3f, 3g, 3h, 3j, 3n, 3o, 3p, 3q, 4e, and 5 through 17.

c. Support personnel and non-crew members whose contributory role in the accident was attributed to duties such as mechanic, petroleum, oils, & lubricants (POL) handler, air traffic controller, technical inspector, medical officer. For each of these individuals, fill in blocks 1a, 2a through i, 3g, 3n, 3p, 3q, 4e, 5, 6, 7, and 10 through 17.

d. Supervisory personnel who may have contributed to the accident. For these individuals, fill in blocks 1a, 2a through 2i, 5, and 10 through 17.

3-12. DA Form 2397-9, Part X, Injury/Occupational Illness Data

a. DA Form 2397-9 (see fig 3-11 ) will be completed for each individual who was injured or sustained an occupational illness as a result of the aircraft accident.

b. The accident investigation board shall reference and comply with AR 40-21 .

c. It is mandatory that autopsies be performed on all deceased crew members. 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 Combat Readiness Center (CSSC-O), Fort Rucker, AL 36362-5363, for inclusion into the historical copy of the report.

3-13. DA Form 2397-10, Part XI, Personal Protective Escape/Survival/Rescue Data

DA Form 2397-10 (see fig 3-12 ) will be completed for all crew members aboard an aircraft involved in an accident requiring a technical report. In addition a DA Form 2397-10 will be completed 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, Part XII, Weather/Environmental

DA Form 2397-11 (see fig 3-13 ) will be completed for all aircraft accidents requiring a technical report. This form does not negate the requirement for the substantiating weather data addressed in paragraph 3-17 . Weather/environmental information submitted on DA Form 2397-11 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, and surviving crew members.

3-15. DA Form 2397-12, Part XIII, Fire

DA Form 2397-12 (see fig 3-14 ) will be completed for each technical report of aircraft accident in which fire occurs (see table 3-6 ).

3-16. DA Forms 2397-13, Index A and 2397-14, Index B

DA Form 2397-13 (see fig 3-15 ) and DA Form 2397-14 (see fig 3-16 ) will be completed for all aircraft accidents requiring a technical report.

3-17. Substantiating data

a. Instruction. DA Form 2397-13 , 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. The information attached to the left side of the report folder will aid in completing the remainder of the DA Form 2397-series.

b. Requirements. TAB items 1, 2, 4, 6, 7, and 9 of DA Form 2397-13 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 3-17 d .

c. Special considerations.

(1) Social Security Numbers. None of the substantiating documents require an SSN. If any of the documents on the left side of the report have an SSN listed, black out the number with a black felt tip marker.

(2) 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.

(3) 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.

(4) 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. Underline 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.

(1) TAB 1-Copy of orders appointing investigating board. A copy of the original signed orders appointing the board and any amendments will also be appended. (See AR 385-10 ).

(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, as a minimum append a brief synopsis of the weather existing before, during, and immediately after the accident, authenticated by the closest weather service. Otherwise, if weather or weather services are suspected, the information to be provided should include, but not limited to the following:

(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, (for example, DD Form 175-1 , (Flight Weather Briefing)).

(c) Copies of pertinent weather advisories and related forms.

(3) TAB 3-Certificate 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, cost to repair or replace each component, number and cost of man-hours, and total cost of repair. Refer to this DA Pam 385-40, chapter 1, paragraph 1-10 and the AMDF 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-Diagrams and/or 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.

(a) Arrows should be placed on the face of the map depicting magnetic north and the wind, with numerical values, which existed a the time of the accident.

(b) 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.

(c) Also, significant events occurring along the depicted flight path should be numbered at the point they occurred and explained by footnotes.

(d) 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-Copy of Product Quality Deficiency Report ( SF 368 ). Include a copy of each deficiency report submitted as a result of the accident. All failed or suspected failed parts/systems must be reported on a PQDR. When a materiel failure is the sole cause of the accident and a PQDR is not submitted, the accident will be charged to the accident unit in accordance with AR 385-10 .

(6) TAB 6-Special technical reports and 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-Weight and Balance Clearance Form F-Transport/Tactical (DD Form 365-4). 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-Copy of directives, regulations, and so forth. Pertinent portions of written documents relating to cause factors will be extracted, underlined/annotated, and appended to the accident report.

(9) TAB 9-Medical data. Toxicological reports, preferably done by the AFMES, 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 chapter 2, 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 11-Army Aviators Flight Record ( 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 crew member for the appropriate period preceding the accident should be included.

(12) TAB 12-Aircraft Status Information Record ( DA Form 2408-13 ). Append a copy of DA Form 2408-13 to the accident report if maintenance or materiel deficiencies are discovered.

(13) TAB 13-Uncorrected Fault Record ( DA Form 2408-14 ). Append copies of DA Forms 2408-14 applicable to the accident aircraft if a materiel problem related to an uncorrected fault is involved.

(14) TAB 14-Equipment Modification Record ( DA Form 2408-5 ). Append copies of applicable DA Forms 2408-5 when necessary to substantiate maintenance errors, omissions, which caused or contributed to the accident.

(15) TABs 15 through 18-Other. Substantiating data that have a bearing on an accident and are not covered by other information items listed on DA Form 2397-13 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 annotated.

(b) Copies of crew member post-accident flight evaluations.

(c) Copies of DA Form 2028 (Recommended Changes to Publications and Blank Forms) when changes in publica- tions are recommended.

(d) Results of special investigations conducted by individuals/agencies in support of the accident investigation.

(e) Portions of transcripts of ATC logs, tower tapes, media news accounts, fire, rescue and law enforcement reports, and relevant portions of intra-cockpit voice recordings.

(f) Copies of DA Form 2408-18 (Equipment Inspection List) when necessary to show compliance or noncompliance with Safety of Flight messages and similar directives and publications.

3-18. Miscellaneous

A list may be beneficial to the local safety 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-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- series on the right. If the accident report will contain more than one DA Form 2397-series because of a multiple aircraft event, keep each DA Form 2397-1 and its associated forms together and file in a manner that will permit view of the "case aircraft" DA Form 2397-1 and its associated forms first.

c. Tab and index each item on the left and right sides of the folder as shown in figure 3-18 .

d. File the completed DA Form 2397-13 , Index A, on top of substantiating data on the left side of the folder and file the completed DA Form 2397-14 , Index B, on top of the DA Forms 2397-series on the right side of the folder. The items to be included as substantiating data are addressed in paragraph 3-17 . Additional items may be included as determined by the board.

e. The front of the folder will be marked with the following information:

(1) "Limited or General Use."

(2) Safety Accident Investigation Report of U.S. Army Class (A - D) Accident.

(3) Aircraft mission, type, design, and series (MTDS) and Serial No. (UH60LXXXXXXX).

(4) Date of accident: (mmddyyyy).

(5) Location of accident: (DA Form 2397-1, block 7).

(6) Unit: (DA Form 2397-1, block 9).

3-20. DA Form 2397-AB, Abbreviated Aviation Accident Report

DA Form 2397-AB , (AAAR) (see fig 3-17 ) is required for all manned aircraft ground accidents regardless of class and Class C, D, E, and F flight or flight-related accidents/incidents. (See tables 3-2 through 3-6 and tables 3-8 and 3-9 for additional information.) The AAAR only reduces the reporting requirements and should not affect the quality or extent of the accident investigation. This form may also be used to report aviation Class A and B accidents during combat operations when the submission of the DA Form 2397-series is deemed not practicable by the senior tactical commander (see AR 385-10 ).

a. Investigation and submission of the DA Form 2397-AB will be according to AR 385-10 .

b. Submit AAARs in legible hand-printed or typed copy via mail, fax, courier, electronic mail (e-mail), or can be submitted through the automating reporting system. Work copies on plain paper will be acceptable, but each data element must reference the respective block of the DA Form 2397-AB.

(1) The mailing address is as follows: Commander, U.S. Army Combat Readiness Safety Center, (CSSC-O), Quality Control Support Branch, Bldg 4905, 5th Ave, Fort Rucker, AL 36362-5363.

(2) The e-mail address is: usarmy.rucker.hqda-secarmy.mbx.safe-accident-information@mail.mil .

(3) The automating reporting system allows for quick and easy reporting through the USACRC Web site: https://safety.army.mil .

c. For Class A, B and C accidents (those reported on DA Form 2397-AB), attach all additional information or forms required or deemed appropriate. For example, summaries of witness interviews, expanded narratives, ECOD/ACOD, PQDR, lab/Corpus Christi Army Depot (CCAD) reports, other DA Form 2397-series, additional personnel information sections, and additional AAAR forms for involved aircraft other than the case aircraft.



Figure 3-1. Aviation Accident/Incident Notification, Reporting Requirements, and Suspenses


3-21. DA Form 2397-U, Unmanned Aircraft System Accident Report

DA Form 2397-U (UASAR) is required for all UAS aviation accidents (flight, flight-related, and aircraft ground) including Aerostats, regardless of the class. The UASAR provides a report form that is specific in the characteristics and operational parameters of UAS. The UASAR is required for accidents involving an UAS with an engine in operation or an operational Aerostat that results in injury or property damage. Aerostats are considered operational when the Aerostat system platform (or launch pad) is manned and power is applied to winches and other safety release devices as part of the launching process. If an engine is not in operation or the Aerostat is not operational at the time of the accident then the injury or property damage will be reported on the appropriate ground accident report ( DA Form 285 or 285-AB). If a manned aircraft is involved in the same accident as an unmanned aircraft the accident will be investigated and reported as a manned aircraft accident using the DA Form 2397 Technical Report or DA Form 2397-AB AAAR; the DA Form 2397-U will be added to the manned aircraft report as the other aircraft involved. The manned aircraft will always be the case aircraft. Injuries or fatalities resulting from an operational UAS accident are reported on DA Form 285 or 285-AB, as appropriate.

a. Investigation and submission of the DA Form 2397-U will be in accordance with AR 385-10 .

b. Submit UASARs in typed or legible hand-printed copy via mail, fax, courier, electronic mail (e-mail), or through the automated reporting system.

(1) The mailing address is as follows: Commander, US Army Combat Readiness/Safety Center (G3, Data Quality Control Division), Bldg 4905, 5th Avenue, Fort Rucker, AL 36362-5363.

(2) The e-mail address is: usarmy.rucker.hqda-secarmy.mbx.safe-accident-information@mail.mil .

(3) The automated reporting system allows for quick and easy reporting through the USACR/SC Website: https://safety.army.mil .

c. Attach all additional information or forms required and/or deemed appropriate (for example, summaries of witness interviews, expanded narratives, PQDR, ECOD/ACOD, lab/CCAD reports, contractor reports, other DA Form 2397-series, additional personnel information sections, and, if applicable, additional UASAR forms for involved aircraft other than the case aircraft).

d. Detailed instructions for completing the UASAR are in paragraph 3-37 of this chapter.

3-22. Completion instructions for DA Form 2397, Part I, Statement of Reviewing Officials




Figure 3-2. Example of a completed DA Form 2397, Part I, Statement of Reviewing Officials


a. Also see paragraph 3-3 .

b. Complete instructions as follows:

(1) Block 1. The initial reviewing official(s) will indicate the official's organization as follows:

(a) State concurrence or nonconcurrence with the findings and recommendations. 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) Identify those area(s) recommended for improvement by the investigating board that are beyond the resources available to the command.

(d) Authenticate comments with signature, appropriate signature block, organization, and date 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 and 3.

(2) Block 2. Army Headquarters reviewing authority. Army Headquarters commanders or their designated represent- atives will provide written concurrence or nonconcurrence for each finding and recommendation made by the accident investigation board.

(a) Indicate reasons for nonconcurrence. Also, include any additional recommended actions.

(b) The reviewing authority will make note of those areas recommended for improvement by the accident investiga- tion board or subordinate reviewing officials on which action can or will be completed. If corrective action is beyond the purview or capability of the Army Headquarters reviewing authority, this will be stated.

(c) Authenticate comments with signature, appropriate signature block, and organization at the close of remarks.

(3) Block 3. This block is reserved for USACRC use and will be completed by the USACRC to show coordination/ follow-up taken in response to recommendations requiring DA-level action.

(4) Block 4. Enter the case number as shown in table 3-6 .

3-23. Completion instructions for DA Form 2397-1, Part II, Summary




Figure 3-3. Example of a completed DA Form 2397-1, Part II, Summary





Figure 3-3. Example of a completed DA Form 2397-1, Part II, Summary—continued


a. Also see paragraph 3-4 .

b. Complete instructions as follows:

(1) Blocks 1a and 1b. Check the appropriate box to indicate the appropriate classification and category for the accident. Accident classifications and categories are defined in AR 385-10 and chapter 1 of this DA Pam.
Note. Accident classification is based solely on property damage or injury/illness severity. For example, fatal, permanent partial disability. In accordance with AR 385-10, 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 morning nautical twilight and official sunrise. Dusk is that period of time between official sunset and end evening nautical twilight.

(4) Block 4. Check the appropriate box. Tactical landing zones under positive ATC. For example, 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 USAR component facilities are considered "on post" and "on airfield" when there is intent to use the military facilities on that airport, (for example, visit the unit, acquire fuel, and conduct training).

(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 submitted with the technical report. Paragraph 3-4 specifies when additional DA Forms 2397-1 are required.

(7) Block 7. Enter the name of the closest city, state, and country to the accident site. Enter the military grid reference or latitude/longitude.

(8) Block 8. Enter appropriate information for the aircraft addressed by this form. Organization aircraft assigned and unit identification code (UIC) pertaining 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 the Army Headquarters command.
Note. For U.S. Army Reserve (USAR) or Army National Guard (ARNG) units on active duty status, if the unit of assignment is other than the USAR or ARNG, enter the unit of assignment chain of command in block 9b. Enter the AGR or (ARNG) unit chain of command in block 9a.

(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 Army Headquarters command and explain in the analysis paragraph of DA Form 2397-3 . If the accident unit is the same as listed in block 9a, leave blank. Further guidance for determining accountability is contained in AR 385-10 , paragraph 3-9 .

(10) Block 10.

(a) Block 10a. If the aircraft identified in block 25c 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 materiel 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 paragraph 1-10 . The ECOD 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 is not operational, 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 (For example, damaged buildings, destroyed crops, broken utility poles and lines, livestock) in the space "Other Damage Civ" provided. Report the total dollar value of all injuries for this aircraft, as recorded in block 19, DA Forms 2397-9, Part X, Injury/Occupational/Illness Data. The cost is computed using the standard injury and illness costs contained in table 1-1 of this pamphlet. Injuries or fatalities to non-DOD personnel (For example, private citizens) are not included in accident injury/occupational illness cost. Show ownership of all damage by entering one of the codes listed in table 3-3 .

(b) Block 10b. Complete this block only for accidents involving a multiple aircraft event. The information will be entered only on the DA Form 2397-1 applying to the "case aircraft" identified in block 25c. 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 app 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 survivable. If no seat positions meet the criteria, the accident is nonsurvivable. 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 in-flight 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 "in-flight." For fires beginning after the initial crash impact has begun, check "post-crash." Check both boxes if in-flight and post-crash fires occurred. If "in-flight," "post-crash," or "other" boxes is checked, ensure that a DA Form 2397-12 is completed. For the purpose of this block, movement of the aircraft under its own power is considered in-flight. If other is checked, explain in narrative ( DA Form 2397-3 ).

(14) Block 14. Check the "Yes" block if any occupant had difficulty or required assistance during egress. Leave blank for nonsurvivable 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 .

(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 ( DA Form 2397-2 ) and "special investigation" portion of the narrative ( DA Form 2397-3 ).

(c) Block 16c. Check "Yes" if a Digital Source Collector (DSC) was installed, specify type in 16c(2). Explain in the narrative ( DA Form 2397-3 ) portion of the report.

(d) Block 16d. If "Yes," explain and enter name of field training exercise in "the preflight phase" of the narrative ( DA Form 2397-3 ).

(e) Block 16e. Check "Yes" only if heads-up display was in use at the time of accident.

(f) Block 16f. If an emergency locator transmitter was installed, check "Yes." Explain any malfunctions in the narrative ( DA Form 2397-3 ).

(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.

(a) Block 18a. Use the mission symbols on DA Form 2408-12 or as specified in 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."

(b) Block 18b. Check the appropriate box to indicate if the mission was a single- or multi-aircraft operation.

(19) Block 19. Enter the number of personnel in the appropriate boxes.

(a) Columns B through E (Disabling) - combine the injuries reported in blocks 1b through 1e of DA Forms 2397-9.

(b) Columns F through G (Nondisabling) - combine those injuries reported in block 1f and 1g of DA Forms 2397-9. Ensure the number of personnel reported as injured agrees with the number of injured personnel reported on DA Forms 2397-9 for this aircraft.

(c) Block 19f, "Multiple Acft Event," is completed only on the DA Form 2397-1 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. For "Flight Duration," enter hours and tenths of hours, and for "Phase of Operation," enter appropriate code(s) (maximum of three) from the list at table 3-4 . "Over gross" 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. Aircraft weight is the estimated take-off weight.

(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/occupational illness, property damage, or further materiel failure.

(c) Block 21c. 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 "D," "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 present and contributing findings reported in blocks 1 and 2 of the DA Form 2397-2 , the analysis portion of the DA Form 2397-3 , and the cause relationship block elements checked on DA Forms 2397-7, Part VIII, Maintenance and Materiel Data, 2397-8, Part IX, Personal Data, and 2397-11, Part XII, Weather/Environmental.

(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 the cause of the accident. Continue on letter-size 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 25. Enter the case number. The case number is a 19-digit numerical entry consisting of an 8-digit date (Block 25a), 4-digit hour of the day (Block 25b), and the 7-digit tail number of the "case aircraft" (Block 25c). This case number will be placed on each form of the DA Form 2397-series accompanying the report, as indicated in table

(26) Block 26. Block 26. If the accident involves a multiple aircraft event, block 26 will be completed only on additional DA Forms 2397-1, addressing the other aircraft. Leave blank if it is a single aircraft accident.

Table 3-1A. Elements of a human error present and contributing finding
FINDING (Present and Contributing: Human Error - Individual Failure):
Required Information Example
1. Explanation of when and where the mistake/error occurred in context of the accident sequence of events. While conducting day, nap-of-the-earth aircrew training at 50 feet above ground level (AGL) and 10 knots indicated air speed (KIAS)…
2. Aircraft and individual involved by duty position. the Pilot in Command (PC) and Pilot (PI) of the UH-60…
3. Identification of mistake made (ref aviation-specific mistakes/errors in DA PAM 385-40 , Table B-1 ) and an explanation of how task/activity was performed improperly. NOTE: Only one mistake/error per finding. improperly scanned. That is, both crewmembers failed to properly scan for obstacles when they both became visually fixated on an animal on the ground…
4. Directive (ATM, SOP, FM, TM, and so forth) or common practice governing performance of task/activity. in contravention of TC 1-237 , Task 2026.
5. Consequences of mistake/error. As a result, the aircraft main rotor blades were damaged when they made contact with a tree at approximately 50 feet AGL. There were no injuries.
6. Identification of reasons (root causes/system inadequacies) for the mistake/error {ref System Inadequacies in Table B-5 of DA PAM 385-40}. NOTE: The finding may contain multiple System Inadequacies (Individual, Standards, Leader, etc.) The PC's and PI's actions were a result of overconfidence in each other's ability to clear the aircraft and maintain obstacle clearance.
7. Brief explanation of how each reason (root cause/system inadequacy) contributed to the mistake/error. The PC and PI allowed the aircraft to fly too close to known obstacles resulting in damage to the main rotor blades.

Notes:
1. FINDING 1: (Present and Contributing: Human Error- Individual Failure): While conducting day, nap-of-the-earth aircrew training at 50 feet AGL and 10 KIAS, the PC and PI of the UH-60L improperly scanned. That is, both crewmembers failed to properly scan for obstacles when they both became visually fixated on an animal on the ground in contravention of
TC 1-237 , Task 2026. As a result, the aircraft main rotor blades were damaged when they made contact with a tree at approximately 50 feet AGL. There were no injuries. The PC's and PI's actions were a result of overconfidence in each other's ability to clear the aircraft and maintain obstacle clearance. The PC and PI allowed the aircraft to fly too close to known obstacles resulting in damage to the main rotor blades.


Table 3-1B. Elements of a materiel failure present and contributing finding
FINDING (Present and Contributing: Materiel Failure):
Required Information Example
1. Explanation of when and where the materiel failure/malfunction occurred in the context of the accident sequence of events. During engine run-up of the CH-47D with rotor blades turning…
2. Name and PN or NS of the part, component or system that failed. the retention bolts (P/ N NAS624H-5) securing the fixed droop stop to the aft rotor system red blade pitch shaft….
3. Mode of failure (corroded, burst, twisted, decayed, etc.)(see DA PAM 385-40, Appendix B , Table B-3 for definitions and examples) NOTE: Only one failure per finding. The pressure on the engaged threads allowed the threads to strip from the nuts.
4. Consequences of materiel failure. The pressure on the engaged threads allowed the threads to strip from the nuts. This failure allowed the fixed droop stop and bolts to separate from the aircraft. As a result, during shutdown, with both engine condition levers at stop and the main rotor blades coasting slowly, the aircraft red main rotor blade contacted the fuselage…
5. Identification of reasons (root causes/system inadequacies) materiel failure/malfunction caused or contributed to accident. NOTE: The finding may contain multiple System Inadequacies (Design, Manufacture, and so forth). The droop stops failed due to improper installation by the manufacturer during aircraft overhaul.
6. Brief explanation of how each reason (root cause/system inadequacy) contributed to materiel failure/ malfunction. That is, the bolts (P/ N NAS624H-5) installed in the separated fixed droop stop, though nearly identical in appearance, were 1/8-inch shorter than the bolts (P/ N NAS624H-7) required by TM 55-1520-240-23P1.

Notes:
1. FINDING 1 (Present and Contributing: Materiel Failure). During engine run-up of the CH-47D with rotor blades turning, the retention bolts (P/ N NAS624H-5) securing the fixed droop stop to the aft rotor system red blade pitch shaft failed. The pressure on the engaged threads allowed the threads to strip from the nuts. This failure allowed the fixed droop stop and bolts to separate from the aircraft. As a result, during shutdown, with both engine condition levers at stop and the main rotor blades coasting slowly, the aircraft red main rotor blade contacted the fuselage, resulting in minor fuselage and main rotor blade damage. The droop stops failed due to improper installation by the manufacturer during aircraft overhaul. That is, the bolts (P/ N NAS624H-5) installed in the separated fixed droop\stop, though nearly identical in appearance, were 1/8-inch shorter than the bolts (P/ N NAS624H-7) required by TM 55-1520-240-23P1.


Table 3-1C. Elements of an environmental factor present and contributing finding
FINDING (Present and Contributing: Environment):
Required information Example
1. Explanation of when and where the environmental factor occurred in the context of the accident sequence of events. While ground-taxiing to the parking ramp…
2. Aircraft and if applicable, the individual(s) involved by duty position. the AH-64D…
3. Description of environmental factor encountered(see DA PAM 385-40, Appendix B, Table B-4 for definitions and examples). NOTE: Only one failure per finding. encountered an unforecast sudden microburst with winds exceeding 80 knots.
4. Consequences of environmental effect. As a result, the aircraft became airborne in a nose-low condition and subsequently entered a right spin from which the crew was unable to recover.
5. Explanation/identification of reason(s) environmental conditions caused the accident. Microbursts are environmental events that cannot be seen or forecasted with present meteorological measuring equipment nor are they visible to aircraft crewmembers. They are normally a phenomenon associated with thunderstorms; however, there were no thunderstorms reported or visible in the vicinity.

Notes:
1. FINDING 1 (Present and Contributing: Environment). While ground-taxiing to the parking ramp, the AH-64D encountered an unforecast sudden microburst with winds exceeding 80 knots. As a result, the aircraft became airborne in a nose-low condition and subsequently entered a right spin from which the crew was unable to recover. The aircraft struck the ground causing aircraft damage and injuring one crewmember. Microbursts are environmental events that cannot be seen or forecasted with present meteorological measuring equipment nor are they visible to aircraft crewmembers. They are normally a phenomenon associated with thunderstorms; however, there were no thunderstorms reported or visible in the vicinity.

3-24. Completion Instructions for DA Form 2397-2, Part Ill, Findings and Recommendations




Figure 3-4. Example of a completed DA Form 2397-2, Part III, Findings and Recommendations





Figure 3-4. Example of a completed DA Form 2397-2, Part III, Findings and Recommendations—continued


a. Also see paragraph 3-5 .

b. Complete instructions as follows:

(1) Block 1. Instructions for reporting findings and recommendations. Each finding must be substantiated by the written analysis portion of the narrative ( DA Form 2397-3 ). Findings fall into one of five categories:

(a) Present and contributing.

(b) Suspected present and contributing.

(c) Present and contributing to the severity of the injury/occupational illness or extent of property damage.

(d) Present but not contributing.

(e) Special observations. (This is noted at the end of the narrative only.)

(1) Findings. As a minimum, the following elements of information will be addressed for each Present Contributing, Suspected Present Contributing, and Present Contributing to the Severity of Injury/Occupational Illness or Extent of Damage finding in the order stated. See table 3-1 .

(a) An explanation of when and where the error, materiel failure, or environmental factor occurred in the context of the accident sequence of events. For example, "During preflight," "During takeoff," "While employing."

(b) Identification of the individual involved by duty position; or the name and PN or 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 , table B-1 for mistake/error categories. The error could be one of commission or omission. For example, 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. Refer to appendix B, table B-3 for material failures/malfunctions. For example, corroded, burst, twisted, decayed. Enter only one task error, malfunction or environmental condition code per present and contributing factor.

(d) Identification of the directive, (for example, ATM, SOP, Field Manual (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/occupational illness 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 circum- stances that cause errors resulting in making further damage/injury or occupational illness inevitable.

(f) Identification of the reasons (system inadequacy(ies)) the human, materiel, environmental conditions contributed to the accident. Refer to the list and examples of system inadequacy(ies) provided in appendix B , table B-5 . The present and contributing finding may contain multiple system inadequacies (training, individual, leader, and so forth).

(g) A brief explanation of how each reason contributed to the error, materiel failure, or environmental factor.

(h) In addition, for Present and Contributing to the Severity of Injury/Occupational Illness or Extent of Damage findings, the board should also: (1) Report those factors that contributed to the severity or injury or extent of damage; (2) Summarize personnel injuries attributable to the defects in support equipment, PPE or crashworthiness design as findings in this category; (3) Address injuries sustained from failure to provide equipment; for example, seatbelts; (4) Separate the findings and recommendations in this category from those that caused the accident and precede them with the following statement: "THE FINDING(S) LISTED BELOW DID NOT DIRECTLY CONTRIBUTE TO THIS ACCIDENT; HOWEVER, IT/THEY DID CONTRIBUTE TO THE (SEVERITY OF INJURIES) OR (ACCIDENT DAMAGE)."

(i) Present but Not Contributing findings are those that did not cause or contribute to the accident or to the severity of injuries: (1) 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 personnel and equipment if not corrected. Reporting these deficiencies will ensure they receive command attention throughout the chain of command to include DA-level action; (2) The findings and recommendations in this category will be separated from those that caused the accident or those that did not cause the accident but contributed to the severity 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 HAVE AN ADVERSE EFFECT ON THE SAFETY OF FUTURE OPERATIONS."

(2) 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 contributed to the accident and for each Present but not Contributing finding that might have an adverse effect on the safety of future operations. 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. For example, 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 (company, troop, battalion), higher level (brigade, division, corps, Army Headquarters), and DA (to include Army Headquarters with Army-level proponency) 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. For example, "DA Level Action: None," "Unit Level," "Higher Level," and "DA Level" 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 Army Headquarters, and DA-level activities.) In cases where an Army Headquarters is the highest level proponent for a recommended action having Army-wide application, the Army Headquarters will be listed in the "DA Level" category.

(2) Block 2. Enter a coded summary of the present and contributing findings and recommendations to include duty, role, phase of operation, mistake/errors, ATM tasks, system inadequacy(ies). Blocks 2a, 2b, and 2c pertain 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 present and contributing findings reported in block 1 or the continuation sheet.

(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), Aircrew Training Manual Task No. Enter the ATM task number being performed at the time the mistake/error was made. Enter "NA" if no ATM task applies.

(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. Enter only one code.
Note. An abbreviated list of codes and associated mistake/errors, system inadequacy(ies), corrective measures, materiel failures, and environmental conditions is provided at
table 3-7 and/or appendix B , which contains expanded descriptions and examples of the abbreviated codes. Also, prefix corrective codes with "U" for unit, "H" for higher, and "A" for DA to indicate the level of command to which the remedial action is directed.

(f) System inadequacy(ies). 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 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. (See table 3-7 and app B ).

(g) Remedial corrective measures/recommendations. In the spaces provided to the right of each system inadequacy(ies), enter the codes for the corrective measures selected to correct that specific system inadequacy. (See table 3-7 and app B).

(h) Continue entries. Continue the entries in blocks 2a, b, and c until all personnel who made errors contributing to the accident, specified in the present and contributing 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 to continue entries. For each duty code entered in blocks 2a, b, and c, ensure that a DA Form 2397-8 is completed for each individual.

(i) Block 2d, Materiel. An entry is required for all materiel failure(s)/malfunction(s) that caused or contributed to the accident as specified in the present and contributing findings of block 1 above. If more than one materiel failure was involved, use block 2d of an additional DA Form 2397-2 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.

(l) Block 2d(3), Failed part number. Enter the manufacturer's PN. The number should coincide with the PN listed in block 3c of DA Form 2397-7.

(m) Block 2d(4), Failure code. Enter the code that best describes the materiel failure category. (See table 3-7 and app B).

(n) System inadequacy(ies). Enter the codes of the system inadequacy(ies) that caused or permitted the materiel failure/malfunction to become an accident cause factor. If system inadequacy(ies) 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 human mistake/error and consider the failure/malfunction as a result of human mistake/error instead of a materiel failure. The mistake/error would then be recorded in block 2a, b, and/or c.

(o) Remedial corrective measures/recommendations. Enter codes for corrective measures in the spaces located to the right of each system inadequacy(ies).

(p) Block 2e, Environmental. This block is to summarize causal environmental conditions that had an adverse effect on human or equipment performance as related to the accident. Examples include unpredictable weather phenomena (wind/turbulence) resulting in airframe damage; bird strikes damaging aircraft. For the environment to be considered to have caused or contributed to an accident, it must have been unavoidable or unknown at the time of the accident. If the environment does not meet the criteria, a human 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 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), Condition code. Enter the code for the environmental factor. (See table 3-7 and app B ).

(t) System inadequacy(ies). Enter the code of the system inadequacy that caused or permitted the environmental factor to become an accident cause.

(u) Remedial corrective measures. Enter corrective 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 (see table 3-6).

3-25. Completion instructions for DA Form 2397-3, Part IV, Narrative




Figure 3-5. Example of a completed DA Form 2397-3, Part IV, Narrative





Figure 3-5. Example of a completed DA Form 2397-3, Part IV, Narrative—continued





Figure 3-5. Example of a completed DA Form 2397-3, Part IV, Narrative—continued





Figure 3-5. Example of a completed DA Form 2397-3, Part IV, Narrative—continued


a. Also see paragraph 3-6.

b. Completion instructions. Block 1. Narrative account of investigation. The board will report, in narrative form, the facts, conditions, and circumstances as established during the investigation and present this information in four sections (history of flight, human factors, materiel factors, and analysis). The first three sections will contain factual data. The analysis section is reserved for the board's documentation of its conclusions/opinions concerning the accident cause relationships. Chapter 2, paragraph 2-8 , explains procedures for development of formal written analysis. Additional subheadings may be added as deemed necessary. It is important that the narrative address all of the chronological events and evidence that had a bearing on the cause of the accident and/or have the potential for adversely affecting safety of future operations. For accidents in which the investigation board determines that human error, materiel failure/malfunction or environmental conditions were a factor, that portion of the narrative will be completed in its entirety, as specified in the instructions below. The history of flight, personnel background, personnel management, meteorological, airworthiness, laboratory analysis, and analysis portions will be completed for all accidents. For the remaining subheadings which the investigation board determines were not a factor, enter after the subheading "Investigation revealed not a factor" and proceed to the next 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.

(1) History of the flight.

(a) 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.

(b) 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.

(c) Post flight 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 post crash 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.

(2) Human factors. For accidents resulting from causes other than human factors, the human factors part of the narrative may be sharply reduced by making a statement like "none" for the subheadings except for subheadings addressing personnel background information, personnel management, and meteorological conditions.

(a) 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 instructor pilot/standardization pilot (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 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 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 the 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.

(b) Personnel management.

(1) Individual. 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 MTDS aircraft assigned to the mission. Explain irregularities in the individual's training folder.

