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NCMAS 

National Commission on 

Military Aviation Safety

Report to the President and the Congress of the United States

DECEMBER 1, 2020

MILITARY AVIATION LOSSES FY2013–2020

224 Lives

$11.6 billion

186 aircraft
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NCMAS 

National Commission on 

Military Aviation Safety

Report to the President and the Congress of the United States

DECEMBER 1, 2020

Cover image: U.S. Air Force F-22 Raptors from the 199th Fighter Squadron Hawaii 

Air National Guard and the 19th Fighter Squadron at Joint Base Pearl HarborHickam perform the missing man formation in honor of fallen servicemembers during 

a Pearl Harbor Day remembrance ceremony. The missing man formation comprises 

four aircraft in a V-shape formation. The aircraft in the ring finger position pulls up 

and leaves the formation to signify a lost comrade in arms. (Department of Defense 

photo by U.S. Air Force Tech. Sgt. Michael R. Holzworth.)
2

The National Commission on Military Aviation Safety dedicates its work 

to the men and women who serve in the aviation units of the U.S. Army, 

U.S. Navy, U.S. Marine Corps, and U.S. Air Force.

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NCMAS 
i

More than 6,000 U.S. noncombat military aviation 

mishaps occurred between 2013 and 2018. These 

mishaps occurred during training or routine operations. 

They claimed the lives of 198 servicemembers and civilians 

and cost the nation more than $9.41 billion in damages, 

including 157 destroyed aircraft. 

The U.S. Congress created the National Commission 

on Military Aviation Safety in 2019 to examine the rates 

and causes of mishaps and recommend ways to improve 

aviation safety. While this Commission was conducting its 

study, military aviation mishaps claimed another 26 lives, 

29 aircraft, and $2.25 billion.

The seven commissioners represent a diversity of 

individual experiences in military operations, national 

defense policy, aircraft manufacturing, and aviation 

safety. We share a devotion to saving lives and improving 

readiness in the Services’ aviation units. Supported by a 

dedicated staff led by Major General Gregory A. Feest, 

U.S. Air Force Retired, this Commission reviewed the 

military aviation mishap reports from 2013–2018, 

consulted previous studies, interviewed experts in 

military and commercial aviation safety, and met with 

servicemembers in aviation units across the Services. 

We visited more than 200 aviation-related military 

and civilian organizations across the spectrum of 

missions and aircraft, meeting with thousands of aviation 

professionals of all ranks. In nonattributional town halls 

and roundtables, servicemembers shared their experiences 

and concerns. The insights and information they shared 

with us aligned with trends we saw in the empirical 

data. We came away from our visits impressed with the 

patriotism, dedication, and level of effort throughout 

the ranks of America’s military aircrews and maintainers. 

We also came away deeply troubled by the chronic 

fatigue we saw among these brave servicemembers. The 

current operations tempo (OPTEMPO) is leading to 

unsafe practices and driving experienced aviators and 

maintainers out of the force.

In addition to the operational demand, our findings 

focus on four areas where Congress and the Department 

of Defense can take immediate steps to reduce aviation 

mishaps: Pilots should fly; maintainers should maintain; 

data can save lives; funding should be consistent. 

We, the members of the National Commission on 

Military Aviation Safety, thank the Services’ safety centers 

for their assistance to the Commission throughout the 

course of this study. We thank the commanders who 

hosted us and provided unfettered access to the people 

serving in their units. We thank every one of those 

men and women for their service and for their candid 

comments. Protecting their safety is a moral imperative 

and critical to ensuring that they can continue to serve 

the United States of America as effective, experienced 

aviation professionals so essential to our national security. 

Letter from the Commission

OUR COMMITMENT

General Richard A. Cody (USA, Retired), Chairman

The Honorable Scott C. Donnelly

The Honorable Preston Geren

The Honorable Joseph W. Hagin

The Honorable Richard F. Healing, Vice Chairman

General Raymond E. Johns (USAF, Retired)

The Honorable Dabney R. Kern
ii

Our Commitment i

Executive Summary v

Aircrews and Maintainers v

Data Deficiencies and the Need for 

a Joint Safety Council vi

Consistent and Predictable Resourcing vi

Conclusion vii

Mission and Method 1

Conducting Its Study 2

The Human-Machine-Environment Framework 3

Chapter 2: Assessing Mishap Rates 5

Assessing and Characterizing Mishap Rates 5

Visualizing and Contextualizing the Rates 5

Comparing the Period Means 9

Identifying Troubling Trends 10

The Commission’s Assessment and Findings 12

Additional Assessment 13

Chapter 3: Military Aviation Safety Data 15

Assessing the Causes and Contributing 

Factors of Mishaps 15

The Human Factors Analysis and 

Classification System (HFACS) 15

The Limitations 16

Preemptive Aviation Safety Data Collection 20

Chapter 4: The Joint Safety Council 23

The Safety Success of Commercial Aviation 23

Establishing a Joint Safety Council 25

Chapter 5: The Human/Machine Interface 29

Physiological Episodes 29

No Single Problem, No Single Solution 29

Prioritizing the Human 32

Chapter 6: Sustaining the Machine 37

Aviation Supply System 37

Overcoming Supply Deficiencies 38

Depot Maintenance 38

Facilities 38

Aircraft Transition Issues 39

Chapter 7: The Need for Consistent and 

Predictable Funding 41

Continuing Resolutions 41

Chapter 8: The Demand Environment 45

More Demand than Capacity 45

Additional Duties 47

Chapter 9: Maintainers as Aviation 

Professionals 51

Measuring Training Efficacy 52

On-the-Job Training 52

Experience Matters 53

Talent Management for Aviation Maintainers 55

Maintainers Want to Maintain 55

Chapter 10: Protecting Investment 

in Aircrews 59

Pilot Training 59

The Right Training Medium 62

In Memoriam 67

Appendixes

A. Congressional Charter for the National 

Commission on Military Aviation Safety A-1

B. Recommendations B-1

C. Commissioners and Staff C-1

D. Commission Engagements D-1

E. Bibliography E-1

F. Technical Appendix F-1

G. Key Military Aviation Safety Policy 

Guidance G-1

H. Joint Safety Council Proposed Legislation H-1

I. Glossary and Acronym List I-1

TABLE OF CONTENTS
iii

List of Graphics

Figure 1-1: Mishaps, Fatalities, Destroyed Aircraft, 

and Estimated Costs Across DoD for Fiscal Years 

2013–2018 1

Figure 1-2: Mishap Classifications During Study 

Period, Fiscal Years 2013–2018 2

Figure 1-3: Human-Machine-Environment Framework 3

Figure 2-1: Visualizing Class A Mishap Rates 6

Figure 2-2: Class A Aggregate Mishap Estimated 

Derived Costs (in Millions) by Service for Fiscal 

Years 2007–2018 6

Figure 2-3: Visualizing Class B Mishap Rates 7

Figure 2-4: Class B Aggregate Mishap Estimated 

Derived Costs (in Millions) by Service for Fiscal Years 

2007–2018 7

Figure 2-5: Visualizing Class C Mishap Rates 8

Figure 2-6: Class C Aggregate Mishap Estimated 

Derived Costs (in Millions) by Service for Fiscal 

Years 2007–2018 8

Figure 2-7: Comparing the Fiscal Years 2007–2012 

and Fiscal Years 2013–2018 Rate Means Across 

the Services and Mishap Classes 9

Figure 2-8: Class A Mishap Rates and Rolling 

Averages by Service for Fiscal Years 2007–2018 10

Figure 2-9: Class B Mishap Rates and Rolling 

Averages by Service for Fiscal Years 2007–2018 11

Figure 2-10: Class C Mishap Rates and Rolling 

Averages by Service for Fiscal Years 2007–2018 11

Figure 2-11: Visualizing Class A-C Mishap Rates 12

Figure 2-12: Mishap Rates for Fiscal Years 2013–2019 13

Figure 3-1: Aviation Mishap Categories and 

Subcategories 16

Figure 3-2: Flight, Flight-Related, and Ground Mishaps 

by Class and Service for Fiscal Years 2013–2018 17

Figure 3-3: The DoD HFACS 18

Figure 5-1: Air Force Physiological Episodes by 

Aircraft Type for Fiscal Years 2013–2018 30

Figure 5-2: Navy and Marine Corps Physiological 

Episodes by Aircraft Type for Fiscal Years 2013–2018 30

Figure 5-3: Air Force Physiological Episodes in Fighter 

and Trainer Aircraft for Fiscal Years 2013–2018 30

Figure 5-4: Navy and Marine Corps Physiological 

Episodes in Fighter and Trainer Aircraft for Fiscal 

Years 2013–2018 30

Figure 5-5: Human Systems Integration in 

the Acquisition Planning Process 34

Figure 7-1: Days Under a Continuing Resolution: 

Department of Defense, Fiscal Years 2002–2019 42

Figure 8-1: OPTEMPO 46

Figure 9-1: Army AH-64 Helicopter Maintainer Average 

Months of Service by Skill Level and 

Fiscal Year 53

Figure 9-2: Army Aircraft Maintenance Senior Sergeant 

Average Months of Service by Skill 

Level and Fiscal Year 54

Figure 9-3: Air Force Refuel/Bomber Aircraft Maintainer 

Average Years of Service by Skill 

Level and Fiscal Year 54

Figure 10-1: Army AH-64D Course Changes 59

Figure 10-2: Navy and Marine Corps F-18 

Course Changes 59

Figure 10-3: Air Force F-16 Course Changes 59

Figure 10-4: Examples of Cost Comparison of Actual 

Flight Hours to Simulators, Fiscal Year 2019 62

Figure F-1: Class A Mishap Rates F-1

Figure F-2: Class B Mishap Rates F-2

Figure F-3: Class C Mishap Rates F-2

Figure F-4: Class A–C Mishap Rates F-3

Figure F-5: Fatalities and Destroyed Aircraft 

by Service for Fiscal Years 2007–2018 F-4

Figure F-6: Mishap Classification Criteria Changes 

per DODI 6055.07, Mishap Notification, 

Investigation, Reporting, and Record Keeping F-5

Figure F-7: Army Top 10 HFACS Applications 

in Class A Mishaps for Fiscal Years 2013–2018 F-6

Figure F-8: Air Force Top 10 HFACS Applications 

in Class A Mishaps for Fiscal Years 2013–2018 F-6

Figure F-9: Navy Top 10 HFACS Applications 

in Class A Mishaps for Fiscal Years 2013–2018 F-7

Figure F-10: Marine Corps Top 10 HFACS Applications 

in Class A Mishaps for Fiscal Years 2013–2018 F-7

Figure F-11: Army Top 10 HFACS Applications in 

Class B Mishaps for Fiscal Years 2013–2018 F-8

Figure F-12: Air Force Top 10 HFACS Applications 

in Class B Mishaps for Fiscal Years 2013–2018 F-8

Figure F-13: Navy Top 10 HFACS Applications in 

Class B Mishaps for Fiscal Years 2013–2018 F-9

Figure F-14: Marine Corps Top 10 HFACS Applications 

in Class B Mishaps for Fiscal Years 2013–2018 F-9

Figure F-15: Army Top 10 HFACS Applications in 

Class C Mishaps for Fiscal Years 2013–2018 F-10

Figure F-16: Air Force Top 10 HFACS Applications 

in Class C Mishaps for Fiscal Years 2013–2018 F-10

Figure F-17: Navy Top 10 HFACS Applications 

in Class C Mishaps for Fiscal Years 2013–2018 F-11

Figure F-18: Marine Corps Top 10 HFACS 

Applications in Class C Mishaps for Fiscal Years 

2013–2018 F-11
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National Commission on Military Aviation Safety

Marines with Marine All Weather Attack Squadron 224, 

Marine Aircraft Group 31, 2nd Marine Aircraft Wing, prepare 

an F/A-18 for flight at Naval Air Facility El Centro, California. 

(Department of Defense photo.)
v

EXECUTIVE SUMMARY

“What do you think will cause the next 

aviation mishap?”

The National Commission on Military Aviation Safety 

asked thousands of pilots and maintainers this question 

during visits to military flight lines. Across the country, 

certain answers were consistently repeated, regardless 

of Service, rank, or airframe: insufficient flight hours, 

decreasing proficiency levels, inadequate training 

programs, excessive administrative duties, inconsistent 

funding, risky maintenance practices, and a relentless 

operations tempo. 

The Commission also independently assessed this 

same question. The Commission reviewed thousands of 

mishap reports, consulted volumes of secondary research, 

and conducted data analysis to determine why mishap 

rates have increased. The Commission also utilized its 

resident knowledge and experience: two retired fourstar military aviators; a former member of the National 

Transportation Safety Board and Director of Safety and 

Survivability for the Navy; a former Secretary of the 

Army who had previously served as Acting Secretary of 

the Air Force and as a member of Congress; an engineer 

turned CEO for major aircraft manufacturers; a White 

House Deputy Chief of Staff for Operations who served 

four presidents; and a former Navy helicopter pilot who 

oversaw Air Force One and Marine One while director of 

the White House Military Office. 

This report shares critical perspectives from the 

flight line and addresses the safety concerns that so many 

aviators and maintainers candidly shared. This report 

also covers broader topics in the Commission’s statutory 

charter, such as aviation mishap rates, unexplained 

physiological episodes, and aviation maintenance delays. 

The complete list of the Commission’s recommendations 

is provided in Appendix B. 

During its study, the Commission realized that 

many aviation safety issues are uniquely interconnected 

and require collaborative, cross-cutting solutions. For 

example, increasing spare parts inventories does little 

good if there are not enough experienced maintainers to 

install them. Fixing one issue may require fixing several 

related issues, and all solutions must be crafted to work 

in concert. In this report, the Commission took special 

care to balance competing and sometimes conflicting 

priorities, and its recommendations are proposed with an 

understanding of the importance of harmonization. 

Our findings and recommendations focus on four 

areas where Congress and the Department of Defense can 

take immediate steps to reduce aviation mishaps: Pilots 

should fly; maintainers should maintain; data can save 

lives; and funding should be consistent. 

Aircrews and Maintainers

The Commission found that aviation and maintenance 

experience, the key to doing a job safely and efficiently, 

is declining. Newly trained pilots and maintainers are 

reporting to operational units without basic skills. 

Flight hours are being replaced with simulator hours, 

yet the simulators are often outdated, out of service, 

or unavailable. Aircrews and maintainers are saddled 

with additional nonaviation duties that are more valued 

than their primary duties for purposes of promotion. 

Furthermore, 

on top of their 

experience gaps, 

some aircrews 

are experiencing 

physiological 

episodes when 

an aircraft’s 

environmental 

systems fail to 

meet the needs of 

the pilot. 

This report addresses these issues in detail. Two 

chapters address the shortcomings in initial training, 

follow-on training, and personnel management of 

aircrews and maintainers. One chapter examines the 

effects of a relentless pace on military aviation for both 

machine and personnel. Another chapter discusses the 

human-machine interface and recommends changes in 

the acquisition process to better meet the needs of the 

pilot during aircraft design and modification. 

“Additional Duties. . . We 

have an instructor pilot 

trying to get a forklift 

license.”

—USAF Junior Officer 
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National Commission on Military Aviation Safety

However, while addressed in separate chapters, 

these are compounding problems. A reduction in flight 

hours for new pilot training adds to the requirements for 

operational units. These units, already overtasked from 

a high operations tempo, must then conduct training 

to develop basic 

skills for new 

personnel. This 

stagnates the units’ 

ability to conduct 

high-level training. 

In other words, 

junior pilots and 

maintainers are starting their careers a lap behind, and 

then never catching up, all while their units buckle under 

the additional stress of getting them up to speed. This, 

in turn, leads to further costs. By being overworked, 

overstressed, and overloaded with additional duties 

unrelated to aviation, the morale and readiness of 

aircrews and maintainers erode. Experienced aircrews 

and maintainers leave the Services and are replaced 

by personnel with no expertise. The average level of 

experience falls, and the cycle repeats. 

To address these issues, the Commission 

recommends a multipronged approach. As outlined in 

the report, the Services must improve the training of 

new pilots and maintainers to broaden their experience 

and limit the burden on operational units. Additionally, 

the Services must increase the retention of experienced 

aircrews and maintainers through better personnel 

management, increased bonuses, and better schooling 

opportunities. The Services, having invested years and 

millions of dollars in initial, on-the-job, and advanced 

training, must focus the careers of aviation professionals 

on their aviation duties. Furthermore, to increase safety 

and readiness, the Services must ensure that aircraft are 

designed to match the needs of the aircrew who fly them. 

Without such complementary solutions, the U.S. military 

could be left with the worst of all worlds: increased costs, 

decreased readiness, and eroded safety margins. 

Data Deficiencies and the Need for a Joint 

Safety Council

During its study, the Commission identified numerous 

data deficiencies in military aviation. Due to poor data 

collection and analysis, the Services and the Department 

of Defense are missing out on valuable opportunities 

to reduce risk, prevent mishaps, and optimize human 

performance. This is repeatedly referenced in the report. 

For example, one chapter explains how the Department 

lacks sufficient data collection methods and analysis 

capabilities to reduce risks and improve safety, while the 

Services lack standardized procedures and consistent 

processes in their mishap reporting. Another chapter 

examines how improved pilot monitoring could 

help identify, understand, and reduce unexplained 

physiological episodes. Additional chapters discuss the 

need for improved data collection to measure training 

efficacy for pilots and maintainers.

In studying these issues, the Commission reviewed 

the current practices of commercial aviation, which has 

successfully used data analytics to identify and reduce 

safety risk. While certain commercial practices are 

limited in their applicability to military aviation, the 

Commission identified policies and practices that offer 

opportunities to 

reduce risk and 

improve safety. 

For example, 

compared to the 

commercial sector, 

the Commission 

determined that 

the Department 

of Defense is not properly organized to conduct data 

analytics, coordinate aviation safety activities, develop 

safety standards or data collection requirements, or review 

the Services’ implementation of aviation safety programs.

The Commission recommends creating a Joint Safety 

Council. Reporting to the Deputy Secretary of Defense, 

the council would be responsible for establishing military 

aviation safety standards, collecting and analyzing 

safety data, and developing safety priorities. Led by 

safety officials from the Services, the council would 

have the necessary expertise and authority to monitor 

and coordinate aviation safety programs across the 

Department. This recommendation is further outlined 

in Chapter 4, and a legislative proposal is contained in 

Appendix H.

Consistent and Predictable Resourcing

The question of the next mishap was not hard to 

answer at one Marine base, where a junior Marine told 

the Commission that his unit was reusing expendable 

$5 filters on aircraft. The unit, he explained, still had 

missions to do even if there was no money to purchase 

new filters. This was one of the egregious examples the 

Commission found, and it was a direct result of funding 

suddenly being withdrawn to meet other priorities. 

Inconsistent funding, and the tolerance it fosters for 

maintenance shortcuts, were the likely causes of the 

next mishap at this unit.

“We are doing 12-hour 

days, five days a week, 

and hardly flying.”

—F-22 Pilot 

“Guys are going to take 

risks they don’t even 

know is a risk.”

—Marine Supervisor
vii

Executive Summary

A lack of consistent funding is especially pernicious 

to military aviation safety. Flying, like surgery and 

other highly technical professions, is a perishable skill 

that needs 

routine practice 

to maintain 

proficiency. When 

a unit’s funding 

is restored in the 

last part of a fiscal 

year, it simply 

cannot make up 

for lost training 

and deferred 

maintenance. 

Late funding, no matter the amount, cannot reverse the 

impact of months of insufficient flying hours, missing 

parts, and deferred maintenance. Timing is everything.

By far the greatest and most preventable source of 

unpredictable funding is Congress’s use of continuing 

resolutions. The Department of Defense has begun the 

fiscal year with a continuing resolution for 13 of the past 

18 fiscal years. As continuing resolutions have become 

more common, their average duration has also increased. 

There is near universal agreement that continuing 

resolutions significantly degrade readiness, waste money, 

and put the lives of Servicemembers at unnecessary risk. 

The Commission concurs and heard examples from 

every Service of how inconsistent funding degrades 

virtually every aspect of military aviation. However, 

empirical research on the impact of continuing 

resolutions is lacking. Therefore, while the Commission 

first recommends that the Department of Defense and 

Congress resource military aviation in a consistent and 

predictable manner, the Commission also recommends 

that Congress require a comprehensive, data-driven 

analysis of continuing resolutions’ impact on military 

aviation.

Conclusion

In line with the Commission’s statutory charter, this 

report provides a comprehensive review of military 

aviation safety. The issues outlined above remain 

illustrative, not exhaustive. Overall, this report addresses 

numerous topics related to military aviation, including 

mishap rates, safety data, unexplained physiological 

effects, sustainment management systems, funding, 

operations tempo, training, and talent management. Each 

of these topics warrants careful review and attention, 

particularly due to the stakes involved. 

