United States General Accounting Office

GAO Briefing Report to the Ranking Minority

Member, Subcommittee on Military

Procurement, Committee on National

Security, House of Representatives

February 1996 MILITARY AIRCRAFT

SAFETY

Significant

Improvements Since

1975

GAO/NSIAD-96-69BR

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-270647 

February 1, 1996

The Honorable Ike Skelton

Ranking Minority Member

Subcommittee on Military Procurement

Committee on National Security

House of Representatives

Dear Mr. Skelton:

In May 1995, you noted that a number of military aircraft accidents had

occurred over a period of a few weeks, resulting in the death of more than

a dozen crew members and passengers. You requested that we conduct a

review of military aircraft accidents. Our objectives were to identify

(1) historical trends in aircraft accidents involving deaths or extensive

aircraft damage (Class A flight mishaps), (2) investigations performed to

determine the causes, and (3) examples of actions taken to reduce the

number of aviation accidents. We also analyzed investigation summaries to

identify the primary factors contributing to mishaps and reviewed studies

which addressed the relationship of operating tempo to aviation safety. As

agreed, we did not address your concern about alleged mishandling of

mishap investigations in the Air Force because the Department of Defense

(DOD) Inspector General was already examining those allegations. This

report reflects the information in our briefing to you on January 22, 1996.

Background A measure of aviation safety within DOD is the mishap rate—number of

Class A flight mishaps per 100,000 flying hours. DOD defines a Class A flight

mishap as one involving a DOD aircraft with an intent to fly, that resulted in

damages totaling $1 million or more, a destroyed aircraft, a fatality, or a

permanent total disability. DOD requires that Class A mishaps be

investigated so that causes can be identified and corrective actions taken

to prevent future occurrences.

Service safety centers1

 play a key role in maintaining aviation mishap

statistics, establishing safety policies, disseminating safety information,

reviewing mishap investigation reports, tracking recommendations, and

performing safety studies. In addition, the safety centers analyze trends to

identify potential safety hazards.

1

These centers are the Naval Safety Center, Norfolk, Virginia; Air Force Safety Agency, Kirtland Air

Force Base, New Mexico; and the Army Safety Center, Fort Rucker, Alabama. In addition to its

involvement in Navy safety, the Naval Safety Center also monitors investigations of Marine Corps

aviation mishaps.

Page 1 GAO/NSIAD-96-69BR Military Aircraft Safety
B-270647 

Results in Brief DOD aviation safety has improved significantly over the last 21 years.

Between fiscal years 1975 and 1995 for example, the annual number of

Class A mishaps decreased from 309 to 76, while the number of fatalities

decreased from 285 to 85. During this period, Class A mishaps per 100,000

flying hours, referred to as the mishap rate, also decreased from about

4.3 to 1.5. The value of Class A losses remained fairly constant over the

last 6 years, ranging from a high of about $1.6 billion in fiscal year 1993 to

a low of $1.2 billion in fiscal year 1994.

Although DOD requires that the services report and investigate Class A

aviation mishaps, service requirements differ as to who convenes the

investigation board and who participates as voting members. For example,

until recently only the Army required safety center investigators as voting

board members. Past GAO and Air Force studies have questioned the

independence of the investigators because of their organizational ties to

the mishap command. The Air Force has recently directed changes to

enhance the independence of its investigations.

Each of the services have taken steps to reduce aviation mishaps, such as

tracking mishap investigation recommendations and disseminating safety

information in manuals, newsletters, videos, and messages. Recent safety

initiatives include risk management and human factor studies. The Army,

for example, is developing a series of profiles for predicting whether an

aviation training mission is low, medium, or high risk. A subsequent

system will provide guidance for assessing operational risks and reducing

them to acceptable levels.

In fiscal years 1994 and 1995, human error was reported as a contributing

cause in 73 percent of the Class A flight mishaps. However, in a 1994

report,2

 examining its historical flight mishap data, the Air Force found no

direct correlation between operating tempo and safety mishaps. In 1995,

the Air Force Blue Ribbon panel reported some evidence connecting pace

of operations to aviation safety. Service statisticians, however, told us that

the relatively low incidence of Class A flight mishaps makes it difficult to

draw inferences and identify statistical correlations of variables with

mishap rates.

Agency Comments In commenting orally on a draft of this report, officials from the Office of

the Secretary of Defense, Air Force, Army, and Navy generally concurred

2

Safety Challenge: Identifying and Addressing Recent Trends in USAF Flight Mishaps, Office of the

Chief of Safety, Headquarters, United States Air Force, September 1994.