(2) 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, PC, Instrument Examiner (IE), Unit Trainer (UT), and so forth. Review the procedures involved in selecting the crew for the mission. Describe timeliness of notification, compatibility 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 post-accident flight evaluations were administered, summarize results. Highlight weaknesses in proficiency if appropriate, especially the performance of tasks duplicating those involved in the accident.

(3) 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.

(4) 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 altitude, aircraft design limitations as found in applicable operators manual, configurations, and so forth.

(5) Communications/air traffic services. Describe evidence relating to communications equipment (adequacy of visual and electronic signals, and so forth.) and the communication that occurred or failed to occur among the crew, between crew and passengers, and between crew and outside services; for example, ATC, operations, flight service station (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.

(6) Navigation aids. Describe adequacy of navigation aids (very high frequency omni-directional range (VOR), non-directional beacon (NDB), instrument landing system (ILS), and so forth.) Consider Federal Aviation Administration (FAA) or other agency publications, Notices to Airmen, pilot reports, and so forth.

(7) 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.

(8) Ground support services. Describe evidence that relates to the role of ground support services in the accident. Consider POL personnel, ground guides, fire guards, and so forth.

(9) 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 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 PPE; for example, helmet, visor, clothing, survival vest components, and so forth.

(10) 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.

(11) 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.

(12) 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.

(3) 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 failures/malfunctions and omit damage that resulted from crash forces exceeding design limits. References can be made to the wreckage distribution diagram, photographs, reports, records, and so forth. Include the following areas:

(a) 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.

(b) Digital source collectors. Report information obtained from digital source collectors, if applicable. The board's analysis of this data, however, should be included in the analysis portion of the report.

(c) Airframe. Use subparagraphs to report evidence obtained in the examination of the airframe structure and landing gear components.

(d) 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.

(e) Power plant. 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.

(f) 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.

(g) Transmissions/gearboxes and drive train. Report condition and describe any faults noted and cause, if known.

(h) Laboratory analysis. Report the results of aircraft fluids, components, and parts submitted for laboratory analysis.

(i) Crash site information. Describe adequacy of the crash site/airfield (heliport, helipad, pick-up zone (PZ), landing zone LZ), and so forth), to include dimensions, lighting and marking, obstructions, type and condition of surface, slopes, and so forth.

(j) 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.

(k) 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 corrective 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; for example, "... 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; for example, "before the mission," "during takeoff," "during a nap of the earth (NOE) deceleration," "while installing a hydraulic line," "during the in-flight ejection," "during the crash sequence," and so forth.

(c) Identify the duty position of the person who erred, became injured, or the name and PN or the NSN of the part, component or system that failed; for example, "the pilot"; "the mechanic"; "the fuel control, NSN 2915-00-157-2313"; "the input bevel gear, PN 2040405009;"and so forth.

(d) Identify the error in the context of a listed mistake/error category; for example, "incorrectly diagnosed the emergency at hand," "failed to assign responsibilities," failed to detect," and so forth. If a materiel failure is being reported, explain the type of failure; for example, "overheated," "vibrated, ""frayed," "decayed," and so forth. If an injury/occupational illness is being reported, explain if the individual "struck" or "was struck by" the injury-causing agent. See Appendix B for explanations.

(e) Cite the directive or standard the mistake/error category failed to comply with; for example, "contrary to standard and description for task 1411, TC 1-251 ;" and so forth. 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; for example, "He failed to initially increase collective to maintain the altitude of the tail rotor"; "He excessively torqued the nut, PN 12345," and so forth.

(g) Describe the consequences of the error, materiel failure, environmental factor, or the resulting injury/occupational illness; for example, "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 anti-torque control"; "As a result, the aircraft landed hard"; "As a result, the pilot sustained a compression fracture of the T12-L1 vertebrae," and so forth.

(h) A complete error statement could read as follows: "During an NOE deceleration, the pilot improperly responded to the emergency as described for standard, task No. 1411, TC 1-251. 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 anti-torque control."

(4) Each statement of error, materiel failure, environmental factor or injury/occupational illness will be followed by statements identifying the system inadequacy(ies) that caused or permitted the error/failure/injury or occupational illness to occur or an environmental factor to become a cause. The system inadequacy(ies) statements are the most important part of the analysis. The system inadequacy(ies) causing or permitting an error, failure, or injury/occupational illness to occur or an environmental factor to become a cause are more important from a remedial standpoint than the error, failure, injury/occupational illness, or environmental factor itself. Each system inadequacy(ies) statement will contain the following information:

(a) A transition phrase to tie the system inadequacy(ies) to the error/failure/injury or occupational illness; for example, "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...," and so forth.

(b) Identification of the system inadequacy(ies) category(ies); for example, "...because of inadequate motivation/mood (attitude)," "...inadequate supervision by the unit operations officer," "...because of inadequate quality control on the part of the manufacturer," "...because of inadequate seat design," and so forth.

(c) An explanation of how or why each system inadequacy(ies) caused or permitted the error/failure/injury/environmental factor: For example, "During the pilot's last standardization flight evaluation, the IP told the pilot he did not perform the NOE deceleration properly 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," and so forth.

(5) Once the preceding elements of information are reported for each error, failure, injury/occupational illness, 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(ies) 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.

3-26. Completion instructions for DA Form 2397-4, Part V, Summary of Witness Interview




Figure 3-6. Example of a completed DA Form 2397-4, Part V, Summary of Witness Interview





Figure 3-6. Example of a completed DA Form 2397-4, Part V, Summary of Witness Interview—continued


a. Also see paragraph 3-7 .

b. Complete instructions as follows:

(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 and 5. Self-explanatory.

(5) Block 6. List DSN number if applicable.

(6) Block 7. Enter date(s) statement(s) was/were made.

(7) Block 8. Summarize aviation experience and background. For example, "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 Military Occupational Specialty (MOS) and approximate total flight hours for non-aviator crew members drawing flight incentive pay.

(8) Block 9. Enter location of witness at the time of the accident relative to flight path/impact of aircraft.

(9) Block 10. 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," to designate which interview session the interviewer conducted.

(10) Block 11. 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. The interviewer will sign and date the confidentiality statement if "Yes" was checked that a promise of confidentiality was offered and "Yes" was checked that a promise of confidentiality was requested by the witness.

(11) Block 12. 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.

(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 crew members are the best source of information pertaining to the accident chronology of events. The chronology for the "History of Flight," DA Form 2397-3 , 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(ies) listed in the instructions for completing the DA Form 2397-2 are useful for determining what should be addressed in the crew member witness summaries.

(c) Consolidating. When several witnesses, other than crew members, provide essentially the same observations, it is not necessary to prepare a separate DA Form 2397-4 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 12, 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 . Additionally, he heard a grinding noise in the area of the aircraft's transmission and felt 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 13. Enter the case number shown on DA Form 2397-1.

(13) Block 14. Interviewer will read block 14a or 14b to each witness, depending upon the category and/or circumstances of the witness.

(14) Block 15. Those witnesses who were offered a promise of confidentiality must indicate acceptance or refusal by initialing the appropriate statement. The witness giving the statement will print his/her name directly above the "Name of witness" line.

3-27. Completion instructions for DA Form 2397-5, Part VI, Wreckage Distribution




Figure 3-7. Example of a completed DA Form 2397-5, Part VI, Wreckage Distribution


a. Also see paragraph 3-8 .
Note. The current electronic version of DA Form 2397-5 does not allow the entry of information in block 1 of the form itself. An alternate method for submission of block 1 information is to attach an appropriate diagram containing the block 1 information (for example, Word, PowerPoint). The actual DA Form 2397-5 with block 2 information should be included in addition to the attached document. The electronic version of the form provides a dropdown menu, allowing the attachment of external files to the form. Click on the dropdown window located at the center top of the form and follow the dropdown display.

b. 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 wind flow. Identify wind direction in degrees and velocity in knots.

c. Complete instructions as follows:

(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. For example, structure, trees, power lines.

(c) Terrain marks made by aircraft in crash sequence. For example, earth gouge length, width, and depth, snow or earth pushed in front of aircraft.

(d) A profile view of the wreckage distribution, especially if the impact occurs on sloped terrain or on obstacles in the flight path.

(e) If 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 it 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, for example, fuselage, nose, wing, 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 , 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.

3-28. Completion instructions for DA Form 2397-6, Part VII, In-flight or Terrain Impact and Crash Damage Data




Figure 3-8. Example of a completed DA Form 2397-6, Part VII, In-flight or Terrain Impact and Crash Damage Data





Figure 3-8. Example of a completed DA Form 2397-6, Part VII, In-flight or Terrain Impact and Crash Damage Data—continued


a. Also see paragraph 3-9 .

b. Complete instructions as follows:

(1) Block 1. This block is required for in-flight collisions, such as a midair collision, wire strike, bird strike, or tree strike. 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, 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 1a. Estimate or analytically determine and enter the knots indicated airspeed or true airspeed just before impact.

(b) Block 1b. Estimate or analytically determine and enter the vertical speed (feet per minute) just before impact, and check whether "Up" or "Down." If zero, enter "0" in space provided and do not check "Up" or "Down" box.

(c) Block 1c. Enter the flight path angle (degrees) at major impact and check whether "Up" or "Down."

(d) Block 1d. Enter the pitch and roll angles (degrees) at moment of impact and check the appropriate direction.

(e) Block 1e. Check obstacle(s) struck while aircraft was in flight. For example, contact with a hangar building would be checked as "Other." Specify in the block. Also enter collision height above the ground.

(f) Block 1f. 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 1h. 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. For example, in a five-cable power transmission line, only three cables may be struck.

(i) Block 1i. Check whether or not a Wire Strike Protection System (WSPS) was installed. Also check whether or not the WSPS cut the wire.

(j) Block 1j. Enter outside diameter of tree limb, pole, bush 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 (feet 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 and 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 crash 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 or a forward pitching motion, check "Down."

(4) Block 4.

(a) Block 4a. Estimate or analytically determine and enter the vertical force (Gs) at the aircraft CG. Check whether the force was "Up" or "Down."

(b) Block 4b. Estimate or analytically determine and enter the longitudinal force (Gs) at the aircraft CG. Check whether the force was "Fore" or "Aft."

(c) Block 4c. Estimate or analytically determine and enter the lateral force (Gs) 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 (see table 3-16 ).

(6) Block 6. Use only for aircraft other than "case aircraft" in accidents involving more than one aircraft. Enter serial number of other aircraft only on each DA Form 2397-6 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 (5), (6), (7), and (8) should be checked. Information in this block shall agree with the injury/occupational illness mechanism identified in DA Form 2397-9 and the LSE failure modes identified in DA Form 2397-10, Personal Protective/Escape/Survival/Rescue Data.

(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 leg floor fitting is pushed upward by at least 2 inches with respect to the other three fittings, check the box. The same applies to sideward or fore-aft movement of the seat leg floor fittings.
Note. Photographs should be made of the deformed areas checked under items a through f. At least two photos should be obtained, and they should be taken along mutually perpendicular axes to help offset the effect of distortion.

(8) Block 8. This block indicates the displacement of heavy aircraft components so their potential for injury/ occupational illness or for ignition of fires may be evaluated. Only those components expected to be a major hazard are listed under items a through e. Block f provides for the displacement of other heavy components, such as engines, prop blades, electrical boxes, which could be a hazard to personnel. Columns 1 through 4 describe the displacement of the components from their normal position.

(a) Blocks 8a-d. These components are potentially the most hazardous on rotary-wing aircraft. Displacement of single rotor transmission and/or rotor blades are to be checked in items "a" and "c" while tandem rotor aircraft are to be checked in items a, b, c, and d as appropriate. If the main rotor hub(s) remain attached to their blades, the hub is assumed an integral part of the blade(s) and is checked under item c or d. If the hub(s) remain attached to the transmission(s), the hub is assumed an integral part of the transmission and displacement is checked under item "a" or "b."

(b) Block 8e. Check landing gear displacement. Specify which landing gear, wheel, or skid displaces by simply stating the location on the aircraft. For example, left front, center front, right front, left rear, center rear, right rear. If more than one gear displaces, continue the identities shown above in remarks block (block 11) to indicate the displacement.

(c) Block 8f. Check this box(es) to identify displacement of heavy component(s) not shown above. If more than one mass is involved, explain in block 11.

(1) Column 1. Check box(es) in this column if sufficient displacement has occurred to cause the component to be hazardous even though injuries may not be present. For helicopter transmissions, it is probable that a 10-degree tilt of the transmission and rotor mast will result in a hazardous condition due to fuselage rotor blade strike potential. Likewise, a 6-inch displacement of the transmission, along any axis, will probably result in a hazardous condition. Check the box for rotor blade(s) (item c or d) if it is determined that further blade rotation would result in an occupiable volume blade strike.

(2) Column 2. Check box if a major component is separated completely from its normal structural attachment even though the component may still be held by flexible attachments such as control cables or rods and electrical wires.

(3) Column 3. Check this box if component actually deformed or penetrated the cockpit "container" sufficiently to create a hazard.

(4) Column 4. Check this box if component actually deformed or penetrated the cabin "container" sufficiently to create a hazard. Photographs should be made of the displaced components checked under items a through f. At least two photos should be obtained, and they should be taken along mutually perpendicular axes to help offset the effect of distortion.

(9) Block 9.

(a) Block 9a. Check whether or not aircraft is equipped with crash-resistant fuel system.

(b) Block 9b. If aircraft is equipped with crashworthy fuel system, check to determine whether the breakaway valves in the fuel system did separate.

(c) Block 9c. Check whether or not flammable fluid spillage occurred. If "Yes" box is checked, complete block e.

(d) Block 9d. Check whether or not aircraft was equipped with auxiliary fuel tanks and indicate if the tanks were internal or external. Also, check the appropriate box which best describes the crashworthiness of the tanks. If the tanks are partially crashworthy, check "No" and explain in the remarks.

(e) Block 9e. In the space corresponding with the amount of flammable fluid spilled, enter the type of fluid which was spilled. For example, JP-8, 7808. For example, 15 gallons of JP-8 fuel were spilled so enter "JP-8" under the fuel column, adjacent to the 10-20 amount line. The amount of spilled fluid can be estimated by:

(1) The difference between quantity of liquid remaining and fluid before accident.

(2) A knowledge of the probable mode of failure in the fluid system. For example, did fluid trickle out at slow rate, or did it gush out all at once?

(10) Block 10. Identify one or more spillage sources by writing the name of the part causing or permitting leakage. Rows 7, 8, and 9 may be used to list other sources such as coolers, accumulators. Also, write in the manufacturer's PN and the NSN. The exact identity of the part causing leakage is desired, not the component or assembly. State the cause of fluid spillage in Remarks. For example, a shift of cargo may have crushed the internal auxiliary fuel tanks.

(11) Block 11. Explain in remarks any additional data the investigation board deems appropriate.

3-29. Completion instructions for DA Form 2397-7, Part VIII, Maintenance and Materiel Data




Figure 3-9. Example of a completed DA Form 2397-7, Part VIII, Maintenance and Materiel Data


a. Also see paragraph 3-10 .

b. Complete instructions as follows:

(1) Block 1. Applies to the aircraft and not the component or part that failed. Enter data from aircraft records. If additional DA Forms 2397-7 are needed for multiple failed parts from the same aircraft, it is not necessary to duplicate this information.

(a) Block 1a. Enter the total time on the airframe until the time of the accident. Obtain data from DA Form 2408-13, Status Information.

(b) Block 1b. Obtain data from DA Form 2408-15 (Historical Record for Aircraft).

(c) Block 1c. Enter the date of the last phase inspection. Obtain data from DA Form 2408-15.

(d) Block 1d. Enter the hours flown since the last phase inspection.

(e) Block 1e. Enter the 6-digit UIC for the organization that performed the last phase inspection.

(2) Block 2. This block shows the causative role of materiel, maintenance, design, and manufacture as they pertain to the major component/part reported in block 3 of this form.

(a) Block 2a. Check the appropriate box to show whether or not materiel failure/malfunction of the component/part in block 3 had a causative role in the accident.

(b) Block 2b. Check the appropriate box to show whether or not a maintenance act of omission or commission had a causative role in the accident.

(c) Block 2c. Check the appropriate box to show whether or not design had a causative role in the accident. Design is a factor when the component/part failed to perform its specified function because of design inadequacies.

(d) Block 2d. Check the appropriate box to show whether or not manufacture had a causative role in the accident. Manufacture is a factor when the component/part was not manufactured to meet proper design specifications.
Note. If maintenance was checked as a cause factor in block 2, explain in block 6 or continuation sheet. Provide the TM or other directive requirement for the maintenance and how the error was committed or the omission of a requirement(s) related to the major component/part shown in block 3. Complete a DA Form 2397-8 for person(s) committing the error.

(3) Block 3. Fill out major component and part columns in complete detail for each item of materiel whose failure or malfunction contributed or is suspected of contributing to the cause of the accident. Blocks a through k applies to the component or part, not the aircraft.

(a) Blocks 3a and b. Obtain from appropriate parts manual. When the major component is an engine, transmission, or gearbox and the aircraft is equipped with more than one like item, identify which major component is listed. For example, No. 1 engine, forward transmission, 42-degree gearbox.

(b) Block 3c. The PN should be taken from the part or component if possible. The TM will be used as a source for the PN only if it cannot be determined from the part.

(c) Blocks 3d and e. Obtain from appropriate TM.

(d) Block 3f. Enter the serial number from the item of materiel. If the number differs from that contained in the DA Form 2408-16, state this fact in block 6 or on a continuation sheet.

(e) Block 3g. Obtain from appropriate TM.

(f) Block 3h. Extract this information from DA Form 2408-16 and DA Form 2410 (Component Removal and Repair/ Overhaul Record). Enter the type, date, and hours since the last special inspection on the listed item of materiel, For example, "overspeed," "hard landing." For components/parts installed during aircraft production, enter "N/A."

(g) Blocks 3i and j. Enter the type and cause of failure codes from DA Pam 738-751 , table 1-2.

(h) Block 3k. Obtain from Standard Form 368, Deficiency Report.

(4) Block 4.

(a) Block 4a. Check the appropriate block to show status of aircraft warning system(s) for the failed part at time of emergency. If inoperative is checked, explain in block 6 or on a continuation sheet.

(b) Block 4b. Check the appropriate box to indicate if the warning systems indication of the failure/malfunction provided to the crew was correct for the failed part. If incorrect, explain in block 6 or on a continuation sheet. (c) Block 4c. Check the appropriate block to indicate the initial indication of the failure. For example, a hydraulic warning light illuminates followed by stiffness in the controls. Check the "Warning System" block to indicate what first alerted the crew to a failure/malfunction.

(5) Block 5.

(a) Block 5a. Specify the organization/laboratory that performed the TDA.

(b) Block 5b. Enter the USACRC control number, if applicable.

(6) Block 6. Explain delays in shipment of failed part, fluid samples, or any other materiel related data deemed appropriate by the board president. If additional space is required, attach continuation sheet.

(7) Block 7. Enter the case number shown on the DA Form 2397-1.

(8) Block 8. Use only for aircraft other than "case aircraft" in accidents involving more than one aircraft. Make entry only on the form identifying the maintenance and materiel data for other aircraft.

3-30. Completion instructions for DA Form 2397-8, Part IX, Personal Data




Figure 3-10. Example of a completed DA Form 2397-8, Part IX, Personal Data





Figure 3-10. Example of a completed DA Form 2397-8, Part IX, Personal Data—continued


a. Also see paragraph 3-11 .

b. Complete instructions as follows:

(1) Block 1.

(a) Block 1a. Check "Definitely" box if person made an error that caused or contributed to the accident. Do not check the "Definitely" box unless the relationship of the error to the accident is fully substantiated in the present and contributing findings of DA Form 2397-2 and analysis part of the DA Form 2397-3 . Check the "Suspected" box if the individual committed an error that is suspected to have caused or contributed to the accident. Suspected factors must also be fully substantiated in the present and contributing findings of the DA Form 2397-2 and the analysis of the 2397-3. Check "None" or "Undetermined" box, as appropriate.

(b) Block 1b. Check the appropriate box.

(2) Block 2. Most items are self-explanatory. Record hours as appropriate. For items d through l, the 24-, 48-, and 72-hour periods are calculated to the time of the accident.

(3) Block 3. Most items in block 3 are self-explanatory. The sources for this information will be the individual's individual aircrew training folder (IATF) folder and DA Form 759 (Individual Flight Record and Flight Certificate-Army). Those items requiring further explanation are indicated below.

(a) Blocks 3a-h. Can be obtained from Part III of the individual's DA Form 759.

(b) Blocks 3i-k. Can be obtained from Part II of the individual's DA Form 759.

(c) Block 3l. Enter the ATM task number that best describes flight profile (takeoff, climbs, turns, straight and level, hovering autorotation) that was in progress when the emergency situation developed. An event becomes an emergency whenever an error by the crew, a materiel failure, an obstacle strike, or other unpredictable event creates a need for an emergency response. If no ATM task applies, leave blank and explain the flight profile/activity in block 10.

(d) Block 3m. Pertains to the ATM task required to cope with the emergency. A tail rotor strike may result in a loss of antitorque control, thereby requiring the performance of the task procedures prescribed for an antitorque malfunc- tion. If no ATM task applies, leave blank and explain the flight profile/activity in block 10.

(e) Block 3n. If "Yes" box is checked, identify in block 9 the condition for which the waiver was granted and the headquarters authorizing the waiver (DA, U.S. Army Medical Department Activity (MEDDAC)). If waiver data clarification is needed, enter a brief explanation in block 10.

(f) Block 3o. Report an "S" for satisfactory or "U" for unsatisfactory. If result is "U," enter a brief explanation in block 10. If the evaluation has been delayed, enter a "dash" to indicate information is not available and explain delay in block 10.

(g) Block 3p. Enter date of post-accident medical examination or admission to a medical facility for treatment of injuries resulting from the accident. For non-survivors, enter date of autopsy.

(h) Block 3q. Check the appropriate box to indicate if the blood and urine laboratory test required by AR 385-10 , paragraph 3-16, were accomplished.

(i) Block 3r. Enter the individual's date of redeployment from a combat theater, if applicable, (yyyymmdd).

(4) Block 4. Flight and crew duty experience will be completed for all crew members specified in paragraph 3-11 , requiring a DA Form 2397-8 . The source of this data is the individual's DA Forms 759 and 759-1. Flight experience will be recorded to the nearest hour (no tenths).

(a) Block 4a(1). Pertains to flight experience, involving military operations, by category of aircraft. Combat, imminent danger, and flight experience in accident MTDS aircraft is also recorded in this block.

(b) Block 4a(2). Civilian. Civilian flight experience regardless of duty, not involving military operations (For example, flying clubs, instructional, hobby, pleasure, commercial) is to be entered in this block by category of aircraft.

(c) Block 4a(3). Total time. Self-explanatory.

(d) Blocks 4b and e. Duty experience. Block b pertains to rated aviator duties and item e pertains to other crew duty experience. Enter the total time for the duty listed. The source of this information is the individual's DA Form 759-1 .

(e) Block 4c. Flight condition experience. Enter the total flight hour experience in block 4c(1) for flight conditions listed. The source of this information is the individual's DA Form 759-1.

(f) Block 4d. Monthly flight hours. Pertains to flight time in accident MTDS aircraft for the current calendar month plus the preceding 30, 60, and 90 days up to and including the accident flight.

(5) Block 5. Pertains to maintenance, medical, support, and other non-rated personnel only.

(a) Blocks 5a, 5b, and 5c, Enter the individuals MOS designation and title. The information source is the individual's personnel qualification record.

(b) Block 5d. Enter the task number associated with the error the individual committed. The source of the task number will be the Soldier's Manual, ATM, or TC 1-210 (the Commander's Guide) that addresses the task.

(c) Block 5e. Self-explanatory.

(d) Block 5f. Applies to government civilian employees. Source of information is the individual's job description and performance standards. If "No" box is checked, enter a brief explanation in block 10.

(6) Block 6. Enter the case number shown on DA Form 2397-1 (see table 3-6 ).

(7) Block 7. Complete block 7 only if form applies to personnel associated with an aircraft other than "case aircraft" in accidents involving a multiple aircraft event.

(8) Block 8. Record toxicological laboratory analysis results. In the "Specimen Tested" column, enter "blood," "urine," to indicate the source of the specimen. If no specimen was tested, enter "None." If carbon monoxide is detected, enter a % in the results block. If not present enter a "Neg" in the results block. Enter "Pos" or "Neg"in the results block for other drugs identified as present and the drug name in the appropriate box. If a drug(s) was administered by medical personnel following the accident but prior to collection of the test specimen, record this information in block 10. Use standard terminology to report methods and results. In accordance with AR 385-10 , chapter 3, the tests listed as items a, b, and c, are MANDATORY for ALL crew members and/or any fatality even if there seems to be no apparent likelihood of positive results. Timelines of the test is important and the specimens should be acquired as soon as possible following the accident. Significant results should be briefly explained in block 10 and thoroughly discussed in the analysis part of the narrative ( DA Form 2397-3 ). If specimen testing was required by AR 385-10 but not accomplished, explain why it was not accomplished in block 10, remarks.

(9) Block 9. Complete block 9 if block 3n is checked "Yes" or autopsy report reveals significant findings of preexisting diseases/defects. For waivers, enter the approval authority for the waiver and the date of issuance in the appropriate block.

(10) Block 10. Significant medical history pertinent to the accident investigation should be briefly explained in block 10. Medical history that contributed to the accident or may have had bearing on the accident will be explained on the DA Form 2397-3 .

(11) Block 11. Self-explanatory.

(12) Block 12. Enter the individual's social security number.

(13) Block 13. Enter grade code. Select code from Table 3-8.

(14) Block 14. Enter "M" to indicate male or "F" to indicate female.

(15) Block 15. Enter duty code. For crew members enter the duty code recorded on the DA Form 2408-12 . For other personnel, select code from list at table 3-5 .

(16) Block 16. Enter personnel service code. Select service code from list at table 3-9.

(17) Block 17. Enter a 6-digit UIC of unit to which this individual was assigned at time of accident.

3-31. Completion instructions for DA Form 2397-9, Part X, Injury/Occupational Illness Data




Figure 3-11. Example of a completed DA Form 2397-9, Part X, Injury/Occupational Illness Data


a. Also see paragraph 3-12 .

b. Complete instructions as follows:

(1) Block 1. Check the appropriate box to indicate the highest degree of injury/occupational illness for this individual. Degrees of injury/occupational illness are defined below:

(a) Block 1a. Self-explanatory.

(b) Block 1b. Permanent Total Disability. Any nonfatal injury or occupational illness that in the opinion of competent medical authority, permanently and totally incapacitates a person to the extent that he cannot follow any gainful employment.

(c) Block 1c. Permanent Partial Disability. Any injury or occupational illness that does not result in death or permanent total disability, but in the opinion of competent medical authority, results in permanent impairment through loss or loss of use of any part of the body, with the following exceptions: Loss of teeth; Loss of fingernails or toenails; Loss of tips of fingers or tips of toes.

(d) Block 1d. Days Away from Work (Days lost).

(e) Block 1e. Workday(s) of Restricted Work Activity.

(f) Block 1f. Medical Treatment Beyond First Aid.

(g) Block 1g. First aid only.

(h) Block 1h. Missing and Presumed Dead. Individual not located at the time of the report.

(2) Block 2. If block "d" and "e" was checked in block 1, enter number of days away from work, the number of days hospitalized, and days of restricted work activity in spaces provided. Ensure that days away from work (2a) is not inclusive of the days hospitalized (2b).

(a) Block 2a. Days Away From Work. The actual or estimated number of days lost that the individual could not work excluding the day of the injury/occupational illness. Include quarters, bed rest, convalescence leave, or time that a physician indicated the individual could not work regardless of whether the individual was scheduled to work. Count all calendar days including weekends and holidays. For example, if the individual was injured on Friday and the individual could work on Monday, if the physician or licensed health care professional indicated they should not work over the weekend, enter 2 days. If there is no information from the physician, enter 0 days. Enter the appropriate number in block 2a.

(b) Block 2b. Days Hospitalized. The actual or estimated number of days the individual was hospitalized as an inpatient/admitted receiving treatment. Days hospitalized for "observation only" are only included if a workday is missed. Enter the appropriate number of days hospitalized in block 2b.

(c) Block 2c. Days of Restricted Activity. (Person is temporarily unable to perform regular duties; job transfer, light duty/profile.) Enter the actual or estimated number of days the individual was unable to perform one or more routine job functions (regularly performed by the individual at least once per week), or could not work a full workday they would otherwise have been scheduled to work; or a physician or licensed health care professional recommends that the employee not perform one or more routine functions of his/her job, or unable to work a full workday they would otherwise have been scheduled to work. Enter the number of days of restricted activities in block 2c. The day count may be stopped if the employee leaves the job for a reason unrelated to the injury or illness or the count reaches the cap of 180 days.

(3) Block 3. If the person was unconscious, enter the duration in hours and minutes, and show the cause and mechanism, if known, in block 5. If none, check none.

(4) Block 4. If amnesia was present, show duration and explain in block 6. If amnesia was not present, check none.

(5) Block 5. Describe individual injuries in descending order of severity and associated cause factors, using the applicable information codes following these instructions.

(a) Column a. Enter number "1" for most severe injury/occupational illness followed by "2," "3," until all injuries have been listed. Only six injuries can be recorded per individual per form. Use additional DA Forms 2397-9 when greater than six injuries are coded.

(b) Columns b through e. Using information codes at table 3-10 following these instructions, enter the appropriate numeric and/or alpha numeric code in each column. In the appropriate space below the code, enter the word(s) describing the injury/occupational illness.

(c) Columns f and g. Enter the action code and qualifier code from table 3-10 that best describe the injury/ occupational illness mechanism (how the injury/occupational illness occurred).

(d) Columns h, i, and j. Enter the subject, action, and qualifier codes from table 3-10 which best describe, from an engineering viewpoint, what aspects of the aircraft contributed to the injury/occupational illness cause factors (why injury/occupational illness occurred). The purpose of these columns is to select those subjects, action, and qualifier codes that form a sentence or phrase that describes what aspect of the engineering/design of the aircraft should be looked at for potential modification to avoid a similar injury/occupational illness in a future similar accident. For example, if the occupants of an aircraft sustained post-crash burns due to fuel lines breaking in the crash sequence, one could code: Subject: "10, Fuel lines," Action: "03, Broke," Qualifier: "07, Improperly."

(6) Block 6. Enter any additional information which further clarifies information coded on the DA Form 2397-9 . For instance, if the flight surgeon thinks the available codes do not describe the injuries, the mechanism of injury/ occupational illness, or the injury/occupational illness cause factors, this block provides the opportunity for further description. It is imperative that any additional information be linked to a specific block/column on the form.

(7) Block 7. Check the appropriate box to indicate whether or not an autopsy was performed. If an autopsy was not performed on a fatally injured Soldier, civilian, or Army contractor, explain why in block 6.

(8) Block 8. Report the official cause and date of death, based on an autopsy report, if possible.

(9) Block 9. Check the appropriate duty status for government personnel.

(10) Blocks 10 through 14. Enter appropriate information for the individual concerned.

(11) Block 15. Block 15a through 15i entry are required for all injured individuals.

(12) Block 16. Enter individual's unit UIC.

(13) Block 17. Enter the case number shown on DA Form 2397-1.

(14) Block 18. Use only in cases involving more than one aircraft. Enter the serial number of other aircraft only on the DA Form(s) 2397-9 that pertains to personnel injuries associated with the other aircraft.

(15) Block 19. Enter the injury or occupational illness/fatality cost in accordance with DA Pam 385-40, table 1-1 .

3-32. Completion instructions for DA Form 2397-10, Part XI, Personal Protective Escape/Survival/ Rescue Data




Figure 3-12. Example of a completed DA Form 2397-10, Part XI, Personal Protective Escape/Survival/Rescue Data


a. Also see paragraph 3-13 .

b. Complete instructions as follows:

(1) Block 1. Check the appropriate box. If the "Yes" box is checked, ensure that a DA Form 2397-9 is completed for this individual.

(2) Block 2. Personal protective/restraint/survival equipment. The first column lists the major, common items of equipment worn/used by aircrew members and passengers. Report ONLY those items which had a role in the cause/ prevention/reduction of an injury/occupational illness or failed to function as designed. Also list in block 2(o) or 2(p) other protective/survival items of equipment which, if available, could have prevented/reduced an injury/occupational illness or assisted in the rescue and survival efforts. Complete the columns to the right of each item that had a role in the accident, as follows: For columns (2) - (9) enter "Y" for "yes," "N" for "no," and "U" for "unknown." For column 10, select the appropriate equipment information codes from table 3-11 .