During the Commission’s six-year study period, 

aviation mishaps cost the U.S. military 198 lives, 157 

aircraft, and well over $9 billion in damages. To reduce 

these unacceptable costs, the Commission stresses that 

systemic problems require integrated solutions that 

prioritize safety. The cost of doing anything else is simply 

too high. 

“I can always use 

more money, but the 

thing I really need is 

predictability: budget for 

five years, [and] get it on 

October 1.”

—Senior USAF Leader
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National Commission on Military Aviation Safety

Photo that sets the tone for the chapter. TBD

Members of the National Commission on Military Aviation Safety speak with 

an advanced individual training student at Joint Base Langley-Eustis, Virginia. 

(U.S. Air Force photo by TSgt. Robert Hicks.)
1

One hundred ninety-eight military personnel and 

civilians died in U.S. military aviation mishaps 

between fiscal years 2013 and 2018 in non-combat 

operations. The total cost of equipment lost or damaged 

in these mishaps was more than $9.41 billion, including 

157 aircraft destroyed (Figure 1-1). 

Beginning in the summer of 2017, all of the Services 

experienced a series of high-profile mishaps over the next 

12 months that called into question the overall state of 

military aviation safety. A Marine Corps KC-130 came 

apart in the sky over Mississippi, killing 15 Marines 

and one Navy corpsman. An Army UH-60 crashed into 

the sea during a night exercise off the coast of Oahu, 

Hawaii, killing all five aboard. A Navy C-2A Greyhound 

ditched into the Philippine Sea with three fatalities. An 

Air Force Thunderbird F-16C crashed in Nevada, killing 

the pilot. A Puerto Rico Air National Guard C-130H 

Hercules on its retirement flight to Davis-Monthan Air 

Force Base, Arizona, crashed after takeoff in Georgia, 

killing all nine aboard. During the same time period, Air 

Force and Navy pilots experienced a mysterious spike 

in unexplained physiological episodes (hypoxia-like 

symptoms). As investigators struggled to find the root 

causes for these episodes, both the Air Force and Navy 

grounded their fleets of T-6 trainers. 

This spate of fatal mishaps combined with the 

increase of reported physiological episodes prompted 

the U.S. Congress to establish the National Commission 

on Military Aviation Safety in the John S. McCain 

National Defense Authorization Act (NDAA) for Fiscal 

Year 2019. The Commission’s charter, as spelled out 

in that law, charged the commissioners to “undertake 

a comprehensive study of United States military 

aviation mishaps that occurred between fiscal years 

2013 and 2018.” The charter (see Appendix A) gave the 

Commission five tasks to accomplish in its study:

1. to assess the rates of military aviation mishaps 

between fiscal years 2013 and 2018 compared to 

historic aviation mishap rates;

2. to assess the underlying causes contributing to 

the unexplained physiological effects;

3. to assess the causes contributing to delays in 

aviation maintenance and limiting operational 

availability of aircraft;

Chapter 1: 

MISSION AND METHOD

Figure 1-1: 

Mishaps, Fatalities, Destroyed Aircraft, and Estimated Costs Across DoD for Fiscal Years 2013–2018

2013 2014 2015 2016 2017 2018 2013-

2018

Number of Class A Mishaps1 48 49 53 42 52 56 300

Number of Class B Mishaps1 78 80 85 90 83 82 498

Number of Class C Mishaps1 786 836 869 909 982 899 5,281

Number of Class A-C Mishaps1 912 965 1,007 1,041 1,117 1,037 6,079

Number of Fatalities2 24 22 38 39 36 39 198

Number of Destroyed Aircraft2 30 27 24 28 27 21 157

Class A–C Mishaps Estimated Total 

Derived Costs (in billions)2 $1.57 $1.48 $1.31 $1.78 $1.87 $1.39 $9.41

Source: 1Service safety centers; 2Force Risk Reduction database.

Human Environment

Machine
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National Commission on Military Aviation Safety

4. to assess the causes contributing to military 

aviation mishaps; and

5. to make recommendations on the modifications, 

if any, of safety, training, maintenance, 

personnel, or other policies related to military 

aviation safety.

The charter also directed the Secretary of Defense, 

in coordination with the Secretary of each military 

department, to submit, within 120 days from the 

Commission’s delivery of its report, an assessment of the 

Commission’s findings and conclusions and a plan for 

implementing the recommendations. 

Conducting Its Study

The Commission approached these tasks with an 

understanding that readiness is inextricably tied to safe 

operations. The Commission’s view of aviation mishaps 

encompassed both the events leading directly to the 

mishaps as well as the incidents themselves. The study 

analyzed the full spectrum of operational conditions and 

institutional factors far beyond quantitative data. 

The Commission conducted its own primary 

research and analysis to arrive at its assessments and 

recommendations. The study focused on three streams 

of information: analyzing the mishap reports and 

quantitative data; consulting volumes of secondary 

research; and, most importantly, traveling to 82 locations 

to meet with aviation professionals. In addition to 

extensive quantitative data, the Commission found 

significant value in hearing personal experiences and 

concerns directly from Service personnel. The Services’ 

safety centers connected the Commission with points of 

contact for the site visits and with subject matter experts 

and other data sources. 

Mishap Reports and Quantitative Data

The Commission reviewed Class A, B, and C mishap 

reports (see Figure 1-2) from the military departments’ 

safety centers for the 2013–2018 time period of the study, 

plus data from fiscal years 2007 through 2012 for historical 

comparison. The Commission studied and analyzed all of 

the mishap reports and looked for trends in the types of 

mishaps and the circumstances that directly or indirectly 

contributed to these incidents. The Commission did not 

reinvestigate or re-adjudicate any incident, investigation, 

or Service determination: the Commission accepted the 

thousands of mishap reports’ narration and findings as 

presented. 

Figure 1-2: 

Mishap Classifications During Study Period, 

Fiscal Years 2013–2018

Class A At least $2 million in damage and/or death or 

permanent disability.

Class B More than $500,000 but less than $2 

million in damages, and/or permanent 

partial disability or three or more people 

hospitalized.

Class C At least $50,000 but less than $500,000, 

and/or nonfatal injuries that require time off 

from work.

Class D At least $20,000 but less than $50,000, 

and/or recordable injury or illness that 

cannot be classified as an A, B, or C mishap.

Class E Depends on Service definition.

Additional data the Commission gathered included 

flight hours, staffing levels, readiness rates, maintenance 

experience levels, changes in training syllabi, and DoD 

budgets. To broaden its analytical efforts, the Commission 

employed the Research and Analysis Center at the Naval 

Postgraduate School in Monterey, California, drawing on 

the resources of the multi-Service Research Facilitation 

Laboratory. 

Literature and Document Review

The Commission also benefited from consulting an 

abundance of studies, directives, and instructions covering 

military aviation safety over the past 25 years. Studies came 

from government sources (Congress, the Congressional 

Research Service, the Office of Management and Budget, 

the Congressional Budget Office, the Government 

Accountability Office, and professional military education 

institutions), federally funded research and development 

centers (CNA, RAND, and IDA), think tanks, academic 

and research institutions, and government-commissioned 

evaluations produced by consulting and professional 

services organizations. A bibliography is included in 

Appendix E. The Commission also elicited information, 

insights, advice, and recommendations from subject matter 

experts inside and outside the Department of Defense.

Flight Line Experience

The Commission met with more than 200 organizations 

and military aviation units, reaching all of the many 

different types of flying communities in each of the 

Services, a distinction that separates this report from 

previous studies. The Commission hosted hundreds of 
3

Chapter 1: Mission and Method

town halls and roundtable discussions with thousands 

of Service personnel. The purpose was to hear firsthand 

the experiences and concerns of aircrews and maintainers 

across all Services, components, and ranks. In addition to 

meeting with each unit’s senior leaders, the Commission 

intentionally sought out junior personnel for their insights. 

To encourage candor from participants, commanders did 

not attend the town halls with their subordinates, and 

comments were noted without direct attribution. This 

fostered open and uninhibited dialogue. Additionally, the 

Commission visited major air carriers, civilian helicopter 

operators, Federal Aviation Administration officials, 

and aircraft manufacturers to explore best practices in 

commercial aviation and safety-related trends in aviation 

technology. A list of the Commission’s site visits and other 

engagements is in Appendix D.

The Human-Machine-Environment 

Framework

Early in this process, the Human-MachineEnvironment interface emerged as the framework for 

the Commission’s study (see Figure 1-3). The Human

includes not only the physiology, experience, proficiency, 

and currency of aviators and maintainers, but also the 

ethos that comes with being a Soldier, Sailor, Marine, 

or Airman: a devotion to duty, a make-it-work attitude, 

and an earnest commitment to professionalism and 

leadership. The Machine is the aircraft, the complex 

technical platform designed to accomplish a wide array 

of missions, and the equipment needed to sustain it. The 

Environment includes operations ranging from peacetime 

training to combat preparation during which aircrews 

accomplish their mission and maintainers sustain the 

aircraft. Environment also includes the institution 

and infrastructure that support these operations: 

resources, policies, budgets, 

organizational structures, logistics, 

facilities, accountability, and 

operations tempo (OPTEMPO). 

The Human, Machine, and 

Environment must work together 

in harmony to optimize safety and 

readiness. The Commission found 

that any imbalance, misalignment, 

or disharmony increases the risk of 

a mishap. A system of systems is at 

play, with interdependencies and 

vital connections among them.

Source: National Commission on Military Aviation Safety

Figure 1-3:

Human-Machine-Environment Framework

Multigenerational 

Workforce

Human 

Factors

5th Generation 

Aircraft

Aging Aircraft

Culture

Training

Personnel

Supply 

Chain

Policy, Processes, 

and Systems

Resources

Budget

Human

Environment

Machine

Maintenance

OPTEMPO

Data Equipment

Physiological 

Episodes
4

National Commission on Military Aviation Safety

A pilot with Marine Fighter Attack Squadron 211 completes preflight checks in 

an F-35B Lightning II Joint Strike Fighter aboard HMS Queen Elizabeth at sea. 

(Department of Defense photo.)
5

Chapter 2: 

ASSESSING MISHAP RATES

Advancing technology and concerted safety efforts 

have made recent years the safest period in aviation 

history. According to the Bureau of Transportation 

Statistics, the U.S. air carrier total accident rate per 

100,000 flight hours has decreased from 1.77 in 1965 

to 0.20 in 1990 and reached 0.17 in 2017. A 2020 

Massachusetts Institute of Technology study finds that 

the risk of traveling on commercial airlines has dropped 

from one death per 350,000 boardings globally from 

1968–1977 to one death per 2.7 million boardings from 

1998–2007 to a current rate of one death per 7.9 million 

boardings. Similarly, military aviation has recorded 

substantial improvements in mishap rates since the 

1950s. 

Within this broader context, Congress tasked this 

Commission “to assess the rates of military aviation 

mishaps from fiscal years 2013 through 2018 compared to 

historic aviation mishap rates.” The Commission calculated 

mishap rates by Service and across the Department of 

Defense for fiscal years 2013–2018, comparing the rates of 

those years against the previous six fiscal years, 2007–2012. 

The Commission’s assessment addressed two questions: (1) 

Are mishap rates higher or lower in fiscal years 2013–2018, 

and (2) are mishap rates moving in the right direction? 

This chapter’s purpose is to show what the rates are and 

how they have changed over the years.

Assessing and Characterizing Mishap Rates

The Commission used a widely accepted standard 

for measuring mishaps: mishaps per 100,000 flight 

hours. Each of the Services’ safety centers provided the 

Commission with historical mishap data and flight hours. 

The Commission calculated the mishap rates for each 

Service as well as an aggregated rate for DoD. 

Mishap Rate = (# of mishaps per year / # of flight 

hours per year) x 100,000

These calculations allowed the Commission to 

compare mishap rates across the Services using a 

common standard while accounting for differing flight 

hours among the Services. The mishap rate reflects the 

occurrence of a mishap and is not influenced by the 

number of fatalities or extent of damage. A mishap that 

results in more than one fatality is counted as a single 

mishap.

The Commission used visualizations, basic 

descriptive statistics, and rolling averages to better 

understand the characteristics and relationships among 

the mishap rates. The Commission examined Class A, 

Class B, and Class C mishaps, the costliest as measured 

by deaths, injury, and aircraft repair costs. Reporting 

for the less severe Class D and Class E mishaps was 

inconsistent throughout fiscal years 2007 to 2018 and 

not included in this analysis.

Visualizing and Contextualizing the Rates

The bottom line is that overall DoD mishap rates 

increased in fiscal years 2013–2018. These higher 

rates are largely due to an increase in Class C mishaps. 

However, as outlined below, the increase in Class C 

mishaps could be a harbinger of more serious safety 

issues. Indeed, the 2019 fiscal year data substantiates the 

Commission’s concerns.

CURRENCY AND PROFICIENCY

Aviators and maintainers depend on being current and 

proficient in their tasks to limit their risk for a mishap. 

Currency, or being current, describes having 

successfully demonstrated a skill or maneuver within 

a certain period of time. 

Proficiency, or being proficient, emphasizes how skilled 

an individual is at performing a task or maneuver, not 

whether the individual is able to perform the task. 

Each of the Services assess proficiency with a tiered 

scale describing the level of skill at which an individual 

is able to successfully complete a task. 

Human Environment

Machine
6

National Commission on Military Aviation Safety

The following visualizations 

illustrate the changes in the mishap rates 

by class and by Service for fiscal years 

2007–2018. They are supplemented by 

tables providing the annual estimated 

costs of mishaps by class and by Service 

for context and perspective.

Figure 2-1 shows the Army, 

Air Force, and Navy had moderate 

fluctuations in Class A mishap rates 

during the fiscal years 2013–2018 

study period. However, the Marine 

Corps consistently had higher Class A 

mishap rates. The higher mishap rates 

in the Marine Corps are consistent with 

problems the Commission observed 

during site visits. These included low 

morale, pilots struggling to maintain 

enough flight hours for currency, 

over-stressed aircrew and maintenance 

personnel overloaded with additional 

duties, poor facilities, and a pattern of 

using shortcuts to keep aircraft flying. 

The Commission assesses that these 

issues contributed to the spike in Class A 

Figure 2-1: 

Visualizing Class A Mishap Rates

0

1

2

3

4

5

6 All DoD

Army

Air Force

Navy

Marine Corps

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

All DoD Army Air Force Navy Marine Corps

Note: The vertical line delineates the Commission’s chartered study period of fiscal years 

2013–2018 from the comparison period of fiscal years 2007–2012

Figure 2-2: 

Class A Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2007-

2012

2013-

2018

Army $311.7 $126.6 $128.1 $237.7 $164.4 $162.9 $42.0 $263.6 $141.8 $167.9 $228.8 $194.1 $1,131.3 $1,038.1

Air 

Force

$364.4 $2,158.6 $470.8 $462.6 $325.5 $498.3 $899.2 $214.1 $405.6 $435.4 $242.0 $489.1 $4,280.2 $2,685.4

Navy $227.0 $616.0 $225.4 $265.8 $201.0 $435.2 $196.1 $538.1 $295.8 $431.1 $367.5 $230.0 $1,970.4 $2,058.6

Marine 

Corps

$160.6 $217.0 $161.1 $232.4 $232.2 $261.3 $259.7 $292.6 $274.8 $542.8 $832.8 $283.6 $1,264.6 $2,486.3

All DoD $1,063.7 $3,118.2 $985.4 $1,198.4 $923.0 $1,357.8 $1,396.9 $1,308.4 $1,118.0 $1,577.2 $1,671.1 $1,196.7 $8,646.5 $8,268.4

Source: FR2 Database

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.
7

Chapter 2: Assessing Mishap Rates

mishaps from fiscal year 2015 to 2017. 

Chapters 9 and 10 explore in greater 

detail the challenges aviation maintainers 

and aircrew face. 

Figure 2-2 shows that the aggregate 

mishap materiel costs for Class A mishaps 

exceeded $1.1 billion during each year 

of the study period. A single $1.4 billion 

mishap destroying a B-2 Stealth Bomber 

in 2008 drove the higher total DoD-wide 

costs for fiscal years 2007 through 2012.

Figure 2-3 shows that fiscal year 

2009 had a massive spike in Class B 

mishaps. While that year is outside 

the Commission’s study period, the 

Commission notes this spike may be 

partially attributable to a change in 

how mishaps were classified that year 

(additional explanation provided in 

Appendix F). During the fiscal years 

2013–2018 study period, Class B 

mishap rates were generally stable 

across the Services with the exception 

of the Navy, which had a continuous 

increase in Class B mishaps from fiscal 

years 2014–2018. The Navy increase 

Figure 2-3: 

Visualizing Class B Mishap Rates

0

1

2

3

4

5

6

7

8

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

All DoD

Army

Air Force

Navy

Marine Corps

All DoD Army Air Force Navy Marine Corps

Note: The vertical line delineates the Commission’s chartered study period of fiscal years 

2013–2018 from the comparison period of fiscal years 2007–2012

Figure 2-4: 

Class B Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2007-

2012

2013-

2018

Army $5.61 $6.48 $10.20 $10.50 $13.95 $10.49 $5.99 $6.12 $13.20 $11.95 $3.51 $8.54 $57.24 $49.31

Air 

Force 

$42.64 $55.84 $69.06 $36.95 $62.76 $34.03 $42.95 $47.48 $47.88 $49.35 $40.43 $49.52 $301.30 $277.62

Navy $13.54 $15.23 $14.24 $10.14 $12.63 $13.64 $16.35 $13.84 $12.41 $16.83 $21.69 $26.31 $79.42 $107.43

Marine 

Corps 

$5.87 $3.63 $8.74 $5.65 $6.74 $9.22 $3.89 $4.47 $6.06 $6.13 $5.89 $4.86 $39.85 $31.31

All DoD $67.67 $81.19 $102.25 $63.24 $96.08 $67.38 $69.18 $71.92 $79.56 $84.26 $71.53 $89.22 $477.80 $465.67

Source: FR2 Database 

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.
8

National Commission on Military Aviation Safety

coincided with an inordinate increase 

in the number of F/A-18 variants 

experiencing Class B mishaps, both in 

flight and on the ground, compared 

to the rest of the fleet. A Navy Safety 

Center investigation found no 

“smoking gun” but pointed to potential 

environmental factors, such as foreign 

object debris (FOD) and bird strikes. 

The majority of ground mishaps, which 

disproportionately happened during 

night operations, occurred when moving 

aircraft. 

Figure 2-4 shows that the costs of 

Class B mishaps during the study period 

were generally lower than the previous 

six years. The total cost of mishaps across 

DoD declined when comparing the 

six-year study period to the previous six 

years. 

Figure 2-5 illustrates a steady increase 

in DoD Class C rates from fiscal years 

2013 through 2018. These increases 

are concerning and are consistent with 

the Commission’s observations. Many 

Class C mishaps are aviation ground 

Figure 2-6: 

Class C Aggregate Mishap Estimated Derived Costs (in Millions) by Service for Fiscal Years 2007–2018

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2007-

2012

2013-

2018

Army $6.18 $7.57 $6.45 $6.97 $12.91 $11.56 $6.10 $8.87 $9.61 $7.64 $8.52 $7.99 $51.65 $48.73

Air 

Force 

$38.77 $37.49 $46.98 $70.66 $68.52 $68.92 $72.69 $70.20 $80.79 $78.09 $86.24 $72.42 $331.34 $460.43

Navy $7.74 $5.65 $7.75 $14.80 $12.96 $14.20 $16.42 $17.47 $18.91 $22.75 $26.15 $19.89 $63.10 $121.60

Marine 

Corps 

$1.71 $3.87 $2.83 $8.06 $5.37 $4.72 $6.13 $7.40 $7.04 $7.99 $9.47 $8.29 $26.57 $46.32

All DoD $54.40 $54.57 $64.01 $100.50 $99.77 $99.40 $101.34 $103.95 $116.35 $116.47 $130.38 $108.60 $472.65 $677.08

Source: FR2 Database

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.

Figure 2-5: 

Visualizing Class C Mishap Rates

0

10

20

30

40

50

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

All DoD

Army

Air Force

Navy

Marine Corps

All DoD Army Air Force Navy Marine Corps

Note: The vertical line delineates the Commission’s chartered study period of fiscal years 

2013–2018 from the comparison period of fiscal years 2007–2012
9

Chapter 2: Assessing Mishap Rates

mishaps due to mishandling of aircraft by inexperienced 

maintenance personnel and insufficient supervision. That 

cause is most apparent in the noticeable increase in Navy 

and Marine Corps Class C rates. Figure 2-5 also shows that 

Air Force Class C rates are notably higher than the other 

Services and varied between 35 and 40 Class C mishaps 

per 100,000 flight hours during the fiscal years 2013–2018 

period. The Commission attributes these consistently 

higher rates, in part, to the higher repair cost of Air Force 

aircraft. The Army Class C rate remains low compared to 

the other Services, which may be attributed to the lower 

cost of repairing damage to the aircraft operated by the 

Army.