Page 2 GAO/NSIAD-96-69BR Military Aircraft Safety
B-270647 

with the findings. The Air Force provided documentation showing that the

recommendations of the Blue Ribbon Panel were being implemented.

Other recommended technical changes were incorporated throughout the

report as deemed appropriate.

Scope and

Methodology

We obtained and analyzed annual statistics, beginning in 1975, on the

number of Class A flight mishaps, fatalities, destroyed aircraft, and dollar

losses. We compared the services’ data, validated mishap rates, and

documented trends. We also analyzed mishap investigation summaries to

document causes contributing to flight mishaps.

We reviewed agency instructions and procedures regarding flight mishap

investigations, interviewed safety officials, and reviewed final reports. We

observed an Air Force safety investigation, discussed the investigation

with board members, and attended the outbrief at the major command. We

did not observe the board’s deliberations. We interviewed National

Transportation Safety Board officials and reviewed their investigation

procedures to provide some comparison with DOD’s safety investigations.

We reviewed studies dealing with the independence of investigations and

the possible relationship of operating factors to aircraft accident rates. We

also identified service initiatives to reduce aviation accidents.

We conducted our work from June 1995 to January 1996 in accordance

with generally accepted government auditing standards.

As arranged with your staff, unless you publicly announce its contents

earlier, we plan no further distribution of this report until 30 days from its

issue date. At that time, we will send copies to other interested

congressional committees and Members of Congress, and the Secretaries

of Defense, the Army, the Navy, and the Air Force. We will also make

copies available to other interested parties on request.

Page 3 GAO/NSIAD-96-69BR Military Aircraft Safety
B-270647 

The major contributors to this report are identified in appendix I. If you or

your staff have any questions concerning this report, please contact me on

(202) 512-5140.

Sincerely yours,

Mark E. Gebicke

Director, Military Operations and Capabilities

Page 4 GAO/NSIAD-96-69BR Military Aircraft Safety
Page 5 GAO/NSIAD-96-69BR Military Aircraft Safety
Contents

Letter 1

Briefing Section I 

Background

8

Criteria for Classes of Flight Mishaps 8

Briefing Section II 

Aircraft Mishap

Trends

10

Decrease in Number of Class A Flight Mishaps (Fiscal Years

1975-95)

10

Decrease in DOD Class A Mishap Rate (Fiscal Years 1975-95) 11

Decrease in Service Class A Flight Mishap Rates (Fiscal Years

1975-95)

12

Decrease in Class A Flight Mishap Fatalities (Fiscal Years

1975-95)

13

Decrease in DOD Rate of Class A Fatalities (Fiscal Years 1975-95) 14

Decrease in Number of Destroyed Aircraft (Fiscal Years 1975-95) 15

Decrease in Rate of Destroyed Aircraft (Fiscal Years 1975-95) 16

Value of Class A Flight Mishap Losses (Fiscal Years 1990-95) 17

Briefing Section III 

Mishap Investigations

18

Each Service Has Own Mishap Investigation Requirements 18

Concerns About Independence of Investigators 20

Briefing Section IV 

Actions Taken by

Services to Reduce

Mishaps

22

Actions Taken by Services to Reduce Mishaps 22

Briefing Section V 

Major Mishap Causes

24

Human Error Was Contributing Factor in High Percentage of

Flight Mishaps

24

Correlation Between Operating Tempo and Mishaps Is

Inconclusive

26

Appendix I 

Major Contributors to

This Report

28

Abbreviations

DOD Department of Defense

Page 6 GAO/NSIAD-96-69BR Military Aircraft Safety
Page 7 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section I 

Background

GAO Criteria for Classes of Flight Mishaps

Criteria for Class A flight mishaps 

include fatality or permanent total 

disability, destroyed aircraft, or damage 

of $1 million or more

Criteria for other classes based 

primarily on dollar value and severity of 

injury 

Page 8 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section I 

Background

Flight mishaps involve any reportable damage to an aircraft that is

preparing to fly, in flight, or completing a landing. Flight mishaps are

classified by DOD according to the severity of resulting injury or property

damage. Class A mishaps involve damage of $1 million or more, a

destroyed aircraft, or a fatality or permanent total disability. The

remaining classes of mishaps are distinguished primarily by their loss

value and severity of injury: Class B accidents involve damage of $200,000

to less than $1 million, permanent partial disability, or inpatient

hospitalization of five or more people; Class C accidents involve damage

of $10,000 to less than $200,000, or a lost-time injury; and Class D

accidents involve damage of less than $10,000.