(a) Column (1). Type. Enter the type of equipment in the "Type" column. For example, helmet- enter HGU-56P; visor-enter clear, or tinted, or anti-laser; glasses-enter prescription, nonprescription, tinted, untinted, contact lenses, inserts, anti-laser, and flight suit-enter aircrew combat uniform (ACU).

(b) Column (2). Required. Enter "Y" for items that were required for the mission by directives. For example, Army regulations, major command/unit SOPs, or "N" for items not required, but which could have reduced the injury/ occupational illness severity.

(c) Column (3). Available. Make appropriate entry for each applicable item that was available to the individual.

(d) Column (4). Used. Make appropriate entry for each applicable item used. Just because an item was available does not mean it was used. Used pertains to the use of an item as intended for the condition/situation.

(e) Column (5). Produced injury/occupational illness. An item of equipment may have produced an injury/occupational illness by its use or by its malfunction. For example, a lapbelt may have produced an injury/occupational illness to the individual (bruise on hip) but still may have prevented or reduced further injuries.

(f) Column (6). Allowed injury. An item of equipment may have allowed injury due to the forces of the accident exceeding the design of the equipment, or an individual not properly wearing or utilizing the item. For example, the chin strap of the helmet not being secured.

(g) Column (7). Prevented injury/occupational illness. An item may have prevented an injury by its use even though the item received damage; for example, damage was done to the helmet, but the individual did not receive an injury. If no injury occurred to the area protected by the item then enter "Y."

(h) Column (8). Reduced injury/occupational illness. An item may have reduced the severity of an injury/occupational illness. For example, the individual received a severe blow to the head and incurred a head injury, but the helmet reduced the severity of the injury.
Note. Columns (6) and (7) cannot be marked "Y" for the same item. An item cannot allow and prevent an injury at the same time. Likewise columns (7) and (8) cannot be marked "Y" for the same item. If an injury is prevented, there is nothing to reduce.

(i) Column (9). Functioned as designed. This column is used to indicate the performance of equipment during the accident sequence to include rescue and survival. For example, if it is determined that the item performed the job for which it was intended, enter "Y" for "yes." If the item was damaged, explain the damage in the "Information Codes" column. For all items that did not perform their intended function, enter "N" for "no" in the "functioned as designed" column and explain in the "Information Codes" column with the appropriate codes.

(j) Column (10). Information codes. The four columns under this title are used to report equipment problems/ conditions pertaining to the performance of personnel, protective, restraint, and survival equipment. There are four blocks provided for each item of equipment to permit the identification of up to four separate problems/conditions. Each item with a problem/condition will be coded with a four-digit information code from table 3-11 . For example, if a helmet dislodged and the individual received a head injury/occupational illness due to its loss, enter "N" in columns (7), (8) and (9) for the helmet row and enter the code 1122 in the "Information Codes" column. For example, 11 (dislodged), 2 (nape strap), 2 (loose). All undamaged items that performed their job do not require codes in the "Information Codes" column.

(k) Survival equipment components. The empty spaces in block 2 (o and p) are to be used to report problems/ conditions with specific items of survival equipment/components. These are to be entered in the "Information Codes" columns using four-digit codes. More than one problem/condition may apply to any of the survival equipment/ components. The first two digits are obtained from the survival equipment/component list and the second two digits are obtained from the problem/condition code at table 3-12 . Examples are —

(1) An aviator' s SDR-5/E strobe light failed during use because the battery became inoperative. Enter "Strobe light" in one of the empty spaces (o or p). The "Type" would be entered as "SDR-5/E." Any other column across the page may be used as applicable. The first four-digit code entered in the first "Information Codes" column should be "8438"; the second four-digit code should be "8440."

(2) An aviator could not get a survival radio before the mission because the radios were locked up in supply. Enter "survival radio" in an available empty space (o or p). The "Type" would be entered as "PRC-112." The four-digit code entered in the "Information Codes" column would be "8101."

(3) In the event of a non-survivable accident in which there were no attempts to use the survival equipment/ components, no entry is required unless the accident investigation board feels such reporting would benefit accident research/analyses.

(4) If an item of equipment is used that is personal property (non-issue), such as, pocket knife or plastic compass, and a problem/condition exists (For example, "lost"), enter the item in blank spaces o or p (block 2) as "Pocket knife" and "Personal" in the "Type" column. The four-digit code in the "Information Code" column should be "9936."

(3) Block 3. Personnel evacuation/escape.

(a) Block 3a. Method of escape. Enter the appropriate information codes from table 3-13 in the space provided.

(b) Block 3b. Location in aircraft. Enter individual's location in the aircraft at the time of the accident in the boxes provided using the codes at table 3-14 . For example, an aviator was in the cockpit, forward section, left side, facing forward, in his seat. Code in sequential blocks 1, 1, 2, 1, 2 (one number per block).

(c) Block 3c.

(d) Block 3d. Exit attempted. Enter information code(s) from table 3-15 in order and in sequence if more than one exit attempt was made. The last coded entry, if more than one exit was attempted, will be the exit used by the individual to egress. For example, the normal exit was tried but it jammed, so exit was made through an opening in the aircraft wreckage. Code "1" in the first box and code "3" in the second box.

(e) Block 3e. Aircraft attitude during escape. Enter information code from table 3-17 to best describe the attitude of the aircraft at time of escape.

(f) Block 3f. Cockpit/cabin condition. Enter the cockpit/cabin condition code from table 3-18 . Consider only that portion of the aircraft this individual occupied at the time of the accident. Disregard post crash fire damage.

(g) Block 3g. Escape difficulties. From table 3-19 select those difficulties the individual experienced. A total of six may be selected. Enter only one two-digit code per block. Occupants fatally injured during the mishap do not require an entry.

(4) Block 4. Cumulative lapsed time for rescue. Enter local time in the appropriate blocks using the 24-hour clock. Lapsed time will be the cumulative number of hours/minutes from time of the accident for each phase. Leave blank if fatally injured at impact.

(5) Block 5. Distance from accident site to actual rescue vehicle at time of accident. Enter nautical miles for airborne rescue vehicles or statute miles for ground rescue vehicles.

(6) Block 6. Personnel survival/rescue. Enter the appropriate information codes in the spaces provided. Use one two- digit code per block.

(a) Block 6a. Survival problems encountered. Review the list at table 3-20 for potential problems this individual may have encountered and enter codes sequentially in the boxes provided. Occupants fatally injured during crash do not require an entry for items a through e.

(b) Block 6b. Means used to locate individual. Enter, in sequence, information codes from table 3-21 for means used to locate individual.

(c) Block 6c. Rescue equipment used. Enter code in sequence of items used from table 3-22 .

(d) Block 6d. Factors that helped rescue. Enter codes from table 3-23 which assisted in the rescue of the individual.

(e) Block 6e. Factors that complicated rescue. Enter the code from Table 3-24 which complicated the rescue of the individual.

(f) Block 6f. Individual's physical condition. Enter the code from table 3-25 which best describes the individual's physical condition.

(g) Block 6g. Vehicle(s) actually performing evacuation. Enter the type vehicle(s) performing the evacuation. If the vehicle is an aircraft, enter the mission, type, design and series. For example, UH-1H, if vehicle is a motor vehicle, state vehicle type; military ambulance, civilian ambulance, private auto.

(h) Block 6h. Other vehicles assisting in rescue. Refer to "g" above and enter the type vehicle(s) which assisted in the rescue.

(7) Block 7. Remarks. Explain failures, malfunctions, injuries, and other problems not adequately defined by code terms. When "other" is coded, use this block to explain details.

(8) Blocks 8 and 9. Self-explanatory.

(9) Block 10. Enter grade code. Select code from table 3-8 .

(10) Block 11. Enter "M" to indicate male or "F" to indicate female.

(11) Block 12. Enter duty code. For crew members, enter the duty code recorded on the DA Form 2408-12 . For other personnel, select code from list at table 3-5 .

(12) Block 13. Enter service code. Select service code from list at table 3-9 .

(13) Block 14. Enter a 6-digit UIC of unit to which this individual was assigned at time of accident.

(14) Block 15. Enter the case number shown on DA Form 2397-1 (see table 3-6 ).

(15) Block 16. Uses only in cases involving more than one aircraft and make entry only on the form identifying personnel from the other aircraft.

3-33. Completion instructions for DA Form 2397-11, Part XII, Weather/Environmental




Figure 3-13. Example of a completed DA Form 2397-11, Part XII, Weather/Environmental


a. Also paragraph 3-14 .

b. Complete instructions as follows:

(1) Block 1. Check the appropriate box to indicate if weather or other environmental condition caused or contributed to the accident. Weather is a definite or suspected factor only when not forecast, improperly forecast or when it was unavoidable in the accident sequence of events. Weather must be supported in the present and contributing findings of the DA Form 2397-2 and the analysis of the DA Form 2397-3 . See chapter 2, paragraph 2-6 , for a complete discussion on determining the environmental role in the accident.

(2) Block 2.

(a) Block 2a. Specify in degrees centigrade. If the temperature is actual, line out "est."

(b) Blocks 2b and 2c. Enter the altimeter setting in inches of mercury (Hg) and altimeter reading in feet at the time of the accident. This must be taken as soon as possible from the accident aircraft's altimeter. If the altimeter was damaged so that the setting cannot be determined, enter "unknown" and explain in block 14 or continuation sheet. Do not use estimates.

(c) Block 2d. Prefix the pressure altitude with a plus or minus.

(d) Block 2e. Check the appropriate box which reflects the general weather conditions at the time and location of the accident.

(3) Block 3. When a scattered, broken, or overcast sky condition is checked, specify the altitude in the space provided.

(4) Block 4. Check the appropriate box.

(5) Block 5. Enter visibility in nautical miles.

(6) Block 6. Obstructions to visibility are shown in the two basic categories of "natural" and "induced." If visibility was restricted, it is extremely important to accurately distinguish between natural and induced.

(a) Block 6a. More than one may apply. For example, both haze and smoke may have existed at the same time during the accident sequence; therefore, both would be checked.

(b) Block 6b. Check the induced obstructions to visibility that existed during the accident sequence. For example, if the crew lost all reference when they came to a hover due to rotor wash picking up and circulating a large cloud of dust, check block 6b(3), "Blowing Dust."

(7) Block 7. Use existing winds at the time of the accident.

(a) Block 7a. Enter the winds aloft at the assigned or en route altitude.

(b) Block 7b(1). Enter surface wind direction in degrees magnetic. If wind direction is varying, (For example, "360 variable 010,") then enter the average wind direction on this line "360/10."

(c) Block 7b(2). Enter surface wind velocity in knots and gust spread. If surface winds are gusty, enter the surface winds as reported. For example, for winds reported as 20 knots gusting to 38 knots, enter as "20G38" (gust spread of 18).

(8) Block 8. Indicate significant weather present at the time of the accident. A maximum of three conditions may be checked.

(9) Block 9. Indicate other environmental factors that caused, contributed to, or may have influenced human performance that caused or contributed to the accident.

(10) Block 10. If aircraft icing was present during the accident sequence, place an X in the "Yes" block and indicate those portions of the aircraft affected by placing an X in the appropriate severity column.

(11) Block 11. To be completed for night accidents only. If item "a" is checked "No," no other entries are required.

(12) Block 12. If turbulence existed, check the appropriate block. C-Continuous (More than two-thirds of the time.); I-Intermittent (One-third to two-thirds of the time.); O-Occasional (Less than one-third of the time.). If no turbulence existed, check "None."

(13) Block 13. Check whether forecast was correct or incorrect. If not known, check "unknown" box.

(14) Block 14. Discuss other environmental factors not covered by this form or items that need further explanation.

(15) Block 15. Enter the case number shown on the DA Form 2397-1 , table 3-6 .

3-34. Completion instructions for DA Form 2397-12, Part XIII, Fire




Figure 3-14. Example of a completed DA Form 2397-12, Part XIII, Fire


a. Also see paragraph 3-15 .

b. Complete instructions as follows:

(1) Block 1. Check the appropriate box to indicate when the fire started.

(2) Block 2. Enter a "1" in the appropriate block for the initial indication of fire. Enter "2," "3," for additional indications.

(3) Block 3. Enter a "1" in the definite or suspected block to show the first location of the fire. When the principal location of the fire is different, enter a "2" to show the principal location. For example, ignition might occur at a broken fuel line to the engine. The fire might then spread to a ruptured fuel cell, causing it to become the principal location of the fire.

(4) Block 4. Check the appropriate box to show the ignition source. If a definite source is not known, investigators are urged to indicate a suspected source. In all cases where a suspected source is indicated, explain in block 10.

(5) Block 5. Check the materiel(s) that were the principal source of the fire.

(6) Block 6. Check the appropriate box(es) to report on the adequacy of ground and aircraft fire extinguishing systems. Ground (Gnd) extinguisher systems include fire trucks, ramp extinguisher. Aircraft fire extinguishing systems include those that are integrally installed (INST) in the aircraft. For example, engine fire extinguishing systems; and/or portable bottle (PORT). Explain in block 10 all malfunctions and failures of the extinguishers/systems. Include nomenclature, NSN, size of extinguisher, type of agent, reason for failure and EIR number.

(7) Block 7 Check the appropriate box to indicate if a fire/smoke detection system was installed and its function. If "undetermined" is checked, explain in block 10.

(8) Block 8. Enter effectiveness of the engine, fuel, and/or electrical shutoff procedure(s).

(9) Block 9.

(a) Block 9a. Check percentage of damage caused by fire. In cases where an in-flight fire results in the crew ejecting from the aircraft, only the fire damage prior to impact should be recorded. The objective of this item is to distinguish between fire damage and impact damage.

(b) Block 9b. The purpose of this item is to determine the occupant's exposure to fire during the emergency evacuation. Complete the items in all cases, even those in which the occupants were trapped or incapacitated and thus unable to escape. Since it is unlikely that the dimension of the fire will be uniform around the aircraft, select the avenue of greatest distance an occupant will have to traverse to escape.

(c) Block 9c. In addition to consumption of available oxygen, aircraft fires generate toxic gases such as carbon monoxide, acrolein, and phosgene. These toxic gases may seriously affect aircraft occupants in two ways: severe contamination, irritation of the mucous membrane of the eyes and respiratory passages, and systemic absorption in sufficient quantity to produce varying degrees of incapacitation. If toxic products are suspected to have affected occupants, record on a DA Form 2397-9 for the affected occupant.

(d) Block 9d. Complete the item even though the equipment was not at the scene of the fire. The objective of this item is to determine the distribution of available firefighting equipment relative to the location of the fire accidents.

(e) Block 9e. If the impact-activated fire extinguishing system was installed on the accident aircraft, check the appropriate block to indicate its function. If not installed checked, "NA."

(10) Block 10. Enter explanations or clarifications of other items on the form and continue remarks on letter-size paper.

(11) Block 11. Enter the case number shown on DA Form 2397-1.

(12) Block 12. Use only in cases involving more than one aircraft and make entry only on the form applying to the other aircraft. For example, other than the one identified in block 11c.

3-35. Completion instructions for DA Forms 2397-13 and 14, Index A and Index B




Figure 3-15. Example of a completed DA Form 2397-13, Index A





Figure 3-16. Example of a completed DA Form 2397-14, Index B


a. Also see paragraph 3-16 .

b. Complete instructions as follows:

(1) Block 1. DA Forms 2397-13 and 2397-14. Enter the MTDS of the accident aircraft.

(2) Block 2. DA Forms 2397-13 and 2397-14. Enter the case number shown on DA form 2397-1, table 3-6 .

(3) Block 3. DA Forms 2397-13 and 2397-14. Place an "X" in the block opposite each item to indicate whether the information is "enclosed" or "Not Applicable." An "X" on the "See Remarks" block requires an explanation in block 4"Remarks" section of the form

(4) Block 4. DA Form 2397-13 and 2397-14. The remarks are used to indicate that required information is being delayed or not available to the accident investigation board. Remarks pertaining to delayed information will contain an estimated forwarding date. Remarks pertaining to unavailable information will include reasons for non-availability. Also, when the accident board inserts multiple documents, or wants to clarify a document under a certain tab, it should be identified in this block.

(5) Block 5. DA Form 2397-14 . Type signature block of all voting board members to include grade, branch, unit address, e-mail address, and telephone number (SSN not required). Each voting board member will sign all copies of the DA Form 2397-14 unless a minority report is submitted in accordance with chapter 2 of this pamphlet. Use a continuation sheet (plain bond paper) if there are more than six voting board members.

3-36. Completion instructions for DA Form 2397-AB, Abbreviated Aviation Accident Report (AAAR)




Figure 3-17. Example of a completed DA Form 2397-AB, Abbreviated Aviation Accident Report (AAAR)





Figure 3-17. Example of a completed DA Form 2397-AB, Abbreviated Aviation Accident Report (AAAR)—continued





Figure 3-17. Example of a completed DA Form 2397-AB, Abbreviated Aviation Accident Report (AAAR)—continued


a. Also see paragraph 3-20 .
Note. Complete the entire form (both sides) for each Class C accident, all aircraft ground accidents and class A and B combat accidents in areas of combat or contingency operations when the submission of the DA Form 2397 series is deemed not practical by the senior tactical commandeer. For Class D and E accidents not involving human error, injury/occupational illness or wire strike and Class F incidents only blocks 1-18 are required. For Class D and E accidents involving human error or injury, complete blocks 1 through 18 21, 22, 23, 24 and any other pertinent blocks. Refer to paragraph 3-20 .

b. The DA Form 2397-AB will be completed as follows:

(1) Block 1. The case number consists of the year, month, and day (YYYYMMDD) of the accident, the local time of the accident, and the seven-digit aircraft serial number. Aircraft serial number must contain seven digits. In those cases where the aircraft serial number is less than seven digits, insert zeros (0) after the model year (first two digits) until seven digits are reflected.

(2) Block 2. Check the boxes corresponding to the appropriate classification per AR 385-10 , paragraph 3-4, and category as defined in the DA Pam 385-40, paragraph 1-9 .

(3) Block 3. Enter the mission, type, design, and series of the aircraft involved in the accident. For example, UH- 60L.

(4) Block 4. Check the appropriate box. Dawn is that period of time between beginning of morning nautical twilight (BMNT) and official sunrise. Dusk is that period of time between official sunset and end of evening nautical twilight (EENT).

(5) Block 5. Enter the number of aircraft involved in the accident and submit additional DA Forms 2397-AB for each additional aircraft. Do not include inoperative aircraft. When completing additional AAAR forms, do not duplicate data already provided on the case aircraft form.

(6) Block 6. Enter the name of the nearest military installation/facility from the accident site.

(7) Block 7. Check the appropriate boxes to indicate whether or not the accident occurred on or off post, or on or off an airfield. Tactical landing zones under positive ATC. For example, 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 USAR component facilities are considered "on post" and "on airfield" when there is intent to use the military facilities on that airport. For example, visit the unit, acquire fuel, and conduct training. Enter the name of the closest city, state, and country to the accident site and Military Grid Reference or latitude/longitude

(8) Block 8. For the organization involved, enter the six digit UIC and abbreviated title of the lowest level organization having operational control of the aircraft at the time of the accident.
Note. For Army Reserve or Army National Guard units on active duty status, if the unit of assignment is other than the Reserve or National Guard, enter the unit of assignment chain of command in block 8. Enter the Army Reserve or Army National Guard unit in block 21a(6).

(9) Block 9. Enter the information pertaining to the organization most responsible/accountable for the accident. If the organization is the same as block 8, leave blank.

(10) Block 10. Pertains to the estimated accident damage cost. Do not include those items excluded from accident cost by this DA Pamphlet, paragraph 1-10 . Enter in blocks 10b through 10h, only the cost associated with the aircraft to which this form pertains. To complete this block:

(a) Block 10a. If "Yes," enter the replacement cost per TB 43-0002-3 in block 10b and do not fill in blocks 10c and 10d (man-hours). If "No," enter AMDF cost of damaged components/parts in block 10b and fill in blocks 10c and 10d (man-hours).

(b) Block 10b. Enter the cost of replacement aircraft or component/part damage, excluding man-hour cost.

(c) Block 10c. Enter only the number of man-hours required to repair aircraft damage.

(d) Block 10d. Man-hour cost pertains to aircraft damage only, based on current cost criteria specified in this DA pamphlet. Other man-hour cost will be included in block 10e (Other Damage Military).

(e) Block 10e. Enter all costs to other military property resulting from the accident (includes inoperative aircraft).

(f) Block 10f. Enter the damage cost to civilian property.

(g) Block 10g. Enter the injury/occupational illness cost of all personnel. The cost can be obtained by adding the cost from block 19 of DA Form 2397-9 or injury/occupational illness criteria at table 1-1 .

(h) Block 10h. Enter the total of blocks 10b through 10g.

(i) Block 10i. Leave blank unless block 5 indicates multiple aircraft are involved. Enter the total of blocks 10h when multiple aircraft accidents are involved.

(11) Block 11. Complete the general data block as follows:

(a) Block 11a. Enter the mission as shown on the DA Form 2408-12 or AR 95-1 . For maintenance operations with or without intent for flight, enter "S" for service. If none enter "NA." Also, check the appropriate box to indicate if the mission was a single or multi-ship operation.

(b) Block 11b. Check the appropriate box which indicates the type flight plan on file at the time of the accident.

(c) Block 11c. Check the appropriate box to indicate whether or not a DSC was installed and type.

(d) Block 11d. Check the appropriate box to indicate whether or not night vision device (NVDs)/system was in use at the time of the accident/incident. If "Yes," enter NVD used in the space provided.

(e) Block 11e. Check the appropriate box to indicate the phase of operation when the fire started. Identify in the summary, the combustible material and the ignition source of the fire.

(f) Block 11f. If "Yes," is checked for Class C and above accidents, complete a DA Form 2397-6 and attach it to the report. For Class D, E, and F, explain the type and source of spillage in block 15.

(g) Block 11g. Check the appropriate box to indicate whether or not the subject aircraft was participating in a field training exercise (FTX). If "Yes," enter the FTX name in the space provided.

(12) Block 12. Enter the flight parameters at the times indicated. Flight parameters pertains to both flight and ground operations of the aircraft.

(a) Block 12a. Enter the listed flight parameters at the onset of the emergency. Enter a maximum of three phase of operation codes listed at table 3-4 .
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/occupational illness, property damage, or further materiel failure."

(b) Block 12b. Enter the flight parameters at the time of the first major impact/accident, except in those cases where an in-flight strike occurred, resulting in a second impact, in which case the second impact will be recorded here. This block may duplicate block 12a (emergency phase). Enter a maximum of three phase of operation codes listed at table

(13) Block 13. Enter up to three event codes (see table 3-2 or app F ) that best categorize the accident/incident. Enter the event code that best describes the accident/incident in the first space. Exception: Enter events 12, 40, and 45 in the first space if applicable.

(14) Block 14. Enter "D," "S," or "U" in the appropriate block to indicate whether or not human, materiel, or environment factors played a definite, suspected, or undetermined role in the accident/incident. Each indicated contrib- uting cause factor will be substantiated by the findings (block 24), and by the summary (block 15), for all accidents. In addition, complete the appropriate block pertaining to the cause factor (block 16) for definite or suspected materiel factors.

(15) Block 15. Enter a concise summary of events from the initial onset of the emergency until the aircraft is at rest, to include injuries resulting from the accident. Specify the actual errors/failures/effects and the root causes. The specified errors/failures/effects and root causes should be supported in the narrative of the summary. The summary should substantiate the findings entered in block 24. For D, E, and F accidents/incidents not involving human error, describe all materiel and environmental contributing factors, fire ignition sources, and combustible materiel cases involving fire. Also, enter PQDR number, category, and status when materiel deficiencies are involved.
Note. Attach a completed
DA Form 2397-3 if the board determines that more narrative information is required. See DA Form 2397-3 completion instructions for figure 3-4 .

(16) Block 16. This block must be completed if a material factor is indicated in block 14b. Enter the requested data for materiel failure/malfunction resulting from FWT, or for a maintenance or manufacture error and/or design deficiency over when the Army had no control (for maintenance error, over which the Army has control, block 21 must be completed with an accompanying human error, present and contributing finding). A PQDR is required for all materiel accidents in accordance with AR 385-10 , chapter 3 and DA Pam 738-751 , chapter 3. Component data is required only on those involving the power and drive trains. For example: engine, transmission, gearboxes, combining transmission.

(17) Block 17. Check this block to reflect the environmental conditions present at the time and location of the accident/incident. This block must be completed for all reports. Environmental contributing factors will be checked and substantiated in the summary or findings, depending upon the classification and circumstances.

(18) Block 18. For Class C and above accidents, enter the data for the investigation board president. For Class D and E accidents, and for Class E and F incidents, enter the safety officer/representative submitting the report. Include the e- mail address of the board president/ASO/POC.
Note. For Class D, E, and F reports not involving human error/injury or occupational illness, no further entries are required.

(19) Block 19. Complete this block for night Class C and above accidents or night relevant dawn and dusk accidents involving human error, when NVD or environmental factors are present.

(20) Block 20. Complete this block for all wire strikes.

(21) Block 21. Complete this block for all Class A, B, and C accidents for crew members with access to the controls regardless of the accident cause factor. Also, complete this block for all personnel who had a causative role or was injured as a result of the accident/incident (Class A-F). This block is not required for materiel failure Class D and E accidents, Class E and F incidents, where the only cause of the failure was FWT. If more than three personnel are involved, use additional forms as necessary. Use the instructions for block 21a for completing blocks 21b and 21c.

(a) Block 21a. (1). Enter the individual's last name, first name, and middle initial.

(b) Block 21a. (1). Enter the individual's social security number.

(c) Block 21a. (2). Enter the individual's pay grade. For example, O4, W3, GS-09, W-10. See table 3-8 .

(d) Block 21a. (3). Enter the individual's gender.

(e) Block 21a. (4). Enter the duty position code as shown on DA Form 2408-12 for the flight, or from the list at table 3-5 .

(f) Block 21a. (5). Enter the personnel service code of the individual from the list at table 3-9 .

(g) Block 21a. (6). Enter the UIC of the unit to which the individual is assigned at the time of the accident.

(h) Block 21a. (7). Check "D," "S," "N," or "U" to indicate the individual's casual role in the accident.

(i) Block 21a. (8). Check the box to indicate if the individual was on the flight controls at the time of the accident or if his previous control input had any influence on the accident.

(j) Block 21a. (9)(a). Check if blood and urine samples were taken (required for Class C and above accidents).

(k) Block 21a. (9)(b). If the results are positive, attach the AFMES results and address in findings at block 24 (authorized medication excluded).

(l) Block 21a. (10)(a). Enter the total number of hours this individual slept during the 24-hour period preceding the accident.

(m) Block 21a. (10)(b). Enter the total number of hours this individual worked in the 24 hours preceding the accident.

(n) Block 21a. (10)(c). Enter the total number of hours this individual flew in the 24 hours preceding the accident.

(o) Block 21a. (11)(a)(b). If the individual is a rated aviator, check the appropriate box to indicate his/her RL and FAC level.

(p) Block 21a. (11)(c). Enter the date the individual redeployed from a combat zone.

(q) Block 21a. (12). Check the appropriate box to indicate if the individual was injured. If "Yes" is checked, a DA Form 2397-9 is required to be submitted for each individual injured as a result of the accident. Accidents involving injury/occupational illness require a physician or flight surgeon (if a flight surgeon is not available, an Army medical officer may be appointed) to be a member/advisor of the board. Instructions for completing the DA Form 2397-9 are contained in this pamphlet.

(r) Block 21a. (13). Enter the total number of flight hours this individual has accrued in the accident aircraft mission, type, design, and series.

(s) Block 21a. (14). Enter the total number of flight hours in all aircraft.

(22) Block 22. Pertains to Class C and above accidents only.

(a) Block 22a. Any deformation of occupiable space constitutes a compromise for the purpose of this report. If "Yes" is checked, a DA Form 2397-6 is required to be submitted with the DA Form 2397-AB . Instructions for completing the DA Form 2397-6 are contained in this pamphlet. Pertains to Class C and above accidents only.

(b) Block 22b. Check the appropriate box to indicate if post-crash escape/rescue/survival difficulties were a factor for this individual. If "Yes," submit a DA Form 2397-10 for the individual(s). Instructions for completing the DA Form 2397-10 are contained in this pamphlet.

(c) Block 22c. Check the appropriate box to indicate if protective/restraint equipment functioned as designed. If "No", submit a DA Form 2397-10 for the individual(s). Additionally, check "No" and submit DA Form 2397-10 on the individuals if protective/restraint equipment was needed but not available, or was a contributing factor in the accident. Instructions for completing the DA Form 2397-10 are contained in this pamphlet.

(23) Block 23. Check the block(s) that best describe the cause(s) of the accident and substantiate each box checked in the findings.

(24) Block 24. Instructions for writing findings and recommendations are contained in paragraph 3-23 , block 1, of this pamphlet. Completion instructions for DA Form 2397-2 are contained in this pamphlet.

(25) Block 25. Enter the substantiating data submitted with the DA Form 2397-AB.

(26) Block 26. For Class C and above accidents only. Class C and above accidents will be forwarded through the reviewing chain of command for signature and comment in accordance with higher headquarters directions. Block 26a will be signed by the unit commander. Block 26b may be signed by any higher level chain of command. Block 26c approving authority is either the ACOM, ASCC or DRU commander or that commander's designated representative.
Note. Supplemental DA Form 2397-AB. Follow-up data, (for example, CCAD, Deficiency Report (DR), PQDR) teardown results are to be submitted as required. Complete only block 1 (case number) and those blocks for which the supplemental data applies.

3-37. Completion instructions for DA Form 2397-U, Unmanned Aircraft System Accident Report (UASAR)




Figure 3-18. Example of a completed DA Form 2397-U, Unmanned Aircraft System Accident Report (UASAR)





Figure 3-18. Example of a completed DA Form 2397-U, Unmanned Aircraft System Accident Report (UASAR)—continued





Figure 3-18. Example of a completed DA Form 2397-U, Unmanned Aircraft System Accident Report (UASAR)—continued


a. Also see paragraph 3-21 . Complete the entire form for all UAS accidents, regardless of accident class.

b. Complete the UASAR, DA Form 2397-U , as follows:

(1) Block 1, Accident Case Information. Complete this block as follows:

(a) Block 1a, Date of accident. Enter the year, month, and day of the accident in YYYYMMDD format.

(b) Block 1b, Time (Local). Enter the local time of the accident using the 24 hr clock.

(c) Block 1c, UA Tail Number. Enter the Unmanned Aircraft's (UA) tail number Exception: some UAS (for example, the gMav SUAS) do not have a tail number. In that case enter the UAS serial number.

(2) Block 2, Accident Class/Category. Complete this block as follows:

(a) Block 2a, Classification. Check the box corresponding to the appropriate accident classification per AR 385-10 , paragraph 3-4.

(b) Block 2b, Category. Check the box corresponding to the appropriate accident category as defined in the paragraph 1-9 a (1)-(3) of this pamphlet.
Note. Block 2b does not apply to Class E FWT materiel failure incidents, leave blank.

(3) Block 3, UAS MTDS. Enter the mission, type, design, and series (MTDS) of the UAS involved in the accident (examples: RQ-7B, MQ-1C).

(4) Block 4, Period of Day. Check the appropriate box.
Note. (Dawn is between the beginning of morning nautical twilight (BMNT) and official sunrise; Day is between official sunrise and official sunset; dusk is between official sunset and the end of evening nautical twilight (EENT); and night is between EENT and BMNT.)

(5) Block 5, Aircraft Involved. Complete this block as follows:

(a) Block 5a, Number of Aircraft Involved. Enter the number of aircraft involved in the accident.
Note. (If more than one aircraft is involved, submit additional DA Forms 2397-U for each UA and
DA Form 2397-AB for each manned aircraft. Do NOT include damaged aircraft that were NOT being operated at the time of the accident. When completing additional forms, do not duplicate data already provided on the case aircraft form.)

(b) Block 5b, In Flight/Mid-Air Collision. Check the appropriate box to indicate whether or not this accident involved an in flight/mid-air collision.

(6) Block 6, Nearest Military Installation. Enter the name of the military installation/facility nearest to the accident site.

(7) Block 7, Accident Location. Complete this block as follows:

(a) Block 7a, On/Off Post. Check the appropriate box to indicate whether the accident occurred on or off post.

(b) Block 7b, On/Off Airfield. Check the appropriate box to indicate whether the accident occurred on or off an airfield.
Note. (Tactical landing zones under positive ATC (for example: Corps' instrumented airfield, Division's VFR helipad, stagefields and support bases, UA Launch and Recovery Site) are considered "on post" and "on airfield" for reporting purposes. Also, UA accidents occurring on joint-use civil airports and on civilian airports with USAR component facilities are considered "on post" and "on airfield" when there is intent to use the military facilities on that airport.)

(c) Block 7c, City. Enter the name of the city nearest to the accident site.