Figure 2-6 shows that as Class C mishap rates 

have increased within DoD, so have the aggregate costs 

to repair the damage. Overall, Class C mishap costs 

increased during the study period and peaked at over 

$130 million in DoD-wide costs in 2017. 

“It is a matter of inches or seconds that make 

the difference between a Class C or a Class A,” the 

commanding general of the Army’s Combat Readiness 

Center said in June 13, 2018, testimony before a House 

subcommittee. 

The Commission is concerned with the Class C 

trends, which can be leading indicators of more serious 

Class A and B mishaps. Commercial aviation enterprises 

thoroughly record and closely track minor mishaps and 

near misses as a way to prevent major accidents. 

Comparing the Period Means

To directly compare the mishap rates of fiscal years 

2013–2018 with those of fiscal years 2007–2012, the 

Commission calculated a mean rate for the two periods. 

This statistic takes into account any changes across the 

period and does not emphasize any one year. 

Period Mean Mishap Rate = (sum of # of mishaps in 

period / sum of # of flight hours in period) x 100,000

The Commission calculated the mean for each period 

by Service and by mishap class, as shown in Figure 2-7. 

The changes in the means help answer whether the 

rates for fiscal years 2013 through 2018 have increased, 

decreased, or stayed the same compared to fiscal years 

2007 through 2012. Figure 2-7 shows that the Army 

experienced decreases in all mishap classes with the 

greatest rates of reduction in the Class A and B rate 

means. The Air Force had a small decrease in Class A 

rate means, a larger decrease in Class B means, and an 

increase in Class C means. The Navy and Marine Corps 

both experienced increases in Class A and Class C rate 

means, with a dramatic increase for the Marine Corps. 

Figure 2-7: 

Comparing the Fiscal Years 2007–2012 and Fiscal 

Years 2013–2018 Rate Means Across the Services 

and Mishap Classes

MISHAP RATE 

CATEGORY SERVICE

FY07-12 

MISHAP 

RATE MEAN

FY13-18 

MISHAP 

RATE MEAN

Class A

Army 1.77 1.19

Air Force 1.15 1.11

Navy 1.15 1.34

Marine Corps 2.43 3.30

All DoD 1.41 1.33

Class B

Army 1.33 1.03

Air Force 4.21 2.62

Navy 2.55 2.50

Marine Corps 3.29 2.78

All DoD 3.00 2.23

Class C

Army 7.16 6.47

Air Force 33.44 36.18

Navy 9.44 16.54

Marine Corps 9.70 20.69

All DoD 19.45 23.37

Source: National Commission on Military Aviation Safety analysis
10

National Commission on Military Aviation Safety

Overall, Navy and Marine Corps Class B means both 

decreased, a small decrease for the Navy and greater 

decrease for the Marine Corps. The largest increase was 

in Class C mishap rates, particularly the Marine Corps, 

which more than doubled its mishap mean between the 

two periods. The Navy also had a significant increase.

Identifying Troubling Trends

The Commission also calculated four-year rolling 

averages to identify trends and determine if rates were 

heading in the right direction. 

Rolling Average = (Mishap rates of the current year + 

prior year + two years prior + three years prior) / 4

In Figures 2-8, 2-9, and 2-10, the scales of the vertical 

axes vary among the graphs to more easily visualize trends. 

The Commission concentrated on the rolling averages for 

fiscal years 2016–2018 because it includes data entirely 

from the Commission’s assigned study period. 

The Army Class A rolling averages have largely 

decreased since fiscal year 2007. The Air Force similarly 

showed decreasing rolling averages, a trend that is 

threatened by the increase in Class A mishaps in fiscal 

year 2018. In the Navy, the trend of decreasing rolling 

averages ended in fiscal year 2013 and has been generally 

increasing since. Likewise, while the Marine Corps had a 

notable drop in its fiscal year 2018 Class A mishap rate, 

its increasing rolling averages are concerning.

The Class B rolling averages for the Navy increased 

for fiscal years 2015–2018, and increased for the Marine 

Corps for fiscal years 2016–2018. By contrast, the 

Air Force Class B rolling averages decreased for fiscal 

years 2016–2018. The Army rolling averages remained 

consistently low, but did increase in fiscal years 2014 and 

2018.

Most notably, the Air Force Class C rolling averages 

are substantially higher than the other Services, and 

the Navy and Marine Corps Class C rolling averages 

significantly increased during fiscal years 2013–2018. The 

Army rolling averages have remained consistently low, 

particularly when compared to the other Services, but did 

increase for fiscal years 2016–2018.

Further information and charts are in Appendix F. 

Class A 4-Year Rolling Average

Class A Mishap Rate

0

1

2

3

20072008200920102011201220132014201520162017

2018

ARMY

Class A 4-Year Rolling Average

Class A Mishap Rate

0

0.5

1

1.5

2 A 4-Year Rolling Ave

A Mishap Rate

200720082009201020112012201320142015201620172018

NAVY

Class A 4-Year Rolling Average

Class A Mishap Rate

0

0.5

1

1.5

2 A 4-Year Rolling Av

A Mishap Rate

200720082009201020112012201320142015201620172018

AIR FORCE

Class A 4-Year Rolling Average

Class A Mishap Rate

0

1

2

3

4

5

20072008200920102011201220132014201520162017

2018

MARINE CORPS

Figure 2-8: 

Class A Mishap Rates and Rolling Averages by 

Service for Fiscal Years 2007–2018

Note: The scales of the vertical axes vary to more easily visualize trends. 

To compare across the Services or see the overall perspective, please refer 

to Figure 2-1.
11

Chapter 2: Assessing Mishap Rates

Figure 2-9: 

Class B Mishap Rates and Rolling Averages by 

Service for Fiscal Years 2007–2018

Figure 2-10: 

Class C Mishap Rates and Rolling Averages by 

Service for Fiscal Years 2007–2018

Class B 4-Year Rolling Average

Class B Mishap Rate

0

0.5

1

1.5

2 B 4-Year Rolling Average

B Mishap Rate

200720082009201020112012201320142015201620172018

ARMY

Class B 4-Year Rolling Average

Class B Mishap Rate

0

1

2

3

4

5

6

7

200720082009201020112012201320142015201620172018

AIR FORCE

Class B 4-Year Rolling Average

Class B Mishap Rate

0

1

2

3

4 B 4-Year Rolling Average

B Mishap Rate

200720082009201020112012201320142015201620172018

NAVY

Class B 4-Year Rolling Average

Class B Mishap Rate

0

1

2

3

4

5

6

7

200720082009201020112012201320142015201620172018

MARINE CORPS

Note: The scales of the vertical axes vary to more easily visualize trends. 

To compare across the Services or see the overall perspective, please 

refer to Figure 2-3. 

Note: The scales of the vertical axes vary to more easily visualize trends. 

To compare across the Services or see the overall perspective, please 

refer to Figure 2-5.

Class C 4-Year Rolling Average

Class C Mishap Rate

0

1

2

3

4

5

6

7

8

9

10

C 4-Year 

C Mishap 

200720082009201020112012201320142015201620172018

ARMY

Class C 4-Year Rolling Average

Class C Mishap Rate

0

5

10

15

20

25

200720082009201020112012201320142015201620172018

NAVY

Class C 4-Year Rolling Average

Class C Mishap Rate

0

10

20

30

40

50

200720082009201020112012201320142015201620172018

AIR FORCE

Class C 4-Year Rolling Average

Class C Mishap Rate

0

5

10

15

20

25

30

200720082009201020112012201320142015201620172018

MARINE CORPS
12

National Commission on Military Aviation Safety

The Commission’s Assessment 

and Findings

To address any questions about general 

trends in mishaps between the study 

period and the historical period, the 

Commission looked at the Class A-C 

aggregate results. Overall, mishap rates in 

DoD increased in fiscal years 2013–2018 

(Figure 2-11). As the previous sections 

demonstrated, the higher rate is largely 

due to an increase in Class C mishaps. 

In reflecting on the totality of its 

assessment, the Commission is particularly 

concerned with the increases in Navy 

and Marine Corps Class A mishap 

rates, especially Marine Corps Class A 

mishap rates. The higher mishap rates 

in the Marine Corps are consistent with 

Commission site visits where Marine 

Corps aviation units were some of the 

most over-tasked, over-stressed, and 

under-resourced units the Commission 

observed. 

The Commission heard concerns 

from many in the field that the conditions 

were set for a potential increase in mishap 

rates. Subsequent chapters provide 

greater explanation of where latent risk 

resides throughout the Human-MachineEnvironment framework and conclude 

with recommendations to abate the risks, 

hopefully in time.

Figure 2-11: 

Visualizing Class A-C Mishap Rates

0

10

20

30

40

50

60

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

All DoD

Army

Air Force

Navy

Marine Corps

All DoD Army Air Force Navy Marine Corps

Note: The vertical line delineates the Commission’s chartered study period of 

fiscal years 2013–2018 from the comparison period of fiscal years 2007–2012
13

Chapter 2: Assessing Mishap Rates

Additional Assessment

Although Congress ended the Commission’s study 

window at 2018, the mishap rate data for fiscal year 2019 

became available as the Commission continued its work 

through 2020 (Figure 2-12). The Commission reviewed 

the fiscal year 2019 data and found that it underscored 

the concerns the Commission heard on its site visits. 

The Army and Air Force mishap rates in fiscal year 

2019 did not significantly change the Commission’s 

assessment discussed earlier in this chapter. However, the 

Navy and Marine Corps both had significant increases 

that warrant discussion. Most notably, the Navy’s 2019 

Class A mishap rate was higher than any other year 

the Commission examined (fiscal years 2007–2018). 

The Marine Corps Class A mishap rate also increased 

in fiscal year 2019 and continued to be the highest of 

any Service, but was still lower than in fiscal year 2017. 

Additionally, the Marine Corps Class B mishap rate more 

than doubled from fiscal year 2018 to 2019, which easily 

constituted the highest Class B mishap rate of any Service 

during the Commission’s entire study period. 

Class A-C mishaps resulted in 198 fatalities and cost 

the Services more than $9.4 billion between fiscal years 

2013 and 2018. These are human and financial costs that 

should not be trending upward by any percentage. These 

trends can be reversed if the full range of causes for all 

classes of mishaps are fully understood and addressed. 

The first step is identifying those causes.

Figure 2-12: 

Mishap Rates for Fiscal Years 2013–2019

FISCAL YEAR 2013 2014 2015 2016 2017 2018 2019

Army A Mishap Rate 0.90 1.56 1.45 0.93 1.03 1.31 1.38

Air Force A Mishap Rate 1.21 0.72 1.17 0.96 1.03 1.58 1.54

Navy A Mishap Rate 1.06 1.78 1.28 0.93 1.55 1.44 2.41

Marine Corps A Mishap Rate 2.98 2.28 3.29 3.81 5.19 2.49 3.36

All DoD A Mishap Rate 1.21 1.29 1.39 1.13 1.41 1.55 1.82

Army B Mishap Rate 0.81 0.68 1.67 1.27 0.69 1.07 0.92

Air Force B Mishap Rate 2.58 3.18 2.50 2.95 2.41 2.11 2.06

Navy B Mishap Rate 2.12 1.54 2.09 2.43 3.33 3.49 2.29

Marine Corps B Mishap Rate 2.23 2.66 2.88 2.54 3.03 3.32 7.14

All DoD B Mishap Rate 1.96 2.11 2.24 2.42 2.25 2.27 2.17

Army C Mishap Rate 5.11 4.98 6.68 6.37 7.81 8.59 5.06

Air Force C Mishap Rate 34.00 37.90 35.05 36.13 38.77 35.31 36.32

Navy C Mishap Rate 11.57 12.92 15.24 19.01 21.05 19.48 17.62

Marine Corps C Mishap Rate 14.51 16.69 19.32 22.46 26.80 25.75 21.85

All DoD C Mishap Rate 19.79 22.00 22.86 24.40 26.66 24.85 23.80

Source: Services’ safety centers
14

National Commission on Military Aviation Safety

A Naval Aircrewman prepares for a training flight in an 

MH-60S Knighthawk assigned to the “Black Knights” of 

Helicopter Sea Combat Squadron 4, during a training exercise 

at Naval Air Facility El Centro, California. (U.S. Navy photo by 

Chief Mass Communication Specialist Shannon Renfroe.)
15

Chapter 3: 

MILITARY AVIATION 

SAFETY DATA

To make an assessment of causes contributing to 

military aviation mishaps, the Commission took an 

expansive look at aviation data collection practices within 

the Department of Defense (DoD). The Commission 

first reviewed more than 6,000 mishap reports from 

fiscal years 2013 through 2018. Second, the Commission 

studied military and civilian data collection methods 

aimed toward preventing or mitigating aviation losses. 

Throughout this effort, the Commission found a number 

of issues and concerns for present and future military 

aviation safety. Aviation safety data collection, processing, 

and analysis must be improved before the data can be 

used effectively to improve military aviation safety across 

the DoD.

In reviewing and analyzing aviation safety data 

collection within the Defense Department, the 

Commission: 

• Utilized Class A through Class C military aviation 

mishap reports provided by the Services’ safety 

centers and DoD’s safety database, the Force Risk 

Reduction (FR2) database managed by the Office 

of the Undersecretary of Defense for Personnel and 

Readiness;

• Studied safety investigation reports for Class A 

mishaps to identify trends in the most severe mishaps;

• Reviewed relevant DoD and Service directives and 

memorandums;

• Researched military aircraft and aviation personnel 

data collection equipment and programs;

• Reviewed previous government and academic reports; 

• Interviewed DoD and Service leaders about their 

safety programs; 

• Collaborated with the individual Service safety 

centers on data collection and analysis; 

• Elicited input from aviators, maintainers, unit 

commanders, and senior military leadership; 

• Interviewed academic and commercial aviation 

experts on safety best practices and the Human 

Factors Analysis and Classification System (HFACS); 

• Visited several commercial aviation companies;

• Consulted with the Federal Aviation Administration 

to review their safety management systems, data 

collection processes, and analysis of mishap data. 

DoD and the Services collect safety-related data in 

varying ways with equally varying degrees of success and 

utility for improving safety. Service safety center leaders 

noted a decrease in aviation mishaps over the past few 

decades, but that the same mishaps continue to occur 

year after year. In an era of limited financial resources 

and manpower, the ever-escalating price tags of modern 

aircraft and the cost of training aircrew and maintainers 

require constant vigilance to keep aviation personnel and 

assets safe. The Department and Services have failed to 

take full advantage of commonly available trend analysis 

models and tools that could give them the ability to 

effectively collect, analyze, and operationalize safety data. 

As we have learned from industry and society at large, 

good data is the starting point for best practices and for 

making actionable military aviation safety decisions.

Assessing the Causes and Contributing 

Factors of Mishaps

As the Commission turned to understanding the “causes 

contributing to military aviation mishaps,” it used some 

of the standard fields that are required to be included 

for all mishaps. First, it analyzed the type of mishap, 

categorized as flight, flight related, and ground mishaps 

(see Figure 3-1). 

Figure 3-2 indicates that flight mishaps were the 

most frequent category among Class A mishaps while 

ground operations mishaps were most frequent among 

Class C mishaps. The number of flight-related mishaps 

was significantly lower for all classes than the other 

two categories. The vast majority of flight mishaps 

are attributed to aircrew errors. Service safety officials 

reported that most ground operations Class C mishaps 

are related to maintenance incidents.

The Human Factors Analysis and 

Classification System (HFACS)

In its review of mishap safety data, the Commission 

found the information provided a historical perspective 

on individual mishaps. Historical records show that 80 

percent of aviation mishaps are attributed to human 

Human Environment

Machine
16

National Commission on Military Aviation Safety

factors (aircrew and maintenance errors). The remaining 

20 percent of mishaps are attributed to aircraft issues 

(malfunctions or design errors) and nature-related issues 

(bird strikes or weather). 

Like the Services and DoD, the Commission used 

the DoD Human Factors Analysis and Classification 

System (HFACS) codes to understand the causal and 

contributing factors in its analysis of the human element 

of mishaps. DoD’s HFACS is a solid framework and 

a key component of every investigation. This system 

identifies a broad range of human errors within 1) unsafe 

acts of operators (e.g., aircrew), 2) preconditions for 

unsafe acts, 3) unsafe supervision, and 4) organizational 

influences. The goal of HFACS is not to attribute blame 

but to understand the underlying operational or cultural 

factors that led to a mishap. Such knowledge can spur 

measures that prevent future mishaps.

A single mishap may include many codes from 

various categories or bins as investigators identify all 

of the events, decisions, and conditions leading to the 

mishap. Comprehensively identifying even second- and 

third-level causes are key to identifying trends that create 

risks, paving the way for proactive preventive measures. 

As Figure 3-3 on pages 18-19 shows, individual 

HFACS codes are grouped into four larger categories (the 

boxes with orange headings) and subdivided into smaller 

bins (the boxes with gray headings). They are given an 

individual alphanumeric code to indicate their category 

and bin. 

Based on the Commission’s review of all Class A 

mishap reports from fiscal years 2013 through 2018, the 

distribution across the four largest HFACS categories 

was 43 percent as Acts, 38 percent as Preconditions, 

10 percent as Organization, and 9 percent as Supervision. 

Looking at the next lower echelon, “PerformanceBased Errors” and “Judgment and Decision-Making 

Errors” were the most common errors cited by mishap 

investigators. 

Analysis at the code level revealed the top three most 

commonly applied codes are “Procedure Not Followed 

Correctly” (AE103), “Inadequate Real-Time Risk 

Assessment” (AE 201), and “Wrong Choice of Action 

during an Operation” (AE206). Charts with the most 

commonly applied codes by mishap class and Service 

during the study period, the Commission’s most granular 

analysis, are in Appendix F. 

All these codes can lead the safety center investigators 

to research underlying causes for these occurrences, 

which, in turn, could lead to studying such factors as 

training, staffing, maintenance delays, and other core 

issues that led to that mishap and remain present and 

unaddressed.

The Limitations

Military Mishap Data Collection

Precise data collection from an aviation mishap is 

critical in understanding what happened and can be a 

valuable source of information to prevent future mishaps. 

The Services’ safety centers usually conduct extensive 

investigations on Class A and B mishaps. Safety officials 

at the command or unit level perform investigations of 

Class C and below mishaps. Causal and contributory 

Figure 3-1: 

Aviation Mishap Categories and Subcategories 

SUBCATEGORY SUBCATEGORY CHARACTERISTICS

Flight

A mishap where there is intent for flight and damage to DoD aircraft. Explosives, chemical agent, or missile 

events that cause damage to an aircraft with intent for flight are categorized as flight mishaps to avoid dual 

reporting. (Mishaps involving factory-new production aircraft until successful completion of the post-production 

flight are reported as contractor mishaps.)

Flight 

Related

A mishap where there is intent for flight and no reportable damage to the aircraft itself, but the mishap involves 

fatality, reportable injury, or reportable property damage. A missile that is launched from an aircraft, departs 

without damaging the aircraft, and is subsequently involved in a mishap is reportable as a guided missile 

mishap. 

Ground 

Operations

A mishap where there is no intent for flight that results in damage to an aircraft or death or injury involving an 

aircraft. This applies to aircraft both on land and on board ship. Damage to an aircraft when it is being handled 

as a commodity or cargo is not reportable as an aircraft mishap.

Source: DoD Instruction 6055.07, June 6, 2011 Table 1
17

Chapter 3: Military Aviation Safety Data

information for Class A and B mishaps generally is 

comprehensive. However, the Commission noted a lack 

of standardization and inconsistent reporting structures 

across the Services even in the Class A mishap reports, 

which are prepared with the highest degree of expertise 

among the mishap classes. Reporting on Class C 

investigations also is inconsistent and often incomplete, 

though Service safety leaders note that Class C mishaps 

are potentially the best indicators of elevated risk for 

more serious mishaps. Commercial enterprises actively 

track and react to Class C-type incidents as a preventive 

measure and to promote a reporting culture. Military 

aviation does not. Given the increasing numbers of Class 

C mishaps described in the previous chapter, this is an 

area of concern the Services should address. 