Our review focused on Class A flight mishaps only.

Page 9 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in Number of Class A Flight 

Mishaps (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

50

100

150

200

250

300

350

Fiscal Year

Number of Mishaps

Navy/USMC Air Force Army

Between fiscal years 1975 and 1995, military aircraft were involved in 3,828

Class A mishaps, which resulted in 3,810 fatalities and 3,483 destroyed

aircraft.

The annual number of DOD Class A flight mishaps decreased from 309 in

fiscal year 1975 to 76 in fiscal year 1995. The Navy/Marine Corps reduced

the number from 158 to 34, the Air Force from 99 to 32, and the Army from

52 to 10.

Page 10 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in DOD Class A Flight 

Mishap Rate (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

1

2

3

4

5

Fiscal Year

Mishaps per 100,000 Flying Hours

DOD’s Class A mishap rate, calculated as the number of accidents per

100,000 flying hours, declined from about 4.3 in fiscal year 1975 to 1.5 in

fiscal year 1995.

Page 11 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in Service Class A Flight 

Mishap Rates (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

2

4

6

8

Fiscal Year

Mishaps Per 100,00 Flying Hours

Navy/USMC Air Force Army

As with the number of mishaps, each of the services has also experienced

an overall downward trend in its mishap rate since fiscal year 1975. In

particular, the Navy/Marine Corps mishap rate dropped significantly from

7.3 mishaps per 100,000 flying hours in fiscal year 1975 to 2.2 in fiscal year

1995. Air Force rates were reduced from about 2.8 to 1.5 during that

period. Army aviation experienced its best year in fiscal year 1995 with a

Class A mishap rate of 0.8—a reduction from 3.5 in fiscal year 1975.

Page 12 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in Class A Flight Mishap 

Fatalities (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

50

100

150

200

250

300

Fiscal Year

Number of Fatalities

Navy/USMC Air Force Army

The annual number of aviation fatalities has dropped significantly since

fiscal year 1975, when DOD reported 285, including 141 in the Air Force, 103

in the Navy/Marine Corps, and 41 in the Army. In fiscal year 1995, fatalities

had fallen to 85, including 53 in the Air Force, 17 in the Navy/Marine

Corps, and 15 in the Army.

Page 13 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in DOD Rate of Class A 

Fatalities (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

1

2

3

4

5

Fiscal Year

Fatalities per 100,000 Flying Hours

The number of DOD aviation fatalities per 100,000 flying hours fell from

about 4 in fiscal year 1975 to 1.7 in fiscal year 1995.

Page 14 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in Number of Destroyed 

Aircraft (Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

50

100

150

200

250

Fiscal Year

Number of Destroyed Aircraft

Navy/USMC Air Force Army

The number of destroyed aircraft resulting from flight mishaps fell

significantly between fiscal years 1975 and 1995. In fiscal year 1975, 221

were destroyed, including 117 Navy/Marine Corps, 52 Air Force, and 52

Army. The number of destroyed aircraft fell to 67 in fiscal year 1995, when

the Navy/Marine Corps reported 31, the Air Force 29, and the Army 7.

Page 15 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Decrease in Rate of Destroyed Aircraft 

(Fiscal Years 1975-95)

1975 1980 1985 1990 1995

0

1

2

3

4

Fiscal Year

Destroyed Aircraft per 100,000 Flying Hours

Since fiscal year 1975, the annual rate of destroyed aircraft per 100,000

flying hours was reduced from 3.1 to 1.3.

Page 16 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section II 

Aircraft Mishap Trends

GAO Value of Class A Flight Mishap Losses

(Fiscal Years 1990-95)

1990 1991 1992 1993 1994 1995

0

500

1,000

1,500

2,000

Fiscal Year

Dollars in millions

Navy/USMC Air Force Army

Since fiscal year 1975, the services report the cost of Class A flight

mishaps at about $21 billion. The value of Class A losses has been fairly

constant over the last 6 years, ranging from a high of approximately

$1.6 billion in fiscal year 1993 to a low of $1.2 billion in fiscal year 1994.

Even given that fiscal years 1994 and 1995 had generally low mishap rates,

the value of Class A losses still exceeded $2.5 billion during that time,

totaling about $1.2 billion in fiscal year 1994 and $1.3 billion in fiscal year

1995.

Page 17 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section III 

Mishap Investigations

GAO Each Service Has Own Mishap 

Investigation Requirements

Army - Safety center provides voting 

board president and recorder.