(d) Block 7d, State. Enter the state in which the accident occurred.

(e) Block 7e, Country. Enter the country in which the accident occurred.

(f) Block 7f, Grid and/or Lat/Long. Enter the Military Grid Reference and/or latitude/longitude for the accident site.

(8) Block 8, Organization Involved. Complete this block as follows:

(a) Block 8a, Unit Designation. Enter the unit designation for the lowest level organization having operational control of the UAS at the time of the accident.

(b) Block 8b, Unit Identification Code. Enter the unit' s six-digit Unit Identification Code (UIC).

(c) Block 8c, Home Station. Enter the unit's home station.

(d) Block 8d, Army Headquarters. Enter the organization's Army Headquarters (the ACOM, ASCC, or DRU).
Note. (For Army Reserve or Army National Guard units on active duty status, if the unit of assignment is other than the Reserve or National Guard, enter the active duty unit information. Also, enter the UIC of the Army Reserve or Army National Guard unit in block 19a(6).)

(9) Block 9, Accountable Organization. Complete this block as follows:
Note. (If this organization is the same as block 8, leave blank).

(a) Block 9a, Unit Designation. Enter the unit designation of the organization most responsible/accountable for the accident.

(b) Block 9b, Unit Identification Code. Enter the organization' s 6-digit Unit Identification Code (UIC).

(c) Block 9c, Home Station: Enter the organization's home station.

(d) Block 9d, Army Headquarters. Enter the organization's Army Headquarters (the ACOM, ASCC, or DRU).

(10) Block 10, Accident Cost Data. Do not include those items excluded from accident cost in DA Pam 385-40, paragraph 1-10 . Enter in blocks 10b-i, only the cost associated with the UA/UAS to which this form pertains. Complete this block as follows:
Note. Fair Wear and Tear (FWT) materiel failure, where there is no corresponding damage to other components, is not considered damage, enter "0" or leave blank.

(a) Block 10a, UA Total Loss. Check the appropriate box to indicate whether the UA is a total loss. If "Yes", enter the replacement cost in block 10b and leave blocks 10c & d (man-hours) blank.

(b) Block 10b, UA Damage or Replacement Cost (excluding man-hours). If "Yes" is checked in block 10a, enter the current replacement cost (in whole dollars) for the UA. If "No" is checked in block 10a, enter the current cost (in whole dollars) to repair the UA to which this form pertains including component/part damage, but excluding man-hour cost. Cost to replace or repair the UA will be calculated at the current cost at the time of the accident.
Note. (Some UAS are contractually bound to receive ECOD/ACOD from the manufacturer who may not be required to break out man-hours cost. In that case, enter the cost to repair as provided by the manufacturer.)

(c) Block 10c, Number of Man-Hours. If block 10a is "No", enter the number of man-hours required to repair the damaged UA.
Note. (Some UAS are contractually bound to receive ECOD/ACOD from the manufacturer who may not be required to break out the number of man-hours or man-hours cost. In that case, leave blank.)

(d) Block 10d, Man-Hours Cost. If block 10a is "No", enter man-hour cost (in whole dollars) pertaining only to this aircraft's damage, based on current cost criteria specified in this DA pamphlet. Other man-hour costs will be included in block 10e (Other Damage Military).
Note. (Some UAS are contractually bound to receive ECOD/ACOD from the manufacturer who may not be required to break out the number of man-hours or man-hours cost. In that case, leave blank.)

(e) Block 10e, Other UAS Sub-Systems Cost. Enter the estimated/actual cost (in whole dollars) to repair or replace other UAS sub-systems (such as GCA, GDT, TALS, Arresting Gear, and so on) as a result of the accident. Cost to replace or repair the UAS sub-systems will be calculated at the current cost at the time of the accident.
Note. (Some UAS are contractually bound to receive ECOD/ACOD from the manufacturer who may not be required to break out man-hours cost. In that case, enter the cost to repair as provided by the manufacturer.)

(f) Block 10f, Other Damage Cost-Military. Enter all costs (in whole dollars) to other military property resulting from the accident (including inoperative aircraft).

(g) Block 10g, Other Damage Cost-Civilian. Enter the damage costs (in whole dollars) to civilian property.

(h) Block 10h, Injury/Occupational Illness Cost. Enter the injury/occupational illness cost (in whole dollars) for all personnel. The total cost can be computed by sum totaling the dollar amount found in block 19 of each DA Form 2397-9 completed or by using the cost standards table in DA Pam 385-40, table 1-1 .
Note. A DA form 2397-9 is required to be submitted for each individual receiving an injury/occupational illness as a result of the accident. Instructions for completing DA Form 2397-9 are in DA Pam 385-40, paragraph 3-31 .

(i) Block 10i, Total cost (this UAS). Enter the total of the dollars in blocks 10b through 10h.

(j) Block 10j, Total Cost (All Aircraft). Leave blank unless block 5 indicates multiple aircraft are involved. Enter the total cost (in whole dollars) for all aircraft (manned and unmanned) when multiple aircraft are involved.

(11) Block 11, General Data. Complete this block as follows:

(a) Block 11a, Mission. Complete this block as follows:

(1) Block 11a(1), Type Mission. Enter the symbol for the mission as shown on the DA Form 2408-12 and/or from AR 95-23 (para 2-5 b ).

(2) Block 11a(2), Aircraft Mode. Check the appropriate box to indicate if the mission was single-ship, multi-ship (more than one aircraft on same mission), or Manned/Unmanned Teaming (cooperative employment). If Manned/ Unmanned Teaming is checked, complete block 11a(3).

(3) Block 11a(3), Level of Interoperability (LOI). Check the appropriate box to indicate the LOI at the time of the accident. LOI refers to degree of manned aircraft control of the UAS during manned/unmanned teaming (cooperative employment). There are 5 levels: 1=Reception of the secondary product, 2=Direct data receipt, 3=Payload control, direct data receipt, 4=Flight control, payload control, direct data receipt, and weapons system operations, 5=Full function and control (only authorized when performing emergency procedures). Refer to AR 95-23 , appendix C.

(4) Block 11a(4), Simultaneous UA Operation. Check the appropriate box to indicate whether or not multiple unmanned aircraft were being operated simultaneously from the same ground control station (GCS). If "YES", specify the number, and MTDS, in the space provided.

(b) Block 11b, Flight Plan. Check the appropriate box to indicate the type flight plan (Military, Civil, or Operations on file at the time of the accident.
Note. (Units may be using a locally developed form or
DA Form 1594 as an Operations Log.)

(c) Block 11c, Flight Rules. Check the appropriate box to indicate the flight rules the UA was flying under at the time of the accident.

(d) Block 11d, Mission/Training. Complete this block as follows: Complete this block as follows:

(1) Block 11d(1), At what level was the mission/training conducted? Check the appropriate box to indicate the level at which the mission/training was conducted.

(2) Block 11d(2), Who approved the mission/training? Enter the Rank and Position of the individual that approved the mission/training.

(3) Block 11d(3), Was a mission brief completed? Check the appropriate box to indicate whether or not a mission brief was completed.

(4) Block 11d(4), Who was in charge during the mission/training? Enter the Rank and Position of the individual that was in charge during the mission/training.

(5) Block 11d(5), Who was the senior leader present during the mission/training? Enter the Rank and Position of the senior leader present during the mission/training.

(e) Block 11e, Risk Management (RM). Complete this block as follows:

(1) Block 11e(1), RM Performed? Check the appropriate box to indicate whether or not a risk management was performed. If "YES", complete blocks 11e(2) - 11e(7).

(2) Block 11e(2), Who performed the RM? Enter the Rank and Position of the individual that performed the risk management.

(3) Block 11e(3), RM Approved? Check the appropriate box to indicate whether or not the risk management was approved.

(4) Block 11e(4), Who accepted the risk(s)? Enter the Rank and Position of the individual that accepted the risk(s).

(5) Block 11e(5), What was the level of risk after controls applied? Check the appropriate block to indicate the level of risk after the controls were applied.

(6) Block 11e(6), How was the RM process communicated? Check the appropriate box (check all that apply) to indicate how the risk management process was communicated.

(7) Block 11e(7), Accident event identified/considered during RM process? Check the appropriate box to indicate whether or not the accident event was identified/considered during the risk management process. If "YES", complete blocks 11e(7)(a)-11e(7)(d).

(a) Block 11e(7)(a), What was the level of the identified risk? Check the appropriate box to indicate the level of the identified risk.

(b) Block 11e(7)(b), Was the control measure(s) applied? Check the appropriate box to indicate whether or not the control measure(s) was applied.

(c) Block 11e(7)(c), Who was responsible for implementing the control(s)? Enter the Rank and Position of the individual responsible for implementing the control(s).

(d) Block 11e(7)(d), Was the potential for the accident event accepted as residual risk? Check the appropriate box to indicate whether or not the potential for the accident event was accepted as residual risk.

(f) Block 11f, Digital Source Collector (DSC). Complete this block as follows:

(1) Block 11f(1), DSC installed? Check the appropriate box to indicate whether or not a Digital Source Collector was installed. If "YES," specify the type of DSC in the space provided.

(2) Block 11f(2), Was the data captured and preserved? Check the appropriate box to indicate whether or not the DSC data was collected and preserved. If "YES," specify the storage location of the DSC data in the space provided.

(g) Block 11g, Fire. heck the appropriate box to indicate if and when there was a fire during the accident sequence. If "Other," specify in the space provided.

(h) Block 11h, Hazardous Material Spillage. Check the appropriate box to indicate whether or not a hazardous material spillage occurred. If "Yes" and this was a class A, B, or C accident, complete a DA Form 2397-6 (form completion instructions are in para 3-28 of this pamphlet) and attach it to the report (note the attachment in block 21); for Class D, E, and F accidents explain the type and source of spillage in block 12, Summary.

(i) Block 11i, Did the accident occur while on an exercise? Check the appropriate box to indicate whether or not the subject UAS was participating in an exercise or while at a training facility (FTX, NTC, JRTC, named event such as Desert Eagle, and so on). If "Yes," enter the name of the exercise in the space provided.

(12) Block 12, Summary. Enter a concise summary of events from the initial onset of the emergency until the aircraft came to rest, to include injuries/occupational illness resulting from the accident. Specify the actual errors/ failures/effects and the root causes. The specified errors/failures/effects and root causes should be supported in the narrative of the summary. The summary should substantiate the findings entered in block 20. Refer to figure 3-5 of this pamphlet for narrative examples. Enter the SF 368 PQDR number, category, and status when materiel deficiencies are involved. Use a continuation sheet(s) on plain bond paper as necessary. Note: Attach a completed DA Form 2397-3 (form completion instructions are in para 3-25 of this pamphlet) if the board determines that more narrative information is required.
Note. Note the attachment in block 21.

(13) Block 13, Flight Data Enter the flight parameters at the times indicated in the table. Flight parameters pertain to both flight and ground operations of the aircraft.

(a) Block 13a, At Emergency/Onset. Enter the listed flight parameters at the onset 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/occupational illness, property damage, or further materiel failure."

(1) Block 13a(1), Flight Duration. Enter the duration of the flight in hours and tenths of hours in the spaces provided.

(2) Block 13a(2), Phase of Operation. Enter a maximum of 3 codes from table 3-4 of this pamphlet in the spaces provided or specify the phase of operation if there is no code for it in the table.

(3) Block 13a(3), Altitude MSL. Enter the aircraft's altitude (Mean Sea Level) in the space provided.

(4) Block 13a(4), Altitude AGL. Enter the aircraft's altitude (Above Ground Level) in the space provided.

(5) Block 13a(5), Airspeed KIAS. Enter the aircraft's speed (Knots Indicated Air Speed) in the space provided.

(6) Block 13a(6), UA Weight. Enter the aircraft's weight (pounds) in the space provided.

(7) Block 13a(7), UA Overgross Weight for Conditions? Check the appropriate box to indicate whether or not the UA was over gross weight limitations. If "YES," explain in block 12 and/or block 20.

(b) Block 13b, At Impact/Accident or Termination. Enter the listed flight parameters at the time of the first major impact/accident or termination. Exception: in those cases where an in-flight strike occurred, resulting in a second impact, record the second impact in this block. This block may duplicate block 13a (At Emergency).

(1) Block 13b(1), Flight Duration. Enter the duration of the flight in hours and tenths of hours in the spaces provided.

(2) Block 13b(2), Phase of Operation. Enter a maximum of 3 codes from table 3-4 of this pamphlet in the spaces provided or specify the phase of operation if there is no code for it in the table.

(3) Block 13b(3), Altitude MSL. Enter the aircraft's altitude (Mean Sea Level) in the space provided.

(4) Block 13b(4), Altitude AGL. Enter the aircraft's altitude (Above Ground Level) in the space provided.

(5) Block 13b(5), Airspeed KIAS. Enter the aircraft's speed (Knots Indicated Air Speed) in the space provided.

(6) Block 13b(6), UA Weight. Enter the aircraft's weight (pounds) in the space provided.

(7) Block 13b(7), UA Overgross for Conditions? Check the appropriate box to indicate whether or not the UA was over gross weight limitations. If "YES," explain in block 12 and/or block 20.

(c) Block 13c, Flight Control Malfunction. Check all boxes that apply. Flight Control System related accidents could be the result of Human, Materiel, and/or Environmental factors. In addition to this block, complete blocks 15a-c as applicable.

(14) Block 14, Type Events. Using appendix F , table F-3 of this pamphlet enter up to a maximum of three event codes that best categorize the accident/incident. The 3 codes should be listed in the sequence of occurrence. If there is no code for the event in the table, specify the Type of Event(s) in the space(s) provided.

(15) Block 15, Accident Cause Factors. Indicate if Human, Materiel, or Environment cause factors (H/M/E) played a role in the accident/incident by selecting "D" if definite, "S" if suspected, "U" if undetermined, or "N" if None/No in the appropriate block. Accident Cause Factors contributing to the accident will be substantiated in block 12, Summary, and/or block 20, Findings and Recommendations.

(a) Block 15a, Human Factors. Check the appropriate box (D, S, U, or N) to indicate if Human Factors played a role in the accident. If D or S is checked, complete blocks 15a(1)(a)-(e).

(1) Block 15a(1), System Inadequacies (SI). Using figure 2-1 of this pamphlet, determine the System Inadequacy(s) responsible for the Human Factor(s). An accident may have multiple human factors and, therefore, multiple system inadequacies. Include all identified system inadequacies. The form allows for the entry of up to three codes for each system inadequacy.
Note. (If more than 3 are identified, use a continuation sheet.)

(2) The primary table for System Inadequacy codes is table B-5 , appendix B , of this pamphlet. Additional aviation specific codes can be found in table B-1 . If there is no code(s) for the identified system inadequacy in either table, write in that which that best describes the failure.

(a) Block 15a(1)(a), Support Failure. Enter up to 3 codes to identify the support failure.

(b) Block 15a(1)(b), Standards Failure. Enter up to 3 codes to identify the standards failure.

(c) Block 15a(1)(c), Training Failure. Enter up to 3 codes to identify the training failure.

(d) Block 15a(1)(d), Leader Failure. Enter up to 3 codes to identify the leader failure.

(e) Block 15a(1)(e), Individual Failure. Enter up to 3 codes to identify the individual failure.

(b) Block 15b, Materiel Factors. Check the appropriate box (D, S, U, or N) to indicate if Materiel Factors played a role in the accident. If D or S is checked, complete blocks 15b(1) and 15b(2)(a)-(g).

(1) Block 15b(1), Type. Check the appropriate box(s) to indicate the type of materiel failure and/or malfunction. Check all that apply.

(2) Block 15b(2), Component and Part Data. Complete blocks 15b(2)(a)-(g) for the component and/or part that failed or malfunctioned. Enter the requested data for materiel failure and/or malfunction resulting from FWT, maintenance error, manufacturing defect or error, and/or design deficiency. Component column data is required "only" for those items involving power and drive trains; for example, engine, transmission, gearboxes, and so forth. For maintenance error, over which the Army has control, block 19 must also be completed. This is a three column chart. Column 1 is for the UAS sub-system (UA, GCS, GDT, TALS, FTS, ATLS, etc), column 2 is for the component, and column three is for the part. Note: If more than one UAS sub-system had a materiel causal factor, attach additional forms for each sub-system. An EIR/ SF 368 (Product Quality Deficiency Report, PQDR) is required for all materiel accidents in accordance with paragraph 3-9b(1), AR 385-10 and paragraph 3-2, DA Pam 738-751 . Attach a copy of the SF 368 to this report and note the attachment in block 21.

(a) Block 15b(2)(a), Nomenclature. Enter the noun nomenclature in the space provided.

(b) Block 15b(2)(b), Type, design, and series. Enter the Type, design, and series in the space provided.

(c) Block 15b(2)(c), Part Number. Enter the part number in the space provided.

(d) Block 15b(2)(d), NSN/Manufacturer's Number. Enter the National Stock number (NSN) or Manufacturer's Number (if no NSN assigned) in the space provided.

(e) Block 15b(2)(e), Manufacturer's Code. Enter the code to identify the manufacturer in the space provided.

(f) Block 15b(2)(f), Serial Number. Enter the item's serial number in the space provided.

(g) Block 15b(2)(g), Cause of Failure/Malfunction. Column 1 intentionally left blank; in column 2 check the appropriate box; and in column 3 enter the applicable Failure Codes (maximum of 2) using DA Pam 738-751 , table 1-2, (TAMMS-Aviation).

(c) Block 15c, Environmental Factors. Check the appropriate box (D, S, U, or N) to indicate if Environmental Factors played a role in the accident.

(1) Block 15c(1), General. This block identifies specific meteorological weather conditions at the time the accident occurred. Check all applicable boxes (more than one may apply).
Note. "VMC and IMC are NOT environmental "causal" factors if the conditions were forecast."

(2) Block 15c(2), Weather Factors. Enter up to three codes from table 3-26 of this pamphlet in the spaces provided to indicate weather factors that played a role in the accident. If there is no code(s) for the weather condition in the table, specify the factor(s) in the space(s) provided.

(3) Block 15c(3), Environmental Signal Factors. Check the appropriate box(s) to indicate the environmental signal factors/conditions at time of the accident. If "other" is checked, specify the signal factor(s) in the space provided.
Note. If the "signal" problem was not environmental related, but rather the result of human and/or materiel factors, DO NOT enter it in this block; enter it in block 15a and/or block 15b.

(4) Block 15c(4), Other Environmental Factors. Enter a maximum of three codes from table 3-27 of this pamphlet in the spaces provided to indicate other environmental factors that played a role in the accident. If there is no code(s) for the other environmental factors in the table, specify the factor in the space(s) provided.

(16) Block 16, Loss of Link (LOL). Enter D (definite), S (suspected), U (undetermined), or N (none/no) as appropriate to indicate if Loss of Link played a role in the accident. If D or S is checked, complete blocks 16a-d. LOL can be the result of Human, Materiel, and/or Environmental factors. In addition to blocks 16a-d, complete blocks 15a- 15c as/if applicable.

(a) Block 16a, Link Lost. Check the appropriate box to indicate whether it was a loss of uplink, downlink, or unknown.

(b) Block 16b, Type of Link. Check the appropriate box to indicate the type of link lost. If "other" is checked, specify the type of link in the space provided.

(c) Block 16c, UA distance from GCS at time of LOL. Enter the distance (nautical miles) the UA was from the GCS at the time that the link was lost.

(d) Block 16d, LOL Factors. Check the appropriate box(s) to indicate LOL Factors. Check all that apply.

(17) Block 17, Take-Off/landing Data. Complete block 17a if the accident occurred during the take-off phase or block 17b if it occurred during the landing phase. Accidents occurring during T/O or Landing could be the result of human, materiel, and/or environmental factors. In addition to blocks 17a & 17b, complete blocks 15a-15c as/if applicable. If the accident did NOT occur during the takeoff or landing phase, leave blank.

(a) Block 17a, Take-off (T/O) Phase. Complete this block, if the accident occurred during the take-off phase of flight, as follows:

(1) Block 17a(1), T/O Method. Check the appropriate box to indicate the method of T/O. Examples of "manual" include joystick and hand launched.

(2) Block 17a(2), T/O Accident Factors. Check the appropriate box(s) to indicate T/O accident factors. Check all that apply.

(b) Block 17b, Landing Phase. Complete this block, if the accident occurred during the landing phase of flight, as follows:

(1) Block 17b(1), Landing Method. Check the appropriate box to indicate the method of Landing. Example of "manual" is joystick flown.

(2) Block 17b(2), Landing Accident Factors. Check the appropriate box(s) to indicate Landing accident factors. Check all that apply.

(18) Block 18, Type of Strike. Check the appropriate box to indicate whether or not a "strike" occurred and the type. If "Other" is checked, specify the type of strike in the space provided.

(19) Block 19, Personnel Data. Complete this block for class A, B and C accidents for all crewmembers occupying UAS flight crew station, regardless of the accident cause factor. Also, complete this block for all personnel who had a causative role or had injury/occupational illness as a result of the accident/incident (Class A-F). This block is not required to be completed for class C, D and F materiel failure accidents/incidents if the only cause of the failure was FWT. If more than three personnel are involved, use and attach additional forms as necessary. Use the instructions for block 19a to complete blocks 19b and 19c.

(a) Instructions.

(b) Block 19a, Name. Enter the individual's last name, first name, middle initial and complete (1)-(14).

(1) Block 19a(1) (SSN). Enter the individual's social security number.

(2) Block 19a(2), Grade. Enter the individual's pay grade. For example, O4, W3, GS-11, WG10 (refer to table 3-8 of this pamphlet).

(3) Block 19a(3) (Gender). Check the appropriate box to indicate the individual's gender.

(4) Block 19a(4), Duty Position. Enter the duty position/seat code as shown on the DA Form 2408-12 for the flight or in table 3-5 of this pamphlet.

(5) Block 19a(5), Service Code. Enter the personnel service code of the individual from table 3-9 of this pamphlet.

(6) Block 19a(6), UIC Assigned. Enter the six position UIC of the unit to which the individual was assigned at the time of the accident.

(7) Block 19a(7), Contributing Role. Check D (definite), S (suspected), U (undetermined), or N (none/no) to indicate the individual's contributing role in the accident.

(8) Block 19a(8), On Flight Controls. Check the appropriate box to indicate if the individual was on the UAS flight controls at the time of the accident or if his/her previous control input had any influence on the accident.

(9) Block 19a(9) (Lab Testing). Check the appropriate box to indicate the results of lab testing (testing required for class A, B and C accidents). If the test result was "positive", attach the Armed Forces Institute of Pathology (AFIP) results to this report and address it in block 20 (authorized medication excluded). Note the AFIP attachment in block 21.

(10) Block 19a(10), Amount of Activity. Complete this block as follows:

(a) Block 19a(10)(a), Hours Slept: Enter the total number of hours this individual slept during the 24-hour period preceding the accident.

(b) Block 19a(10)(b), Hours Worked. Enter the total number of hours this individual worked during the 24-hour period preceding the accident.

(c) Block 19a(10)(c), Hours Flown. Enter the total number of flying hours for this individual during the 24-hour period preceding the accident.

(11) Block 19a(11), Individual Status. Complete this block as follows:

(a) Block 19a(11)(a), Readiness Level (RL). If the individual is a UAS operator, check the appropriate box to indicate his/her RL.
Note. Mission Preparation and Mission Qualification indicate SUAS operator status.

(b) Block 19a(11)(b), Flight Activity Code (FAC). If the individual is a certified UAS operator, check the appropriate box to indicate his/her FAC.
Note. (FAC is not applicable to SUAS operators, check NA).

(c) Block 19a(11)(c), Redeployment Date. Enter the date (YYYYMMDD) of the individual's last redeployment from a combat zone.

(12) Block 19a(12), Injury/Occupational Illness. Check the appropriate box to indicate if the individual was injured or had an occupational illness as a result of this accident. If "Yes" is checked, a DA Form 2397-9 (refer to para 3-30 of this pamphlet for form completion instructions) is required to be submitted for each individual injured or had an occupational illness as a result of this accident (note the attachment in block 21). Accidents involving injury/ occupational illness require a physician or physician's assistant to be a member/advisor of the board.

(13) Block 19a(13). MTDS Flight Hours. Enter the total number of flight hours the individual has accrued in the accident aircraft mission, type, design, and series (MTDS).

(14) Block 19a(14), Total Flight Hours. Enter the total number of flight hours the individual has accrued in all UAS.

(a) Block 19b(1)-(14). Complete as above for 19a(1)-(14).

(b) Block 19c(1)-(14). Complete as above for 19a(1)-(14).

(20) Block 20, Findings and Recommendations: Instructions for writing findings and recommendations are contained in paragraph 3-5 , table 3-1 , and paragraph 3-24 of this pamphlet. Use additional/continuation sheets, as required. Accident causal/contributing factors identified in block 15 must be substantiated in this block.

(21) Block 21, List of Attachments. List all substantiating data (examples include continuation sheets, ECOD/ACOD, C C A D , P Q D R , A F I P R e s u l t s , R A W , M s n B r i e f , p h o t o s , m a p s , w e i g h t & b a l a n c e , w e a t h e r b r i e f , D A f o r m s 2397-series, and so on) submitted with this DA Form 2397-U . Note that not all the above is required. The board always has the option of submitting any substantiating data it deems necessary to support the accident investigation and report.
Note. If this is a class A or B accident, refer to paragraph 3-17 of this pamphlet and submit those document and forms, pertinent to this accident investigation and report.

(22) Block 22, Board President/ASO/POC. For class A, B and C accidents, enter the Name, Signature, and Date of the investigation board president. For class D, E, and F enter the information for the safety officer or POC representative submitting the report.

(a) Block 22a, Grade. Enter the individual's Grade (not rank).

(b) Block 22b, Branch. Enter the individual's Branch.

(c) Block 22c, E-mail. Enter the individual' s e-mail address.

(d) Block 22d, Address & Tel No. (DSN & Comm). Enter the individual's mailing address and telephone numbers (DSN & Commercial) in the space provided.

(23) Block 23, Command Review: Required for class A, B, and C accidents only. The reference for determining the individuals responsible for performing the Command Review is AR 385-10 , paragraph 3-17.

(a) Unit Commander. Enter the individual's organization, name (last, first, MI), rank, and signature. Indicate comment by checking the applicable box.

(b) Reviewing Official. Enter the individual's organization, name (last, first, MI), rank, and signature. Indicate comment by checking the applicable box.

(c) Approving Authority. Enter the individual's organization, name (last, first, MI), rank, and signature. Indicate comment by checking the applicable box.

(d) DA Review. Enter the individual's organization, name (last, first, MI), rank, and signature. In column 6, enter the date (YYYYMMDD) the report is approved for entry into the Army Safety Management Information System (ASMIS).
Note. Submission of Supplemental UAS Accident Report (
DA Form 2397-U ): Follow-up data (for example, CCAD, DR (PQDR), ECOD/ACOD, and teardown results) are to be submitted as required. Using DA Form 2397-U (UASAR) complete only Block 1a-c (Accident Case Information), Block 21 (List of Attachments), and those blocks to which the supplemental data applies.

Table 3-2. Accident/incident event codes associated with manned and unmanned aircraft accidents (see app F-1 and app F-2 )
Code Type event Code Type event
01 Precautionary landing (PL) 53 Missing aircraft
02 Forced landing(FL)/UAS flight ter- mination system (FTS) deployed 54 FOD (other than event 45)
03 Aborted takeoff 55 Dynamic rollover
04 Human factor 56 Maintenance operational test
05 Cargo 57 Weapons related
06 Personnel handling 58 Lightning strike
07 External stores 59 Rescue operations
08 Multiple aircraft event 60 Object strike
09 Misappropriated aircraft 61 Air-to-ground collision
10 Unmanned aircraft/Drone aircraft 62 Stump strike
11 Contractor aircraft accident 63 Antenna strike
12 Aircraft ground accident 64 Engine overtorque/overload
13 Laser-induced/related 65 Whiteout
14 Fratricide 66 Tiedown strike
15 Single-engine landing (multi-engine aircraft only) 67 Parachute deployment
16 Uncommanded control input 68 Mast bumping
17 Cockpit airbags 69 Structural icing
18 Icing 70 Engine failure, power loss, or internal
19 (Reserved for future addition) 71 Transmission failure
20 Refueling 72 Vertical fin strike
21 Midair collision 73 Spike knock
22 Helocasting 74 Seatbelt/restraint harness strike
23 Hard landing 75 Blade flapping
24 Wheels up-landing
25 Landing gear collapse/retraction 76 Fuel exhaustion
26 Undershoot 77 Fuel starvation
27 Overshoot or overrun 78 Animal strike
28 Ditching 79 Battery fire/overheat
29 Ground loop/swerve 80 Excessive yaw/spin
30 Collision with ground/water 81 Tail boom strike
31 Aircraft collisions on the ground Material Factor Event Codes
32 Other collisions 82 Airframe
33 Rotor overspeed 83 Landing gear/arresting hook
34 Fire and/or explosion on the ground 84 Power train (except event 47 and 70)
35 Fire and/or explosion in the air 85 Drive train (except event 71)
36 Equipment loss or dropped object 86 Rotor/propellers
37 In-flight breakup 87 Hydraulics system
38 Spin or stall 88 Pneumatic system
39 Abandoned aircraft 89 Instruments
40 Flight-related accident 90 Warning system
41 Instrument meteorological condition (MC) 91 Electrical system
42 Rappelling 92 Fuel system
43 Fast rope 93 Flight control
44 Overstress 94 Utility/environmental control system
45 Turbine engine 95 Avionics
46 Rotor/prop wash 96 Cargo handling equipment
47 Engine overspeed/overtemp 97 Armament
48 Brownout 98 Night vision device
49 Bird strike A1 Launcher malfunction
50 Tree strike A2 Tactical Automated Landing System (TALS) Landing/recovery
51 Wire strike A3 Arresting gear failure (drum, strap, pendant)
52 In-flight breakup A4 Flight Termination System (FTS) failure/malfunction
A5 Automatic Take Off and Landing System (ATLS) Failure/Malfunction Landing
A6 Automatic Take Off and Landing System (ATLS) Failure/ Malfunction Take-Off
A7 Battery failure
A8 Flight Termination System (FTS) Deployment
A9 Test Flight
B1 Ground Control System (GCS) Failure/Malfunction
B2 Ground Data Terminal (GDT) Failure/Malfunction
B3 Ground Power Generation Equipment Failure/Malfunction
B4 Loss of Downlink
B5 Loss of Link
B6 Loss of Uplink
B7 Other UAS Equipment Failure/Malfunction
C1 Excessive High Winds during Aerostat Operation
C2 Tether Strike
C3 Aerostat Blown Down
C4 Mooring Station Failure


Table 3-3. Ownership of damaged property
Code Owner Code Owner
A Active Army N Army National Guard
B Army contractor R Army Reserve
C Non-appropriated fund S Commercial
F Foreign Government T Private/civilian
J Air Force (includes Reserve/ARNG components) X Unknown
K Navy (includes Reserve components) Y Ownership not elsewhere coded
L Marine (includes Reserve components) Z Undetermined
M Government, other (for example, FAA, FBI, Customs)


Table 3-4. Phase of operation
Code Operations
A Starting engine/run-up
B Stationary (engines running)
C Taxi
D Takeoff/catapult/launch
E Hover IGE
F Climb (after takeoff phase is completed and climb to altitude is established)
G Cruise
H Combat maneuver (masking, unmasking, gun run, evasive action)
I Descent (does not include approach)
J Approach (prior to landing/termination, including UAS ATLS and TALS)
K Emergency autorotation
L Go-around (the intended landing/termination is aborted, including UAS ATLS and TALS aborts)
M Landing (aircraft touchdown until forward motion stops or aircraft clears surface)
N Low level (constant airspeed and altitude below 500 feet AGL)
O Contour (varying altitude and airspeed, while generally following the contours of the earth's surface/obstacles)
P NOE (varying airspeed and altitude, generally following the earth's surface/foliage for concealment)
Q Hover OGE
R Crash (crew has no control over the aircraft attitude)
S Aerobatics
T Termination w/power (planned/attempted termination of an autorotation is to hover)
U Undetermined/unknown
V Power recovery (the process of returning the aircraft to power; flight from an engine-out configuration)
W Training autorotation
X Formation
Y Preflight activity (any activity prior to the flight that caused or contributed to the accident), for example: mission planning, crew assignment, training, loading UA on launcher, preflight.
Z Refueling (to identify the type refueling being conducted, use an additional code preceding the Z code) For example, code in-flight refueling as "GZ", G=Cruise & Z=Refueling
2 Turning
3 Deceleration
4 Level off
5 Shut down
6 Flight Termination System (FTS) deployed (UAS)
7 Automatic Return Home Mode (UAS)
8 Holding pattern (includes UAS loitering on station to perform designated mission)
9 UAS crew hand-off (UA in-flight)
10 UAS crew hand-off (UA on ground, prior to take-off)
11 UA hand-off (manned/unmanned teaming, cooperative employment)
12 Aerostat Moored
13 Aerostat Flight
14 Aerostat Recovery
15 Aerostat Launch
16 Altitude Adjustment (raising or lowering the Aerostats elevation)


Table 3-5. Duty position codes
Code Duty description
ABC Aviation battalion commander
AC Aircraft commander
ADC Approach-departure controller
AMC Air mission commander
AO Unmanned Aircraft Operator
AOP Assistant Operations Officer
AOS Assistant Operations SGT
ART Armament/Arms Technician
AS AFTP Supervisor
ASO Aviation Safety Officer
AUC Aviation unit commander
AVT Avionics technician
CC Company Commander
CE Crew chief or flight engineer
CET Combat-equipped troops or jumpers
CP Copilot
DC Deputy commander
DCO DA/DOD-level commander
DEP Design & engineer personnel
DS Direct supervisor
E Electrician
EO External operator
FAC FWD Air Controller
FC Flight commander
FCO Flight leader
FCT Weather personnel
FFT Crash rescue/firefighters
FI Flight Engineer Instructor
FSP Flight service personnel
FTM Fuel team member
FTS Fuel team supervisor
G-3 G-3
GC Ground unit commander
GCA Final controller
GG Ground guide or "Follow me" service
GM General mechanic
GO Ground Observer
GSY Other ground support personnel
IE Instrument flight examiner
IP Instructor pilot
IO Instructor Operator
JPM PARA Jump Master
LCO Supervisor or unit commander
LO Liaison Officer
MC Mission coordinator
MCO Major commander/Supervisor
ME Maintenance test flight evaluator
MFP Manufacturing or rework personnel
MO Flight surgeon/medical officer/attendant
MP Maintenance test pilot
MPO Mission Payload Officer
MS Maintenance supervisor
OAY Others Aboard Aircraft
OGY Others not aboard aircraft
OP Operations Officer
OPN Operations Dispatcher, etc.
OR Gunner, Technical Observer, Aircraft Maintenance Personnel, Photographer
PAX Passenger
PC Pilot in command
PF Pathfinder
PI Pilot
PL Platoon Leader
PO Mission Payload Operator
PPM Power plant mechanic
PT Pilot trainee
PTM Power train mechanic
PTO Pilot trainee, observer
PTR Pilot trainee, rated
RAP Rappeller
RM Rappeller Master
RS Rappeller Safety
SI Standardization flight engineer instructor
SM Structure/airframe mechanic
SO Standardization instructor operator
SP Standardization instructor pilot
S3 S3
TI Technical Inspector
TWC Tower personnel
UNK Unknown
UT Unit trainer
UAG Unmanned Aircraft System Ground Crewmember
NR Not reported
UAO Unmanned Aircraft Observer
XO Executive Officer
XP Experimental test pilot
ZR Rated passenger


Table 3-6. Accident case number
Digits Information
1 & 4 4 Digits of the year in which the accident occurred. For example, 2008, 2009.
5 & 6 A 2-digit designator for the month in which the accident occurred. For example, 01=Jan, 09=Sep, 11=Nov.
7 & 8 A 2-digit designator for the day of the month in which the accident occurred. For example, 01, 02, 03.
9 - 12 A 4-digit designator for local time of day accident occurred. For example, 0930, 2200.
13 - 19 The serial number of the "case aircraft" involved.