Both a 2003 Congressional Research Service report 

to Congress and a 2018 Government Accountability 

Office report also identified these problems. “DoD has 

taken a number of steps to ensure that the safety centers 

provide more complete and consistent data to [the Office 

of the Secretary of Defense] on aviation mishaps,” the 

GAO report said. “However, there are several gaps in its 

current approach to collecting, reporting, and analyzing 

aviation mishap data. Specifically, because standardized 

data elements are not being collected across the safety 

centers, DoD is limited in its ability to compare mishap 

data across the military services and must engage in 

inefficient and time-consuming efforts to align the 

data with reporting requirements.” The Commission 

confirmed these findings are still true of the data reviewed 

for this study. Until this problem is addressed fully, the 

DoD safety program will languish and continue to repeat 

its safety and mishap mistakes. 

The Services cited inconsistencies in how 

investigations are conducted when they cautioned the 

Commission against using only the mishap reports for 

analysis and conclusions, especially for Class C mishaps. 

An official at a safety center said the system is not 

appropriate for data mining because people do not fill 

in the data fields correctly. “The reports are only as good 

Figure 3-2: 

Flight, Flight-Related, and Ground Mishaps by Class and Service for Fiscal Years 2013–2018

CLASS A MISHAP COUNTS CLASS B MISHAP COUNTS CLASS C MISHAP COUNTS

FISCAL 

YEAR ARMY AIR 

FORCE NAVY MARINE 

CORPS ARMY AIR 

FORCE NAVY MARINE 

CORPS ARMY AIR 

FORCE NAVY MARINE 

CORPS

Flight

2013 10 19 4 8 8 32 10 3 44 264 57 19

2014 15 7 15 5 6 37 1 7 42 289 51 19

2015 12 20 9 8 14 36 9 4 45 290 57 19

2016 7 12 7 8 11 38 13 2 38 281 80 21

2017 9 12 9 10 6 36 17 3 52 323 75 22

2018 10 23 8 5 8 26 21 5 54 273 49 22

Flight 

Related

2013 0 1 3 0 1 0 1 0 4 30 3 3

2014 1 2 0 1 1 2 2 0 3 24 4 5

2015 1 1 0 0 1 0 1 0 3 29 5 3

2016 0 2 0 0 0 0 2 0 6 27 2 4

2017 0 1 1 0 0 0 1 0 7 21 8 1

2018 1 0 2 0 1 0 1 0 3 31 4 3

Ground

2013 0 1 2 0 0 13 7 3 9 298 38 17

2014 0 3 0 0 0 14 10 0 6 319 54 20

2015 0 0 2 0 0 9 8 3 12 312 69 25

2016 1 3 1 1 0 14 6 4 11 329 82 28

2017 0 5 3 2 0 6 10 4 9 331 94 39

2018 0 4 2 1 0 10 7 3 15 299 109 37
18

National Commission on Military Aviation Safety

Figure 3-3: 

The DoD HFACS

Resource Problems

OR001 Command & Control 

Resources are Deficient

OR003 Inadequate Infrastructure

OR005 Failure to Remove 

Inadequate/Worn-out Equipment 

in Timely Manner

OR008 Failure to Provide 

Adequate Operational Information 

Resources

OR009 Failure to Provide 

Adequate Funding

Personnel Selection 

& Staffing

OS001 Personnel 

Recruiting & Selection 

Policies are Inadequate

OS002 Failure to Provide 

Adequate Manning/ 

Staffing Resources

Policy & Process Issues

OP001 Pace of OPTEMPO/Workload

OP002 Organizational Program/Policy 

Risks not Adequately Assessed

OP003 Provided Inadequate Procedural 

Guidance or Publications

OP004 Organizational (formal) Training is 

Inadequate or Unavailable

OP005 Flawed Doctrine/Philosophy

OP006 Inadequate Program Management

OP007 Purchasing or Providing Poorly 

Designed or Unsuitable Equipment

Climate/Culture Influences

OC001 Organizational Culture 

(attitude/actions) Allows for 

Unsafe Task/Mission

OC003 Organizational 

Over-confidence or 

Underconfidence in 

Equipment

OC004 Unit Mission/Aircraft/

Vehicle/Equipment Change or 

Unit Deactivation

OC005 Organizational 

Structure is Unclear or 

Inadequate

ORGANIZATIONAL INFLUENCES

Supervisory Violations

SV001 Failure to Enforce 

Existing Rules

SV002 Allowing Unwritten 

Policies to Become Standard

SV003 Directed Individual to 

Violate Existing Regulations

SV004 Authorized Unqualified 

Individuals for Task

Planned Inappropriate Operations

SP001 Directed Task Beyond Personnel 

Capabilities

SP002 Inappropriate Team Composition

SP003 Selected Individual with Lack of 

Current or Limited Experience

SP006 Performed Inadequate Risk 

Assessment -Formal

SP007 Authorized Unnecessary Hazard

Inadequate Supervision

SI001 Supervisory/Command Oversight Inadequate

SI002 Improper Role-modeling

SI003 Failed to Provide Proper Training

SI004 Failed to Provide Appropriate Policy/Guidance

SI005 Personality Conflict with Supervisor

SI006 Lack of Supervisory Responses to Critical 

Information

SI007 Failed to Identify/Correct Risky or Unsafe 

Practices

SI008 Selected Individual with Lack of Proficiency

SUPERVISION
19

Chapter 3: Military Aviation Safety Data

Physical Environment

PE101 Environmental Conditions 

Affecting Vision

PE103 Vibration Affects Vision or 

Balance

PE106 Heat/Cold Stress Impairs 

Performance

PE108 External Force or Object 

Impeded an Individual’s Movement

PE109 Lights of Other Vehicle/Vessel/

Aircraft Affected Vision

PE110 Noise Interference

Technological Environment

PE201 Seat and Restraint System Problems

PE202 Instrumentation & Warning System Issues

PE203 Visibility Restrictions (Not Weather 

Related)

PE204 Controls and Switches are Inadequate

PE205 Automated System Creates Unsafe 

Situation

PE206 Workspace Incompatible with Operation

PE207 Personal Equipment Interference

PE208 Communication Equipment Inadequate

Teamwork

PP101 Failure of Crew/Team Leadership

PP103 Inadequate Task Delegation

PP104 Rank/Position Intimidation

PP105 Lack of Assertiveness

PP106 Critical Information Not Communicated

PP107 Standard/Proper Terminology Not Used

PP108 Failed to Effectively Communicate

PP109 Task/Mission Planning/Briefing Inadequate

Mental Awareness

PC101 Not Paying Attention

PC102 Fixation

PC103 Task Over/Under 

Saturation

PC104 Confusion

PC105 Negative Habit Transfer

PC106 Distraction

PC107 Geographically Lost

PC108 Interference/Interruption

PC109 Technical or Procedural 

Knowledge Not Retained After 

Training

PC110 Inaccurate Expectation

Sensory Misperception

PC501 Motion Illusion - 

Kinesthetic

PC502 Turning Illusion/

Balance - Vestibular

PC503 Visual Illusion

PC504 Misperception of 

Changing Environment

PC505 Misinterpreted/ 

Misread Instrument

PC507 Misinterpretation of 

Auditory/Sound Cues

PC508 Spatial Disorientation

PC511 Temporal/Time 

Distortion

State of Mind

PC202 Psychological 

Problem

PC203 Life Stressors

PC204 Emotional State

PC205 Personality Style

PC206 Overconfidence

PC207 Pressing

PC208 Complacency

PC209 Motivation

PC215 Motivational 

Exhaustion (Burnout)

Physical Problem

PC302 Substance Effects (Alcohol, Supplements, 

Medications, Drugs)

PC304 Loss of Consciousness (Sudden or Prolonged Onset)

PC305 Physical Illness/Injury

PC307 Fatigue

PC310 Trapped Gas Disorders

PC311 Evolved Gas Disorders

PC312 Hypoxia/Hyperventilation

PC314 Inadequate Adaptation to Darkness

PC315 Dehydration

PC317 Body Size/Movement Limitations

PC318 Physical Strength & Coordination (Inappropriate 

for Task Demands)

PC319 Nutrition/Diet

PRECONDITIONS

Performance-Based Errors

AE101 Unintended Operation of Equipment

AE102 Checklist Not Followed Correctly

AE103 Procedure Not Followed Correctly

AE104 Over-Controlled/Under-Controlled Aircraft/Vehicle/System

AE105 Breakdown in Visual Scan

AE107 Rushed or Delayed a Necessary Action

Judgment & Decision-Making Errors

AE201 Inadequate Real-Time Risk 

Assessment

AE202 Failure to Prioritize Tasks Adequately

AE205 Ignored a Caution/Warning

AE206 Wrong Choice of Action During an 

Operation

Violations

AV001 Performs Work-Around 

Violation

AV002 Commits Widespread/

Routine Violation

AV003 Extreme Violation – 

Lack of Discipline

ACTS

Environment

Physical and Mental State
20

National Commission on Military Aviation Safety

as what they put into it,” echoed an official at one of the 

other Service safety centers about Class C investigations. 

A human factors expert at a Service safety center told 

the Commission that this is a DoD-wide issue, pointing 

out that about seven of ten Class A mishap investigation 

reports cite at least one HFACS code, but only three out 

of ten Class C mishap reports cite an HFACS code.

The Commission found that the mishap reports do 

not fully or consistently utilize the HFACS framework 

that can reveal potentially larger or institutional causes 

contributing to mishaps. In addition to needing complete 

data in the mishap reports, analysts need access to 

supplemental personnel, training, acquisition, and certain 

operational data to develop predictive and actionable 

safety plans. For example, personnel shortages leading to 

improperly trained personnel could contribute to a flying 

or maintenance mishap. Safety center investigators do 

not consistently access that information to assess causes 

or contributing factors. Initiatives are underway by each 

of the safety centers to improve its utility of data, but that 

will require broader Service data collection, access, and 

analytical support to develop an effective predictive and 

actionable aviation mishap prevention program.

The Commission heard from the Services’ safety 

centers that if the HFACS limitations were corrected and 

the system used as designed, the mishap reports would 

provide a clearer connection to other important factors, 

including operations tempo, funding, supply chains, 

training, and personnel shortages. 

Aggregating and Analyzing at Higher Levels

Current DoD policy requires the Services to provide 

information to DoD that could identify risk, recommend 

mitigation strategies, and offer lessons learned 

throughout the Department and outside agencies as 

appropriate. However, the lack of data standardization 

across the Services creates interpretation challenges for 

any comprehensive study of military aviation safety. 

Several safety experts in DoD and the Services expressed 

concern to the Commission that the differences in data 

collection, reporting methodologies, and investigation 

standards within the Services stymie attempts to achieve 

clear analysis from mishap report data. Even the structure 

of the reports and the manner in which they are recorded 

and presented hampered the work of the Commission, as 

it has other DoD-level organizations attempting to make 

comparisons and improve aviation safety. Army mishap 

reports, for example, require cross-referencing up to 

three different documents to get all available information 

on one single mishap. The Commission sees value in a 

standard form or cover sheet that includes standardized 

data and HFACS checkboxes that can expedite ongoing 

data collection and analysis across all the Services. While 

the investigations provide causal and contributory 

information on a mishap, they fall short in providing 

DoD or the Services the standardized, comprehensive 

analysis and information needed to build a mishap 

prevention program comparable to commercial aviation. 

The Commission finds that after years of attempts 

to coordinate efforts, and despite the requirements in 

current policy, the Services have fallen short of what is 

needed. A new organizational approach is necessary in 

gathering and analyzing data to effectively improve safety 

and reduce mishaps in military aviation. 

Preemptive Aviation Safety Data Collection 

The Services’ investigations and mishap reports should 

be a more effective tool in proactively preventing 

further mishaps. The Department and the Services have 

some preventative safety programs in place. However, 

consistency and standardization in collecting mishap 

prevention program data are needed. DoDI 6055.19 

establishes the standards for effective data collection 

programs. The Services need to follow that guidance 

to execute an effective mishap mitigation program. 

Data gathering and regular analysis are essential to 

an effective safety program. As the data grows, its 

diagnostic, predictive, and prescriptive analytic power 

grows as well. 

Current DoD instructions direct the Services 

to develop and implement safety programs aimed at 

LEARNING FROM A NEAR MISS

The difference between a near miss and a Class 

A mishap could be as little as inches or seconds. 

Administratively, the difference is a Safety 

Investigation Board (or Aircraft Mishap Board) for a 

Class A and a hazard report for the near miss. “If you 

treat the near-miss as a task that you want to just get 

out of the way because it’s a hazard report, you are 

doing a disservice to the enterprise,” said CAPT John 

D. Boone, director of the Naval School of Aviation 

Safety at Naval Air Station Pensacola, Florida.

He is not suggesting treating every hazard report as a 

Class A or B investigation, but because the squadron 

Aviation Safety Officer could use the hazard as a 

standing Class A and B learning event, “Why not take 

one of those near misses and use that as a Class A or 

B exercise?” Doing a full mishap investigation on that 

near miss would then serve the unit as lessons learned. 
21

Chapter 3: Military Aviation Safety Data

analyzing safety-related issues before a mishap occurs. 

These safety management system programs, such as 

military flight operations quality assurance (MFOQA), 

aviation safety action program (ASAP), line operations 

safety audit (LOSA), and simulator operations quality 

assurance (SOQA) are aimed at gathering information 

from the machine and the human to improve safety. The 

use of these prescriptive tools would help leaders develop 

solutions to mitigate risks before they become mishaps. 

See Appendix G for more information on DoD’s efforts 

to initiate such programs.

DoDI 6055.19 has not been and currently is 

not enforced across the Department. The Services 

established safety programs but failed to implement the 

tools directed by policy, which could have significantly 

improved their programs. If all the Services fully 

employed MFOQA, ASAP, LOSA, and SOQA equally, 

DoD and the Services would have an invaluable 

collection of data that would support the development 

of predictive analysis safety programs. That could lead 

to the reduction or even the elimination of repeated 

mishaps.

THE ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING REVOLUTION

Artificial intelligence algorithms can analyze vast amounts 

of data: the more quality data, the better the output. 

The Services and DoD underutilize artificial intelligence 

and machine learning, which offer untapped potential to 

improve safety.

Three types of analytics could be applied to aviation 

safety. Diagnostic analytics can explain past events and 

make visible what was previously invisible. Predictive 

analytics model future outcomes, such as determining 

a pilot’s likelihood of success completing specific tasks. 

Prescriptive analytics enhances decision making by, for 

example, optimizing the pace of a pilot’s training.

The advanced analytics available through artificial 

intelligence and machine learning could improve safety 

by providing commanders visibility into safe and unsafe 

practices. Across an organization as large as the 

Department of Defense, these analytics could reduce 

human error by better understanding pilot task saturation 

and limitations.

Though much of the data gathered through aircraft 

recorders, pilot sensors, and simulator programs might 

not be immediately applicable, its value for diagnostic, 

predictive, and prescriptive analytics will grow as the 

amount and quality of data grows. 
22

National Commission on Military Aviation Safety

A pilot from Company F, 2nd Battalion, 238th Aviation Regiment, 40th Combat Aviation 

Brigade, finishes a mission aboard a UH-60 Black Hawk helicopter at Camp Buehring, Kuwait. 

(U.S. Army photo by SSgt. Ian M. Kummer.)
23

The Commission sees a seesaw pattern of effort and 

focus with regard to military aviation safety. The 

Services aggressively apply attention and resources when 

there is a major incident, but once the spotlight fades, 

leadership focus and resources move elsewhere. While 

over the long term mishap rates have declined, recent 

progress has flattened and, in some cases, reversed. 

Military aviation faces a complex series of 

challenges in seeking further improvements. As the 

previous chapters have established, flight and mishap 

data collection across the Services is insufficient for 

effective predictive analysis. Additionally, without 

organizational change, the Services are limited in their 

efforts to predict and avoid the next mishap. To help 

chart the path forward, the Commission looked at 

how the commercial aviation community addressed a 

comparable situation.

FINDING

Military aviation safety is inconsistently prioritized 

by the Department and the Services. The chorus of 

concerns heard on site visits coupled with the trends 

in mishap rates are evidence that a data-driven, 

organization-wide approach to achieve proactive 

aviation safety is warranted.

The Safety Success of Commercial Aviation 

Nearly 25 years ago, civil aviation safety was in a similar 

situation to what the Services face today. The accident 

rate had significantly declined over time, but by the mid1990s it had largely flattened, and the rapidly increasing 

civilian air traffic necessitated additional improvements 

to avoid an increase in the number of accidents. Simply 

put, the accident rate was good, but a “flat” accident rate 

in a rapidly growing industry ultimately means more 

accidents. Following a rash of commercial air disasters in 

1994, Congress established the National Civil Aviation 

Review Commission and the President established the 

White House Commission on Aviation Safety and 

Security. Both commissions recommended numerous 

changes to improve aviation safety.

These commissions provided the framework to 

establish the Commercial Aviation Safety Team (CAST), 

a government-industry partnership that developed an 

integrated, data-driven strategy to reduce commercial 

aviation risk in the United States. CAST’s goal was 

to reduce the U.S. commercial aviation fatal accident 

rate by 80 percent in 10 years. The results speak for 

themselves: CAST exceeded its aggressive goal as the 

fatal accident rate fell 83 percent by 2007. Seeking 

opportunity for further improvement, CAST has 

raised its goal and is seeking to reduce the remaining 

fatality risk an additional 50 percent by 2025. A closer 

examination into CAST’s success highlights potential 

improvements for military aviation.

CAST and ASIAS

CAST’s mission is to build a continuous improvement 

framework by proactively identifying safety risks followed 

by developing mitigation strategies and monitoring 

the effectiveness of implementation. CAST’s members 

are commercial airline trade associations, aircraft 

manufacturers, airline and air traffic control employee 

associations, and U.S. and Canadian government aviation 

agencies, including the U.S. Department of Defense. 

To accomplish its mission, CAST works closely with the 

FAA’s Aviation Safety Information Analysis and Sharing 

(ASIAS) program, a collaborative initiative based on data 

analysis and information sharing designed to discover 

safety concerns before an accident occurs.

CAST uses a disciplined, data-driven approach 

to analyze safety information; identify hazards and 

underlying contributing factors; develop safety 

enhancements to address risk; and continuously 

monitor implementation and effectiveness of the 

safety mitigations. CAST also charters joint working 

groups that analyze a variety of systemic safety issues in 

commercial aviation. Significantly, commercial aviation 

is persistent in focusing on and resourcing safety.

The Commission met with FAA officials about CAST 

and was impressed by the program’s collaborative success 

and the functional utility of ASIAS. Despite significant 

Chapter 4: 

THE JOINT SAFETY COUNCIL

Human Environment

Machine
24

National Commission on Military Aviation Safety

differences between the commercial and military aviation 

communities, adopting many of the attributes of these 

commercial safety practices is possible in military aviation.

FINDING

Facing a similar situation 25 years ago, the 

nation’s commercial aviation community created 

CAST (the Commercial Aviation Safety Team), a 

collaborative, government-industry partnership that 

was successful in driving down commercial aviation 

fatal mishap rates. It employed comprehensive data 

analysis and sharing to proactively identify and 

implement safety enhancements before an accident 

occurs. Based on the tenets and success of that 

program, the Commission has determined that the 

Department of Defense needs a similarly focused 

program tailored to the military’s unique missions 

and organizational structure.

Different Missions, Different Organizations

Military aviation, by its nature, will always involve 

more risk than commercial aviation. To reduce risk 

in combat, military aircrews accept greater risk in 

training. Unlike commercial aviation, additional safety 

features on aircraft must be weighed against the cost 

to the combat mission. Since space on the aircraft is 

limited, additional safety systems may mean less combat 

capability. Military aviation requires a careful balance 

between military mission and aviation safety. 

In studying military aviation mishaps, the 

Commission found that the overwhelming majority of 

mishaps could not be attributed to the inherent risk of 

military aviation. Avoiding mishaps caused by pilot error, 

mechanical failures, or inadequate training does not 

require lowering standards or abandoning the warrior 

ethos. In fact, just the opposite is true.

To achieve success comparable to civil aviation, 

the military aviation community needs to reexamine 

how it approaches safety. Identifying risks and reducing 

fatalities require accumulating and analyzing data 

to facilitate accident mitigation and prevention. 

Additionally, DoD has no central clearinghouse to 

analyze this data. There needs to be a single organization 

that empowers the Services’ safety officials, has attention 

from the highest echelons of Department leadership, 

closely coordinates aviation safety efforts, and monitors 

their sustained implementation.

The potential savings in lives and materiel from 

effective safety initiatives could be enormous. As outlined 

in Chapter 2 and Appendix F, Class A mishaps cost 

the Department of Defense 450 lives and almost $17 

billion from fiscal years 2007 to 2018. These losses can 

be reduced by adopting key lessons from commercial 

aviation. For example, if the military were nearly as 

successful in implementing a CAST model to reduce 

Class A mishaps, it would save over two dozen lives and 

more than a billion dollars each year. Achieving such 

The Federal Aviation Reauthorization Act of 1996 established 

the National Civil Aviation Review Commission, which, pursuant 

to its statutory charter, established task forces related to 

aviation funding and aviation safety. The task forces produced 

individual reports, which were then combined into the 

Commission’s final report in December 1997. 