Navy - Standing mishap board from 

command having custody of aircraft. 

Safety center provides non-voting 

member.

Air Force - Prior to Oct. 1995, board 

convened by numbered AF having 

custody of aircraft . No voting board 

member from safety agency. 

Page 18 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section III 

Mishap Investigations

DOD requires investigations of all Class A flight mishaps in order to

determine the causes and reduce future risks of property damage, injuries,

or deaths. However, each service has established its own requirements

regarding how the investigations are performed and reported.

The Army assigns at least two safety investigators from its safety center to

each Class A mishap investigation—the board president and recorder.

Other members of the investigation team are assigned from the command

having the mishap, other Army commands or DOD agencies, or private

industry. The investigating team is responsible for finding the cause(s) and

preparing the final report. Command review and approval occur after

preparation of the draft investigation report.

The Navy requires that aircraft reporting custodians appoint and maintain

standing aircraft mishap boards to investigate Class A flight mishaps.

According to Naval Safety Center data, in about 75 percent of the Class A

mishap investigations, a professional investigator from the center is sent

to assist the board. The Safety Center representative is not a voting

member of the board. However, the Commander of the Naval Safety

Center does not see this as a problem since he is the final endorser of the

report. In addition, although not required by regulation, the Commander

also receives an independent briefing from his representative on the

board’s tentative findings and conclusions. Each endorser up the chain of

command must comment on the report in turn, presenting evidence, if

appropriate, for suggested changes. Endorsements become part of the

report and are available for review as the report goes up the chain.

Following its final endorsement, the Safety Center tracks recommended

corrective action to completion.

Prior to October 1995, the responsible Air Force major command routinely

delegated the responsibility for convening the investigative board to the

numbered Air Force that was the custodian of the mishap aircraft. The

board president, as well as other members, were normally selected from

units within the numbered Air Force. The Air Force Safety Agency

generally did not provide a voting member to participate in the

investigation. Following the investigation, the board briefed its findings to

the major command prior to finalization of the report. In October 1995, the

Air Force implemented several changes to its investigation procedures as a

result of recommendations made by a Blue Ribbon Panel appointed by the

Air Force Chief of Staff.

Page 19 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section III 

Mishap Investigations

GAO Concerns About Independence of 

Investigators

GAO's 1994 report

Navy investigators lack independence

AF Blue Ribbon Panel's report

Undue command influence on board

Lack of experienced investigators

Too much pressure regarding time

Process credibility depends on 

independence of the board 

Page 20 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section III 

Mishap Investigations

A recurring issue of concern has been the independence of accident

investigators. Our 1994 report1

 noted the Navy investigators’ lack of

independence because of the investigators’ organizational ties to the

mishap command. The Navy has not taken action on that finding. A Blue

Ribbon Panel convened by the Air Force to address aviation safety stated

in its 1995 report that mishap investigation boards should be more

independent of the convening authority.2

 As a result of the panel’s

recommendations, the Secretary of the Air Force (1) directed that the

major command not delegate the convening authority for Class A

investigations, (2) mandated safety courses for key board members,

(3) directed that an Air Force safety center representative be a voting

member on all Class A flight mishap investigations, and (4) clarified that

only the voting members of the board can change the final report.

1

Military Training Deaths: Need to Ensure That Safety Lessons Are Learned and Implemented

(GAO/NSIAD-94-82, May 5, 1994).

2

The Blue Ribbon Panel on Aviation Safety, Department of the Air Force (Sept. 5, 1995).

Page 21 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section IV 

Actions Taken by Services to Reduce

Mishaps

GAO Actions Taken by Services to Reduce 

Flight Mishaps

Track recommendations

Disseminate safety information 

Undertake special initiatives

Service safety centers track the implementation of recommendations

stemming from mishap investigations. Within the Air Force, the Safety

Agency maintains a centralized database of open recommendations and

solicits status reports semi-annually. Major operational commanders track

and report their disposition of open recommendations for inclusion in the

safety center database. In the Army, the responsibility for tracking the

status of open recommendations rests with the Safety Center in

coordination with the major commands. The Army Safety Center conducts

Page 22 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section IV 

Actions Taken by Services to Reduce

Mishaps

quarterly reviews of open recommendations and documents the actions

taken on each recommendation. The Navy places responsibility for

ensuring that recommendations are implemented with safety center

analysts, who monitor the recommendations associated with one or more

aircraft models. In addition to tracking recommendations, the services

disseminate a variety of information aimed at reducing flight mishaps. This

information includes changes to manuals and procedures, safety

newsletters, videos of specific mishaps that identify the causes, and safety

messages.