Table 3-7. Accident errors/failures/effects/system inadequacy(ies)/recommendations
Code Description
Errors
P01 Scan
P02 Maintain/recover orientation
P03 In-flight planning
P04 Preflight planning
P05 Estimate distance/closure/control input
P06 Detect hazards/obstacles
P07 Diagnose or respond to an emergency
P08 Coordination
P09 Failed to use or follow checklist
P10 Failed to follow maintenance manual (TM, SOP, TB), instructions while servicing acft/equip
P11 Failed to follow instructions (TM, TB, MWO) while repairing, installing, or adjusting equipment
P12 Inadequate/improper inspection
P13 Failed to read/follow available SOPs, notices, ARs, general rules/principles
P14 Inadequate tool/equip accountability
P15 Failed to secure materiel/equip/cargo
P16 Inadequate/improper LZ/termination point selection
P17 Improperly prepared LZ
Supervisor-Specific Mistakes/Errors
P18 Improper mix/match/number of personnel
P19 Inadequate time allowed for pre-mission preparation
P20 Set/permitted inappropriate launch time for environmental conditions
P21 Permitted selection of inappropriate LZ for intended training or crew experience
P22 Failed to ensure repairs/services/inspections/MWO are in accordance with appropriate TMs, TB, MWOs
P23 Failed to take appropriate/timely action to prevent or stop violation of procedures/unsafe acts acts.
P24 Inadequate mission planning for risk-management, operational, and logistic decisions
P25 Failed to brief/provide information
P97 Insufficient information to determine mistake/error
Materiel Failure/Malfunction
M01 Overheated/burned/melted
M02 Froze (temperature)
M03 Obstructed/pinched/clogged
M04 Vibrated
M05 Rubbed/worn/frayed
M06 Corroded/rusted/pitted
M07 Overpressured/burst
M08 Pulled/stretched
M09 Twisted/torqued
M10 Compressed/hit/punctured
M11 Bent/warped
M12 Sheared/cut
M13 Decayed/decomposed
M14 Electric current action (short, arc, surge)
M97 Insufficient information reported to identify type of failure/malfunction
Environmental Effects/Condition
E01 Illumination (dark,glare)
E02 Precipitation (rain, fog, ice, snow)
E03 Contaminants (fumes, dust, chemicals, FOD)
E04 Noise
E05 Temperature/humidity
E06 Wind turbulence
E07 Vibration
E08 Acceleration/deceleration
E09 Radiation (sunlight, X-ray, LASER)
E10 Work surface/space (slippery floor, cluttered walkway, steep rough road)
E11 Air pressure (explosion, decompression, altitude effects)
E12 Electricity (lightning, arc, surge, short, shock)
E13 Animals (deer, birds, rodents, insects)
E97 Insufficient information reported to identify environmental conditions
System inadequacy(ies)/Root cause(s)/Readiness shortcomings
01 Inadequate/improper supervision by "Higher command"
02 Inadequate/improper supervision by "Staff officer," (or example, operations, safety, supply)
03 Inadequate/improper supervision by "Unit command"
04 Inadequate/improper supervision by "Direct supervisor," (for example, instructor, squad leader, aircraft commander)
05 Inadequate school training
06 Inadequate unit training
07 Inadequate experience
08 Habit interference
09 Inadequate written procedures for operation under normal, abnormal, or emergency conditions
10 Inadequate facilities or services
11 Inadequate/improper equip/materiel design or equipment not provided
12 Insufficient type/number of personnel
13 Inadequate manufacture, assembly, packaging, or quality control
14 Inadequate maintenance (inspection, installation, troubleshooting, record keeping, and so forth)
15 Fear/excitement (inadequate composure)
16 Overconfidence (in self, others, equipment)
17 Lack of confidence (in self, others, equipment)
18 Haste/Attitude (motivation)
19 Fatigue (self induced)
20 Effects of alcohol, drugs, or illness
21 Poor attitude/indiscipline
22 Environmental conditions
97 Insufficient information reported to identify inadequacy/shortcoming/cause
Recommendations/Remedial Measures
01 Improve school training
02 Improve unit training
03 Revise procedures for operation under normal, abnormal, or emergency conditions
04 Ensure personnel are ready to perform (training, experience, psycho physiological state)
05 Inform personnel of problems and remedies (meetings, publications, EIRs)
06 Positive command action (to encourage proper performance and discourage improper performance)
07 Provide personnel resources (number or qualifications) required for job
08 Redesign (or provide) equipment or material
09 Improve (or provide) facilities or services
10 Improve quality control
11 Perform studies to get solutions to system inadequacy(ies)


Table 3-8. Pay grade codes
Grade/Code Description
O1-O10 Commissioned officer
WO1-CW5 Warrant officer
E1-E9 Enlisted service member
GS1- GS 15 & SES 1-5 DOD civilian employee
WG1- WG 15 & WS 16-WS 19 Wage board employee
XN Foreign National
X-1 Foreign officer, all grades
X-2 Foreign enlisted, all grades
CAC Civilian Army contractor employee
CIV Non-DOD civilian
DAC Department of Army Civilian
KAD USMA
ROTC ROTC student
NRPT Not reported
OC WOC/OC
UNK Unknown
UNKE Unknown Enlisted
UNKO Unknown Officer
OTH Personnel other than above


Table 3-9. Personnel service codes
Code Service
A Active Army
B Army civilian
C Army contractor
C1 Army direct contractor
D Non-appropriated fund employee
E0 Other U.S. military personnel
E1 Navy
E2 Air Force
E3 Marine Corps
F0 Foreign
F1 Foreign National Direct Hire
F2 Foreign National Indirect Hire
F3 Foreign National KATUSA
F4 Foreign Military Attached
G Dependent
M Government, Other
N0 National Guard
N1 NG Tech
N2 NG IDT
N3 NG AT
N4 NG ADSW
N5 NG AGR
N6 NG ADT
N7 NG Activated
O Other
P Public
R0 Reserve
R1 Reserve IDT
R2 Reserve AT
R3 Reserve ADT
R4 Reserve FTM
R5 Reserve Tech
R6 Reserve Activated
R7 Reserve AGR
T ROTC
U Unknown
Z Not reported


Table 3-10. Injury/illness terms and codes
NFS-Not Further Specified    
Body Region    
A 00 Body in General
B 00 Head, General 16 Mouth 30 Nasal
01 Head Less 17 Nose 31 Lacrimal
02 Brain 18 Teeth 32 Palatine
03 Ears 19 Tongue 33 Zygoma/Malar
04 Hair 20 Gums 34 Temporal
05 Scalp 21 Chin 35 Parietal Area
06 Skull 23 Frontal 36 Multiple Bonds (Face)
07 Temple 24 Ethmoid 37 Multiple Bones
(Calvarium)
10 Face, General 25 Spheroid
11 Cheeks 26 Vomer 38 Multiple Bones (Basilar)
12 Eyes 27 Occipital Area 39 Multiple Bones (Other)
13 Forehead 28 Mandible 40 Orbit
15 Lips 29 Maxilla Face
C 00 Neck, General
01 Espophagus 08 Vertebra C3 14 Odontoid (Atlanta Multiple Axial)
02 Larynx 09 Vertebra C4 15 Atlanto-occipital
03 Trachea 10 Vertebra C5 16 Jugular Vein
04 Vertebra, General 11 Vertebra C6 17 Carotid Artery
06 Vertebra C1 12 Vertebra C7
07 Vertebra C2 13 Intervertebral Disk
D 00 Trunk, General
10 Abdomen, General 43 Heart 64 Vertebra T5
11 Colon 44 Lungs 65 Vertebra T6
12 Gall Bladder 45 Mammary 66 Vertebra T7
13 Intestines, General 46 Ribs/Sides 67 Vertebra T8
14 Kidney 47 Sternum 68 Vertebra T9
15 Liver 49 Aorta 69 Vertebra T10
16 Pancreas 50 Pelvis, General 70 Vertebra T11
17 Spleen 51 Bladder 71 Vertebra T12
18 Stomach 52 Buttocks 72 Vertebras, Multi-lumber
20 Intestines (large) 53 Genitalia 73 Vertebra L1
21 Intestines (small) 54 Hip 74 Vertebra L2
30 Back, General 55 Rectum/Anus 75 Vertebra L3
31 Scapula 56 Pelvises, NFS 76 Vertebra L4
32 Spinal Cord, General 59 Vertebras, Multi-thoracic 77 Vertebra L5
33 Vertebra, Multiple 60 Vertebra T1 78 Sacryn
40 Chest, General 61 Vertebra T2 79 Coccyx
41 Clavicle 62 Vertebra T3 80 Intervertebral Disc
42 Diaphragm 63 Vertebra T4 81 Vena Cava
E 00 Upper Extremities, General
10 Upper Arm, General 20 Lower Arm, General 31 Finger(s), General
11 Shoulder 21 Wrist 32 Knuckles
12 Elbow 22 Arm Lower, NFS 33 Thumb
13 Arm Upper, NFS 34 Hand, NFS
F 00 Lower Extremities, General
10 Leg Upper, General 21 Ankle 32 Ball
11 Knee 22 Leg Lower, NFS 33 Heel, NFS
12 Leg Upper, NFS 30 Foot, General 34 Toes
20 Leg Lower, General 31 Arch 35 Foot, NFS
X 97 Not reported
Y 99 Other
Z 98 Unknown
Body Aspect, Primary
  01 Right   97 Not Reported    
  02 Left   98 Unknown    
  03 Bilateral/Both   99 Other (Specify)    
  09 Medial/Mesial/Midline      
Body Aspect, Secondary
04 Central (incl. internal organs) 10 Medial/Mesial/Midline/Front
05 Anterior/Ventral/Front 11 Whole Body Regions, General
06 Posterior/Dorsal/Back 12 Whole Body Part
07 Superior/Cranial/Upper 98 Unknown
08 Inferior/Caudal/Lower 99 Other (Specify)
Injury/Illness Types or Results
Burns (Chemical)
A
00 Burns, General 03 Third Degree
01 First Degree 04 Fourth Degree
02 Second Degree 05 Burns, Chemical, NFS
Burns (Thermal)
B
00 Burns, General 05 Burns, Thermal, NFS
01 1st Degree 06 1st & 2d Degree
02 2d Degree 07 1st & 3d Degree
03 3d Degree 08 2d & 3d Degree
04 4th Degree 09 3d & 4th Degree
Dismemberments
C
00 Dismemberments, General 03 Decapitation
01 Amputation 04 Dismemberment, NFS
02 Avulsion (Evisceration)
Environmental Exposure
D
01 Decompression/Bends 06 Immersion Foot
02 Frostbite 07 Noise Injury
03 Heat Exhaustion 08 Radiation (Other than Burns)
04 Heatstroke 09 Exposure, NFS
05 Hypothermia
Environmental: Intake
E
01 Asphyxiation 04 Aspiration (Suffocation)
02 Hypoxia 05 Inhalation
03 Ingestion
Fractures
F
00 Fractures, General 08 Transverse
01 Chip/Wedge 09 Oblique
02 Compound (open) 10 Linear
03 Compression 11 Stellate
04 Crushed/Depressed 12 Comminuted
05 Incomplete (Greenstick) 13 Fracture/Dislocation
06 Simple (closed) 14 Blowout
07 Fracture, NFS
Stress Injuries
G
01 Dislocation
02 Sprain (wrenching of joint with stretching or tearing of ligaments)
03 Strain (stretched ligaments or muscles)
04 Stress Injury, NFS
Wounds
H
01 Abrasions (Scraping) 06 Laceration/Cut
02 Bites 07 Puncture, Perforation, or Pene- tration
03 Blister 08 Transection (Cut Across)
04 Contusion (Bruise, Hematoma) 09 Wounds, NFS
05 Crushed
Miscellaneous
I
01 Collapsed Lung 08 Multiple Fatal Injuries
02 Concussion 09 Internal Injury, NFS
03 Dermatitis 10 Multiple Injuries, NFS
04 Exhaustion
(Not Related to Heat or Cold)
11 Flail Chest
05 Foreign Object Retained 96 Injury, NFS
06 Herniation/Rupture 97 Not Reported
07 Inflammation (Irritation) 98 Injury Unknown
Results
Z
00 Results, NFS 52 Paralyzed
04 Amnesia 56 Pneumoconioses
08 Cardiac Arrest 60 Pneumothorax
10 Drowned 64 Poisoning
12 Edema 68 Trauma Shock (Emotional)
16 Embolism 69 Trauma Shock (Physical)
20 Emphysema 69 Shock Due to Trauma (Physi- cal)
24 Exsanguination 72 Syncope (Fainting)
28 Hearing Loss (Acute) 76 Unconsciousness/Coma
32 Hemorrhage 90 Vision Loss
36 Hemo-pneumothorax 84 Repeated Trauma Disorders, NFS
40 Hemothorax 96 Occupational Disorders, NFS
44 Infection 97 Not Reported
48 Occlusion 98 Unknown
99 Other (Specify)
Injury Mechanism (How Injury Occurred)
Action
01 Caught in/under/between 05 Struck by
02 Experienced 06 Thrown from
03 Exposed to 97 Not reported
04 Struck against 98 Unknown
99 Other (Specify)
Qualifier
01 Aircraft 17 Irritating Fluids/Fumes
02 Aircraft fire 18 Litter/Litter support
03 Armor 19 Main rotor
04 Ceiling 20 Multiple injury producing mechanism
(MIPM)
05 Collective 21 Pedals
06 Console 22 Restraint system
07 Cyclic 23 Seat
08 Door 24 Structure forces
09 Excessive deceleration 26 Windshield/window
10 External object 27 Night vision device(s)
11 Floor 28 Tail rotor
12 Gun sight 29 Transmission
13 Helmet 97 Not reported
14 Instrument panel 98 Unknown
15 Internal Object 99 Other (Specify)
16 Intruding Object
Injury/Illness Cause Factors (Why Injury/Illness Occurred)
Subject
01 Aircraft 20 Monkey Harness
02 Armor 21 Qualifier
03 Body/Body Part 22 Restraint System
04 Canopy Removal System 23 Roof/Ceiling
05 Cargo 24 Seat
06 Design 25 Structure
07 Door 26 Transmission
08 Engine 27 Unauthorized Equipment
09 External Objects 28 Upper torso restraint system
10 Fuel Lines 29 Window
11 Fuel tanks/Cell 30 Windshield
12 Fuel vent line 31 Night Vision Device(s)
13 Helmet 32 Occupiable Space
14 Impact 33 Refueling Equipment
15 Instrument Panel 34 Lap Belt
16 Landing Gear 35 Inertial Reel
17 Litter 97 Not Reported
18 Internal Objects 98 Unknown/Unclassified
19 Main Rotor 99 Other (Specify)
Action
01 Absorbed 19 Separated/Dislodged
02 Allowed 20 Spilled
03 Broke 21 Stretched
04 Buckled 22 Trapped/Pinned
05 Caused 23 Used Improperly
06 Collapsed 24 Not Restrained/Secured
07 Crushed 25 Allowed Excessive Motion
08 Displaced 26 Injured outside aircraft
09 Exceeded 27 Bottomed out
10 Flailed 28 Disintegrated
11 Ignited 29 Penetrated Occupied Space
12 Injured 30 Injured During Exit
13 Located 31 Failed to Fully Stroke
14 Not provided 32 Failed to Attenuate For
15 Not used 97 Not Reported
16 Penetrated 98 Unknown
17 Provided 99 Other (Specify)
18 Ruptured
Qualifier
01 During Exit 12 Longitudinal
02 Excessive Loading 13 Occupiable Space
03 Excessive Motion 14 Outside Aircraft
04 Excessively 15 Properly
05 Fuel 16 Vertical
06 Human and Design Limits 17 6-12 Inches
07 Improperly 18 Greater than 12 Inches
08 Inadequate Clearance 19 Less than 6 Inches
09 Insufficient Loads 97 Not Reported
10 Jagged Edges 98 Unknown
11 Lateral 99 Other (Specify)


Table 3-11. Equipment Information Codes
Item Component Condition
Helmet    
10 Retained 0 All 0 No damage
11 Dislodged from acceleration (no blow to helmet) 1 Chin Strap 1 Missing
12 Dislodged from blow 2 Nape Strap 2 Loose
  3 Snap Fastener 3 Torn
  4 Attachments 4 Burned
  5 Shell 5 Slipped/Stretched
  6 Strap Slide Fastener 6 Worn improperly/ Improperly fitted
  7 Pads 7 Fractured or Punctured
  8 Suspension Scratched 8 Scraped/System
  9 Crushable Liner 9 Compressed to half original thickness
Note: Helmet, retained, shell fractured. Enter code "1057." If LASER visor used, so indicate and include date of issue in block 7.
Visor    
Retention Component Condition
20 Retained 1 Face piece 0 No Damage
21 Dislodged 2 Housing (cover) 1 Shattered
  3 Track 2 Cracked
  4 Screws 3 Punctured
  5 Adjusting knob 4 Separated
  6 All 5 Stripped
  9 Other 6 Burned
    7 Missing
    8 Scratched
    9 Other
Note: Visor, retained, face piece cracked. Enter code "2012."
Glasses    
Item Component Condition
30 Retained, Prescription, Clear 1 Lens(es) 0 No Damage
31 Retained, Prescription, Tinted 2 Frame(s) 1 Shattered
32 Retained, Nonprescription 3 Earpiece 2 Broken
33 Dislodged, Prescription, Clear 4 All 3 Bent
34 Dislodged, Prescription, Tinted 9 Other 4 Separated
35 Dislodged, Nonprescription, Tinted 5 Missing
36 Contact, Clear   6 Burned
37 Contact, Tinted   7 Scratched
    9 Other
Note: Glasses, retained, lenses shattered, Enter code "3011."
Flight Suit/Flight Gloves/Flight Jacket/Boots/Other Clothing
Type Configuration Condition
40 Cotton, fire retarded, treated 0 All 0 No Damage
41 Cotton, non-fire retardant or open 1 Sleeves up 1 Torn
42 Wool 2 Sleeves down 2 Burned
43 Leather 3 Shirt out of pants or open 3 Melted
44 Synthetics, non-fire retardant, (for exam- ple, Nylon) 4 Pants out of or bloused over boots 4 Damaged, NFS
45 Fire retardant synthetics, (for example, ACU) 5 Short sleeves 5 Missing
46 Other 6 Worn properly 9 Other
Note: Flight suit (cotton), non-fire retardant; sleeves rolled up, burned. Enter code "4112." In the event crewmembers are wearing other than ACU, (for example, Army green shirt/pants/blouse/shirt) which causes a problem/condition, enter the item(s) of clothing in the blank space (line h, "other clothing.") Specify type. Check the appropriate columns and enter the four-digit information codes in the "Information Code" column.
Restraint Equipment Codes (Items I through M)
Lap Belt/Shoulder Harness/Gunner Harness/Inertial Reel
Component Condition Location
50 Webbing (Strap/belt) 1 Broke 1 At end fitting
51 Hardware fittings 2 Slipped 2 At anchor fitting
52 Lock 3 Stretched 3 At buckle
53 Cable 4 Torn/cut 4 At slide adjustment
54 Mount 5 Failed to properly lock 5 At guide
55 Lap Belt, general 6 Worn loosely 6 In automatic lock
56 Shoulder harness 7 Bent 7 In manual lock
57 Inertial reel 8 Torn Free 8 Between attaching points
  9 Burned/melted 9 Other, general
  0 Missing 0 All locations
Note: Shoulder harness broke at guide. Enter code "5615." Inertial reel lock failed to lock in automatic lock. Enter code "5256."
Seat/Litter
Component Condition Location
60 Back Rest 1 Bent/Distorted 1 Front
61 Seat Pan 2 Broken 2 Rear
62 Support/Legs 3 Bottomed out 3 Right
63 Anchor fittings 4 Displaced 4 Left
64 Track 5 Torn/Ripped 5 Center
65 Brace 6 Torn free 6 Longitudinal
66 Pole or Frame 7 Stroked 7 Vertical
67 Canvas/Netting 8 Did not stroke 8 Lateral/Diagonal
68 Energy attenuator 9 Missing 9 All
69 Litter support 0 No Damage 0 Removed/not installed
70 Armor, Sliding 10 Burned/melted
71 Armor, Hinged    
72 Armor, Fixed    
73 Seat, General    
74 Litter Carousel    
Note: The front leg(s) of a pilot's seat was/were torn free. Enter code "6261." A longitudinal energy attenuator stroked on impact. Enter code "6876." The litter carousel had been removed, by direction of the unit commander, to facilitate rapid loading of patients during combat conditions. Enter code "7490."


Table 3-12. Equipment information codes
Survival equipment/components Survival Equipment Problem/Condition
79 Cockpit airbags
80 Survival vest
81 Survival radio
82 Pen flare
83 Signal flare
84 Strobe light
85 Mirror
86 Flashlight
87 Compass
88 Panel marker
89 Reflective tape
90 Night vision goggles/devices
91 Helmet sighting system
92 Night vision imaging system
93 NBC protective clothing
94 NBC protective mask
95 Life preserver
96 Life raft
97 Survival kit (see Note 1)
98 First aid kit (see Note 2)
99 Other (specify), (for example, Parachute, Oxygen, Mask, Body Armor).
01 Not available-supply problem
02 Not available-left behind
03 Damaged, unable
04 Damaged, unusable
05 Failed to operate
06 Operated partially
07 Difficulty locating
08 Beyond reach
09 Connection/closure problems
10 Release/disconnect problems
11 Inadvertent released/disconnect
12 Inadvertent actuation
13 Actuation problems
14 Actuated by other person
15 Improper use
16 Unfamiliar with use
17 Cold hampered use
18 Injury hampered use
19 Water hampered use
20 Other equipment interfered
21 Donning/removal problem
22 Poor fit
23 Leaked
24 Materiel deficiency
25 Design deficiency
26 Hang-up/entanglement
27 Dragging (parachute only)
28 Nonstandard configuration
29 Aided in location/rescue
30 Not effective in location/rescue
31 Equipment produced injury
32 Failure/relay in using; compromised survival use
33 Maintenance/installation error
34 Problem experienced by others in actuation/release of equipment
35 Discarded
36 Lost
37 Deteriorated, not usable
38 Failed during use
39 Broken
40 Battery inoperative
41 Burned
42 Locally procured item
98 Other

Notes:
1. Survival Kit. Specify type, then match the component with the problem/condition with the appropriate code from the problem/condition code list. Example, the food packet in the cold climate survival kit had deteriorated and was usable. Enter SURVIVAL KIT in an available open space (o or p), "type" would be cold climate, and the code 9737 should be entered in the "information code" column.
2. First aid kit. Specify type, then match the component with the problem/condition with the appropriate code from the problem/condition code list. Example, the provodine iodine leaked inside the tropical first aid kit. Enter FIRST-AID KIT in an available open space, "type" would be entered as "tropical," and the four-digit code "9823" would be entered in the "Information Codes" column.


Table 3-13. Method of evacuation/escape
Method of escape Information codes
Did not egress, (for example, fatally injured) 1
Exit unassisted 2
Assistance required 3
Blown/thrown out/fell out 4
Jumped prior to impact 5
Unknown if attempt was made 7
Other (specify in Remarks) 8
Egress method undetermined 9


Table 3-14. Location in aircraft
Aircraft station Information codes
Cockpit 1
Engineer 2
Passenger 3
Gunner 4
Crew Chief 5
Other (specify in Remarks) 8
Undetermined 9
Longitudinal Location
Forward section 1
Center section 2
Aft section 3
Undetermined 9
Lateral Location
Center 1
Left side 2
Right side 3
Undetermined 9
Direction Facing
Forward 1
Aft 2
Sidefacing 3
Undetermined 9
Use of Seat
Not in seat 1
In seat 2
Litter 3
Undetermined 9


Table 3-15. Exit attempted
Exit attempted Information codes
Normal exit 1
Emergency exit 2
Opening in aircraft wreckage 3
Cut through canopy 4
Canopy removal system 5
Cargo hatch 6
Other (specify in Remarks) 8
Undetermined 9
Fatal-None attempted 0


Table 3-16. Exit used
Exit used Information codes
Normal exit 1
Emergency exit 2
Opening in aircraft wreckage 3
Cut through canopy 4
Canopy removal system 5
Cargo hatch 6
Other (specify in Remarks) 8
Undetermined 9
Fatal-None used 0


Table 3-17. Aircraft attitude at time of Escape
Aircraft at rest Information codes
Upright A1
Inverted A2
Nosed Over A3
Lying on left side (More than 45 degrees from upright) A4
Lying on right side (More than 45 degrees from upright) A5
Tail low A6
Other (specify in Remarks) A8
Undetermined A9
Fatal-Did not escape A0
Aircraft in Motion Codes
Level B1
Inverted B2
Nose low B3
Left bank B4
Right bank B5
Nose high B6
Other (specify in Remarks) B8
Undetermined B9


Table 3-18. Cockpit/Cabin Condition
Condition Information codes
No damage 01
Survivable 02
Partially survivable 03
Nonsurvivable 04
Undetermined 09


Table 3-19. Escape difficulties
Difficulties Information codes
Difficulty locating canopy jettison mechanism 01
Difficulty releasing canopy/door 02
Difficulty releasing restraints 03
Difficulty reaching exit due to obstructions 04
Difficulty reaching exit due to injuries 05
Difficulty reaching exit due to aircraft attitude 06
Difficulty reaching exit due to personal equipment hang-up 07
Canopy/door jettison problem 08
Canopy/door jettison failure (automatic) 09
Could not open canopy/door (mechanical failure) 10
Could not open canopy/door (jammed due to structural deforma- tion) 11
Could not open canopy/door (Other, specify in Remarks) 12
Could have but did not open canopy/door 13
Exit inaccessible (out of reach) 14
Hampered by controls 15
Hampered by body armor 16
Hampered by seat armor 17
Hampered by seat 18
Hampered by airframe structure 19
Hampered by components of power train 20
Hampered by cargo or loose equipment 21
Hampered by armament system components 22
Hampered by clothing 23
Hampered by injuries 24
Personal equipment factor (Other than hang-up) (specify in
Remarks)
25
Hampered by others aboard 26
Hampered by high temperature of exit surfaces 27
Parachute entanglement 28
Failure of lap belt to open 29
Smoke, fumes 30
Fire 31
Spilled fluids 32
Confusion 33
Anthropometric problem 34
Unconscious 35
Darkness-no visual reference 36
Cold 37
In rushing water 38
Intruding object (tree, rock, aircraft structure) (specify in Remarks) 39
Lack of emergency evacuation during preflight briefing 40
Lack of in-flight warning 41
Briefing not followed 42
Panic 43
Disorientation 44
Dazed 45
Other (specify in Remarks) 98
Undetermined 99
None 00


Table 3-20. Survival problems
Problems Information codes
Inadequate flotation gear 01
Inadequate cold weather gear 02
Lack of signaling equipment 03
Lack of other equipment (specify in
Remarks)
04
Entanglement (parachute) 05
Dragging (parachute) 06
Parachute hardware problems 07
Entrapment in aircraft 08
Pulled down by sinking chute 09
Pulled down by body armor 10
Unfamiliar with procedure 11
Confused 12
Incapacitated by injury/ occupational ill- ness 13
Poor physical condition 14
Exposure (heat, cold, sunburn) 15
Fatigue 16
Weather 17
Topography 18
Darkness 19
Thrown from raft 20
Hampered by rotor downwash 21
Problem boarding rescue vehicle 22
Thirst 23
Hunger 24
Insects 25
Sharks 26
Unfamiliar with equipment 27
Dazed 28
Animals 29
No problems encountered 30
Other (specify in Remarks) 98


Table 3-21. Means used to locate individual
Means Information codes
Survivor located rescuers 01
Accident observed 02
Accident site located w/o aid of signals or equipment 03
Individual located w/o aid of signals or equipment 04
Other aircraft orbiting scene to direct rescue personnel 05
Radio or radar vector or DF steer 06
Aircraft radio after mishap 07
Radar chaff 08
Sonar buoy 09
Walkie-talkie 10
Fire 11
Beacon (emergency locator transmitter) 12
Aircraft radio prior to mishap 13
Radio (survival type) 14
Telephone 15
Corner reflection 16
Reflective tapes 17
Mirror 18
Reflective surface other than code, 16, 17, or 18 (specify in remarks) 19
Raft 20
Flight clothing 21
Parachute 22
Signal flare 23
Smoke flare 24
Aircraft lights 25
Pen gun flare 26
Tracers 27
Strobe light 28
Flashlight 29
Signal wand 30
Smoke 31
Dye marker 32
Whistle 33
Voice 34
Gunfire 35
Signals on surface 36
Not applicable 37
Other (specify in Remarks) 98


Table 3-22. Rescue equipment used
Item Information codes
Sling 01
Seat 02
Cargo net 03
Rope 04
Life ring 05
Basket 06
Axe 07
Saw 08
Raft 09
Webbing cutters 10
Cable 11
Grapnel 12
Boarding ladder 13
Knife 14
Makeshift carrier/support 15
First-aid equipment 16
Forest penetrator seat 17
Helicopter platforms 18
Stretcher/litter 19
Cable cutters 20
Helicopter rescue boom 21
Not applicable 22
Other (specify in Remarks) 98


Table 3-23. Factors that helped rescue
Item Information codes
Rescue personnel training 01
Training of person to be rescued 02
Aircraft emergency escape means 03
Personal equipment 04
Accident plans 05
Availability of rescue equipment 06
Survivor's techniques 07
Suitability of rescue equipment 08
Coordination of rescue effectors 09
Survival training (specify in Remarks) 10
Emergency locator transmitter 11
Electronic tracking equipment 12
Not applicable 13
Other (specify in Remarks) 98


Table 3-24. Factors that complicated rescue
Factors Information codes
Failure of rescue vehicle (mechanical problems) 01
Inadequacy of rescue vehicle 02
Failure of rescue equipment 03
Inadequacy of rescue equipment 04
Inadequacy of rescue personnel 05
Inadequate medical equipment 06
Inadequate medical facilities 07
Vehicle operator factor (poor procedure) 08
Rescue crewman assist hesitancy 09
Fire 10
Entrapment in aircraft 11
Physical limitations of rescue personnel 12
Physical limitations of person rescued 13
Carelessness by rescue personnel 14
Inappropriate actions of person rescued 15
Rescue vehicle accident 16
Communication problems 17
Entanglement by deployed parachute 18
Topography 19
Interference from other vehicles 20
Victim pulled away by extreme forces 21
Weather 22
Darkness 23
Weight/drag problems due to parachute 24
Hampered by equipment of person rescued 25
Floating debris 26
Primary rescuer delayed by other rescuers 27
Hampered by helicopter downwash 28
Head wind 29
Poor visibility 30
High sea state 31
Mechanical problems 32
Other obstructions (specify in Remarks) 33
Rescuers lost 34
No problems 35
Vehicle operator not available 36
Vehicle not ready 37
Vehicle crew not available 38
Communication breakdown 39
Completing previously assigned duties 40
Lack of information about crash site 41
Poor radio reception/transmission 42
Telephone line busy 43
Poor radio discipline 44
Aircraft radio equipment inoperative 45
Poor radio procedures 46
Lack of emergency locator transmitter 47
Lack of electronic tracking equipment 48
Other (specify in Remarks) 98


Table 3-25. Inidividual's physical condition
Condition Information codes
Fully able to assist 01
Partially able to assist 02
Immobile or unconscious 03
Fatal 04

Chapter 4
Ground Accident Reporting

4-1. Introduction

a. In accordance with AR 385-10 , chapter 3, ground accidents will be reported on the DA Form 285 series forms. This chapter provides instruction for completing a full report of investigation and an abbreviated report of investigation.

b. All on-duty Class A and B accidents and other classes of accidents investigated by a formal board (on or off- duty) require a full report of investigation. For exceptions, refer to AR 385-10 . The full report of investigation includes the following:

(1) DA Form 285-A, Index A.