Titled “A Consensus for Change,” the report highlighted 

the looming aviation gridlock due to increased growth and 

demand. “If this gridlock is allowed to happen, it will result 

in a deterioration of aviation safety, harm the efficiency 

and growth of our domestic economy, and hurt our position 

in the global marketplace.” The report also noted the 

catastrophic impact of a flat accident rate. “If there is no 

change in the accident rate, and the anticipated growth 

occurs, there will be a large airliner accident somewhere in 

the world every 7–10 days by the year 2010.” 

To avoid such heavy costs, the Commission recommended 

“broad and sweeping changes in the ways the FAA is 

managed, sets its priorities, assesses and achieves 

performance outcomes, and is financed.” To reduce 

the accident rate, the Commission recommended “a 

comprehensive and concerted program by government and 

industry that will require new ways of doing business with 

each other and a greater emphasis on cooperation and 

collaboration.” 

As one example, the Commission recommended the FAA 

and aviation industry “develop a strategic plan to improve 

safety, with specific priorities based on objective, quantitative 

analysis of safety information and data.” A recommendation 

for improving aviation safety programs included looking 

“deeper than accidents and incidents to identify latent and 

emerging problems and fix them before a mishap occurs.”

CIVIL AVIATION COMMISSIONS
25

Chapter 4: The Joint Safety Council

success is certainly easier said than done. Any attempt 

to adopt safety practices from commercial aviation must 

consider how it differs from military aviation. 

In June 2003, DoD chartered the Defense Safety 

Oversight Council (DSOC) to “provide governance on 

DoD-wide efforts to reduce mishaps, incidents, and 

occupational illnesses and injuries.” The DSOC, chaired 

by the Under Secretary of Defense for Personnel and 

Readiness, was directed to meet quarterly to discuss 

safety and occupational health issues. Over the years, the 

DSOC lost its top-level support, resulting in diminished 

stature and impact. The DSOC did not meet from fiscal 

year 2010 to July 2018. 

It is this Commission’s assessment that DoD needs 

a fully funded aviation safety organization with greater 

visibility within the Office of the Secretary of Defense. 

FINDING

The Department of Defense currently lacks a single 

authority focused solely on aviation safety. Without 

empowered leadership focused on aviation safety at 

a high level within the Department, aviation safety 

will never get the consistent emphasis and resourcing 

it needs to make saving lives and protecting 

investments in personnel and equipment a priority.

Establishing a Joint Safety Council

To help bridge the gap between commercial aviation 

practices and military aviation realities, the Commission 

recommends that Congress establish a Joint Safety Council 

(JSC) to provide DoD leadership the information needed 

to strengthen DoD aviation safety initiatives and coordinate 

aviation safety activities across the Department and the 

Services. The JSC will develop aviation safety standards 

and evaluate the Services’ implementation of aviation safety 

programs. A legislative proposal for establishing the Joint 

Safety Council is provided in Appendix H.

Recognizing that the successful implementation of 

aviation safety programs requires cooperation from the 

Services, the Commission recommends that the JSC be 

composed primarily of Service representatives. This will 

ensure that the JSC’s directives, recommendations, and 

programs properly account for each Service’s unique 

aircraft, culture, and mission. The Commission’s intent 

is for the JSC to augment and support, not supplant, the 

Services’ existing safety programs. 

FINDING

The military departments’ safety centers are best 

positioned to investigate their aviation mishaps and 

manage the Services’ safety programs. A formal 

collaborative effort among the Services, working with 

the Department of Defense, will result in better data 

management and analysis and the infrastructure to 

support improvement in aviation safety.

The White House Commission on Aviation Safety and 

Security, established by Executive Order 13015 on August 

26, 1996, was tasked with developing “a strategy designed 

to improve aviation safety and security, both domestically 

and internationally.” Six months later, the White House 

Commission released its final report. 

For aviation safety, the Commission determined “the principal 

focus should be on reducing the rate of accidents by a 

factor of five within a decade.” To achieve this ambitious 

goal, the Commission proposed focusing “on several key 

areas: expanded use of partnerships; reengineering of the 

FAA’s regulatory and certification processes; greater focus 

on human factors and training; and the faster introduction 

of proven new technologies.” The Commission provided 14 

recommendations related to aviation safety. 

Several of these recommendations addressed data collection 

and training. For example, the Commission recommended 

the FAA “work with the aviation community to develop and 

protect the integrity of standard safety databases that can be 

shared in accident prevention programs.” In explaining this 

recommendation, the Commission pointed out “[t]here are a 

number of separate safety data collection efforts,” but 

“[m]any of these efforts either duplicate existing data, 

report the same information, or are not interconnected or 

integrated.” In another recommendation, the Commission 

highlighted the prevalence of flight crew errors and 

determined that additional “[r]esearch, technology, training, 

and sharing of safety data can reduce human error.” 

Furthermore, the Commission recommended the FAA 

“develop better quantitative models and analytic techniques 

to inform management decision-making.”
26

National Commission on Military Aviation Safety

This intent is further demonstrated by the JSC’s 

proposed voting structure. The voting members of the 

Council would be each military Departments’ directors 

of safety and an additional member from each military 

Service. A member of the Senior Executive Service (SES) 

would serve as a full-time JSC deputy, assisting the chair 

in managing the responsibilities of the JSC. One of the 

directors of safety would serve as the chair and be dual 

hatted as DoD’s Director of Aviation Safety. The deputy 

would serve as vice chair of the council. 

To ensure sufficient status, oversight, and 

accountability, the Commission recommends that the 

Council report to the Deputy Secretary of Defense and 

that each of the Services’ directors of safety be an officer 

in the grade of O-8. The Council’s duties would include 

setting DoD standards for aviation safety, identifying 

and prioritizing aviation safety programs throughout the 

Department, and overseeing and inspecting the Services’ 

implementation of such programs. 

While this Commission’s mandate is limited to 

proposing recommendations for improvements to 

aviation safety, Congress should consider expanding this 

Commission’s recommendation to all military operational 

safety.
27

Chapter 4: The Joint Safety Council

RECOMMENDATIONS

The Department of Defense must establish aviation safety responsibilities within the Office of the Secretary 

of Defense to ensure sufficient status, experienced and highly qualified personnel, and adequate funding to be 

effective in preventing injury, death, and damage. The following recommendations will create a coordinated, 

robust, proactive, data-driven aviation safety program that incorporates the best aviation safety practices from 

all relevant sources to become effectively predictive and preventive instead of reactive. 

The Commission recommends:

4.1 Congress mandate, authorize, and fund 

the creation of a Joint Safety Council 

that reports to the Deputy Secretary of 

Defense. The Joint Safety Council would 

support and coordinate the capability of 

the Services’ safety centers to identify and 

mitigate safety risks to reduce the number 

of aviation mishaps. The Joint Safety 

Council must be fully funded, staffed, and 

charged with developing and overseeing 

Defense-wide safety policies for the 

Secretary of Defense. It must have funding 

as a program element and unlimited access 

to the requisite databases. 

4.2 The Joint Safety Council oversee the 

Services’ implementation of robust 

Safety Management Systems that include 

programs such as MFOQA (military flight 

operations quality assurance), LOSA (line 

operations safety assessment), HUMS 

(health and usage monitoring system), 

and CVFDR (cockpit voice and image 

flight data recorders) from aircraft; SOQA 

(simulator operational quality assurance) 

from simulators; in-flight physiological 

data from aviators; and ASAP (aviation 

safety action programs) from aviators and 

maintainers. These programs should be 

based on best practices from commercial 

and military enterprises.

4.3 The Joint Safety Council set the 

requirements for mishap investigations 

in each of the Services to include the 

same Human Factors Analysis and 

Classification System (HFACS) codes 

for all Class A, B, and C mishaps. The 

Secretary of Defense will mandate that 

Class C mishap investigations use DoD 

reporting standards and data collection 

fields including HFACS codes.

4.4 That members of the Joint Safety Council 

will be the military Departments’ chiefs 

of safety, all of whom should be the grade 

of O-8, and an additional representative 

from each of the military Services. 

The chair, selected among the military 

Departments’ chiefs of safety every two 

years, would serve in a dual-hatted role as 

the Department of Defense’s Director of 

Aviation Safety. The vice chair should be 

a career Senior Executive Service position 

appointed by the Secretary of Defense. 

The vice chair’s responsibilities should 

be focused entirely on the mission and 

activities of the Joint Safety Council. The 

vice chair will report to the chair.
An F-35B pilot connects an air 

hose to her flight suit at Marine 

Corps Air Station Beaufort. 

(U.S. Marine Corps photo by 

Sgt Ashley Phillips.)
29

As aircraft become more technologically advanced, 

the need for a better understanding of the HumanMachine interface grows. For the past 10 years, the 

Services have been aggressively pursuing unexplained 

physiological episodes (UPEs) in military aircraft. For 

the next generation of aviators, aircraft will reach new 

levels of performance and pose increasing physiological 

challenges. Keeping the aviator safe while performing 

at the highest levels requires a fuller knowledge of the 

human in high-performance flight in order to build both 

human and machine survival into the aircraft’s design. 

Congress tasked the National Commission on 

Military Aviation Safety to assess the underlying causes 

contributing to unexplained physiological episodes in 

military aircraft, a major safety issue that surfaced with 

F-22 pilots experiencing an unusual number of hypoxialike episodes around 2010. 

The Commission pursued several avenues of 

information. It examined the studies and mitigation 

efforts of the Department of Defense spanning the 

past nine years in numerous aircraft communities. The 

Commission met with organizations researching the 

physiological episodes: the Air Force’s 711th Human 

Performance Wing; the Navy Medical Research Unit 

Dayton; the Air Force Life Cycle Management Center; 

the Army Aeromedical Research Laboratory; the 

Navy Physiological Episodes Action Team (PEAT); 

the Air Force PEAT; the Air Force, Army, and Navy 

safety centers; and members of the NASA Engineering 

and Safety Center. The Commission gained valuable 

information and understanding from members of a 

collaborative ad hoc working group called Characterizing 

and Optimizing the Physiologic Environment in Fighters 

(COPE-Fighter), comprised of medical practitioners, 

physiological experts, aviation researchers, engineers, 

and aviators. The Commission also discussed the issue 

with military personnel on visits to operational units and 

interviewed engineers and managers developing the next 

generation of Air Force aircraft. 

Technological advancement incorporated in new and 

in-development aircraft is critical to developing the most 

effective warfighting capabilities possible. Still missing 

is a full understanding of the physiological limits of 

human performance. The Commission found that even 

the newest aircraft in the inventory lack the sensors and 

recorders required to achieve that understanding.

Physiological Episodes

In 2011, the Air Force grounded the F-22 for five 

months because of the increasing number of unexplained 

physiological episodes. What initially surfaced as a fifthgeneration platform’s problem quickly proliferated as 

pilots began to report similar hypoxia-like symptoms in 

other aircraft, new and old, and across multiple Services 

and communities: the F-15, F-16, F/A-18, and F-35 

fighters; the T-6, T-45, and T-38 trainers; the low-altitude 

A-10 attack jet; even C-130 transports. Different oxygen 

systems, different cockpits, different missions, different 

ages of airframes, all had aircrews experiencing varying 

degrees of physiological episodes. 

From fiscal years 2013 through 2018, the Air Force 

experienced 718 physiological episodes. The Navy and 

Marines experienced 699 physiological episodes. Figures 

5-1 and 5-2 show which fighter and training aircraft 

experienced the most physiological episodes; Figures 5-3 

and 5-4 display the top five aircraft per fiscal year. 

No Single Problem, No Single Solution

Although initially unexplained, the overwhelming 

majority of physiological episodes have been explained 

with in-depth research. The physiological symptoms 

arising from these episodes, in addition to hypoxialike symptoms, include dehydration, temporal 

Chapter 5: 

THE HUMAN/MACHINE 

INTERFACE

Human Environment

Machine
30

National Commission on Military Aviation Safety

distortion, mental exhaustion, spatial disorientation, 

and hyperventilation. The broad range of physiological 

episodes made finding root causes extraordinarily 

challenging for researchers. They are unpredictable and 

inconsistent, even when the same aviator is flying the 

same aircraft and executing the same maneuvers. They 

also are not easily replicable by researchers trying to 

better understand what is happening to the individual 

inside the aircraft. 

FINDING

 No single cause is responsible for physiological 

episodes. 

Source: National Commission on Military Aviation Safety

Figure 5-1: 

Air Force Physiological Episodes by Aircraft 

Type for Fiscal Years 2013–2018

0

50

100

150

200

250

T-1

A

F-22F-35

-10

T-38

F-15

T-6

F-16

16 21

36

48 52

149

175

220

Figure 5-2:

Navy and Marine Corps Physiological Episodes 

by Aircraft Type for Fiscal Years 2013–2018

0

50

100

150

200

T-6B

F/A

F/A-18A

-18D

EA-18G

F/A-18F

T-45C

F/A-18E

F/A-18C

10 6

38

97 104

125

152 150

Source: National Commission on Military Aviation Safety

Figure 5-4:

Navy and Marine Corps Physiological 

Episodes in Fighter and Trainer Aircraft 

for Fiscal Years 2013–2018

0

10

20

30

40

50 EA-18G

F/A-18F

T-45C

F/A-18C

F/A-18E

201320142015201620172018

Figure 5-3:

Air Force Physiological Episodes in Fighter and 

Trainer Aircraft for Fiscal Years 2013–2018

0

20

40

60

80

100

120 A-10

T-38

F-15

T-6

F-16

201320142015201620172018
31

Chapter 5: The Human/Machine Interface

The Services have made significant progress in 

addressing the problem, with almost 94 percent of reported 

physiological episodes now explained. The Services used 

directed funding from Congress and reallocated resources 

to mount collaborative research initiatives and address 

specific issues, community by community. The Navy and 

Air Force Physiological Episodes Action Teams responded 

to physiological episodes as they occurred, finding causes 

and developing solutions for many of the previously 

unexplained physiological episodes. The PEATs visited 

installations to provide training for aviators, maintainers, 

and their families. 

The Commission considers the co-location of the Air 

Force Research Lab, the 711th Human Performance Wing, 

and the Navy Medical Research Unit Dayton at WrightPatterson Air Force Base, Ohio, a best practice. The ability 

to share resources, researchers, and results have greatly 

advanced physiological studies for the benefit of all the 

Services. 

FINDING

Several organizations and ad hoc groups have 

aggressively pursued this issue. The Commission 

finds that more seamless collaboration and 

integration among stakeholders could spur further 

and faster advancement in the discovery of the 

remaining unexplained root causes for physiological 

episodes.

In 2017, the T-6 began experiencing issues with 

its Onboard Oxygen Generating System (OBOGS). 

Studies by the Navy and other government and academic 

institutions revealed problems in the OBOGS hose 

component. In 2019, to resolve the issue, the Navy 

altered cleaning procedures for the system. The Air 

Force later adopted the procedures. Aircrews also 

received additional briefings to recognize and respond to 

physiological episodes and mitigate their effects. 

FINDING

After the causes of physiological episodes have been 

determined, the Services have taken aggressive 

action to alleviate the problem through equipment 

fixes or mitigating practices by aircrew and 

maintenance. Long-term fixes sometimes encounter 

funding challenges. 

As researchers identify potential solutions, their 

findings and recommendations move to aircraft program 

offices where they must compete with other priorities for 

limited resources. Despite the unexplained physiological 

issues impacting the jet aircraft community, and the 

efforts the Navy and Air Force have undertaken to find 

and mitigate root causes, no program of record has been 

established to coordinate efforts directly focused on 

eliminating the problem. 

Factoring In Humans

The Commission found that military aviators at all levels 

of flying experience remain concerned about physiological 

episodes. Some aviators expressed reluctance to report 

physiological episodes, concerned that the resulting 

medical attention would lead to grounding or greater 

scrutiny. There is a widespread perception that episodes are 

the pilot’s fault, not a failing or inadequacy of the machine 

or training. Given that some pilots also are unaware 

they have had a physiological episode, the Commission 

is confident, and operational aviators corroborate, that 

an undeterminable number of episodes go unreported. 

Unreported physiological episodes will continue without 

some means of monitoring the aviator in flight.

Experts in every organization expressed a common 

refrain: “More study is needed on the human.” Much of 

an aviator’s mission performance in flight is measured and 

assessed; however, the physiological response of the aviator 

is not. Measuring difficulty with breathing is complicated 

by factors such as altitude, tactical maneuvers, G-suit 

constrictions, and the aviator’s physiology and physical 

condition at the time of flight. The research laboratories 

can neither replicate all conditions of flight nor capture the 

full range of physical conditions aviators encounter over a 

succession of flights. 

Lacking physiological recording devices, 

researchers are unable to persistently gather objective 

data from aviators in flight sufficient to enhance their 

understanding of physiological episodes. Researchers 

are exploring biometric monitoring systems that can be 

integrated into flight suits, helmets, and masks in order 

to collect the necessary data without interfering with 

the aviator’s operation of the aircraft. In the interim, 

the Services are using commercially available data 

collection tools, such as “slam sticks” that measure cabin 

pressure, and smart watches that measure blood pressure 

and heart rate. A more promising step in studying the 

human in flight is a joint U.S. Navy/NASA initiative 

placing sensors inside the mask that measure pressure, 

temperature, and CO2 concentration.
32

National Commission on Military Aviation Safety

FINDING

The most effective means to understand and 

prevent future unexplained physiological episodes 

is to gather and evaluate data on what is happening 

real time to aircrew during actual flight, from initial 

aircraft development throughout the operational 

life cycle—akin to a “black box” for the pilot. Greater 

understanding of the warfighter’s capabilities—

including the task of breathing—during actual flight is 

as important as measuring the machine’s capabilities. 

Such data also offers other benefits, such as 

establishing substantive physiological standards or 

accommodations for aircraft assignments. 

The Commission heard many comments from 

experts about the lack of in-flight biometric monitoring 

of the pilot. The aircraft is fully wired to document its 

performance through a wide range of maneuvers and 

conditions; yet the operator is not monitored. Such data 

collection is integral to understanding the pilot’s experience. 

With that information, the pilot can be properly equipped 

and prepared to carry out missions, allowing the Services to 

protect their multibillion-dollar investments in both pilot 

and machine. 

FINDING

The most effective investment in preventing 

physiological episodes occurs in the design, 

development, and test phases. Instrumentation that 

monitors the pilot in flight as part of the weapons system 

provides early problem detection and at the lowest cost 

to resolve human-machine interface problems.

Prioritizing the Human

The Commission identified challenges in using 

standards set for an outdated notion of a military pilot, 

first established in the 1940 Pensacola Study of Naval 

Aviators when virtually all military pilots were male. 

Until recently, minimum size design specifications for Air 

Force acquisitions were based on a 1967 male-only pilot 

survey. Today’s diverse community of military aviators 

is not the same homogeneous group as in the past. The 

Services need to match 21st century aviators to their 

21st century machines. Systems need to work for a wider 

anthropometric and demographic range of individuals—

male and female, short and tall, those who breathe faster 

or slower. Such factors should be built into the standard 

rather than treated as deviance from the norm. Designing 

systems for the full range of today’s aviators will improve 

Women military aviators must often use equipment 

designed for men. Uniforms, body armor, and facilities that 

were neither designed nor intended for women impact 

their safety, readiness, and proficiency. 

Female fighter pilots have issues with G-suits, the overgarment designed to help pilots maintain consciousness 

in high performance aircraft. The Air Force Life Cycle 

Management Center told the Commission that only limited 

sizes were available. “If a G-suit is impinging on your lungs, 

it will impact your breathing,” said an official there. A pilot 

told the Commission of a female pilot who was being 

medically retired because of nerve damage resulting from 

wearing an issued G-suit that was not designed for her body. 

The Commission also heard about women having problems 

with bladder relief systems, survival vests, harnesses, and 

ejection seats.

The Services are addressing fit for all sexes, heights, and 

body types, the Air Force Life Cycle Management Center 

official said. “We are doing exoskeletons for loadmasters 

to help them carry heavy loads. We are looking for vests 

for women in particular. They are currently unisex and that 

really means male. We are looking to find a better fit for 

them that works with the body armor they need.”

One female Air Force squadron commander told the 

Commission that logistics cannot effectively manage femaletailored equipment. “They don’t have women’s [size] boots. I 

wore 60 pounds of gear, running in shoes that don’t fit me.” 