The services also undertake special initiatives aimed at reducing mishap

rates. Earlier this year, for example, the Air Force convened a panel to

review aviation safety. This panel was appointed on June 23, 1995,

following a spate of aircraft mishaps during the early part of fiscal year

1995, the highly publicized allegations that Air Force mishap investigations

lacked quality and objectivity, and your request that GAO undertake this

review. While the panel found that the long-term trends of reduced mishap

rates reflected favorably on the general soundness of the Air Force’s safety

program, the panel made a number of recommendations aimed at

improving investigation objectivity and reducing human errors as a causal

factor.

Additionally, the Army undertook a study to determine the causes for an

increase in OH-58 helicopter mishaps. The Army determined that a

disproportionate number of accidents had taken place at night and

involved human error. The Army then developed a series of profiles for

predicting whether a mission was low, medium, or high risk. From this,

the Army began using a system to assess the risk prior to each OH-58 night

mission, as well as guidance for reducing the risk to acceptable levels. The

Army attributes the subsequent downward trend in OH-58 accidents to this

initiative. Army officials informed us that they plan to expand the use of

this risk management system to include other aircraft. The Air Force and

Navy are also developing risk assessment programs.

Operational commanders have also ordered flight operations to cease for a

specific time period so that personnel can focus on safety issues.

Additionally, the services have undertaken a number of studies looking at

cause-and-effect relationships and their impact on mishap rates. An

example of an ongoing study concerns two types of Air Force mishaps,

those involving air traffic control operations and those involving rescue

helicopters. Both kinds of mishaps have experienced notable increases

during the past 2 years.

Page 23 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section V 

Major Mishap Causes

GAO

During fiscal years 1994-95, human error 

was a factor in

71 percent of Air Force mishaps

76 percent of Army mishaps

74 percent of Navy/USMC mishaps

Human Error Was Contributing Factor 

in High Percentage of Flight Mishaps 

Page 24 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section V 

Major Mishap Causes

In their efforts to reduce aviation mishaps, the services focus on the

contributing causes that can be grouped by human error, material, and

environmental. On the basis of data reported by the services and our own

analyses, human error contributed to 73 percent of the Class A flight

mishaps in fiscal years 1994 and 1995. Human error, as a contributing

factor, ranged from a high of 76 percent in Army mishaps to approximately

71 percent in Air Force mishaps. The Naval Safety Center provided data

showing that human error was a causal factor in 80 percent of Navy and

Marine Corps Class A flight mishaps for fiscal years 1990 through 1994.

Page 25 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section V 

Major Mishap Causes

GAO Correlation Between Operating Tempo 

and Mishaps Is Inconclusive

1994 Air Force report

No direct correlation 

1995 Blue Ribbon Panel's report 

Operating tempo presents safety risks

Recommended AF review safety 

impact of reduced experience levels

Statisticians say limited number of 

mishaps make correlation difficult

Page 26 GAO/NSIAD-96-69BR Military Aircraft Safety
Briefing Section V 

Major Mishap Causes

While service studies have addressed the relationship of operating tempo

to aviation mishaps, direct correlation has been inconclusive. For

example, in 1994 the Secretary of Defense requested the Air Force

examine the relationship between operating tempo and other readiness

indicators and flight mishap rates. The Air Force’s final report issued in

September 1994, provided no direct correlation between operating tempo

and safety mishaps.

In a September 1995 report, the Blue Ribbon Panel noted that “the current

’Operations Tempo’ in the Air Force presents an obvious operational

safety risk.” The report pointed to many factors contributing to this

assessment such as organizational change, reduced maintenance and

leadership manning within squadrons, and extended duty days of both

flying and maintenance personnel. The panel believed that the Air Force

should take actions to reduce stress on aircrew and maintenance

personnel and recommended that the Air Force review the safety impact

of reduced manning and aircraft numbers without corresponding changes

in operational requirements.

Service statisticians, however, told us that the relatively low incidence of

Class A flight mishaps make drawing inferences and statistical

correlations of variables with mishap rates difficult.

Page 27 GAO/NSIAD-96-69BR Military Aircraft Safety
Appendix I 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Sharon A. Cekala, Associate Director

William E. Beusse, Assistant Director

Norfolk Regional

Office

Hugh Brady, Evaluator-in-Charge

Sharon Reid, Evaluator

Harry E. Taylor, Jr., Evaluator

(703108) Page 28 GAO/NSIAD-96-69BR Military Aircraft Safety
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