(2) Substantiating data.

(3) DA Form 285-B, Index B.

(4) DA Form 285-O, Statement of Reviewing Officials.

(5) DA Form 285, Technical Report of U.S. Army Ground Accident Form. One completed form is required, unless more than one individual is involved (injured or had a causal or contributing role in the accident). An additional form with sections A (blocks 1-5) and B completed is required for each additional individual involved.

(6) Findings and Recommendations. (Typed on plain bond paper).

(7) Narrative of the investigation. (Typed on plain bond paper).

(8) DA Form 285-W, Summary of Witness Interview.

c. All other classes of accidents can be reported on a DA Form 285-AB , Abbreviated Ground Accident Report (AGAR). Abbreviated reports can be submitted using the on-line reporting system, or on an AGAR in legible hand-printed or typed copy by electronic mail, standard mail, FAX, courier, or message format. Work copies on plain paper will be acceptable, but each data element must reference the respective block of the DA Form 285-AB.

(1) The message address is as follows: CDR USACRC FT RUCKER AL //CSSC-CG//.

(2) The mailing address is as follows: Administrative QC, U.S. Army Combat Readiness Center (CSSC-OR), Bldg 4905, 5th Ave, Fort Rucker, AL 36362-5363. Email: usarmy.rucker.hqda-secarmy.mbx.safe-accident-info@mail.mil .

d. The automated reporting system allows for quick and easy reporting at the USACRC Web site: https://safety . army.mil.

e. Table 4-1 summarizes the reporting requirements.

Table 4-1. Ground accident notification, reporting requirements, and suspenses
PEACETIME COMBAT 2
Accident Class Telephonic Notification Worksheet Abbreviated Report
AGAR
Full Report
DA Form 285
Telephonic Notification Worksheet AGAR ONLY by any means possible (auto- mated, e-mail, fax, hand carry, mail)
ON-DUTY A & B Immediately 1 Not required IAI/CAI-90 days Immediately 1 As time Permits
(Not to Exceed 60 days)
C Not required Within 90 days Not required Not required As time Permits
(Not to Exceed 60 days)
D & E Not required Within 30 days Not required Not required As time Permits
(Not to Exceed 30 days)
OFF-DUTY A & B Immediately 1 Within 30 days Not required Immediately 1 As time Permits
(Not to Exceed 30 days)
C, D, & E Not required Within 30 days Not required Not required As time Permits
(Not to Exceed 30 days)

Notes:
1. USACRC must be notified IMMEDIATELY by phone at DSN 558-2660/2539/3410 or COM (334) 255-2660/2539/3410 or notify safety rep forward (during combat).
2. When the senior tactical commander determined that the situation, conditions or time does not permit normal peacetime investigation and reporting.

4-2. DA Form 285, Technical Report of U.S. Army Ground Accident

a. The DA Form 285 is a five page form and is available at the USACRC Web site: https://safety.army.mil under the Accident Reporting and Investigation Tab.

(1) The entire report is required for on-duty Class A and B accidents according to AR 385-10 .

(2) Instructions are organized by sections and keyed to the block numbers of the form.

(3) The form may be completed by typing or legibly printing the data in the appropriate blocks. Items may be continued on a blank sheet of paper and attached to the report.

(4) When more than one person is involved (caused/contributed and/or injured), complete an additional DA Form 285 (sections A and B) for each person.

b. For supplemental reports, sections A (blocks 3a, 4, and 5), B, and pertinent blocks to be changed/added will be completed and forwarded through the appropriate chain of command to USACRC.

4-3. Findings and recommendations

a. Findings and recommendations will be completed for all Class A and B on duty accidents requiring a report according to AR 385-10 (see table 4-2 ). Findings fall into one of five categories:

(1) Present and contributing.

(2) Suspected present and contributing.

(3) Present and contributing to the severity of the injury/occupational illness or extent of property damage.

(4) Present but not contributing.

(5) Special observations.

b. Each finding must be fully substantiated in the analysis portion of the narrative of the investigation.

c. As a minimum, the following elements of information will be addressed for each present contributing, suspected present contributing, and present contributing to the severity of injury/occupational illness or extent of damage finding in the order stated (see table 4-2 ).

(1) An explanation of when and where the error, materiel failure, or environmental factor occurred in the context of the accident sequence of events, (for example, "walking," "lifting," "while driving an M1114 on a dirt road," "while employing an M16A2 on a range.")

(2) Identification of the individual involved by duty position (do not use individual's name), or the name, and PN or NSN of the part, component, or system that failed or a description of the environmental factor, as appropriate.

(3) Identification of the mistake/error and an explanation of the how the task was performed improperly. Refer to appendix B for mistake/error categories. The error could be one of commission or one of omission, (for example, 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, (for example, corroded, burst, twisted, decayed). See appendix B for definitions and examples.

(4) Identification of the directive (for example, SOP, FM, TM) or common practice governing the performance of the activity/task or function. In lieu of a written directive, the error may represent performance that is contrary to common practice.

(5) An explanation of the consequences of the mistake/error, materiel failure, or environmental condition. An error may directly result in property damage or injury/occupational illness. A materiel failure may have an immediate effect on equipment or its performance, or it may create circumstances that results in error, injury/occupational illness or make further damage inevitable. (For example, as a result, the vehicle rolled, the passenger was fatally injured, and the vehicle was damaged.)

(6) Identification of the reasons (root cause(s)) the human, materiel, environmental conditions caused or contributed to the accident (why it happened). Refer to the list and examples of root cause(s)/system inadequacy(ies) at appendix B.

(7) A brief explanation of how each reason (root cause/system inadequacy) influenced the error, materiel failure, or environmental factor.

d. In addition, for Present and Contributing to the Severity of Injury/occupational illness or Extent of Damage findings, the board should also:

(1) Summarize personnel injuries attributable to defects in LSE, PPE, or crashworthiness design as findings in this category.

(2) Address injuries sustained from failure to use provided equipment (for example, seatbelts).

(3) Separate the findings and recommendations in this category from those that caused the accident and preceding them with the following statement: "THE FINDINGS(S) LISTED BELOW DID NOT DIRECTLY CONTRIBUTE TO THE CAUSE FACTORS INVOLVED IN THIS ACCIDENT; HOWEVER, IT/THEY DID CONTRIBUTE TO THE SEVERITY OF INJURY(IES) AND/OR EXTENT OF DAMAGES(S)."

e. "Present but Not Contributing" findings are those that did not cause or contribute to the accident or to the severity of injuries.

(1) 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 personnel and equipment if not corrected. Reporting these deficiencies will ensure they receive command attention throughout the chain of command to include DA-level action.

(2) The findings and recommendations in this category will be separated from those that caused the accident or those that did not cause the accident but contributed to the severity 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 PERSONNEL AND EQUIPMENT."

Table 4-2. Ground Finding Examples (Human, Materiel, Environmental)
Human Cause Factor — Ground Example
FINDING 1 (Present and Contributing: Human Error — Training, Leader)
Required Information Example
1. Explanation of when and where the error occurred in context of the accident sequence of events. While receiving driver's training on an unimproved road during New Equipment Training (NET) at the Yankee Training Center,
2. Identification of individual involved by duty position and equipment involved (if applicable). the student driver of an M1117 Armored Security Vehicle (ASV)...
3. Identification of mistake/error made (ref ground-specific mistakes/errors in DA Pam 385-40, table B-2 ) and an explanation of how task/activity was performed improperly. oversteered the vehicle. That is, while descending a hill on a dirt/gravel road, he made abrupt and excessive steering inputs causing the vehicle to swerve uncontrollably from one side of the road to the other...
4. Directive (SOP, FM, TM, etc.) or common practice governing performance of task/activity or function. in contravention of AR 385-10 , AR 600-55 , and TC 21-305 .
5. Consequences of mistake/error. Consequently, the vehicle departed the roadway, slid into a ditch, pivoted and rolled four times, coming to rest in an upright position. The vehicle sustained substantial damage. The gunner and passenger were critically injured when they were ejected from the vehicle during the rollover sequence. The driver and senior occupant received minor injuries.
6. Reason(s) {root cause(s)/system inadequacy(s)} for the mistake/error {ref System Inadequacies in Table B-5 of DA Pam 385-40}. The student driver's actions were the result of inadequate unit training and inexperience.
7. Brief explanation of how each reason (root cause/system inadequacy) contributed to the error. The unit failed to ensure the student driver received the required prerequisite training, testing and a learner's permit for the ASV before allowing him to attend NET and operate the vehicle on an unimproved road. Due to the student driver's lack of experience, he was unfamiliar with the handling characteristics of the ASV and over-steered the vehicle causing loss of control.*
*NOTE: When 'Leader' is identified as a system inadequacy/root cause, this will probably lead to a second finding, in which case a mistake/error will be assigned to the leader/command and the root cause(s)/system inadequacy(s) for that mistake will be identified. When a finding is written on a leader/command, it is important to determine why that mistake/error was made so that, if necessary, the problem can be brought to the attention of senior Army leadership. For example, if inadequate risk management is identified, was it due to a support problem (lack of sufficient resources), a standards problem, and so forth.
NARRATIVE EXAMPLE FOR HUMAN ERROR
FINDING 1 (Present and Contributing: Human Error — Training, Leader)
While receiving driver's training on an unimproved road during New Equipment Training (NET) at the Yankee Training Center, the student driver of an M1117 Armored Security Vehicle (ASV) over-steered the vehicle. That is, while descending a hill on a dirt/gravel road, he made abrupt and excessive steering inputs causing the vehicle to swerve uncontrollably from one side of the road to the other in contravention of AR 385-10 , AR 600-55 , and TC 21-305 . Consequently, the vehicle departed the roadway, slid into a ditch, pivoted and rolled four times, coming to rest in an upright position. The vehicle sustained substantial damage. The gunner and passenger were critically injured when they were ejected from the vehicle during the rollover sequence. The driver and senior occupant received minor injuries.
The student driver's actions were the result of inadequate unit training and inexperience. The unit failed to ensure the student driver received the required prerequisite training, testing and a learner's permit for the ASV before allowing him to attend the NET and operate the vehicle on an unimproved road. Due to the driver's lack of experience, he was unfamiliar with the handling characteristics of the ASV and over-steered the vehicle causing loss of control. The Board concluded the senior occupant did not properly supervise the student driver.
Materiel Cause Factor — Ground Example
FINDING 1 (Present and Contributing: Materiel Failure)
Required Information Example
1. Explanation of when and where the materiel failure/malfunction occurred in context of the accident sequence of events. While traveling on an interstate highway at approximately 55 mph,...
2. Name and part number (PN) or national stock number (NSN) of the part, component, or system that failed. the left front tire (NSN 2610-01-214-1344) of a M925A2...
3. Mode of failure (see DA Pam 385-40, appendix B for definitions and examples). failed (burst).
4. Consequences of materiel failure. As a result, the vehicle veered sharply to the left, striking a guardrail.
5. Identification of reasons (root causes/system inadequacies) materiel failure/malfunction caused or contributed to accident. The cause of the tire failure was inadequate quality control by the manufacturer. That is, a defect (weak spot) in the tire wall was not detected during the manufacturer's inspection process.
6. Brief explanation of how each reason (root cause/system inadequacy) contributed to the materiel failure/malfunction. The inadequate quality control allowed a defective tire to be distributed and placed in service. During normal operation, the tire failed causing personal injuries and equipment damage.
NARRATIVE EXAMPLE FOR ENVIRONMENT
FINDING 1 (Present and Contributing: Materiel Failure)
While traveling on an interstate highway at approximately 55 mph, the left front tire (NSN 2610-01-214-1344) of a M925A2 failed (burst). As a result, the vehicle veered sharply to the left, striking a guardrail. The impact caused the driver to strike his head on the steering wheel, and he received minor injuries. The left front and side of the vehicle received substantial damage.
The cause of the tire failure was inadequate quality control by the manufacturer. That is, a defect (weak spot) in the tire wall was not detected during the manufacturer's inspection process. The inadequate quality control allowed a defective tire to be distributed and placed in service. During normal operation, the tire failed causing personal injuries and equipment damage.
Environmental Cause Factor — Ground Example
FINDING 1 (Present and Contributing: Environment)
Required Information Example
1. Explanation of when and where the environmental factor occurred in context of accident sequence of events. At approximately 1915 hours, a severe thunderstorm passed through...
2. Identification of individual involved by duty position and/or equipment involved. the heliport in Camp Doha, Kuwait...
3. Description of environment involved. with estimated sustained winds of 40 mph and gusts to 60 mph.
4. Consequences of environmental effect. As a result, two temporary sunscreen shelters were destroyed and four helicopters that were secured on the ramp were damaged. One UH-60A was damaged as the temporary shelter under which it was parked was destroyed.
5. Explanation of reason(s) environmental conditions caused/contributed to accident. The property damage was caused by an abrupt, rapidly developing thunderstorm that was neither forecasted nor expected. The exposed aircraft were secured on the ramp in accordance with established policy.
NARRATIVE EXAMPLE FOR ENVIRONMENT
FINDING 1 (Present and Contributing: Environment)
At approximately 1915 hours, a severe thunderstorm passed through the heliport in Camp Doha, Kuwait, with estimated sustained winds of 40 mph and gusts to 60 mph. As a result, two temporary sunscreen shelters were destroyed, and four helicopters that were secured on the ramp were damaged. One UH-60A was damaged as the temporary shelter under which it was parked was destroyed. One destroyed shelter was blown into and damaged another UH-60A secured on the ramp. The high winds also overcame the main rotor blade tie downs for two AH-64 aircraft, causing extensive damage due to excessive blade flapping. The property damage was caused by an abrupt, rapidly developing thunderstorm that was neither forecasted nor expected. The exposed aircraft were secured on the ramp in accordance with established policy.

f. Each finding will be followed by recommendations having the best potential for correcting or eliminating the reasons for (root cause(s)/readiness shortcoming(s)/system inadequacy(ies)) the error, materiel failure, or environmental factor that caused or contributed to the cause of the accident (see app B-6 for definitions and examples).

(1) Recommendations should not focus on punitive steps addressing an individual's failure in a particular case.

(2) To be effective at preventing accidents in the future, recommendations must be stated in broader terms. The board should not allow the recommendation to be overly influenced by existing budgetary, material, or personnel restrictions.

(3) In developing the recommendations, the board should view each recommendation in terms of its potential effectiveness; for example, design improvement of a part that has a history of recurring failure is a better solution than recommending procedures to accommodate the deficiency.

(4) Each recommendation will be directed at the unit, command, or activity which is best capable of implementing the actions contained in the recommendation. The actions required at unit level (company, troop, battalion), higher level (brigade, division, corps, Army Headquarters), and DA (to include Army Headquarters with Army-level ACOM, ASCC, DRU proponency) levels of command will be addressed in each recommendation.

(5) If there is no recommendation at a particular command level, state "None," (for example, "DA-level Action: None").

(6) In cases where an Army Headquarters is the highest level proponent for a recommended action having Armywide application, the Army Headquarters will be listed in the "DA-level" category.

4-4. Narrative of investigation

a. Narrative. A narrative of the investigation will be completed for all on-duty Class A and B accident reports required by DA Pam 385-40 (see fig 4-2 ).

(1) The investigation board will report, in narrative form, the facts, conditions, and circumstances as established during the investigation and present this information in four sections (history of events, human factors, materiel factors, and analysis). The first three sections will contain only factual data.

(2) The analysis section is reserved for the board's documentation of its conclusions/opinions concerning the accident cause relationships. Chapter 2, paragraph 2-8 , explains procedures for development of formal written analysis. Additional subheadings may be added as deemed necessary.

(3) It is important that the narrative address all of the chronological events and evidence that had a bearing on the cause of the accident and/or have the potential for adversely affecting the safety of future operations.

(4) For accidents in which the investigation board determines human error, materiel failure/malfunction, or environ- mental conditions were a factor, that portion of the narrative will be completed in its entirety, as specified in the instructions below. The history of events, personnel background/management, meteorological, and analysis portions will be completed. For the remaining subheadings which the investigation board determines were not a factor, enter after the subheading "Investigation revealed not a factor" and proceed to the next subheading.

(5) Opinions concerning the accident cause will be discussed only in the analysis section.

(6) Individual names will not be included in the analysis portion of the narrative. Personnel will be referred to by duty position, (for example, the driver, civilian passenger, the gunner).

b. History of events.

(1) Pre-accident phase. Report type of mission, activity or event, its purpose, how the organization became tasked with it, and who authorized it. Identify the individual(s) involved in the accident/injury or occupational illness, to include duty, unit/organization assigned, and how they were selected for and informed of the mission, activity or event. Describe the actions of the personnel involved in preparing for the mission, activity or event to include planning, application of risk management orders, and/or briefings. Describe vehicle/equipment/vessel/structure involved, to include type, serial/lot numbers, inspections conducted and the dispatching process. Describe facts which may indicate whether or not an undue sense of urgency was associated with the mission, activity, or event and if there were any delays prior to the onset of the operation.

(2) Accident phase. Indicate when the vehicle/personnel departed on the mission, activity or event and continue until the accident occurred. If the mission, activity or event involved more than one routine segment, requiring multiple activities, functions or stops before the accident occurred, concisely summarize these events until addressing the segment involving the accident. If the segment involving the accident contained an emergency, give a detailed description of the onset of the emergency to include where and when it occurred, symptoms, warnings, indications, and instrument readings. Also, describe actions/reactions of the personnel between the time of the emergency and the conclusion of accident.

(3) Post-accident phase. Briefly describe the condition of the equipment/vehicle/structure/vessel, to include whether or not the equipment was still operating and the condition of personnel immediately after the accident. Reserve details of damage to various equipment/vehicle/structure components for the materiel factors portion of the narrative.

(a) If a post-accident fire occurred, so indicate and explain how and when it was extinguished, if applicable.

(b) Describe how the accident site was located.

(c) Summarize rescue and first-aid efforts, to include who notified rescue/medical/police of accident, response time, type of equipment used in the evacuation, who administered first aid/cardiopulmonary resuscitation and their medical qualifications.

(d) Briefly summarize egress of occupants from vehicle/equipment, time of arrival at the medical facility, medical facility providing treatment, and time of death, if applicable. Reserve details of the egress, rescue, and evacuation for rescue operations portion of the narrative.

c. Human factors investigation. For accidents resulting from causes other than human factors, the human factors portion of the narrative may be sharply reduced by making a statement like "none" for the subheadings except for subheadings addressing personnel background/management.

(1) Personnel Background/Management Information. Personnel background is extremely important in terms of providing a complete and informative profile of the principal persons involved. The sources of information will include, but are not limited to, personnel, training records, friends, peers, subordinates, superiors, and the persons themselves. Background information should primarily address:

(a) Briefly summarize service background, to include date of service entry (or the civilian equivalent), training, experience, type of assignments, and qualifications acquired prior to joining current unit.

(b) Report evidence of safety/traffic violations and prior accident experience on the primary personnel involved. If involved in a prior accident, explain their role.

(c) Describe experience in mission/duty/activity relative to the accident mission/duty/activity, also describe if the individual received his/her qualifications by on-the-job training (OJT) or attending a school. Discuss only those pre- service activities/experiences which are accident related.

(2) Personnel management. Personnel management should primarily address how the individual was managed by the unit/organization to which assigned at the time of the accident.

(a) Review how the unit/organization has managed each individual involved. Begin with date of assignment to current unit/organization.

(b) Review experience, training and qualifications upon assignment and report how individual was tasked, trained, and otherwise managed up to the date of the accident.

(c) Describe how the unit/organization prepared the individual with qualifications and readiness to perform the mission/activity/event. Indicate whether or not the individual was qualified to perform the mission/activity/event involved in the accident.

(d) Explain irregularities in the individual's training folder.

(e) Also discuss whether the individual was medically qualified to perform the mission/activity/event involved in the accident.

(f) Discuss additional duties and the percentage of time given them versus their primary duty.

(g) Report qualifications acquired since assignment to unit such as OJT and schooling.

(h) Review the procedures involved in selecting the personnel involved for the mission/activity/event.

(i) Describe timelines of notification, compatibility of personnel for the mission/activity/event, and their relative experience for the mission/activity/event.

(j) Describe involved personnel in terms of their professional reputations in unit, opinions of peers, subordinates, and others who have worked with/for them.

(k) Describe the individuals' sleep, work, and dietary habits and use of alcohol and nicotine. Review unit sleep/rest policy. Report whether or not a sleep/rest policy was in effect, being monitored, and complied with.

(l) Highlight weaknesses in proficiency, if appropriate, especially the performance of tasks duplicating those involved in the accident.

(m) Discuss if the individual was receiving medication before the accident. Report the name of the medication, type, source, dosage, potential side effects, and possible effect on performance. Summarize the findings of the post-accident medical examination, including the results of appropriate toxicological analyses. If the individual sustained fatal injuries, briefly summarize autopsy report (if available), to include cause of death.

(n) The same scope of information is usually not necessary for personnel not directly involved, but if it is suspected or known that other personnel played a role in the accident, summarize their background, experience and qualifications. This part of the narrative can involve commanders/supervisors, operations personnel, supply and weather personnel, maintenance personnel, and others, if applicable.

(3) Vehicle/equipment/suitability. Describe suitability of the vehicle/equipment/structure/vessel involved to perform the mission/activity/event. Consider primary purpose versus use at the time of the accident, equipment design limitation as found in applicable operator's manual, configurations.

(4) Communications. Describe evidence relating to communications equipment (adequacy of visual and electronic signals) and the communication that occurred or failed to occur among and between personnel, (for example, base station, operations, command and control, agency to agency, service to service). Consider language difficulties, clarity of spoken words, static, interference, adequacy and precision of instruction, and so forth. Summarize tape recordings of communications between crew and other stations, if applicable.

(5) Meteorological information. Describe weather conditions that prevailed throughout the mission/activity/event and conditions that existed at the accident site at the time of the accident. Include sky condition, visibility, winds, temperature, 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. If the actual weather differed significantly from the forecast, include a discussion of the information that was available to the forecaster. For parachute accidents evaluate the winds aloft (at drop altitude) and surface winds. If the accident occurred at night, include details of moon illumination if it applied to the accident.

(6) Support services. Describe evidence that relates to the role of support services in the accident. Consider ground guides, road guards, traffic signs, fire stations, POL and dispatch procedures.

(7) Accident survivability.

(a) Discuss crashworthiness/construction of the vehicle/equipment/structure in terms of crash/collapse sequence, impact conditions, kinematics, and crash impact forces.

(b) Indicate whether the restraint systems failed or malfunctioned and the adequacy of the vehicle/equipment structure to maintain occupiable space and attenuate crash forces.

(c) Explain occupant injury/occupational illness relationship to crashworthiness.

(d) Explain if injuries occurred during or after the crash/accident sequence.

(e) Include the performance of PPE. For example, seatbelt, visor, helmet, roll bar, and clothing. Discuss in terms of usage and nonusage.

(8) Rescue operations. Discuss details of egress, survival, and rescue investigations. Describe where individuals were located in vehicle/structure/equipment, how and where they exited, difficulties encountered, and position of vehicle/equipment 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.

(9) 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 night vision devices played a role in the accident, the applicable agency/program manager should be notified and a determination made as to their involvement.

(10) Witness interview. Briefly indicate number of witnesses interviewed and identify duty position and experience. Summarize pertinent witness observations and indicate whether or not witnesses generally agreed concerning accident events. In the analysis, describe major conflicts in the provided information and resolution of inconsistencies in the information. Opinions regarding witness credibility should also be reserved for the analysis section.

d. Materiel factors investigation. This report provides results of any special investigation in the appropriate sub- paragraphs. Those accidents that do not involve materiel failure/malfunctions may be abbreviated, to include negative reports. Identify and discuss damage resulting from pre-accident materiel failure/malfunctions and omit damage that resulted from crash/impact forces exceeding design limits. References can be made to the wreckage distribution diagram, photographs, reports, and records. Include the following:

(1) Vehicle/equipment/structure/vessel worthiness. Describe the worthiness of the vehicle/equipment/structure.

(a) Investigation should include, but not be limited to, maintenance records, historical records, interviews with maintenance personnel, operator preventive maintenance records, and dispatch records.

(b) Identify all deficiencies, or discrepancies found during the investigation that had a role in the accident, or may not have had a role but, if not corrected could impair safe operations; however, reserve discussion of the results of discrepancies/deficiencies for the analysis portion of the narrative.

(2) Systems. Use subparagraphs to report evidence obtained in the examination of fuel, steering/control, hydraulic, electrical, frame, tire, weapon, suspension, and brake systems. Note all discrepancies.

(3) Engine. Report the evidence obtained during examination of the engine(s). Include indications of power at impact, if available.

(4) Transmission. Report condition and describe any faults noted.

(5) Laboratory Analysis. Describe any laboratory analysis done on materiel to include: Where it was done, why it was done, when it was done and exactly what was done to what.

(6) Accident site information. Describe the accident site, to include grid location, dimensions, lighting and marking, obstructions, type and condition of surface, or any other peculiarities found.

(7) Fire. Discuss the role of fire, to include when it occurred, manner in which the fire was detected, ignition source, combustible material, location, propagation, method, and degree of success in extinguishing.

e. Analysis.

(1) The analysis paragraph summarizes the narrative and discusses 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 will discuss the influence of command activity, or lack thereof, in the context of its role in the accident or the prevention of accidents. An example of an analysis organizational structure may be found in the USACRC Army Accident Investigator's Handbook, which can be found at https://safety.army.mil . As a minimum, the analysis part of the narrative will provide the following information:

(a) Identify the errors, materiel failures, or environmental factors involved in the accident in the context of the accident sequence of events. To accomplish this task, the board will use the listings of mistake/errors, materiel failures/ malfunctions, and environmental factors and the explanations, examples, and key words contained in appendix B .

(b) Discuss the results/effects of the errors/materiel failures/environmental factors.

(c) Identify the system inadequacy(ies)/root cause(s) that caused or permitted the errors/materiel failures/environ- mental factors to occur. To fulfill this task, the board will use the explanations, examples, and key words contained in appendix B .

(d) Report preventable injuries in the context of the accident sequence of events and explain how they occurred.

(e) Identify the root cause(s)/readiness shortcoming(s) that caused or permitted injuries to occur.

(f) Discuss the command/management influence relative to cause factors and accident prevention.

(g) Indicate whether risk management was performed, who accepted the risk, what the residual risk was, and include whether the accident event was considered during the risk management process.

(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/ materiel failures/environmental factors that occurred. From this review, the board should consider:

(a) 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(s) concerning the accident cause and preventable injuries (if and why they occurred).

(b) The explanation(s) should be discussed and tested against the evidence gathered during the investigation.

(c) 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) The investigation board should initially outline and structure the correlation of cause-related errors/materiel failures/environmental factors and associated root cause(s)/readiness shortcoming(s). When the outline has been com- pleted, 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, (for example, "... human error-leader failure.")

(b) Describe when or where the error/failure/injury or occupational illness/environmental factor occurred in the context of the accident chronology of events, (for example, "Before the mission/activity/event...", "While installing a hydraulic line...", "During steering...", "During the crash sequence....")

(c) Identify the duty position of the person who erred, became injured, or the name and PN and NSN of the part, component or system that failed, (for example, "the mechanic"; "the brake line, PN 1-234-5678-9"; "the driver.")

(d) Identify the error in the context of a listed mistake/error category, (for example, "inadequate planning," "excessive speed," "improper passing.") See table B-2 .

(1) If a materiel failure is being reported, explain the type of failure; for example, "overheated," "vibrated," "frayed," "decayed," and so forth. See table B-3.

(2) If an injury is being reported, explain if the individual "struck" or "was struck by" the injury-causing agent. Refer to DA Form 285, block 28.

(e) Cite the directive or standard the mistake/error category failed to comply with, (for example, "contrary to standard and description for task 5007, TC 1-135").

(1) 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.

(2) If the error represents performance that is unacceptable, it is contrary to common practice.

(f) Describe the specifics of the error, (for example, "he excessively torqued the nut, PN 12345").

(g) Describe the consequences of the error, materiel failure, environmental factor, or the resulting injury/occupational illness.

(h) A complete failure statement could read as follows: "While driving an M1114, Up-Armored HMMWV, a section of the right front brake line, PN 1-234-5678-9, eroded through. As a result, all brake fluid was lost and subsequent loss of effective braking."

(4) Each statement of error/materiel failure, environmental factor, or injury/occupational illness will be followed by statements identifying the system inadequacy(ies)/root cause(s) that caused or permitted the error//materiel failure/ injury or occupational illness to occur or an environmental factor to become a cause. The system inadequacy(ies)/root cause(s) statements are the most important part of the analysis. This information is more important from a corrective action standpoint than the error/materiel failure, injury/occupational illness, or environmental factor itself. Each system inadequacy(ies)/root cause(s) statement will contain the following information:

(a) A transition phrase to tie the system inadequacy(ies)/root cause(s) to the error/materiel failure, or injury/ occupational illness, (for example, "The driver exceeded the posted speed limit because...", "The brake line eroded to a point of failure because..."; "The driver sustained the back injury because...")

(b) Identification of the specific system inadequacy(ies)/root cause(s); for example, "because of inadequate motiva- tion/mood (attitude)," "inadequate supervision by the unit operations officer," "because of inadequate quality control on the part of the manufacturer," "because of inadequate seat design".

(c) An explanation of how or why each system inadequacy(ies)/root cause(s) permitted or caused the injury/ occupational illness or error/materiel failure/environmental factor.

(5) Once the preceding elements of information are reported for each error/materiel failure, injury/occupational illness, or environmental factor in the manner stated, the resulting conclusions (findings) can stand on their own. There could be more than one system inadequacy(ies)/root cause(s), depending upon the circumstances. The point to be made is that system inadequacy(ies)/root cause(s), which caused or permitted an error/materiel failure, or environmental cause must be made visible before effective corrective actions can be recommended.

(6) The analysis paragraph of the narrative does not have to be limited to explaining and concluding what caused or contributed to the accident, injuries or damage. It should also address present but not contributing hazards if they could adversely affect the safety of operations. There are provisions for reporting non-cause-related hazards. They are contained in the instructions for completing the findings and recommendations.