During the Commission’s visit to NAVAIR, a representative 

described two primary problems: “There’s either a lack of 

knowledge of customizable solutions, or women do not take 

the other solutions because they want to fit in.” 

Lagging efforts to remedy these issues are unacceptable. 

As a female Air Force pilot said, “When we talk aviation 

safety, it isn’t just mishaps. It is also about making sure 

our equipment doesn’t hurt us and works for us.” The 

Commission agrees.

FEMALE FIT OF EQUIPMENT
33

Chapter 5: The Human/Machine Interface

human performance and prevent the expenditure of 

hundreds of millions of dollars to retrofit aircraft systems 

after production.

Acquisition Standards and Processes

The Commission closely reviewed new aircraft in 

development to see if the lessons learned from the 

Services’ analysis of physiological episodes in today’s 

aircraft are being applied to tomorrow’s aircraft. The 

Commission found that in the early stages of aircraft 

development, programs remain overly focused on 

aircraft capabilities without the proper consideration of 

the human. There must be a balance. The Commission 

sees two areas where this imbalance could be addressed: 

by adding aircrew safety into the force protection key 

performance parameter; and by incorporating human 

systems integration, safety technologies, and datacollecting systems earlier in the design process.

Key Performance Parameters

Key Performance Parameters (KPPs) are the evaluation 

criteria that systems must meet or exceed to be credited as 

meeting operational goals. Currently, DoD’s acquisition 

process has four mandatory KPPs: system survivability, 

force protection, energy, and sustainment. KPPs are 

specified in the Capabilities Development Document 

that directs requirements for system-level performance 

attributes. After gathering information from the Joint 

Staff J8 Force Protection Division, the Commission 

determined that the force protection KPP is the best 

place to incorporate additional requirements to give 

greater priority to human safety. 

Updating the KPP would enhance the performance 

of the aircrew in the aircraft and provide better protection 

against injury or death for the occupants. Mishap 

prevention measures could include systems for ground 

and aircraft collision avoidance and spatial disorientation 

recovery. With the vital need for data collection to 

enhance predictive initiatives, the force protection 

KPP should also include cockpit voice and flight data 

recording systems as well as biometric sensing for the 

aircrew. 

The technology for such systems already exists. To 

fully evaluate costs and benefits, acquisition officials 

should factor in the potential for achieving long-term 

lifecycle savings. For example, the Air Force has fielded 

in its F-16 Block 40/50 aircraft the Automatic Ground 

Collision Avoidance System (Auto-GCAS), which 

prevents controlled flight into terrain (CFIT). Air Force 

statistics show that CFIT was responsible for 75 percent 

of all F-16 pilot fatalities. Since being fielded in 2014, 

Auto-GCAS has prevented the crash of 10 aircraft and 

saved the lives of 11 Air Force pilots. Similarly, cockpit 

voice and flight data recorders and military flight 

operations quality assurance (MFOQA) systems discussed 

in Chapter 3 have proven to produce critical information 

needed to improve safety performance through incident/

mishap reconstruction, training, procedural changes, and 

predictive maintenance.

FINDING

From the earliest stages of acquisition, the machine’s 

operational capabilities dominate the development of 

aircraft while aircrew safety gets too little attention. 

Current acquisition practice does not give enough 

consideration to the cost avoidance and savings that 

mishap avoidance systems and aircraft and simulator 

data collection and analysis processes can provide 

when prioritizing capabilities. 

Human and Safety Systems Integration

Two engineering disciplines, system safety engineering 

and human factors engineering, should play an essential 

role in balancing the human and machine from the 

beginning of the requirements and acquisition process. 

According to Military Standard 882E, human systems 

integration (HSI) is “the integrated and comprehensive 

analysis, design, assessment of requirements, concepts, 

FORCE PROTECTION KPP STANDARDS 

OF PROTECTION

The Force Protection KPP includes protection from 

environmental effects, which covers standards for 

acceptable pressure/oxygen levels for personnel, 

including pressurization and/or supplemental oxygen; 

acceptable temperature limits for personnel (with or 

without PPE); standards for acceptable vibration/acoustic 

limits for personnel (with or without PPE); and acceptable 

G-force loading limits for personnel (with or without 

PPE) under normal operations. Protection from crash 

events attributes include standards for crash survivable 

G-force loading limits for personnel (with or without PPE); 

protection from impact trauma, including seats and 

retaining systems; preservation of occupied space; and 

protection from post-crash fuel spills and fires.
34

National Commission on Military Aviation Safety

and resources for system manpower, personnel, 

training, safety and occupational health, habitability, 

personnel survivability, and human factors engineering.” 

Department of Defense Directive 5000.01, The Defense 

Acquisition System, September 9, 2020, states that 

“Human systems integration planning will begin in the 

early stages of the program life cycle. The goal will be to 

optimize total system performance and total ownership 

costs, while ensuring that the system is designed, 

operated, and maintained consistent with mission 

requirements.” The timeline in Figure 5-5 shows where 

human systems integration subject matter experts and 

strategies can be employed for significant positive impact 

on system development. 

The Commission reviewed recent and current 

aviation acquisition programs and found that the 

recommendations in the Air Force Human System 

Integration Guidebook were often overlooked during the 

requirements process. 

The latest jet fighter to enter the Services’ inventory, 

the F-35 Joint Strike Fighter, first flew in 2006, before 

unexplained physiological episodes began surfacing with 

SYSTEMS ENGINEERING DISCIPLINES

System Safety Engineering is a discipline that 

employs specialized knowledge and skills in applying 

scientific and engineering principles, criteria, and 

techniques to identify hazards and then to eliminate 

those hazards or reduce the associated risks when the 

hazards cannot be eliminated.

Human Factors Engineering is a multidisciplinary 

effort to generate and compile information about 

human capabilities and limitations. This information 

is applied to equipment, systems, software, facilities, 

procedures, jobs, environments, training, staffing, and 

personnel management to produce safe, comfortable, 

and effective human performance. It focuses on how 

people interact with tasks, machines or computers, 

and the environment.

[Source: AcqNotes.com.]

Figure 5-5: 

Human Systems Integration in the Acquisition Planning Process

Source: Department of Defense Directive 5000.01, The Defense Acquisition System, September 9, 2020

CAPABILITIES 

BASED 

ASSESSMENT

MATERIEL

SOLUTION 

ANALYSIS

TECHNOLOGY 

DEVELOPMENT

ENGINEERING AND 

MANUFACTURING 

DEVELOPMENT

ICD CDD CPD

Materiel 

Development 

Decision

Design 

Readiness 

Review

AoA AoA

Plan

HSI Subject 

Matter Expertise

• DOTMLPF 

Analysis

• Analysis of 

Materiel and 

non-Materiel 

Approaches

HSI 

Considerations HSI Subject Matter Expertise

A B C

DOTMLPF = Doctrine, Organization, Training, Materiel, 

Leadership and Education, Personnel and Facilities

AoA = Analysis of Alternatives

ICD = Initial Capabilities Document

CDD = Capability Development Document

CPD = Capability Production Document
35

Chapter 5: The Human/Machine Interface

the F-22. The Services began taking possession of F-35 

variants in 2015. To date, a total of 49 physiological 

episodes have been reported across the three variants. 

Better human systems integration could have mitigated 

or even prevented these physiological episodes. 

The Commission believes every multimillion-dollar 

investment in weapons systems and aviator training must 

be accompanied by proactive efforts to ensure that the 

pilot is physiologically capable of safely operating the 

aircraft through all of its designed flight regimens. 

RECOMMENDATIONS

With modern aviation machines placing unprecedented stress on human physiology, the Department of 

Defense and the Services must adopt an aggressive, proactive approach to understanding the physiological needs 

of aviators and to developing additional capabilities that improve the human-machine interface, including 

aircraft and cockpit design, testing, and subsequent modifications. 

The Commission recommends:

5.1 The Joint Safety Council (Commission 

recommendation on page 27) lead a 

robust review into the effects on humans 

in aviation operational environments, 

including physiological episodes. The JSC 

shall have a program element to conduct 

further research into determining and 

mitigating unexplained physiological 

episodes. 

5.2 Program offices address human physiology 

concerns and analyze physiological effects 

throughout the aircraft testing phases for 

T-7, B-21, Future Vertical Lift, and other 

next-generation platforms early in the 

initial aircraft and cockpit design and with 

any materiel modification of the aircraft. 

5.3 The Department of Defense and the 

Services develop physiological standards 

for each airframe to use in screening and 

training to ensure that the pilot/operator 

is able to successfully perform at optimal 

levels across the spectrum of the weapons 

system’s capabilities.

5.4 The Department of Defense, with input 

from each of the safety centers, update 

and modify the Force Protection key 

performance parameters (KPP) to better 

incorporate Aviation Human Systems 

Safety. 

5.5 That the Force Protection Functional 

Capability Board include representative 

capabilities such as ground and other 

aircraft collision avoidance; cockpit voice 

and flight data recording; biometric 

sensing for aircrew; and a spatial 

disorientation recovery system used for 

instrument meteorological conditions 

and brownout.
36

National Commission on Military Aviation Safety

An Air Force aircraft maintenance 

craftsman with the 435th 

Contingency Response Squadron 

conducts “hot pit” refueling for 

an F-16 Fighting Falcon assigned 

to the 510th Fighter Squadron, 

Aviano Air Base, Italy, during an 

exercise at Graf Ignatievo Air Base, 

Bulgaria. (U.S. Air Force photo by 

SrA Savannah L. Waters.)
37

Chapter 6: 

SUSTAINING THE MACHINE

Across the spectrum of site visits, interviews, and 

town halls, the Commission observed and heard 

problems relating to aircraft parts, depot work, facilities, 

and fleet transitions.

Among these several issues, obtaining parts—on time 

and functional—was a constant complaint. Notably, at 

one Navy installation, when noncommissioned officers 

(NCOs) were asked about parts, the Sailors replied with 

laughter. Simply put, the current supply systems are not 

meeting the needs of unit-level maintainers and are a 

significant cause of non-operational aircraft.

During its study, the Commission saw and heard of 

worrisome shortcuts taken by maintenance crews trying 

to meet their mission. In seeking to deliver mission 

capable aircraft, maintainers stated they often resort to 

cannibalizing parts from other aircraft, using shortcuts, and 

fielding aircraft with numerous deferred repairs. Although 

cannibalization is not a new practice, maintainers from all 

Services told the Commission this has been an increasing 

practice over the past several years. While no maintainer 

told the Commission that they were knowingly putting 

unsafe aircraft in the air, they acknowledged the danger of 

compounding risks on top of each other.

Aviation Supply System

The DoD aviation supply system is large, complex, and 

confusing. The Commission heard from hundreds of 

Servicemembers about the daily problems they face in 

getting parts to keep aircraft flyable. The complaints 

about spare parts came in three forms: (1) parts cannot be 

obtained in a timely manner; (2) parts do not work; and 

(3) parts do not exist. 

First, for a military that operates around the globe 

and must maintain combat readiness, parts need to 

be available in a timely manner. For example, as the 

Commission heard during a visit at one Air Force base, 

when an actuator failed on a deployed aircraft in the 

Pacific, the only replacement parts were in two locations 

on the other side of the world. The maintenance group 

commander was forced to have an actuator taken off of 

a working plane at his home base in the United States 

and flown to the aircraft so it could be fixed. “The 

powers that be don’t understand the positioning of parts 

strategically around the globe,” that commander told 

the Commission. “I need it fixed today.” He called this 

lack of supply chain visibility a “systemic subversion of 

established business rules.” By contrast, in the modern 

commercial and retail markets, customers around the 

world are able to order, track, and quickly receive aviation 

parts through a variety of suppliers.

Second, the Commission heard many complaints 

that spare parts in their existing stock often do not work. 

In one instance, a maintenance squadron pulled the 

same component from the supply shelf three times before 

getting one that was serviceable. The Commission also 

heard numerous complaints that components repaired by 

contractors failed to perform when needed.

Finally, in some cases, and especially with legacy 

aircraft, the necessary parts simply do not exist. As 

aircraft are extended beyond their planned service life, 

parts that were designed to last the originally planned 

life of the aircraft begin to fail. In many cases, the 

industrial base to produce these parts is insufficient or 

non-existent, especially when planned retirement dates 

are extended, and second- and third-tier vendors have 

moved on to other products. For example, when the Air 

Force set the retirement date of the A-10 Thunderbolt, 

small and mid-size companies producing parts for that 

aircraft began retooling for other projects. When the 

retirement was postponed, the supply system was no 

longer in place. A Marine Corps CH-53E commander 

told the Commission that the supply system was 

not designed to support an aircraft so far beyond its 

published planned retirement date.

AIRCRAFT AVAILABILITY

Aircraft availability is the percentage of a fleet in 

mission-capable condition and not in a depotpossessed or unit-possessed nonreportable (UPNR) 

status. UPNR status includes aircraft in the unit 

awaiting completion of planned or unplanned 

maintenance or that require engineering dispositions. 

Human Environment

Machine
38

National Commission on Military Aviation Safety

In sum, the lack of a functioning supply system 

that delivers working parts in a timely manner has a 

significant negative impact on aircraft availability and 

readiness. The Commission visited commercial aviation 

entities with supply systems that use inventory tracking 

and robust delivery systems to get parts delivered 

anywhere in the world the next day. For commercial 

enterprises, responsive customer service is essential to 

the business’s bottom line. For the military Services, the 

lack of parts creates aircraft availability issues that hinder 

pilots from getting their required flight hours. 

Overcoming Supply Deficiencies

When parts are not available, maintainers routinely 

resort to aircraft cannibalization, stripping parts from 

one aircraft to make other aircraft operational. “We are 

cannibalizing multiple times a day,” a Marine senior 

NCO told the Commission. Further emphasizing the 

prevalence of cannibalization, or “canning,” across all 

military fleets, the Commission saw a sign prominently 

displayed in one unit that said, “Supply can’t...so we 

CAN [cannibalize].” 

Cannibalization impacts aircraft availability and 

maintenance efficiency. Instead of simply replacing the 

part, maintenance crews must remove the part from one 

aircraft and install it on another aircraft. This increased 

workload further exacerbates readiness problems. Each 

step also incurs some risk that the aircraft or part will be 

damaged. 

Additionally, when replacements for expired parts 

are not available from any source, maintainers must turn 

to engineers to determine whether the part’s life can 

be extended. As a senior Air Force maintainer told the 

Commission, when parts would not be available for over 

a year, “we’re going to the engineers to get a work-around. 

That’s why we’ve been able to fly aircraft well past their 

service life.” When engineers make the decision to extend 

the service life, aircrew are forced to accept the additional 

risk. As one maintainer noted, “We could negate those 

risks by having a more robust supply system, and then 

the engineers don’t need to do the workarounds.”

Depot Maintenance

A 2019 Government Accountability Office report found 

ongoing problems at military depots and rated five of 

seven aviation depot facilities as poor performers. From 

fiscal years 2008–2018, the Navy’s on-time performance 

rating fell by nearly a third, even as the number of aircraft 

scheduled for repair declined. The Air Force similarly 

experienced decreased on-time performance despite 

a decreasing number of aircraft scheduled for repair. 

According to the GAO, “depot maintenance delays, 

among other challenges, limit the Navy, Air Force, and 

Marine Corps’ ability to keep aviation units ready by 

reducing the number of aircraft that are available to 

squadrons for conducting full spectrum training.” 

The GAO report’s conclusion matched what the 

Commission heard on its visits. For example, in one 

roundtable, maintenance group personnel described 

fixing up aircraft delivered from other wings, saying it 

takes about two months to get those planes up to their 

standards. “Is there a base where you hate to get an 

airplane from?” the Commission asked. “The depot,” 

someone replied, followed by general consensus. 

Most troubling, Navy and Air Force units described 

finding foreign objects in aircraft—tools in engines, 

gloves in fuel tanks, old wiring still in place. “We get 

interesting stuff coming out of depots,” said a maintainer 

with a Navy helicopter wing. “We had a stuck control, 

took apart the floor, and found bolts in there.” One 

Air Force major command representative told the 

Commission that “jets are coming out of the depot in 

worse shape than when they started.”

FINDING

The aircraft sustainment system, from the supply of 

parts to depot maintenance, is not providing aviation 

units with the quality products and timely services they 

need to sustain operations. Accordingly, aviation units 

are often resorting to cannibalization of other aircraft.

Facilities 

At Naval Air Station Oceana, Virginia, the Commission 

entered a hangar by passing under steel letters that were 

falling off the wall above the hanger’s doors. Broken 

doors forced Sailors to use aircraft tugs to pull the 

massive doors open and closed, one time accidently 

hitting an F/A-18 and causing substantial damage. 

Commissioners stepped around buckled drain gratings 

marked in yellow as a warning to keep aircraft away. The 

fire suppresion system was inoperable, and only two of 

eight bays had working power for aircraft maintenance. 

The Commission found similarly unsatisfactory 

conditions at numerous installations across the Services. 

As a Navy senior executive told the Commission, “I’ve 

toured two naval aviation depot maintenance facilities; 

both are maintaining fifth-generation fighters with advance 

avionics in pre-first generation—I’m talking World War 
39

Chapter 6: Sustaining the Machine

II—aviation maintenance facilities.” The GAO specifically 

noted that more than one-third of the Navy’s aviation 

depot square footage was built in the 1940s. The GAO 

added that outdated facilities have “electrical systems 

built for different weapon systems, historical preservation 

requirements, and suboptimal layouts. It can be difficult 

for a depot to maintain complex, modern weapon systems, 

such as the F/A-18, with facilities that were designed for 

less complex systems.”

Poor facilities and a lack of equipment delay 

maintenance. When only two of eight hanger bays 

can be used to power an aircraft during maintenance, 

maintainers must spend hours moving aircraft from one 

bay to the next. A Marine aircraft wing commander 

estimated his maintainers put in 1,000 miles of towing 

per year, “and we tell them not to have a tow accident.”

Aircraft Transition Issues

Once a Service announces it is replacing a legacy aircraft 

with a new platform, the old aircraft’s support system 

shuts down. As the transition begins, personnel are 

reassigned to the new platform, legacy facilities are 

neglected, and parts availability dwindles. Then, delays 

in aquiring the new platform extend the life of the old 

platform for years. By their nature, aircraft transitions are 

fraught with unpredictability, a process the Commission 

sees repeated over and over again.  

F-35 Lightning II and Legacy Aircraft: According 

to feedback from line units, the F-35 program is perhaps 

the best example of DoD’s pursuit of new technology 

via an erroneous acquisition and planning construct. 

As an F-35 maintenance squadron commander told the 

Commission, “The bean counters got it wrong. They 

said the F-35 is going to be easier to maintain, they 

will need less maintenance. These aircraft take a lot 

more man hours than previously thought, but they’ve 

already appropriated smaller staffing.” The Services are 

devoting critical resources to the F-35 program while 

simultaneously being forced to extend the service lives of 

legacy aircraft. This creates a case of haves and have-nots 

as limited resources are used to support multiple aircraft 

simultaneously. The Commission received numerous 

complaints regarding the F-35’s impact on the AV-8B, 

A-10, and F-16. For example, one commander said his 

F-35 squadrons have 85 Marines just in avionics, while 

his Harrier squadrons have 85 Marines total. 

KC-46 Pegasus and Legacy Aircraft: The 

Commission received similar feedback regarding the 

delayed transition to the KC-46 tanker. For example, 

one unit reported drawing down its KC-135 operations 

before the first KC-46s were delivered. Another unit is 

already divesting its KC-10s even though the first KC-46 

is not scheduled to arrive at the base until the first quarter 

of fiscal year 2022. One commander said, “We may lose 

KC-10s before we get KC-46s.” The Commission also 

received feedback that the Air Force is having trouble 

with failing parts and filling KC-10 flight engineer 

positions. Overall, as reported to the Commission, the 

attempt to prepare for the new tanker’s arrival while 

stretching the life of its predecessors is straining resources. 

CH-53K and CH-53E: In response to continued 

delays with the CH-53K and the need for continued 

mission capacity, the Marine Corps began the RESET 

program to reinvigorate the CH-53E legacy aircraft. 

Personnel at the unit level, who are both sustaining 

aircraft and receiving those returning from RESET, 

expressed concerns to the Commission. For example, a 

squadron leader at Marine Corps Air Station New River 

said that, even after RESET, a lot of his aircraft “don’t 

work. We fly an aircraft that would get antique plates 

from any DMV.” Said a Marine at Marine Corps Base 

Kaneohe Bay, “We have issues with the damper and the 

rotor blades. There’s also some stuff with the hydraulics. 

The Echo is going to be around until 2030. Is the Kilo 

going to fix all of it?”