4-5. DA Form 285-W, Technical Report of U.S. Army Ground Accident, Summary of Witness Interview

a. Instruction. DA Form 285-W , Summary of Witness Interview (see fig 4-3 ) will be completed for all on duty Class A and B accidents. As a minimum, summaries of the interviews with the primary personnel involved/injured will be included. Any individual identified in a finding having a causal or contributing role must be interviewed, if available. The form will also be used to summarize interviews and statements of commanders, supervisors, maintenance 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. Form is available at USACRC Web site: https://safety.army.mil at Accident Reporting & Investigation-Forms.

b. Procedural guidelines. The procedural guidelines instructions are as follows:

(1) All witnesses will be interviewed according to chapter 2, paragraph 2-3 . The investigator will emphasize to the witness that the sole purpose of the accident investigation is for accident prevention. The witness should be further informed that the U.S. Army seeks to isolate the cause(s) 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 page 2 of the DA Form 285-W, contained in block 15, "General Witness Information Briefing." (See fig 4-3 ).

(a) The purpose is to ensure that the witness understands the intent of the interview, who will or can have access to the information, DOD restrictions on the use of the interview, and its public releasability.

(b) If a promise of confidentiality is not offered to the witness, the interviewer will read the section, "No promise of confidentiality offered." As a general rule, ground accidents are "General Use" investigations and the promise of confidentiality cannot be offered unless they meet the criteria outlined in AR 385-10 .

(c) If a promise of confidentiality is to be offered —

(1) The interviewer will read the section, "Promise of confidentiality offered."

(2) The witness will complete block 16, "Availability of Promise of Confidentiality for Limited Use Report of Investigation."

(3) The witness will initial the appropriate paragraph 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.) Summaries of witness interviews will not be signed by the witness.

(4) The interviewer will complete block 12 of the DA Form 285-W and only sign and date the form if "Yes" is checked.

(d) If the witness is willing to be interviewed or make a statement, it will be summarized in "third person" in block 13 of the DA Form 285-W. 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.

4-6. Assembly of the accident folder

An accident folder (see fig 4-8 ) is required for all Class A and B on duty accidents. The recorder will assemble the information as follows:

a. Use folders to enclose the forms and substantiating data for each copy of each report.

b. Post substantiating data to the left side of the accident folder under the completed DA Form 285-A , Index A. Items such as the DA Form(s) 285, Findings and Recommendations, Narrative and Summary of Witness Interview 285-W, are posted on the right side under the completed DA Form 285-B , Index B.

c. Tab and index each item on the left and right sides of the folder as shown in Figure 4-9 .

(1) DA Form 285-A. Place a number for all tabs and provide a brief descriptive title of what the tab contains. As a minimum, TABs 1 through 4 will always be used, TAB 5 is required when there is vehicle, system, and equipment damage or failure.

(2) DA Form 285-B. Place a number for all tabs and provide a brief descriptive title of what the tab contains. As a minimum, TABs A through E will always be used. Type the signature block of all board members, to include, grade, branch, unit address, telephone number, and e-mail address (SSN not required). Use a continuation sheet if there are more than six board members.

d. The front of the folder will be marked with the following information:

(1) Limited or General Use.

(2) Safety Accident Investigation Report of U.S. Army Class (A-B) Accident.

(3) Type Equipment and Serial No.: (M109A2XXXXX).

(4) Date of accident: (ddmmyyyy).

(5) Location of accident: (DA Form 285, block 11).

(6) Unit: (DA Form 285, block 3).

4-7. DA Form 285-A, Index A and DA Form 285-B, Index B

DA Form 285-A (see fig 4-4 ), and DA Form 285-B (see fig 4-5 ) will be completed for all on-duty Class A and B accidents requiring a report.

4-8. Substantiating data

a. Instructions. DA Form 285-A, Index A, lists the information that will be appended to the technical report as substantiating data.

b. Requirements. TAB items 1 through 4 of DA Form 285-A and TAB items A through E of DA Form 285-B are required for all Class A and B on duty accidents. All other items which are necessary to explain or substantiate other parts of the report should be submitted, if appropriate. Additional instructions pertaining to applicability are contained in the paragraphs below.

c. Special considerations.

(1) Social Security Numbers. None of the substantiating documents require an SSN. If any of the documents on the left side of the report have an SSN listed, black out the number with a black felt tip marker.

(2) Legibility. Original copies of substantiating data should not be appended to the report. (Leave originals with the unit for legal/legal accident investigations.) The copies provided, however, will be legible and suitable for additional reproduction.

(3) 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 be annotated to include information which identified the source documents with date and latest change or update information.

(4) Highlighting key words and phrases. Substantiating data referred to by other parts of the report will have key words, phrases, or passages made prominent to complement the review of the accident report. This should be done by underlining or annotating margins, which is preferred in lieu of felt-tipped markers in that the fluid dispensed devices may obliterate the legibility of subsequent copies if and when reproduced.

d. Information items at each TAB on the DA Form 285-A.

(1) TAB 1-Serious incident report/casualty report. A copy of the appropriate document should be included in the report.

(2) TAB 2-Investigation board orders. A copy of the original signed orders appointing the board and any amend- ments will also be appended.

(3) TAB 3-Map of the accident site. Always include a map of the site annotated to show where the accident occurred. A copy of the map sheet portion that includes the accident site annotated with an appropriate scale, distance, and map sheet name is acceptable.

(4) TAB 4-Diagrams and photographs. A diagram of the accident site should be appended to the report if it will assist in clarifying the accident sequence of events. The number and types of photographs, with captions, 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 , paragraph 2-5 e of this pamphlet.

(5) TAB 5-Certificate of damage/ECOD. Completed ECOD(s) or ACOD(s) are required for vehicle/system/equip- ment damage. The ECOD(s) will include an itemized list of damaged components, number and cost of man-hours, and the total cost of repair. If the vehicle/system/equipment is damaged to the extent that the items are classified as a total loss, a statement to that effect, signed by the maintenance officer assigned to the accident investigation board, will suffice in lieu of an ECOD. The statement will reflect the AMDF cost or applicable parts manual costs.

(6) TAB 6-Copy of deficiency reports/PQDR. Include a copy of each deficiency report submitted as a result of the accident. All failed or suspected failed parts/systems must be reported on a PQDR. When a materiel failure is the sole cause of the accident and a PQDR is not submitted, the accident will be charged to the accident unit in accordance with AR 385-10 . Coordinate with unit maintenance personnel for completion of PQDRs.

(7) TAB 7-Copy of directives and regulations. Extracts of directives or manuals that establish the standards for either human or materiel issues will be included in the report. The extracts will be annotated to reflect the source document, usually with the document cover.

(8) TAB 8-Special technical reports and laboratory analysis reports. Append a copy of the results of all fluid (fuel, oil, hydraulic) sample analyses, TDA, or other material-related analyses conducted as a result of the accident.

(9) TAB 9-Copy of uncorrected fault record. Append copies of the appropriate forms, if applicable to the accident vehicle/system/equipment, if a materiel problem related to an uncorrected fault is involved.

(10) TAB 10-Copy of equipment modification record (DA Form 2408-5). Append copies of DA Form 2408-5, if applicable to accident vehicle/system/equipment, when necessary to substantiate maintenance errors, and omissions that had a bearing on the accident.

(11) TAB 11-Weather reports. If weather had no bearing on the outcome of the accident, a brief synopsis by the nearest weather service activity of the weather that existed during the accident will suffice in most cases. If weather contributed or is suspected to have contributed to the accident, the information to be provided will include, but not limited to, the following:

(a) A signed narrative of the weather conditions prior to and during the accident provided by a weather forecaster, briefer, or observer.

(b) A copy of the weather forecast or observation from official files.

(12) TAB 12-Medical data. Copy of toxicology, AFMES autopsy reports, and so forth. Autopsy protocol and pictures of deceased personnel will not accompany the report through channels. This information will be forwarded separately to USACRC (CSSC-O), for inclusion in the file copy of the report. For further discussion on autopsies see chapter 2, paragraph 2-4 .

(13) TAB 13 through 18-Other. Include copies of other substantiating data deemed appropriate by the investigation board or information that is critical to the report and is not available from other sources.

e. DA Form 285-B, Index B. Indexes by Tab the enclosed information required for the accident report. This form also reflects the Board Members information and signatures. Refer to Paragraph 4-14 and Figure 4-5 for entry instructions.

(1) Tab A - Statement of Reviewing Officials (DA Form 285-O).

(2) Tab B - U.S. Army Accident Report (DA Form 285).

(3) Tab C - Findings and Recommendations.

(4) Tab D - Narrative of Accident.

(5) Tab E - Summary of Witness Interviews (DA Form 285-W).

4-9. DA Form 285-O, Technical Report of U.S. Army Ground Accident, Statement of Reviewing

Officials DA Form 285-O (see fig 4-7 ) will be submitted with the copy of the technical report forwarded through channels to the USACRC. If additional space is required, use letter-size paper for continuation sheets.

4-10. Miscellaneous

A list may be beneficial to the local safety 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.

4-11. DA Form 285-AB, Abbreviated Ground Accident Report (AGAR)

DA Form 285-AB is required for all Class C through E on-duty and all off-duty accidents. (See fig 4-7 for an example and table 4-1 for accident notification.) The AGAR only reduces the reporting requirements and should not affect the quality or extent of the accident investigation.

a. Investigation and submission of the DA Form 285-AB will be according to AR 385-10 .

b. One complete form is required. If more than one individual is involved, submit an additional form, completing only blocks 1 thru 5, and 9 thru 37 (38, if applicable) for each person. Involved means any person who was injured or who took actions or made decisions that caused or contributed to the accident.

c. Submit AGARs in legible hand-printed or typed copy via mail, fax, courier, e-mail, or through the on-line reporting system. Work copies on plain paper will be acceptable, but each data element must reference the respective block of the DA Form 285-AB.

(1) The message address is as follows: CDR USACRC FORT RUCKER AL //CSSC-O//.

(2) The mailing address is as follows: Commander, U.S. Army Combat Readiness Center (CSSC-O), Bldg 4905, 5th Ave, Fort Rucker, AL 36362-5363.

(3) The e-mail address is: usarmy.rucker.hqda-secarmy.mbx.safe-accident-info@mail.mil

(4) The automating reporting system allows for quick and easy reporting through the USACRC Web site: https://safety.army.mil .



Figure 4-1. Example of completed DA Form 285, Technical Report of U.S. Army Ground Accident





Figure 4-1. Example of completed DA Form 285, Technical Report of U.S. Army Ground Accident—continued





Figure 4-1. Example of completed DA Form 285, Technical Report of U.S. Army Ground Accident—continued





Figure 4-1. Example of completed DA Form 285, Technical Report of U.S. Army Ground Accident—continued





Figure 4-1. Example of completed DA Form 285, Technical Report of U.S. Army Ground Accident—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued





Figure 4-2. Sample of a narrative investigation and findings and recommendations—continued


4-12. Completion instructions for DA Form 285, Technical Report of U.S. Army Ground Accident

a. Also see paragraph 4-2.

b. Section A-Accident Information. This section should be completed for the report and for any changes to a previously submitted report.

(1) Block 1. Check "original" if this is the first report submitted on the accident. Check "change" if this report is a change or provides supplemental data for a previously submitted report of accident.

(2) Block 2. Enter the six-digit UIC for the specific organizational unit or activity responsible for the accident, (for example, WXXXXX). Guidance on determining accountability for Army accidents is provided in AR 385-10 , chapter 3.

(3) Block 3. For the unit/organization listed in block 2 provide the following data:

(a) Block 3a. Name and full military address of unit/organization, (for example, B Company, 2/18th Cavalry, Fort Bragg, NC XXXXX-XXXX).

(b) Block 3b. The branch of the Army with which the unit/organization is affiliated, (for example, Armor, Infantry, Engineer). Army branches are listed in table 4-3 .

(4) Block 4. Enter the year, month, and day of the accident in the appropriate blocks, (for example, 25 September 2007 would be shown as 20070925).

(5) Block 5. In local military time (24-hour clock), report the time the accident occurred, (for example, 1845).

(6) Block 6. Check the block that best describes when the accident occurred (day or night). Day is from first light to full night (dark). Night is from full night (dark) to first light. Dawn is the period of time between BMNT and official sunrise. Dusk is the period of time between official sunset and EENT.

(7) Block 7. Check either on post or off post, depending on where the accident happened. Note. On post includes all land under DOD control.

(8) Block 8. If the accident occurred on post, state the name of the post, government facility, or installation where it occurred, (for example, Fort Bragg, NC; Federal Center, Atlanta, GA).

(9) Block 9. Check whether or not the accident occurred in a combat theater. "Combat" should be checked if the accident occurred in a theater of hostile fire or enemy action, but not as a result of such fire/action. This includes direct preparation for combat, actual combat, or redeployment from a combat theater immediately following combat.

(10) Block 10. Check if explosives were involved and explain in the narrative. Involved means damage or injury occurred as a result of the functioning, detonation, ignition or release of an explosive or explosive device, or an explosive device was damaged. If "Yes" is checked, provide the information specified in DA Pam 385-40, chapter 5, paragraph 5-3 d , in blocks 52 and 76 and in the narrative, as appropriate. Check the appropriate fields in block 62 if the explosive was exposed to significant environmental conditions and describe in the narrative.

(11) Block 11. Enter accident location information.

(a) Describe the exact location of the accident. Provide the building number or direction and distance from closest landmark, street or highway name/number, city or military installation, state and/or country.

(b) Using the type location information in table 4-4 , choose the type that best describes the location's primary function. For example, a person injured in the kitchen of a private resident would be in "family housing," not in a "dining facility."

(c) Enter the grid coordinate or the latitude/longitude of the accident location.

c. Section B-Personnel Information. Complete this section for each individual involved (caused/contributed and/or injured) in the accident.

(1) Block 12. Enter last name, first name, and middle initial of involved person.

(2) Block 13. Enter the SSN for the individual listed in block 12.

(3) Block 14. Enter the date of birth for the person listed in block 12.

(4) Block 15. Check the appropriate block which reflects the gender of the individual listed in block 12.

(5) Block 16. Enter the rank/pay grade of the individual listed in block 12 (for example, SGT/E5, CPT/O3, GS-11, WG-08). Complete for all government personnel.

(6) Block 17. Enter the full MOS/job series for the individual listed in block 12. For military MOS, give the full series number including the alphabetic character, (for example, 54E20, 11B40). For civilians, give the full job series number or occupational code and include the pay plan and grade or ban (for example, GS-0018-13, WG-07, YA-0018-2). Do not give the job title.

(7) Block 18. Address information for the individual listed in block 12.

(a) Provide individual's full official military address of assignment for all government personnel if it is different than the address listed in block 3a. If different than block 3a, provide the UIC as well.

(b) For injured Army civilians or contractors, and members of the visiting public, enter their home address.

(8) Block 19.

(a) Check the correct block to indicate the duty status of the person listed in block 12 (See glossary for definition of duty status). (This determination applies for safety accident reporting purposes only, and has no relation to compen- sability or line-of-duty decisions.)

(b) If the Soldier was on leave or pass at the time of the accident, check the box and enter the inclusive leave/pass dates, (for example, 10 Jun - 5 Jul '06).

(9) Block 20. Check the appropriate block (for government personnel only) to indicate the current military flight status of the individual listed in block 12.

(10) Block 21.

(a) Enter the local military time the Soldier or employee began work.

(b) State how many continuous hours this individual was on duty without sleep before the accident.

(11) Block 22. Indicate how many hours of sleep (cumulative) this individual had in the last 24 hours before the accident.

(12) Block 23. Days lost or restricted.

(a) Days hospitalized. Enter the actual or estimated number of days the individual in block 12 was hospitalized as an inpatient/admitted receiving treatment. This also includes days hospitalized for observation only.

(b) Days away from work not hospitalized. Enter the actual or estimated number of days lost that the individual could not work excluding the day of the injury/occupational illness. Include quarters, bed rest, convalescence leave, or time that a physician indicated the individual could not work regardless of whether the individual was scheduled to work. Count all calendar days including weekends and holidays. For example, if the individual was injured on Friday and the individual could work on Monday, if the physician or licensed health care professional indicated they should not work over the weekend, enter 2 days. If there is no information from the physician, enter 0 days. You may stop counting days away from work or days of restricted work once the total of either or the combination of both reaches 180 days.

(c) Days restricted. Enter the actual or estimated number of days the individual was unable to perform one or more routine job functions (regularly performed by the individual at least once per week), or could not work a full work day they would otherwise have been scheduled to work; or a physician or licensed health care professional recommends that the employee not perform one or more routine functions of his/her job. Restricted work activities include light duty, profiles, and job transfers.

(13) Block 24. Check "'Yes" if this individual was treated in an emergency room, otherwise check "No."

(14) Block 25.

(a) OSHA log 300 case number. Enter the OSHA log 300 case number for the individual listed in block 12. OSHA log 300 case number is not required for Soldiers or off-duty civilians.

(b) Enter the name of the physician or other health care professional.

(c) If treatment was given away from the worksite, enter the name and address of the facility.

(15) Block 26. Check the block that indicates the severity of the injury/occupational illness to the person listed in block 12. If more than one applies, check the most severe. If fatal is checked, enter the date of death in the space provided.

(16) Block 27 . Select the classification of the person listed in block 12 at the time of the accident. For complete definitions, consult the glossary in sections II and III of this pamphlet. Check only one block.

(17) Block 28. Number in order of the most severe (no more than three - with one being the most severe), the cause of the injury/illness. These numbers should correlate with the information in blocks 29 and 30. For example, an individual's hand was caught between some machinery resulting in fractures. The number "1" would be assigned to "caught in/under/between."

(18) Block 29. Select the body part(s) most seriously injured (no more than three) and number them in order of the most serious first. Enter the number(s) in the appropriate blocks next to the body part(s) affected. Be as specific as possible.

(19) Block 30. For each body part numbered in block 29, place a corresponding number in the block that indicates the type of injury/illness incurred by that body part (no more than three). Be as specific as possible. For example, the number "1" used to indicate item o, Hand, in block 29 is also used to indicate item f, Fractures, in block 30, showing that the most serious injury/occupational illness was to the hand, which was fractured. (If necessary, more than one number can be put into a block).

(20) Block 31. Check the block that best describes the individual's activity/task at the time of the accident (For example, physical training). Check only one block. If the person was engaged in more than one activity at the time of the accident, check the one most relevant to the cause of the accident. For example, a PVT in the back seat was navigating while a passenger in a HMMWV. The HMMWV ran off the road and turned over. The PVT was injured. The most relevant activity for the PVT would be "Passenger." If block 31gg, Parachuting, is checked, complete 31gg (1)-(17) below.

(a) (1) Jumper height - In inches, (for example, 5'8" would be 68").

(b) (2) Jumper weight - In pounds (round up at 1/2 lb or 8 ozs, that is, 168 1/2 lbs would be rounded up to 169 lbs).

(c) (3) Type of Jump - Static line, non-tactical; static line, mass tactical (night or day); freefall, non-tactical; freefall, tactical (night or day), and so forth.

(d) (4) Parachute type/model - Self explanatory.

(e) (5) Equipment - List type of equipment, (for example, rucksack (ALICE), weapon, Modular Lightweight Load-Carrying Equipment.

(f) (6) Weight of equipment - Give approximate weight of jumper's equipment, in pounds.

(g) (7) Wind direction/speed at - jump height, drop zone - What was the wind direction (in degrees) and speed (in knots) at jump altitude and on ground when jumper exited aircraft.

(h) (8) Jump altitude - Altitude jumpers exited aircraft (in feet).

(i) (9) Position in the stick - What number in stick was jumper to exit the door.

(j) (10) Door exited - Self explanatory.

(k) (11) Time pre-jump conducted - date and time (time in zulu).

(l) (12) Date of last jump - Self explanatory.

(m) (13) Type of last jump - See number 3 above.

(n) (14) Number of previous jumps - Self explanatory.

(o) (15) Date graduated basic airborne training - (YYYY/MM/DD).

(p) (16) Type aircraft - Self explanatory.

(q) (17) Accident factors (parachute) - Improper exit, static line injury, broken static line, parachute malfunction, entanglement, lost/stolen air, oscillation, unstable position, dragged on drop zone, tree landing, drop zone hazard (specify), or other. Explain as necessary.
Note. See the glossary, sections II and III for explanation of activities.

(21) Block 32. Provide a short but descriptive explanation of the item checked in block 31.

(22) Block 33. Check "Yes" if activity listed in blocks 31 and 32 was part of a field exercise or a named operation. Indicate the name of the exercise or operation (major and local field training exercise) if it has a name, (for example, Team Spirit, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Check "No" if the activity was not part of a field exercise or named operation. Note. Field exercise and tactical training begin when the individual reports to their primary duty location for movement to the field site and ends when they arrive back at the primary duty location from the field.

(23) Block 34. Check "Yes" or "No" to indicate whether the activity listed in blocks 31 and 32 was part of tactical training.

(24) Block 35. If the individual was participating in any type of training, check the type of training facility being used at the time of the accident. Leave blank, if not applicable.

(25) Block 36. If the individual was participating in any type of training, check the type of training in which he/she was participating. If unit training is selected, also indicate the type of unit training (platoon, crew, or individual). (Leave blank if not applicable.)

(26) Block 37. Indicate how long it had been since the individual received training, before the accident, on the activity listed in blocks 31 and 32.

(27) Block 38. Determine what PPE was required for the activity/task being performed. If PPE was required, determine if it was available and used, available but not used, or not available. Check the appropriate blocks for each item of PPE to indicate availability and use/non-use. If no PPE was required, check the NA (not applicable) column for each type of protective clothing and equipment. For privately owned motorcycle accidents, indicate whether the helmet was Department of Transportation approved.
Note. Restraint systems are those systems such as the Gunners Restraint System in military vehicles.

(28) Block 39.

(a) Indicate whether the individual listed in block 12 was properly licensed to operate the vehicle or equipment that was being operated at the time of the accident. Complete this block whenever operation of a vehicle or piece of equipment requiring a licensed operator is involved.

(b) Check "Yes" if the individual has attended the mandatory 4 hours of classroom instruction in traffic safety and indicate the date of the training, otherwise, check "No." Leave blank if not applicable.

(c) If the individual was operating a motorcycle in this accident, check "Yes," if the individual is motorcycle safety foundation certified enter the date, otherwise, check "No."

(29) Block 40 . Indicate whether any alcohol use by the individual in block 12 caused/contributed to this accident. If "Yes," indicate test results, in space provided, (for example, percent blood alcohol content (BAC), percent BAC).

(30) Block 41 . Indicate whether drug use by the individual in block 12 caused/contributed to this accident. Check "None" or indicate the type of drug suspected of being involved.

(31) Block 42. Indicate if the person listed in block 12 was using a vision-enhancement device (NVG, AN/PVS-5A, NVD, thermal imagery, Forward Looking InfraRed at the time of the accident. If a vision-enhancement device was being used, specify the type in block 42c and the model number in block 42d, even if it did not contribute to the accident. (If caused/contributed, explain in block 63.)

(32) Block 43 . Check the type of guidance (standard/reference), if it exists, that covers correct performance of the activity/task identified in blocks 31 and 32. In the space provided following the selected type of guidance, specify by name/number (for example, FM 21-305 , para 3c). Guidance may be written in state/local laws, ARs, TMs, FMs, Soldier's manuals, SOPs, directives.

(33) Block 44. Indicate if the activity/task was being performed in accordance with the guidance (standard/reference) specified in block 43. If "No," complete blocks 45 through 47.

(34) Block 45 . Indicate whether the individual listed in block 12 made a mistake that caused or contributed to the accident. If "Yes," enter the mistake number from Appendix B and complete blocks 46 and 47. If "No," skip to block 48.

(35) Block 46. Provide a simple explanation of the mistake(s) made by the person listed in block 12 or explain how the activity/task was performed incorrectly. When describing mistakes, be sure to use one or more of the mistakes/ errors listed at Appendix B to identify the specific mistake(s) made by the individual. Include the results or outcome of the mistake(s). For example, "The driver failed to use a ground guide to back the M915 truck, although one was required. As a result, the vehicle collided with a legally parked sedan." For on-duty Class A and B accidents requiring separate findings and recommendations, reference the finding number in this block (see fig 4-1 ).

(36) Block 47 . Identify why the mistake was made or the activity was performed incorrectly. What was the root cause of the mistake? Carefully consider deficiencies in system design, training, procedures, and command climate as well as individual factors such as attitude, haste, and overconfidence. Appendix B contains explanations and examples of root causes. Check the most important root causes (reasons) and explain in block 63. For on-duty Class A and B accidents requiring separate findings and recommendations and narrative of investigation, the root causes should be fully explained in the findings and supported in the analysis portion of the narrative, and referenced in block 63.

(37) Block 48 . If the individual listed in block 12 was operating a vehicle, indicate how long they had been licensed to operate this type of vehicle before the accident.

(38) Block 49. If the individual listed in block 12 was operating a vehicle, indicate total miles they had driven Army motor vehicles (include all Army motor vehicles) before the accident.

(39) Block 50.

(a) Indicate the length of time the individual listed in block 12 had been in the unit shown in block 18 before the accident.

(b) Enter the date the Soldier was assigned or Army civilian/contractor was hired.

(c) Indicate the date of redeployment, if applicable.

(40) Block 51 . Check the appropriate block to indicate which item from section C "Property/Materiel Involved" was associated with the individual listed in block 12. This information is required to ensure that it can be determined who was operating or using, each item of property/materiel involved in the accident. For example, PFC Jones was driving a tank. His name will be in block 12 and his vehicle will be item A in section C. Therefore, the correct entry for block 51 would be "Item A." If the property/materiel associated with the individual will not be items A, B, or C, determine which letter will represent that item (see instructions for section C). Check "Other" and specify the appropriate letter in the space provided.

d. Section C-Property/Materiel Involved. Complete an entire column (For example, column titled Item A) filling in blocks 52 through 59 on each piece of property or item of equipment involved in the accident (whether damaged or not). If the property/materiel experienced a materiel failure/malfunction, also complete blocks 60 and 61. Be sure the same column is used for all blocks. Include Army and non-Army equipment/materiel as well as equipment/materiel whose use or misuse contributed to the accident. Include up to three items of equipment on the initial form. Use additional sheets of bond paper for other equipment, if necessary, continuing letter sequence, (for example, D, E, F, and G). Each column will be used to provide information for one piece of equipment/materiel.

(1) Block 52. Enter the type of property/materiel (for example, sedan, truck, generator) involved in the accident. If explosives were involved, enter the type of explosive and the NSN.

(2) Block 53.

(a) Enter the full military equipment model number and/or civilian make and serial number, (for example, M109A2, M60A2, 2006 Ford Taurus, M16A2 rifle, M4 rifle). If explosives were involved, enter the model number and DODAC or DOD Identification Code (DODIC).

(b) Enter the serial number for Army equipment/materiel, as applicable.

(3) Block 54. Indicate who owns the equipment/materiel.

(4) Block 55. Enter the ECOD or ACOD for each piece of property.

(5) Block 56 . Indicate whether a rollover protection system was installed. If rollover protection systems do not apply to the piece of equipment, check NA (not applicable).

(6) Block 57. Indicate if this specific piece of equipment was being towed at the time of the accident. (Does not refer to post-accident towing of vehicles/equipment.)

(7) Block 58. If the answer in block 57 is "Yes," indicate in which column (item A, B, C, and so forth), the equipment doing the towing is listed.

(8) Block 59 . From the list provided on the form, select the type(s) that best describe the collision in which this property/materiel was involved. More than one collision type might be appropriate for the property/materiel. If so, enter up to three, in sequence, in the blocks provided. If "Other" is selected, specify what type of collision in the space provided. If no collision was involved, leave blank.
Note. If the property listed in blocks 52 and 53 experienced a materiel failure/ malfunction that caused or contributed to the accident, complete blocks 60 and 61. Ensure the information is entered in the same column as the involved property. For example, if item A (blocks 52 and 53) experienced a materiel failure/malfunction, the information about that failure/malfunction should be entered in blocks 60 and 61 in the column entitled "Item A."

(9) Block 60. Complete items "a" through "d" for each component/part whose failure or malfunction contributed to the accident. Enter name/nomenclature of component/part in block 60c. Ensure an EIR/PQDR ( SF 368 ) is prepared and submitted through appropriate channels for each component/part. Include EIR/PQDR number in block 60e (See DA Pam 750-8).

(10) Block 61 . Indicate how and why each component/part failed/malfunctioned by selecting from the lists provided on the form and entering the appropriate number in the blocks provided. Appendix B contains explanations and examples. In block 63, include an explanation of how the materiel failed/malfunctioned and the reason (root cause) for the failure/malfunction. For on-duty Class A and B accidents requiring separate findings and recommendations, the findings should fully explain the failure and cause.

e. Section D-Environmental Conditions Involved.

(1) Block 62. Check the appropriate blocks (no more than three) to indicate the environmental conditions present at the time of the accident. Also check the cause/contributed block if the environmental condition caused or contributed to the accident and explain in block 63 how the environmental condition caused/contributed to the accident.

(2) On-duty Class A and B accidents. For on-duty Class A and B accidents, contributing environmental factors will be fully explained in the findings and analysis portion of the narrative.

f. Section E-Accident Description/Narrative.

(1) Block 63. The investigation board will report, in narrative form on letter-size paper, the facts, conditions, and circumstances as established during the investigation and present this information in accordance with DA Pam 385-40, paragraph 4-4 .

(2) Block 64. Provide the following information for the individual that completed the report. Ensure the information is legible.

(a) Print the name. (First, MI, Last)

(b) Enter the rank.

(c) Enter the title.

(d) Signature of this individual.

(e) Enter the date of the signature.

(f) Enter the telephone number and specify whether it is DSN or commercial.

(g) Enter this individual's e-mail address.

g. Section F-Corrective Action and Command Review.

(1) Block 65. The investigation board will formulate the findings and recommendations on letter sized paper in accordance with paragraph 4-3 and the examples contained in DA Pam 385-40.
Note. The level of command review (company, battalion, division, and so forth) is determined by either the Army Headquarters or installation policy.

(2) Block 66. Provide the name (block 66a), rank (block 66b), and telephone number (block 66e) of the unit commander. Ensure the information is typed or printed legibly, and specify whether the telephone number is DSN or commercial. Also ensure the commander signs and dates the report in blocks 66c and 66d as part of the review process. Enter this individual's e-mail address in block 66f.

(3) Blocks 67 through 69. Provide the names and e-mail address (blocks 67a, 68a, and 69a), titles (blocks 67c, 68c, and 69c), and ranks (blocks 67d, 68d, and 69d) of the individuals in the chain of command who have reviewed this report. Ensure the information is typed or printed legibly. Ensure each individual in the chain of command signs and dates the report in blocks 67b and d, 68b and d, or 69b and d. For on-duty Class A and B accidents, use blocks 1 and 2, DA Form 285-O (Statement of Reviewing Officials), for reviewing official and approving authority comments, included at Tab A of the report, and reference that form in this block. (See para 4-9 .)

h. Section G-Safety Office Use Only. This section is for local safety office use only and should be left blank by all other personnel. The safety office will complete this section on all accidents.

(1) Block 70. Enter the local report number for this accident report.

(2) Block 71. Enter the Army Headquarters of the unit shown in block 2 (the unit responsible for the accident).

(3) Block 72. Check the accident type(s) that best describe this accident. Check all that apply. Consult DA Pam 385-40, chapter 1 , paragraph 1-9 , for definitions. If fratricide is the type of accident, declare it in the narrative, block 63.

(4) Blocks 73 and 74. Provide the name (block 73) and signature, telephone number (block 74a), and the e-mail address (block 74b) of the local safety office POC for information about this report. Ensure the information is typed or printed legibly, and specify whether the telephone number is DSN or commercial.

(5) Block 75. Enter the date the report was completed by the safety office (yyyymmdd).

i. Section H-Explosives/Ammunition Information.

(1) Blocks 76, Explosives/Ammunition Information. If block 10 was checked "Yes," enter the following:

(a) Enter the lot numbers.

(b) Enter the quantity.

(c) Enter the net explosive weight (NEW) of all ammunition and explosives involved.

(d) If explosives or ammunition were involved, enter the model number and DODAC or DODIC.

(2) Blocks 77 and 78. Fill in the required information.
Note. If the explosive/ammunition was exposed to significant environmental conditions, the environmental conditions should be checked in block 62, and an explanation of the conditions and their effect on the explosive/ammunition should be provided in the narrative. Significant E 3 . For example, radiated energy (such as being in close proximity to a radar site), electromagnetic energy, electrostatic energy or high voltage; water or high humidity; or prolonged exposure to direct sunlight.



Figure 4-3. Example of completed DA Form 285-W, Summary of Witness Interview





Figure 4-3. Example of completed DA Form 285-W, Summary of Witness Interview—continued


4-13. Completion instructions for DA Form 285-W, Summary of Witness Interview

a. Also see paragraph 4-5.

b. Block 15. See example of completed DA Form 285-W (see fig 4-3 ).