FINDING

Deteriorating maintenance facilities and significant 

issues with transitioning from legacy platforms to 

new aircraft are contributing to delays in aviation 

maintenance and limiting operational availability of 

aircraft. 

RECOMMENDATION

The Department of Defense and Services 

must improve their planning, contracting, 

and program management processes to 

ensure timely availability of spare parts, 

improve maintenance efficiency, increase 

mission capable rates, and better sustain the 

investment made in aircraft. The Services 

should improve sustainment management 

systems, particularly for legacy aircraft 

and service life extensions, to provide the 

necessary visibility on expiring parts and 

production upgrades. 
40

National Commission on Military Aviation Safety

A pilot assigned to Helicopter Sea Combat 

Squadron 26 performs preflight checks on an 

MH-60S Seahawk helicopter aboard the Waspclass amphibious assault ship USS Kearsarge. 

(U.S. Navy photo by Mass Communication 

Specialist 2nd Class Michael R. Sanchez.)
41

Chapter 7: 

THE NEED FOR CONSISTENT 

AND PREDICTABLE FUNDING

On nearly every site visit, the Commission heard 

about funding problems: not necessarily that there 

was not enough funding, but that it was erratic and came 

in waves. “I can always use more money,” said a senior Air 

Force leader, “but the thing I really need is predictability: 

budget for five years, [and] get it on October 1.”

In May 2019, as a direct result of funding being 

suddenly withdrawn for other priorites, a Marine Aircraft 

Wing Commander issued an order for aviation units to 

minimize ordering new parts through the end of the fiscal 

year. Therefore, rather than order new $5 filters, Marine 

maintainers cleaned old ones by flushing them backwards 

before reinstalling them on the aircraft. “Nobody wants 

to not make the mission,” a Marine Corps junior aviation 

officer told the Commission.

As Secretary of Defense James Mattis said two years 

ago, “Let me be clear: As hard as the last 16 years of war 

have been on our military, no enemy in the field has done 

as much to harm the readiness of the U.S. military than 

the combined impact of the Budget Control Act’s defense 

spending caps, worsened by operating for 10 of the last 

11 years under continuing resolutions of varied and 

unpredictable duration.” 

The Commission’s primary concern is not the 

amount of money currently allocated to military aviation, 

but the predictability and reliability of funding. The 

problems with erratic funding ripple through all levels 

of military aviation. Units cannot adequately plan for 

exercises and training. Pilots have reduced flight hours at 

various points throughout the year, interfering with their 

ability to maintain currency and proficiency. Maintainers 

cannot buy parts, resulting in cannibalization or 

inappropriate maintenance. When funding is restored, it 

is most often too late to be spent optimally.

The inconsistency and unpredictability of funding 

increases costs and decreases readiness. This forces the 

Services to defer new contracts for maintenance and parts. 

In one of several examples, the Commission learned of 

brand-new aircraft, freshly delivered from the assembly 

line, being cannibalized for parts in order to make 

several other aircraft operational. “This is no way to run 

a railroad,” a Marine Aircraft Wing commander told the 

Commission. 

Congress tasked the Commission specifically “to 

make an assessment of causes contributing to delays in 

aviation maintenance and limiting aircraft availability; to 

make an assessment of the causes contributing to military 

aviation mishaps; and to make recommendations on the 

modifications, if any, of safety, training, maintenance, 

personnel, or other policies related to military aviation 

safety.” In the Commission’s assessment, unpredictable 

funding compromises maintenance operations, degrades 

the quality of training, and is a significant cause of 

unavailable aircraft. In the aggregate, inconsistent 

funding increases safety risks. 

FINDING

Consistent, reliable, and timely funding is key to 

sustaining military and aviation readiness and safety.

Continuing Resolutions

The primary source of unpredictable funding is 

Congress’s perennial use of continuing resolutions (CRs). 

The budget has been increasingly subjected to CRs, 

particularly in the years since the 2011 Budget Control 

Act. In fact, the Department of Defense has started 13 of 

the past 18 fiscal years under a CR (see Figure 7-1). As 

CRs have become more common, their average duration 

has also increased. In fact, from 2002 through 2009, CRs 

lasted an average of 33.6 days; from 2010 through 2018, 

CRs averaged 103 days; and the four longest CRs (2011, 

2013, 2017, and 2018) averaged 190.5 days, creating 

uncertainty for longer than six months in each of those 

years. 

The issue of unpredictable funding repeatedly 

came up during site visits. “We don’t plan exercises and 

[mission-related travel] because you don’t know if you 

will have funding,” an Air Force squadron commander 

told the Commission. “I can’t plan my budget and 

make the purchases [needed] and can’t get them the 

[equipment] they need to do safe flight operations.” 

A Navy mid-grade officer told the Commission that 

Human Environment

Machine
42

National Commission on Military Aviation Safety

funding predictability “is a big issue for everyone. We 

don’t know how to plan against the unpredictability.” 

For example, a contractor who supports the Navy by 

providing “adversaries” for air combat maneuver training 

said his company is told to stand down at the beginning 

of almost every fiscal year. Then, months later, the 

company is told to ramp back up, a practice consistent 

with workarounds caused by continuing resolutions. 

This issue is not limited to active duty units or 

personnel. One Air Force Reserve unit commander 

told the Commission, “I redo the annual budget twice 

a quarter.” Reserve component aviation professionals 

described the yo-yo effects of preparing months for a 

deployment that suddenly drops off the schedule at the 

last minute due to cancelled funding. “Reservists need 

predictability for their family and civilian job,” said an 

Air Force Reserve aviator. 

FINDING

Continuing resolutions are disruptive, compromise 

safety, and place lives at risk.

Vulnerability of Military Aviation

The Commission understands that problems related 

to inconsistent funding are not unique to DoD. 

However, military aviation and operational safety suffer 

disproportionate impacts from inconsistent funding in 

three ways. 

First, military flying is an extremely perishable skill. 

The multitude of complex tasks require frequent training. 

Pilots who do not consistently practice demanding 

missions such as low-level flight, flying with night vision 

goggles, air-to-air refueling, or certain combat profiles 

will lose their currency in these skills quickly. Regaining 

currency requires several flights with an instructor pilot, 

costing more than it would have cost to maintain the skill 

in the first place. 

Second, aviation maintenance has minimal surge 

capacity. When funding is delayed, aircraft remain 

grounded waiting for spare parts. When funding is 

restored and the pilots are flying more to regain currency 

and proficiency, the maintenance system struggles to 

catch up on deferred maintenance while keeping pace 

with the higher level of flying. Delayed funding, no 

matter how much, cannot make up for lost time. 

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

NUMBER OF DAYS

FY2019

FY2018

FY2017FY2016

FY2015FY2014

FY2013FY2012

FY2011

FY2010

FY2009

FY2008

FY2007

FY2006

FY2005

FY2004

FY2003

FY2002

Figure 7-1: 

Days Under a Continuing Resolution: Department of Defense, Fiscal Years 2002–2019
43

Chapter 7: The Need for Consistent and Predictable Funding

Finally, the high cost of military aviation makes it 

an attractive “bill payer” during unexpected funding 

shortfalls. While the DoD budget is large, many costs 

are fixed. A continuing resolution keeps funding flat, and 

when fixed costs such as salaries or health care increase, 

that money often comes out of the military aviation 

budget.

FINDING

Continuing resolutions create a domino effect that 

harms maintenance, the ability to purchase parts, 

aircraft availability, and pilot proficiency.

Assessing Costs

Continuing resolutions often leave military aviation 

with the worst of both worlds. CRs increase costs while 

simultaneously reducing the readiness of pilots and 

aircraft. On site visits, the Commission found inoperable 

aircraft and noncurrent aircrews—exactly what one 

would expect after a history of inconsistent funding. 

The Commission looked to empirical research to 

better understand the issue. As the Congressional Research 

Service (CRS) explained in a 2019 brief on Defense 

spending under an interim CR, “Published reports on the 

effect of CRs on agency operations . . . typically do not 

provide data that would permit a systematic analysis of CR 

effects.” Instead, these reports, as with this Commission’s, 

“typically provide anecdotal assertions that such funding 

measures increase costs and reduce efficiencies.” In fact, 

the CRS found only one recent report that successfully 

quantified the effects of continuing resolutions to any 

degree. That study, conducted by RAND in 2019, 

intentionally limited its focus to a discrete and measurable 

impact: procurement awards. The study’s authors 

acknowledged that “many variables can mask CRs’ effects,” 

and any study must “contend with limitations in the 

available data,” so they conducted their analysis by solely 

focusing on one specific area. 

The same type of targeted analysis is necessary for 

military aviation. The Commission cannot overemphasize 

the importance of the effects of CRs on the military 

aviation professionals who brought it up frequently in 

town halls and roundtables. Analysis of prior CRs is 

complicated by the lack of readily available data. This 

issue must be analyzed in a targeted and focused manner. 

Therefore, while the Commission believes that Congress 

first must resource the Department and military aviation 

in a consistent and predictable manner, the Commission 

also sees the need for a comprehensive, data-driven report 

of any future CR’s impact on military aviation.

FINDING

Previous research has not been able to produce 

a comprehensive assessment of the impacts of 

continuing resolutions on military aviation safety, 

readiness, and cost effectiveness. Additional data 

gathering and empirical study is necessary.

RECOMMENDATION

Congress and the administration must 

recognize that consistent, reliable, and 

timely funding is key to sustaining military 

aviation readiness and safety. 

The Commission recommends:

7.1 Congress and the administration 

ensure predictable and reliable 

funding for military aviation and stop 

using continuing resolutions to fund 

national security, military readiness, 

and aviation safety. 

7.2 Congress task the Congressional 

Budget Office to study and report on 

the negative impacts of continuing 

resolutions on military aviation 

readiness and safety.
44

National Commission on Military Aviation Safety

Air Force Reserve pilots with the 709th Airlift Squadron at 

Dover Air Force Base, Delaware, prepare for a mission in 

the C-5M Super Galaxy during an off-station training event 

at Naval Air Station Pensacola, Florida. (U.S. Air Force 

photo by Capt. Bernie Kale.)
45

Chapter 8: 

THE DEMAND ENVIRONMENT

The persistent demand and Servicemembers’ cando ethos have resulted in a chronic state of fatigue 

across military aviation. The all-volunteer force has been 

flying combat missions for more than 30 years. The 

U.S. military has many diverse missions, ranging from 

deterring American adversaries to providing disaster 

relief and humanitarian assistance. While the number of 

missions has increased in each of the past three decades, 

the size of the force has decreased (see Figure 8-1). This 

unsustainable imbalance negatively impacts safety.

More Demand than Capacity

“The business model is terrible,” said a Marine squadron 

commander in a roundtable discussion with the 

Commission. He told of personnel shortages in his unit 

and said, “we’re being tasked with more requirements, 

but we have to do those with the same or a smaller 

force. ‘Do more with less’: you can’t. I know the risk of 

having a mishap is going to go up. This is just reality.” 

The Commission heard similar comments across all four 

Services from regular and reserve components, from 

junior enlisted maintainers to senior Service leaders.

“I just had a phone call...about preparing for [a new 

mission], and like everyone else, nothing is coming off our 

plate,” a high-ranking Pentagon official told commissioners. 

“The volume and frequency of our operations are 

unprecedented.” An Air Force Reserve maintainer attending 

an enlisted roundtable told the Commission that “there’s 

times I’ve felt we were performing tasks and we shouldn’t 

do it because we don’t have the manning. But the tempo 

requires we need to do it.” The other maintainers around 

the table nodded in agreement.

Senior NCOs, the foundation of the military’s getit-done ethos, revealed their frustrations. “Not only do I 

have a shortage of manpower, it’s a shortage of time,” an 

Army combat aviation brigade first sergeant said. “Your 

maintainers are working past duty day and then working 

weekends and then 24-hour operations. It’s completely 

unchecked.” Asked about safety concerns, a senior Marine 

Corps NCO replied, “The OPTEMPO. I do what I can 

to slow that down. I tell the boss we can’t do things. The 

recipe is there for something to occur.” 

Taskings from the Services and from combatant 

commands are piling up. “We need the Air Mobility 

Command to go to Transportation Command and say 

enough,” said a squadron commander during an Air Force 

town hall. “We need to ask for something to drop off the 

back end when we add something else.” A general officer 

on the staff of a major command also spoke of pressure 

from combatant commands: “At some point someone 

needs to bring discipline to the demand signal. We don’t 

have what they need.” Yet, no one feels they can say “No.” 

The tempo is particularly challenging for some career 

fields, such as flight engineers. One KC-10 squadron 

commander said the unit is well below required manning, 

in large part because so many people are leaving the 

unit. “Most of them are getting out before retirement 

date because of burnout. Deploy, deploy, deploy. TDY 

[temporary duty away from home] 270 days a year, the rest 

of the time they are in the [simulators]. They are getting 

one or two weekends a month to [be] with their families. A 

couple people just made tech sergeant, but they are never 

going to sew it on because they’re done. Even promotion 

doesn’t keep them in.” OPTEMPO and PERSTEMPO is 

putting the health of the force at risk. 

DEFINING OPTEMPO AND PERSTEMPO

Title 10 of the U.S. Code defines OPTEMPO and 

PERSTEMPO as follows:

• Operating tempo means the rate at which units 

of the armed forces are involved in all military 

activities, including contingency operations, 

exercises, and training deployments.

• Personnel tempo means the amount of time 

members of the armed forces are engaged 

in their official duties at a location or under 

circumstances that make it infeasible for a 

member to spend off-duty time in the housing in 

which the member resides.

Human Environment

Machine
46

National Commission on Military Aviation Safety

Degrading Future Readiness

Mission requirements are overtasking current military 

personnel while at the same time undercutting the 

training of new entrants. During combat operations, 

military members will accept higher risk. However, 

during routine training and operations, military members 

view the increased risk as a failure of leadership to adjust 

the planning assumptions to reflect actual conditions.

Aviators told the Commission that OPTEMPO 

demands deny them adequate time for the ongoing 

training necessary to keep their warfighting skills current. 

The latest National Defense Strategy and National Military 

Strategy projects greater global competition in the airspace 

and the need to prepare for a high-end fight with near-peer 

adversaries—a radical change from operating in largely 

uncontested airspace over the past 30 years. If units are 

always responding to routine taskings, they are unable 

to devote the necessary time and flight hours to develop 

the skills needed for future conflicts. “I can’t train to fight 

Russia and China. I need relief from hauling crap around 

the [area of responsibility] so that I can actually train,” said 

an Air Force commander. 

FINDING

The PERSTEMPO and OPTEMPO are overstressing 

the current military aviation force structure and 

compromising the readiness standards required of 

military aviation. 

Chronic Fatigue and Burnout

The Commission heard of chronic fatigue and the term 

burnout many times during visits to installations across the 

Services, in both active and reserve components. 

• An Army pilot: “So much is being required of IPs 

[instructor pilots] at the unit, and we have a shortage 

of IPs, and they are getting burned out. That’s why 

our retention rates suck.”

• A Navy leader: “Old jets make us work our people 

harder. We have to work them to death. That’s a 

safety issue. We burn them out.”

• A Marine Corps aviator: “My kids don’t know who 

I am.” Due to deployments, exercises, and constant 

long days, he said, “they don’t know when I am 

Source: National Commission on Military Aviation Safety

Figure 8-1:

OPTEMPO

0

10

20

30

40

50

60

70

Number of 

Active

Operations

Total 

End-Strength

(Active and 

Reserve)

2,000,000

2,100,000

2,200,000

2,300,000

2,400,000

2,500,000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
47

Chapter 8: The Demand Environment

going to be home. That stuff leads to the burnout 

and distraction while flying.”

“Task saturation is a problem,” said a senior Air Force 

maintainer in an F-16 wing, who kept coming back to the 

word tired. “They are tired, sleep deprived. They are tired, 

and with increasing mission and lower manning levels 

and the lack of proficient NCOs to help, NCOs are tired. 

It is just being tired. Knowing that with task saturation 

and sleep deprivation, work performance suffers. We see 

human factors and an increase in mishaps. They don’t have 

experience and are tired. They are tired and are crying for 

help. The response is shut up and color.”

Chronic fatigue manifests itself in retention. “It’s 

not the money or their character or attitude; it’s the 

OPTEMPO. They are getting crushed,” said an Air Force 

logistics officer who was a prior-enlisted crew chief. A 

safety officer for an Army combat aviation brigade stated: 

“Everybody wants more money, but it’s the quality of life 

for me. I’m gone (so often), and it’s just not worth it.” A 

senior Air Force NCO told the Commission that one of 

his staff sergeants left the Air Force to be an automobile 

mechanic. “They’re burned out.”

FINDING

The pervasive sense of burnout and chronic fatigue 

that exists throughout the military aviation enterprise 

is contributing to unsafe conditions. Aircrew and 

maintainers cite the compounding factors of 

OPTEMPO, PERSTEMPO, and the resulting fatigue 

and staffing shortages as the likely cause of “the 

next mishap.” 

Additional Duties

A pilot with an Army combat aviation brigade told the 

Commission he hated driving into work every day. Asked 

why, he replied, “Flying is 5 percent of what I do; about 

95 percent is administrative [duties].” Administrative 

and logistics support personnel have been cut from 

units because of decreasing end-strength or budgets. The 

burden of fulfilling those roles has shifted to aircrew and 

maintainers as “additional duties” that add significantly to 

their OPTEMPO burden while taking time away from 

developing their professional skills. Some report that their 

additional duties have become their full-time jobs. “We 

signed up to be combat fighter pilots, but that’s the fifth or 

sixth most important thing we do,” said a Marine Corps 

pilot. “It’s not the lack of flying, it’s the 12- to 15-hour 

days [doing administrative work]. Allow us to focus on 

flying, putting more priority on that than other duties.” 

Additional duties add to the already unsustainable 

tempo, but their negative impact does not stop there. 

“I would go so far as to say 90 percent of Army 

aviation problems fall under the umbrella of conflicting 

requirements,” one Soldier wrote to the Commission after 

attending a town hall meeting. “Pilots and crew members 

cannot maintain proficiency on any single task if their 

focus is elsewhere. [Increased personnel] could impact 

the problem we face and would have positive impacts on 

morale, retention, proficiency, and accident rates. Soldiers 

don’t leave the Army because they can make more money 

elsewhere. They leave because they are sick of dealing 

with BS that is outside of their job description.” Aviation 

professionals are overtaxed with too many wrong tasks.

FINDING

Diverting aviation professionals from their primary 

aviation duties with additional duties adds to an 

unsustainable workload. Due to personnel cuts, military 

aviation units have experienced cuts in administrative 

support over the past two decades, forcing aviators 

and maintainers to undertake additional administrative 

duties that interrupt their primary aviation tasks and 

contribute to fatigue and burnout. 

SKILLS DEGRADATION

The 433rd Airlift Wing is the Air Force Reserve’s only 

formal training unit providing initial and advanced 

C-5 training. The wing’s instructor pilots (IPs) told the 

Commission that when pilots return for advanced 

training after years in operational units, their skills 

have degraded compared to when they graduated 

from initial training. “Because of OPTEMPO, their 

experience has improved, but their flying skills are 

some of the weakest we’ve seen,” one IP said, offering 

several reasons: 

• they are not flying enough because of additional 

duties; 

• they do not have experienced instructors in the 

operational units to properly train them; 

• they are not getting opportunities to train on the 

techniques they will need to fly against a nearpeer adversary. 
48

National Commission on Military Aviation Safety

Tracking PERSTEMPO 

A significant shortcoming is the lack of quantitative 

data to effectively measure PERSTEMPO and 

assess its impact on units and individuals. Tracking 

individual PERSTEMPO is a necessary first step toward 

understanding the health of the force. The absence 

of focused policy that produces reliable data limits 

DoD and Service leaders’ ability to research, analyze, 

and understand the stress on the force so that they 

can mitigate safety risk. It also impairs efforts to fully 

understand and draw definitive conclusions about the 

impact of PERSTEMPO on military aviation safety and 

readiness.

In a 2018 report, the Government Accountability 

Office concluded that DoD lacked sufficient policy 

and reliable data to monitor PERSTEMPO. This 

Commission concurs with the GAO’s assessment and 

with Congress’ recent efforts to address this issue. 

The Services carefully track the hours of use for 

aircraft and components; the Commission asserts the 

same careful attention should be spent tracking the 

people who fly and maintain these aircraft.

FINDING

The Services are not adequately tracking 

PERSTEMPO for units and individuals and the 

resulting impact on the health of the force.

RECOMMENDATIONS

Policy at all levels must reflect that aviation is a high-demand, low-density specialty with routinely insufficient 

capacity to satisfy all of the demand placed on it. This has overextended the aviation force beyond sustainable 

levels, resulting in chronic fatigue and burnout, which negatively impacts retention. The current high demand 

is forcing the Services to shortchange safety to accomplish current missions. The Services must increase aviator 

and maintainer capacity, reduce additional duties, and focus on proficiency to mitigate the risk.