(1) Block 1. Self- explanatory.

(2) Block 2. Enter general occupation of the witness and duty being performed at time of the accident.

(3) Block 3. Enter the grade of witness. Use codes from table 4-5 .

(4) Blocks 4-5. Self-explanatory. (SSN is not required.)

(5) Block 6. List DSN number if applicable.

(6) Block 7. Enter date(s) of interview(s) was/were made.

(7) Block 8. Enter a summary of experience, expertise, and background in duty/MOS involved in the accident

(8) Block 9. Enter location of witness at the time of the accident relative to the accident.

(9) Block 10. Enter grade and last name of person in charge of interview. If witness is interviewed by different persons in charge on separate occasions, list the lead interviewer.

(10) Block 11. Promise of confidentiality.

(a) Check the appropriate box to indicate if the witness was/was not offered a promise of confidentiality. This can only be offered for limited use investigations. See AR 385-10 .

(b) Also, check the appropriate box to indicate whether or not the witness requested a promise of confidentiality.

(c) If promise of confidentiality was offered and requested/accepted, the interviewer must sign and date the confidentiality statement.

(11) Block 12. Summary of interview, will be completed as follows:

(a) Multiple interviews, same witness. Preface the summary of each interview with the date and indicate if it is the first, second, third, and so forth, interview.

(b) Comprehensiveness. As a general rule, the interview summaries of persons involved/injured in the accident should be summarized in greater detail than the statements of others. This is because the personnel involved are the best source of information pertaining to the accident chronology of events. The chronology for the "history of events," Narrative of Investigation (see para 4-4 ) will most often be obtained from the personnel involved and should be used as a guide in determining what elements of information to include in the interview summaries. If human error appears to be involved in the accident, the mistakes/errors and system inadequacy(ies) listed in the instructions for completing the findings and recommendations (see para 4-3 ) are useful for determining what should be addressed in the witness summaries.

(c) Consolidating. When several witnesses, other than person(s) involved, provide essentially the same observations, it is not necessary to prepare a separate DA Form 285-W 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 a passenger (identify location of passenger) in the vehicle at the time of the accident. Additionally, he heard a grinding noise in the area of the right rear wheel, prior to the brake failure." In cases where it is essential, limited direct quotes of a witness (together with the specific questions they are in response to) may be used. Again, this should be done sparingly and only when necessary. It is important that the statement be the investigator' s summariza- tion 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 13. Enter the date of the accident.

(13) Block 14. Interviewer will read block 15a or 15b to each witness, depending upon the category and/or circumstances of the witness.

(14) Block 15. Those witnesses offered a promise of confidentiality, must indicate acceptance or refusal by initialing the appropriate statement (see fig 4-3 ).



Figure 4-4. Example of completed DA Form 285-A, Index A





Figure 4-5. Example of completed DA Form 285-B, Index B


4-14. Completion instructions for DA Form 285-A, Index A and 285-B, Index B

a. Also see paragraph 4-7 .

b. See figures 4-4 and 4-5 .

(1) Block 1,. DA Forms 285-A and 285-B. Enter the date of the accident (YYYYMMDD).

(2) Block 2, DA Forms 285-A and 285-B. Place an "X" in the block opposite each item to indicate whether the information is "Enclosed" or "Not Applicable." An "X" in the "See remarks" block requires an explanation in block 3 "Remarks" section of the form.

(3) Block 3,. DA Forms 285-A and 285-B. The remarks block is used to indicate that required information is being delayed or not available to the accident investigation board. Remarks pertaining to delayed information will contain an estimated forwarding date. Remarks pertaining to unavailable information will include reasons for non-availability. Also, when the accident board inserts multiple documents or wants to clarify a document under a certain tab, it should be identified in this block.

(4) Block 4,. DA Form 285-B . Type signature block of all voting board members to include grade, branch, unit address, e-mail address, and telephone number (SSN not required). Each voting board member will sign all copies of the accident report unless a minority report is submitted in accordance with chapter 2 of this pamphlet. Use a continuation sheet (plain bond paper) if there are more than six voting board members.



Figure 4-6. Example of completed DA Form 285-O, Statement of Reviewing Officials


4-15. Completion instructions for DA Form 285-O, Statement of Reviewing Officials

a. Also see paragraph 4-9 .

b. See figure 4-6 .

(1) Block 1. The initial reviewing official(s) will indicate the official's organization as follows:

(a) State concurrence or nonconcurrence with the findings and recommendations. 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) Identify those area(s) recommended for improvement by the investigating board that are beyond the resources available to the command.

(d) Authenticate comments with signature, appropriate signature block, organization, and date 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, and so forth.

(2) Block 2. Army Headquarters reviewing authority. Army Headquarters commanders or their designated represent- atives will provide written concurrence or nonconcurrence for each finding and recommendation made by the accident investigation board.

(a) Indicate reasons for nonconcurrence. Also include any additional recommended actions.

(b) The reviewing authority will make note of those areas recommended for improvement by the accident investiga- tion board or subordinate reviewing officials on which action can or will be completed. If corrective action is beyond the purview or capability of the Army Headquarters reviewing authority, this will be stated.

(c) Authenticate comments with signature, appropriate signature block, and organization at the close of remarks.

(3) Block 3. Reserved for USACRC and will be completed by the USACRC to show coordination/follow-up taken in response to recommendations requiring DA-level action.

(4) Block 4. Enter the date of the accident.



Figure 4-7. Example of a U.S. Army Abbreviated Ground Accident Report (AGAR)





Figure 4-7. Example of a U.S. Army Abbreviated Ground Accident Report (AGAR)—continued





Figure 4-7. Example of a U.S. Army Abbreviated Ground Accident Report (AGAR)—continued


4-16. Completion instructions for DA Form 285-AB, Abbreviated Ground Accident Report (AGAR)

a. Also see paragraph 4-11 .

b. See legend for figure 4-7 .

(1) Block 1. Date and time of accident.

(a) Block 1a. Enter the year (for example, 2006).

(b) Block 1b. Enter the month (for example, 06).

(c) Block 1c. Enter the month (for example, 06).

(d) Block 1d. Military time. Enter the local military time (for example, 2315).

(2) Block 2, Period of day. Check the block that best describes when the accident occurred (day or night). Day is from first light to full night (dark). Night is from full dark (full night) to first light. Dawn is the period between BMNT and official sunrise. Dusk is the period of time between official sunset and EENT.

(3) Block 3, Accident class. Enter the accident's classification: A, B, C, D, or E. (See definitions in AR 385-10 , chapter 3).

(4) Block 4, Combat status. Check whether or not the accident occurred in a combat theater. Combat should be checked if the accident occurred in a theater of hostile fire or enemy action, but not as a result of such fire/action. This includes direct preparation for combat, actual combat, or redeployment from a combat theater immediately following combat.

(5) Block 5, Unit Identification. Enter information for the unit or organization responsible for the accident. Guidance for determining accident accountability can be found in AR 385-10 .

(a) Block 5a. Enter the six-digit UIC for the specific organizational unit or activity responsible for the accident (for example, WXXXXX).

(b) Block 5b. Unit address. Enter the full military address of unit/organization (for example, B Company, 2/18th Cavalry, Fort Bragg, NC XXXXX-XXXX).

(c) Block 5c. Unit's Branch. Enter the abbreviation of Army branch the unit is affiliated with (for example, Armor, Infantry, Engineer, and so forth) Army branches are listed in table 4-3 .

(d) Block 5d. Army Headquarters. Enter the abbreviation for the Army commands, Army Service Component Commands, or Direct Reporting Units that the unit/activity belongs to (for example, Army Materiel Command [AMC], U.S. Army Europe and 7th Army, Forces Command, and so forth.)

(6) Block 6, Location of the accident.

(a) Block 6a. Enter the exact location of the accident (for example, building number, street name and address, distance from nearest landmark, and so forth).

(b) Block 6b. Enter one code for primary function of the accident location, see table 4-4 .

(c) Block 6c. Enter the grid coordinate or latitude/longitude for the accident location.

(d) Block 6d. Enter the state or country if outside the United States.

(e) Block 6e. Indicate whether the accident occurred on or off post, and if on post, enter the name of the installation/ activity.

(7) Block 7. Explosives/Ammunition. Check if explosives, ammunition, or pyrotechnics were involved. Involved meaning damage or injury occurred as a result of the functioning, detonation, ignition or release of an explosive or explosive device, or an explosive device was damaged. If "Yes" is checked, provide the information specified in DA Pam 385-40, chapter 5, paragraph 5-3 , in blocks 9, 39, 42, and the synopsis. Check the appropriate fields in block 39 if the explosive/ ammunition was exposed to significant environmental conditions and describe in block 40.

(8) Block 8.

(a) Block 8a. Briefly describe the mission the individual or unit was conducting at the time of the accident. If off duty, state so.

(b) Block 8b. Was the task a Mission Essential Task List task? Check the appropriate box.

(9) Block 9, Vehicle/Equipment/Materiel Involved. "Involved" means vehicle/equipment/materiel/property that is damaged, whose use or misuse contributed to the accident or whose materiel failure/malfunction caused and/or contributed to the accident. Include Army and non-Army equipment/materiel. Use one line for each piece of equipment or item and enter the requested information. Continue on blank paper if necessary (be sure to annotate the block number).

(a) Block 9a. Enter the name of the equipment/materiel involved.

(b) Block 9b. Enter the equipment model.

(c) Block 9c. Enter the equipment serial number (if applicable).

(d) Block 9d. Indicate who owns the vehicle/equipment/materiel (for example, DOD, DA, unit, person).

(e) Block 9e. Enter an estimate of the damage cost for the piece of equipment listed in Block 9a.

(f) Block 9f. From the list below select the type(s) of collision in which this property/materiel was involved. More than one collision type might be appropriate for the property/materiel. If so, enter up to three, in sequence, in the space provided. If "Other" is selected, specify what type of collision in the space provided. If no collision was involved, leave blank.

(1) 1=Going forward and collided with moving vehicle

(2) 2=Going forward and collided with parked vehicle

(3) 3=Collision while backing

(4) 4=Collision with pedestrian

(5) 5=Collision with object (other than vehicle/pedestrian)

(6) 6=Overturned

(7) 7=Ran off road

(8) 8=Jackknifed

(9) 9=Going forward and rear-ended with moving vehicle

(10) 10=Going forward and rear-ended stopped vehicle

(11) 11=Collision while turning

(12) 12=Other (specify)
Note. If the item in block 9a experienced a materiel failure/malfunction that caused or contributed to the accident, complete blocks 9g-9l and block 10. If not, skip to block 11.

(g) Block 9 g - 9l, Materiel malfunction/failure information. Enter the code that indicates how the component/part failed/malfunctioned (mode of failure). See appendix B for list and examples of failure codes. Complete items h through l for each component/part whose failure or malfunction contributed to the accident. Annotate whether an EIR/ PQDR (SF 368) was prepared and submitted through appropriate channels for each component/part.

(10) Block 10. Why Did the Materiel Fail/Malfunction (Root Cause)? Materiel failures/malfunctions can be caused by shortcomings of support. Specific causes may include:

(a) Block 10a. Support - shortcomings in type, capability, amount, or condition of equipment, supplies, services, or facilities (equipment/materiel not provided or improperly designed, inadequate or maintenance, or inadequate facilities/ services). Determine the underlying reason (root cause (s) the materiel failed/malfunctioned and check accordingly (see app B).

(b) Block 10b. Describe how the materiel failed/malfunctioned and explain why (for example, explain mode of failure from block 9f and root cause. Example: Block 9f=M05, and block 10a="Support equip/materiel improperly designed," enter why the improper design caused the materiel to fail or malfunction or malfunction by friction producing movement.

(11) Block 11.

(a) Block 11a. Enter last name, first name, and middle initial of involved person. Include unit name, address, and UIC if it is different from block 5a.

(b) Block 11b. For Army civilians, Army contractors, or members of the visiting public that are injured, enter their home address.

(12) Block 12. Enter the SSN of the individual listed in block 11.

(13) Personnel Classification.

(a) Block 13a. Enter the code for the classification (at the time of the accident) of the person listed in block 11. See table 4-6 .

(b) Block 13b. Date assigned/hired. Enter the date the soldier was assigned or the Army civilian/contractor was hired.

(c) Block 13c. Indicate the date of redeployment, if applicable.

(14) Block 14, MOS/job series. For Army personnel, enter the full MOS or job series of the individual, (for example, 63B10, GS-0018-14).

(15) Block 15. Duty status.

(a) Block 15a. For DOD personnel, check the appropriate box to reflect the duty status at the time of the accident of the individual listed in block 11. (See glossary for definitions of on- and off-duty status). (This determination applies for safety accident reporting purposes only, and has no relation to compensability or line-of-duty decisions.)

(b) Block 15b. If the Soldier was on leave or pass at the time of the accident, check the box and enter the inclusive leave/pass dates (for example, 20060705).

(16) Block 16. Enter the date of birth for the individual listed in block 11.

(17) Block 17. Enter the gender for the individual listed in block 11 ("M" for male or "F" for female).

(18) Block 18. For DOD personnel, enter the rank/pay grade for the individual listed in block 11 (for example, E5, 03, GS-11, WG-08).

(19) Block 19. Check the appropriate box (for government personnel only) to indicate the military flight status of the individual listed in block 11.

(20) Block 20, Most Severe Injury/Occupational Illness. For the individual listed in block 11, complete blocks "a" through "d" for the most severe injury/occupational illness.

(a) Block 20a, Degree. Enter the code that indicates the severity of the injury/occupational illness to the individual list in block 11 from the table below. If more than one applies, enter the most severe. Enter the date of death as indicated on the form. See glossary for definitions.

(1) a=Fatal.

(2) b=Permanent Total Disability.

(3) c=Permanent Partial Disability.

(4) d=Days Away From Work.

(5) e=Restricted Work Activity (Light duty, profile).

(6) f=Medical Treatment Beyond First Aid (Includes cases of loss of consciousness, needle stick/cuts from sharps).

(7) g=First Aid Only.

(8) h=No Injury/Occupational Illness.

(b) Block 20b, Injury/illness type. Enter the one code below that best describes this person's most serious injury/occupational illness type.

(1) A - Burns (chemical)

(2) B - Burns (thermal)

(3) C - Amputation

(4) D - Decompression sickness

(5) E - Asphyxiation (suffocation)

(6) F - Fractures

(7) G - Dislocation

(8) H - Abrasions

(9) I - Concussion

(10) J - Sprains/strain

(11) K - Cuts/lacerations

(12) L - Contusion

(13) M - Puncture wound

(14) N - Hernia, rupture

(15) O - Frostbite

(16) P - Heatstroke

(17) Q - Heat exhaustion

(18) R - Noise injury

(19) S - Needle stick or cuts from sharps

(20) T - Loss of consciousness

(21) U - Other (specify)

(c) Block 20c, Body part. Enter the one code below that best describes the most seriously injured part of this person's body. Body part entered here should be the one with the injury indicated in previous block.

(1) A - Body (General, cannot specify)

(2) B - Head

(3) C - Forehead

(4) D - Eyes

(5) E - Nose

(6) F - Jaw

(7) G - Neck

(8) H - Trunk

(9) I - Chest

(10) J - Heart

(11) K - Back

(12) L - Shoulder

(13) M - Arms

(14) N - Wrist

(15) O - Hand

(16) P - Fingers

(17) Q - Leg

(18) R - Knee

(19) S - Ankle

(20) T - Foot

(21) U -Toes

(22) V - Other

(d) Block 20d, Cause. Enter the one code below that best describes the cause of the most serious injury/occupational illness to this individual.

(1) A - Struck against

(2) B - Struck by

(3) C - Fell from elevation

(4) D - Fell from same level

(5) E - Caught in/under/between

(6) F - Rubbed/abraded

(7) G - Bodily reaction

(8) H - Overexertion

(9) I - Exposure

(10) J - External contact

(11) K - Ingested

(12) L - Inhaled

(13) M - Thrown from

(21) Block 21, Lost time.

(a) Block 21a, Days hospitalized. Enter the actual or estimated total number of days this individual will be hospitalized (inpatient/admitted) receiving treatment. Days hospitalized for "observation only" are only included if they miss a day of work.

(b) Block 21b, Day lost not hospitalized. Enter the estimated or actual number of days this individual will be away from work (totally unable to perform any work, on bed rest/quarters, convalescence leave, or time a physician indicated that the individual could not work regardless of whether the individual was scheduled to work. Count all calendar days including weekends and holidays. For example, if the individual was injured on Friday and the individual could work on Monday, if the physician or licensed health care professional indicated they should not work over the weekend, enter 2 days. If there is no information from the physician, enter 0 days.

(c) Block 21c, Days restricted. Enter the actual or estimated number of days the individual was unable to perform one or more routine job functions (regularly performed by the individual at least once per week), or could not work a full work day they would otherwise have been scheduled to work; or a physician or licensed health care professional recommends that the employee not perform one or more routine function of his/her job. Restricted work activities include light duty, profiles and job transfers.

(d) Block 21d, Treated in Emergency Room. Check if this individual was treated in an emergency room.

(22) Block 22.

(a) Block 22a, OSHA log 300 case number. For injured personnel, enter the OSHA log 300 case number for the individual listed in block 12. OSHA log 300 case number is not required for Soldiers or off-duty civilians.

(b) Block 22b,. Enter the name of the physician or other health care professional who treated the individual. Optional for military personnel.

(c) Block 22c,. If treatment was given away from the worksite, enter the name and address of the facility.

(23) Block 23, Activity. Enter the individual's activity at the time of the accident from the list below. Enter the code that best describes this individual's activity at the time of the accident. Complete block 38 if the activity is parachuting (see DA Pam 385-40, Section II Terms and Section III Special Abbreviations and Terms and glossary for explanation of activities .)

(a) A Soldiering

(b) B Combat soldiering

(c) C Physical training

(d) D Weapons firing/handling

(e) E Engineering or construction

(f) F Communication

(g) G Security/law enforcement

(h) H Firefighting

(i) I Patient care (people/animals)

(j) J Test/study/experiments

(k) K Educational

(l) L Information and art

(m) M Food and drug inspection

(n) N Laundry/dry cleaning services

(o) O Pest/plant control

(p) P Operating vehicle/vessel

(q) Q Handling animal

(r) R Maintenance/repair/servicing

(s) S Fabricating

(t) T Handling material/passengers

(u) U Janitorial/housekeeping/grounds keeping

(v) V Food/drink preparations

(w) W Supervisory

(x) X Office

(y) Y Counseling/advisory

(z) Z Sports

(aa) AA Hobbies

(ab) BB Passenger

(ac) CC Human movement

(ad) DD Horseplay

(ae) EE Bystanding/spectating

(af) FF Personal hygiene/eating/sleeping

(ag) GG Parachuting

(24) Block 24. Briefly describe this individual's activity at the time of the accident. For example, the Soldier was a right rear passenger in the vehicle at the time of the accident; the individual was performing maintenance on a split rim tire in the maintenance shop.

(25) Block 25, Personal Protective Equipment. Determine what PPE was required for the activity/task being performed. If PPE was required, determine if it was available and used, available but not used, or not available. Check the appropriate blocks for each item of PPE to indicate availability and use/non-use. If no PPE was required, check the NA (not applicable) column for each type of PPE. For privately owned motorcycle accidents, indicate whether the helmet was Department of Transportation approved.
Note. Restraint systems are those systems such as the Gunner's Restraint System in military vehicles.

(26) Block 26. Check the appropriate box to indicate whether or not this individual's use of alcohol or drugs (include prescription, over the counter, supplements or illegal drugs) caused or contributed to the accident. If "Yes" is checked, explain in block 40.

(27) Block 27. Equipment this Person was Associated With. Enter the item number (for example, #1, #2) from block 9 that indicates which piece of equipment this individual was associated with.

(28) Block 28. Licensed to Operate Equipment.

(a) Block 28a. If this individual was operating a vehicle or equipment (at the time of the accident) that required a license, complete the following information. Check the appropriate block. If no, skip to block 29.

(b) Block 28b. Check "Yes" if the individual has attended the mandatory 4 hours of classroom instruction in traffic safety and indicate the date of the training. Otherwise, check "No."

(c) Block 28c. If the individual was operating a motorcycle in this accident, check yes if the individual is motorcycle safety foundation certified and enter the date. Otherwise, check "No."

(29) Block 29, Duty Hours.

(a) Block 29a. Enter the time the Soldier or employee began work.

(b) Block 29b. State how many continuous hours this individual was on duty without sleep before the accident.

(30) Block 30, Hours Sleep. Enter the number of hours of sleep (cumulative) this individual had in the past 24 hours.

(31) Block 31, Tactical Training. Indicate whether the activity listed in blocks 23 and 24 was part of tactical training. Field exercise and tactical training begin when the individual reports to his or her primary duty location for movement to the field site and ends when he or she arrives back at the primary duty location from the field.

(32) Block 32, Type Training Facility. If the individual was participating in any type of training, enter the code for the type of training facility being used (see FM 7-1 for definitions). Code/Facility is listed as follows:

(a) A=Garrison

(b) B=Local training area

(c) C=Major training area

(d) D=NTC

(e) E=JRTC

(f) F=CMTC

(g) G=Standard range facility/live fire

(h) H=Other (specify)

(33) Block 33, Last Training. For the activity specified in blocks 23 and 24, enter the number of months since the last time the individual received training prior to the accident.

(34) Block 34, Named exercise. Check "Yes" if activity listed in blocks 23 and 24 was part of a field exercise or a named operation. Indicate the name of the exercise or operation (major and local field training exercise) if it has a name (for example, Team Spirit, Gallant Eagle). Check "No" if activity was not part of a field exercise or named operation.

(35) Block 35, Night Vision System. Indicate if night vision devices were being used by this individual at the time of the accident, (for example, NVG, AN/PVS-14). If used, specify the type. If they caused or contributed to the accident, explain in Block 40.

(36) Block 36. Individual Mistake(s) that Caused/Contributed to the Accident or Severity of Injury or Occupational Illness/Damage.

(a) Block 36a. In your opinion, did this individual make a mistake(s) that caused and/or contributed to the accident? If the answer is "YES", complete Blocks 36b and 36c, and Block 37. If "NO", skip to Block 39.

(b) Block 36b. Enter the code from appendix B , table B-2 , which best indicates the type of mistake made by this individual.

(c) Block 36c. Describe the mistake and how it caused/contributed to the accident. Be specific, (for example, block 36a="Yes"; block 36b="47" (failed to use a ground guide when required); block 36c=" The Mine-Resistant Ambush Protected (MRAP) driver failed to use a ground guide when required. That is, the driver attempted to drive through an Entry Control Point (ECP) which required ground guides. Consequently, he struck a barrier causing extensive damage to the right side of the vehicle."

(37) Block 37. Why the mistake(s) was made (system inadequacies/root causes). Mistakes can be caused by shortcomings of support, standards/procedures, training, leaders, or the individual. There can be more than one root cause selected. Specific causes include-Support-Shortcomings in type, capability, amount, or condition of equipment, supplies, services, facilities, and number and type personnel. Standards/procedures not clear or not practical or do not exist. Training-School training, Unit training, or Experienced/OJT insufficient in content/amount. Leader-Direct, Unit Command, or Higher Command Supervision not ready, willing, or able to enforce known standards. Individual-Soldier knows and is trained to standard but elects not to follow standard (self-discipline-mistake due to own personal factors).

(a) Block 37a. Identify why the mistake was made (specific root cause(s)). See appendix B, Table B-5 for definitions. Enter the mistake number in the box next to the associated root cause. Multiple boxes can be checked.

(b) Block 37b. Describe the root cause(s) and tell how it/they caused the mistake. See appendix B for explanations. For example, if block 37a "Individual-Overconfident, Leader-Direct Supervision" then block 37b might say something like, "The driver was overconfident in his ability to operate the MRAP without a ground guide and the Vehicle Commander (VC) did not properly supervise the driver by allowing him to enter an entry control point (ECP) without a ground guide. This was in contravention of the BN SOP."

(38) Block 38, Parachuting information. If the activity for the individual listed in block 11 is parachuting, complete blocks 38a thru 38q.

(39) Block 39, Environmental conditions. Enter the code(s) (no more than three from the list below) to indicate the conditions present at the time of the accident. Also indicate if the condition caused or contributed to the accident by checking the Caused/Contributed block and, if "YES", explain in Block 40 (see app B). Code/Condition is listed follows:

(a) A=Clear/dry

(b) B=Bright/glare

(c) C=Dark/dim

(d) D=Fog/condensation/frost

(e) E=Mist/rain/sleet/hail

(f) F=Snow/ice

(g) G=Dust/fumes/gasses/smoke/vapors

(h) H=Noise/bang/static

(i) I=Temperature/humidity (cold/heat)

(j) J=Storm/hurricane/tornado

(k) K=Wind/gust/turbulence

(l) L=Vibrate/shimmy/sway/shake

(m) M=Radiation/laser/sunlight

(n) N=Holes/rocky/rough/rutted/uneven

(o) O=Inclined/steep

(p) P=Slippery (not due to precipitation)

(q) Q=Air pressure (bends, decompression, altitude, hypoxia)

(r) R=Lightning/static electricity/grounding

(s) S=Electromagnetic radiation (EMR)

(t) T=OTHER (specify)

(40) Block 40, Synopsis. Provide a brief synopsis of the accident explaining what and how the accident happened. If need be, continue on a separate sheet of paper annotating the block number and attach it to the report. The synopsis should include the events leading up to the accident, the actual accident sequence, and the post-accident scene and actions. For example, if a Soldier was involved in an off-duty POV accident, be sure to indicate where the Soldier was going, where he/she was coming from, and so forth. Also include the following information for off-duty accidents:

(a) Indicate whether the Soldier was on leave, pass, permanent change of station, or temporary duty (TDY)?

(1) How long was the Soldier on leave/pass when the accident occurred?

(2) Did the accident occur while the Soldier was en route to/from his/her destination?

(b) Was the Soldier deployed within the 365 days prior to the accident (yes/no)? If yes:

(1) When did the Soldier return from the deployment?

(2) Where was the deployment?

(3) How long was the deployment?

(c) Was the Soldier recently notified that he/she would deploy soon?

(d) Was there leader contact prior to the accident (yes/no)? If yes,

(1) What level of leadership?

(2) What type of contact (brief, TRiPS, trip planning, counseling, vehicle inspection, other)?

(41) Block 41, Corrective action(s) taken or planned. Briefly describe all actions taken, planned, or recommended to eliminate, or at least reduce, the root cause(s) of this accident and prevent similar accidents from happening (see app B ).

(42) Block 42, Explosive/Ammunition. If block 7 was checked "Yes," enter the lot numbers, quantity, and the NEW of all ammunition and explosives involved. Also, include the model number and DODAC or DODIC.
Note. If the explosive/ammunition was exposed to significant environmental conditions, the environmental conditions should be checked in block 39, and an explanation of the conditions and their effect on the explosive/ammunition should be provided in the synopsis. Significant environmental conditions include the following: extremely high/low temperatures; electromagnetic environmen- tal effects; for example, radiated energy (such as being in close proximity to a radar site), electromagnetic energy, electrostatic energy or high voltage; water or high humidity; or prolonged exposure to direct sunlight.

(43) Block 43, Point of Contact.

(a) Block 43a. Enter the name, rank, and position of the individual from the unit/organization who can answer questions about this accident report.

(b) Block 43b. Enter the phone number for the individual listed in 43a.

(c) Block 43c. Enter the e-mail address for the individual listed in block 43a.

(44) Block 44, Command Review. As locally required.

(45) Block 45, Safety office review.

(a) Enter the name, rank and title of the safety office reviewing official.

(b) Enter the DSN and commercial phone number of the safety office reviewing official

(c) Enter the e-mail address of the individual listed in 45a.

(d) Enter the date the report was reviewed.

(e) Enter the local report number (safety office use only).

Table 4-3. Army branches
Army branch Abbreviation
Adjutant General AG
Air Defense Artillery AD
Armor AR
Army Medical Specialist Corps SP
Army Nurse Corps AN
Aviation AV
Chaplain CH
Chemical CM
Dental Corps DC
Engineers EN
Field Artillery FA
Finance Corps FC
Infantry IN
Judge Advocate General's Corps JA
Medical Corps MC
Medical Service Corps MS
Military Intelligence MI
Military Police MP
Ordnance OD
Public Affairs PA
Quartermaster Corps QM
Signal Corps SC
Space Command SP
Special Forces SF
Transportation Corps TC
Veterinary Corps VC VC


Table 4-4. Types of accident locations
Code Type Location
Maintenance/Fabrication Facility
A1 Vehicle facility (motor pool, maintenance shop)
A2 Aircraft facility (hangar)
A3 Vessel facility (boat overhaul/rebuild facility)
A4 Engineer facility (carpentry/electrical/plumbing shop)
A5 Other maintenance facility
Travel Ways
B1 Pedestrian way (sidewalk)
B2 Vehicle trail (tank trail)
B3 Roadway (street, curb, shoulder, driveway)
B4 Parking lot
B5 Aircraft way (flight line, runway)
B6 Railroad
Other operational facilities/areas
C1 Office building
C2 Communications facility
C3 Construction site
C4 Security/law-enforcement facility
C5 Bridge
C6 Dam
C7 Navigation locks
C8 Barge
C9 Dredge
C10 Floating plant
C11 Vessel (not elsewhere coded)
C12 ARNG/Reserve armory)
Training areas
D1 Range — small arms/individual weapons
D2 Range — crew-served weapons
D3 Range-aerial firing/bombing
D4 Range-infiltration course
D5 Designated nonfiring training area (obstacle/confidence course, parachute drop zone, landing zone, stagefield)
D6 Temporary training area (unit assembly area, bivouac area)
D7 Range-EOD
D8 Range tirehouse
D9 Urban training
Services facilities
E1 Library
E2 Chapel/church
E3 Child-care center
E4 Post office
E5 Laboratory
E6 Medical care facility
E7 Fire station
E8 Commissary
E9 Post exchange
E10 Dining facilities
E11 Service station, gas station, and shopette
E12 Museum
E13 Animal-care facility
E14 Refuse disposal area
E15 Laundry/cleaning facility
Terrain and water locations
F1 Sloped terrain (ditch, mountain)
F2 Wooded terrain (forest, swamp, marsh)
F3 Open terrain (field, desert)
F4 Moving bodies of water (creek, stream, river)
F5 Standing bodies of water (pond, lake, ocean)
F6 Lake shore/beach
Storage facilities
G1 Storage buildings (ammunition bunker, warehouse, barn, storage shed)
G2 Outside storage area (POL dump, property disposal area)
Plants and factories
H1 Heating plant
H2 Printing plant
H3 Electric generating plant (includes power substations)
H4 Ammunition/weapons manufacturing plant
H5 Other industrial plants and factories
Recreation/entertainment facilities
I1 Indoor facilities (bowling alley, gym, movie theater, swimming pool)
I2 Outdoor facilities (playing fields, golf course, swimming pool)
Housing facilities
J1 Family housing
J2 Individual housing (BOQ, barracks, rooms)
Freight and passenger terminals
K1 Airport/airfield (includes control tower)
K2 Rail station/yard
K3 Port/dock/wharf
K4 Vehicle terminal (bus station, truck terminal)
School facilities
L1 Kindergarten through grade 12
L2 Army-operated technical/occupational training facilities/classrooms (university/college classes)
L3 Non-Army-operated technical/occupational training facilities/classrooms (university/college classes)
Hobby shop
M1 Auto hobby shop
M2 Woodworking hobby shop
M3 Other hobby shop


Table 4-5. Pay Grade/Rank codes
Grade/code Description
O1-O10 Commissioned officer
W1-W5 Warrant officer
E1-E9 Enlisted service member
GS1-GS18 & GM13-GM18 DOD civilian employee
WG1-WG18 & WS13-WS18 Wage board employee
NSPS National Security Personnel System
XN Foreign National
X-1 Foreign officer
X-2 Foreign enlisted
CAC Civilian Army contractor
CIV Non-DOD civilian
DAC Department Army civilian
KAD USMA
ROTC ROTC students
NRPT Not Reported
OC WOC/OC
UNK Unknown
UNKE Unknown enlisted
UNKO Unknown officer
OTH Personnel other than above


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Table 4-6. Personnel classification codes
Code Description
A Active Army
B Army civilian
C Army contractor
C1 Army direct contractor
D Non-appropriated Fund employee
E0 Other U.S. military personnel
E1 Navy
E2 Air Force
E3 Marine Corps
F0 Foreign Military
F1 Foreign National Direct Hire
F2 Foreign National Indirect Hire
F3 Foreign National KATUSA
F4 Foreign Military Attached
G Dependent
M Government, Other
NO National Guard
N1 NG Tech
N2 NG IDT
N3 NG AT
N4 NG ADSW
N5 NG AGR
N6 NG ADT