The Commission recommends:

8.1 The Services ensure aviation units have 

sufficient administrative personnel to allow 

aviators and maintainers to concentrate on 

their primary mission, sustain currency and 

proficiency, and meet the unit’s mission 

readiness rates.

8.2 The Department of Defense and 

the Services report aviation units’ 

personnel experience levels and member 

PERSTEMPO.

8.3 The Department of Defense and the 

Services require that proper policies, 

practices, staffing, and all other necessary 

resources are in place to ensure that 

the military’s high demand/low density 

aviation units always are fully prepared 

and standing ready to perform at levels 

commensurate with the critical and 

unique role they perform in securing and 

maintaining our nation’s security. 
49

Chapter 8: The Demand Environment
50

National Commission on Military Aviation Safety

An Aviation Structural Mechanic 2nd Class oversees 

maintenance on an MH-60R Seahawk from the 

“Battlecats” of Helicopter Maritime Strike Squadron 

73 on the flight deck of the aircraft carrier USS 

Nimitz. (U.S. Navy photo by Mass Communication 

Specialist 3rd Class Elliot Schaudt.)
51

Chapter 9: 

MAINTAINERS AS AVIATION 

PROFESSIONALS

Maintaining military aircraft requires highly trained 

and skilled specialists. However, new training 

methods and outdated personnel policies are interfering 

with maintainers’ duties and skill development. This 

comes at a time when operational units are short on 

experience and OPTEMPO is high. Strategic investments 

in developing well-trained maintainers will go far in 

increasing operational readiness and mitigating safety 

risks on the flight line. 

FINDING

Military aviation requires a significant and constant 

investment of time and resources to train and 

develop fully capable maintenance professionals. 

Initial Training

Failing to sufficiently invest in initial training programs 

is a safety risk—one that aggregates over time. “This 

seems irreversible,” said a Navy squadron commander. 

“I have increasingly unqualified people to teach the new 

generation who are then going to be less qualified to train 

the next generation.”

Interviews with entry-level trainees and maintenance 

school instructors reveal that many students have little to 

no mechanical or maintenance experience before joining 

the military. These deficiencies are not addressed during 

initial training. “Coming out of the schoolhouse, most 

don’t know the difference between a Phillips head and a 

standard screwdriver,” a senior Marine Corps maintainer 

said. An Air Force maintenance NCO concurred. “We are 

teaching basic tools now. A lot don’t know what a ratchet 

set is. If you ask for a ratchet set, they bring a socket.” 

FINDING

Initial training across the Services is intended to 

provide maintainers with the basic skills to perform 

primary requirements. The Commission heard grave 

concerns from operational units that the skills of student 

graduates are deficient. 

Mixed Reality for Maintainers

The Services are not shortening their maintenance training 

courses. However, they are relying less on traditional 

hands-on training and more on augmented reality (AR) 

training, including computer-based learning, simulators, 

and virtual reality (VR) to overcome personnel shortages. 

Maintenance supervisors across the Services told the 

Commission that overreliance on computer-based 

training is resulting in undertrained maintainers arriving 

at operational units. They lack the basic skills needed for 

immediate integration into the unit. 

Even entry-level maintainers agree their training is 

inadequate. On one site visit, the Commission heard a 

story about a recently graduated maintainer who was 

instructed to remove a panel. The maintainer did not 

know which tool to use because the computer-based 

training program removed the panel with a click of the 

mouse. When the maintainer actually removed the panel 

for the first time, it landed on his foot. “VR will give 

you familiarization before you walk out and do it,” a 

senior level chief training officer told the Commission. 

“The issue is, when you use VR to remove a panel by 

touching it [on a screen], you don’t realize it’s 35 pounds, 

and you’re out there in 100 degrees—and not an airconditioned room—and you drop it on the ground.” 

Throughout the Commission’s travels, personnel 

in other units shared similar stories about VR learning. 

One young enlisted Air Force maintainer admitted to the 

Commission that he did not know how to remove a panel 

upon arriving at his first unit, and a junior Marine Corps 

maintainer described the training this way: “I checked a 

box that said I got on the computer, moved my person to 

this place [on the screen], pushed this button to take off a 

panel, and I did it safely. It’s a joke.”

Maintenance students typically undergo two phases 

of instruction during training. The first phase is designed 

to introduce the trainee to basic mechanics and tools. 

Instructors told the Commission that this training 

has shifted significantly from hands-on to virtually 

augmented training methods. The second phase turns to 

more aircraft-specific and specialty skills training. Handson training is the teaching method of choice during 

Human Environment

Machine
52

National Commission on Military Aviation Safety

this phase. However, schoolhouses often substitute this 

training with virtual instruction when there is insufficient 

equipment. The outcome is unprepared graduates who 

are not ready for flight line operations. As a result, the 

receiving unit must divert resources to conduct basic-level 

training instead of actual maintenance.

The need to produce more maintainers to 

compensate for personnel cuts in previous years has 

prompted the recent changes to teaching methodology. 

Use of virtual training has increased in all Service training 

programs. Recent graduates told the Commission they 

would have liked more hands-on training before arriving 

at their operational units. An Air Force training group 

commander said he often hears such comments. He 

considers hands-on training for young people a novel, 

cool experience. “Us old guys, we think that for the 

young guys that VR and AR are their bailiwick,” he said. 

“In fact, what’s new to them is actually doing it, the 

hands-on work. That’s what fires them up.”

FINDING

The Services’ training organizations are relying 

more on simulation and virtual reality technologies. 

Operational units believe these decisions result in 

less-skilled graduates. 

To be effective, hands-on training must be conducted 

on realistic equipment that mirrors the actual aircraft 

the students will maintain at operational units. Across 

all Services, the Commission found a need for repairing, 

upgrading, or increasing the number of mock-up trainers 

and tools that students use for hands-on instruction. 

Mock-up trainers should match the Services’ operational 

fleets of aircraft. 

FINDING

There is an urgent need for repair and upgrades of 

equipment at training installations. The Commission 

repeatedly heard reports of outdated, out-ofservice, or non-available trainers. Mock-up trainers 

are not kept current with the aircraft the aviation 

professionals will maintain in operational units.

Measuring Training Efficacy

Augmented reality training tools can enhance maintenance 

skills if quickly reinforced with hands-on training. In 

reviewing training syllabi, the Commission found that 

augmented reality training rarely occurs in conjunction 

with hands-on training, primarily because of personnel 

reductions. Overreliance on augmented reality training is 

having a negative impact on skill retention.

The training programs do not have sufficient data 

collection to reliably measure virtual training’s impact 

on trainees’ skill retention. The Commission also noted 

the lack of an effective feedback loop between the 

operational units and the schoolhouses. Current feedback 

systems have little success gathering the operational 

units’ perspectives and effectively integrating them into 

revisions to training programs. The feedback loop with 

the receiving units is broken. 

FINDING

Training commands have not been applying datadriven measurements for their training methods. The 

feedback loop with the receiving units is broken. 

On-the-Job Training

The impact of initial training shortfalls in the 

schoolhouse is exacerbated by current challenges facing 

on-the-job training (OJT). On-the-job training has 

REALITIES DEFINED

Simulators are training devices replicating the 

environment and controls of an aircraft or system 

(such as aerial refueling or de-icing equipment) for the 

purpose of creating a realistic experience operating 

that aircraft or system in a safe environment. In 

addition to providing an accurate representation of 

the system’s controls, advanced simulators use highfidelity motion and visuals to simulate the system’s 

physical and psychological sensations.

Virtual reality is a computer system that generates 

three-dimensional images on screens inside helmets 

or goggles, creating visual environments the user can 

physically manipulate or respond to by using gloves or 

devices fitted with sensors. 

Augmented reality overlays real-world surroundings 

with computer-generated images, ranging from textual 

labels to immersive experiences.
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Chapter 9: Maintainers as Aviation Professionals

always been integral to the education and training of 

aviation maintainers as they hone their skills. The Services 

count on a cadre of experienced NCO maintainers at the 

operational units to provide that OJT. At almost every 

unit the Commission visited, commanders and senior 

NCOs reported that they were overextended for mission 

requirements and did not have sufficient NCOs to 

provide the necessary OJT.

An important factor in the effectiveness of OJT is 

the ratio of trainers to trainees. The Air Force reported 

that its usual trainer to trainee ratio should be 1:5 or 1:6. 

In one career field, Air Force maintenance crew chief 

ratios are closer to 1:8 or 1:9. The Commission saw the 

same issue in all the Services. With this higher ratio, 

supervisors cannot properly supervise and develop the 

new maintainers. “That peanut butter gets spread so thin 

that people aren’t really getting any peanut butter,” an Air 

Force commander told the Commission. 

The units are caught between competing demands: 

the need to meet readiness goals with aircraft safe to fly 

today, and the need to invest the time to supervise and 

train new maintainers who will be effective tomorrow. 

“We just got a lot of junior Marines,” said a junior 

Marine Corps maintainer. “We are down to five people 

with qualifications. We have guys doing [maintenance] 

without someone supervising them. We don’t have the 

people to do OJT.” 

Operational units expect to receive schoolhouse 

graduates who are able to support basic flight line 

operations when they arrive. The Service training 

commands told the Commission that they saw the role 

of initial training differently. Rather than graduate an 

operationally proficient maintainer ready to contribute 

on the first day, their goal was to produce graduates 

needing OJT before being ready for initial flight line 

duties. The Services need to align their expectations and 

adjust their training strategies and resources.

Experience Matters

“More maintainers would help,” an airlift squadron leader 

told the Commission; “but what would really help is 

more experienced maintainers. It takes about three years 

to get good at your job, doing it every day. We’re not even 

getting to that point with our young airmen.” 

Even when fully manned, many units do not have 

enough skilled personnel with the requisite experience and 

qualifications for certain roles. A unit may have the right 

number of personnel yet still lack the proficiency needed to 

accomplish the mission. For example, a Marine Air Group 

told the Commission it was manned at 103 percent, but 

only 60 to 70 percent met qualifications. “We don’t have 

the skills and experience,” the commander said.

The problems the Commission heard during site 

visits also appear in the personnel data. The Commission 

requested experience-level data from the Services and 

received information from the Army and Air Force. 

Figures 9-1 and 9-2 show examples of Army 

maintainer experience levels in two specialties, measured 

in average months of military service by skill level. It 

reveals substantial decreases in average experience across 

the board. The downward trend in experience was 

Figure 9-1: 

Army AH-64 Helicopter Maintainer Average Months of Service 

by Skill Level and Fiscal Year

0

5

10

15

20

25

30

Skill level 40

Skill level 30

Skill level 20

Skill level 10

2012201320142015201620172018

Average 

Months of 

Service
54

National Commission on Military Aviation Safety

Figure 9-2: 

Army Aircraft Maintenance Senior Sergeant Average Months 

of Service by Skill Level and Fiscal Year

0

5

10

15

20

25

30

35

40

Skill level 60

Skill level 50

2012201320142015201620172018

Average 

Months of 

Service

Figure 9-3: 

Air Force Refuel/Bomber Aircraft Maintainer Average Years 

of Service by Skill Level and Fiscal Year

0

2

4

6

8

10

12

14

16

Skill level 7

Skill level 5

Skill level 3

2012201320142015201620172018

Average 

Years of

Service
55

Chapter 9: Maintainers as Aviation Professionals

equally true for both entry-level maintainers and senior 

supervisors. The Aircraft Maintenance Senior Sergeant 

specialty saw a drop in the average months of experience 

between fiscal years 2012 and 2018, a particular cause 

for concern. A decrease in junior maintainer experience is 

not being offset by experienced leaders, as the experience 

is declining across the board.

Analysis of Air Force experience levels of the Refuel/

Bomber Aircraft Maintenance specialty illustrates a 

trend seen broadly across aviation maintenance. Figure 

9-3 visualizes the changes in average years of service by 

skill level between fiscal years 2012 and 2018. It shows a 

worrisome decrease in the average years of experience for 

7-levels (the senior maintenance leaders) and a shocking 

decrease of more than 50 percent in average years of 

experience for 5-levels (the first-line trainers and leaders).

These steady declines in maintainer experience 

negatively affect readiness and safety. 

FINDING

Maintainer experience has decreased across military 

aviation, especially at mid-levels. 

Talent Management for Aviation Maintainers

The Services’ investment in aviation professionals requires 

an effective plan to retain experienced maintainers. 

“Aviation should be separated and fenced off,” said one 

Marine aviator. “The ground guys don’t feel that way. On 

the ground, you can replace a [infantry] squad leader and 

train someone in two weeks. It takes 3 1/2 years to train 

an aviation squad lead.” The Services need to manage this 

community differently.

Fully qualified aviation maintainers frequently find 

themselves redirected to other assignments, such as drill 

instructor or recruiter. Enlisted maintainers told the 

Commission that, despite their flight line experience, 

their assignments as a drill instructor or recruiter were 

required for promotion. However, a multiyear absence 

from maintenance duties results in lost proficiency. 

Many maintainers returning to the flight line require 

refresher training before they regain minimum currency 

to perform maintenance supervisory functions.

Another challenge occurs when maintainers are 

reassigned from one type aircraft to another. While the 

foundational principles of aviation maintenance are 

similar, each aircraft type is its own complex machine and 

requires specific knowledge. Aviation maintainers told the 

Commision they were forced to move from one platform 

to another, sometimes switching between fixed wing and 

rotary wing. Many of these Servicemembers reported 

that they often did not receive additional training 

before their reassignment. This lack of aircraft-specific 

training fostered negative habit transfer, degraded OJT 

instruction, and resulted in inadequate supervision. If the 

Services improve their policies and training requirements 

when transferring or transitioning maintainers between 

aircraft, experienced maintainers would be better 

prepared to apply their experience appropriately.

FINDING

Maintenance professionals with technical expertise 

are often assigned non-aviation duties, reducing 

aircraft availability.

Maintainers Want to Maintain 

Readiness and safety would improve if aviation 

maintenance professionals stayed in the maintenance career 

field. The current aviation maintenance force is distracted, 

under-resourced, inexperienced, and therefore struggling 

to maintain aircraft. Gate guard duty, motor pool duty, 

and other non-aviation tasks and ancillary training distract 

maintainers from their best use. The Services should focus 

aviation maintainers on doing the work only they can do 

and that will improve aircraft availability rates.

The Commission also explored other ways to 

support the professionalism, long-term development, and 

retention of maintainers. A system of aviation proficiency 

badges or milestone credentials would recognize a 

maintainer for proficiencies. Similarly, payment for 

outside schooling, such as an A&P (Airframe and 

Powerplant) license, in exchange for an additional service 

commitment would foster greater professionalism and 

pride while simultaneously increasing skills and retention. 

As aircraft have become more complex, the technical 

skills required to keep them operational have advanced 

commensurately. Providing enlisted maintainers with 

a promotion system that recognizes technical expertise 

would help keep personnel in uniform. There is room 

for both technical experts and leaders in the ranks of the 

Services’ senior NCOs. Maintainers want the opportunity 

to become masters of their trade while still advancing their 

careers. This would provide a dedicated cadre of experts to 

support new maintainer training and generate the aircraft 

needed to sustain readiness. Let maintainers maintain.
56

National Commission on Military Aviation Safety

RECOMMENDATIONS

Because of the significant investment in time and resources required to train and sustain fully qualified military 

aviation maintainers, and a commercial marketplace competing for such high-demand talent, Congress, the 

Department of Defense, and the Services must regard and manage aviation maintainers as a specialty and their 

training as a career-long pursuit. The Services must develop personnel management processes and career paths 

that account for the complexities of aviation and support aviation safety, readiness, and OPTEMPO. DoD and 

the Services must execute the following measures to recognize achievement and enable aviation professionals to 

focus on their flight line duties, sustain their skills, and promote advancement of their proficiencies. 

The Commission recommends:

9.1 The Services mandate and enforce 

assignments and performance evaluation 

guidance that focus aviation maintainers 

primarily on areas of performing, 

sustaining, and advancing their 

aviation professional skills, knowledge, 

and experience. The Services must 

discourage using aviation professionals 

for assignments and additional duties 

unrelated to their aviation-related 

warfighting fitness, skills requirements, or 

essential supervisory responsibilities. DoD 

and the Services should reduce mandated, 

nonaviation-related ancillary training to 

the minimum. 

9.2 The Services experiment with technical 

specialty enlisted ranks for aviation 

maintenance personnel that include 

unique career paths to ensure that 

maintenance personnel achieve and 

are able to sustain the highest level of 

proficiency and professionalism.

9.3 The Services reward and incentivize the 

professional achievements of aviation 

maintainers with recognition and 

professional development throughout 

their careers. 

a. The Services should establish 

aviation maintenance proficiency 

badges or credentials that 

would recognize and incentivize 

excellence in aviation maintainers 

and empower supervisors with 

support from leaders at the unit 

level to keep aviation maintainers 

focused on their primary flight line 

responsibilities. 

b. The Services should institute a 

tuition-paid A&P (Airframe and 

Powerplant) license option in 

return for an extended enlisted 

commitment meeting a cost/benefit 

threshold.

9.4 The Services implement policies and 

training for transitioning maintainers 

among platforms that require and certify 

proficiency, promote retention, and 

leverage experience for both legacy and 

new platforms. 
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Chapter 9: Maintainers as Aviation Professionals
58

National Commission on Military Aviation Safety

A U.S. Army AH-64E Apache helicopter pilot assigned to Task 

Force Tigershark, 16th Combat Aviation Brigade, 7th Infantry 

Division, prepares to depart for a mission at Jalalabad Airfield, 

Afghanistan. (Department of Defense photo.)
59

Chapter 10: 

PROTECTING INVESTMENT 

IN AIRCREWS

The Apache AH-64D was conducting a low-level, 

night training mission when a part failed, leading 

to damage of the engine, main rotor head and blades, tail 

rotor head and blades, main transmission, gearbox, and 

multiple drive shafts. 

Cause of mishap: materiel failure. 

Notwithstanding the materiel failure, the damage to 

the aircraft was avoidable. The training program, flight 

manuals, and simulator did not prepare the two pilots 

to properly diagnose the failure and take remedial steps. 

The training and information had been removed from 

qualification courses and the operators’ manual in 2010. 

Present and contributing cause of mishap: training 

standards.

Pilot Training

The process of turning men and women into proficient 

military pilots requires a complementary series of 

progressive training programs. Students begin with initial 

pilot training where they learn basic flight skills, then 

progress to advanced training for their specific aircraft. 

Pilot training continues at their operational unit with 

flight qualifications, unit-level training, and exercises.

Pilot shortages have increased pressure on the 

Services’ training commands to produce more pilots 

in less time. The Commission examined an advanced 

training program for one airframe from each Service. 

Figures 10-1, 10-2, and 10-3 demonstrate changes the 

Services have made in these aircraft-specific pilot training 

syllabi to move pilots through the pipeline faster.

An Apache pilot graduating from training in 2018 

had 21 fewer flight hours and 13.6 fewer simulator hours 

than a pilot who graduated in 2012. The number of 

flight hours, simulator hours, and the total course length 

were all shortened. The Army attributed the changes in 

the syllabus to a lack of available aircraft.

Unlike the Army, Marine and Navy pilots learning to 

fly the F-18 did not have their flight and simulator hours 

cut. For both Services, the number of simulator hours 

increased from fiscal years 2010 and 2019. 

Air Force pilots learning to fly the F-16 in 2018 had 

28.1 fewer flight hours as compared to a pilot trained 

just eight years earlier. While some of this time was 

replaced by additional simulator hours, a pilot in 2018 

would report to their operational unit with significantly 

less flight experience. Twenty flights were cut from the 

syllabus.

This reduction in training impacted operational 

flying units. Squadron commanders and instructor pilots 

told the Commission that recent flight school graduates 

Figure 10-1: 

Army AH-64D Course Changes

PROGRAM AND YEAR FLIGHT 

HOURS

SIMULATOR 

HOURS

FY12 AH-64D 95.5 61.6

FY18 AH-64D 74.5 48

Figure 10-2: 

Navy and Marine Corps F-18 Course Changes

PROGRAM AND YEAR FLIGHT 

HOURS

SIMULATOR 

HOURS

FY10 Navy F-18E/F 111.9 80.3

FY19 Navy F-18E/F 108.4 87.9

FY10 Marines F-18C/D 99.9 78.3

FY19 Marines F-18C/D 101.7 82.4

Figure 10-3: 

Air Force F-16 Course Changes 

PROGRAM AND YEAR FLIGHT 

HOURS

SIMULATOR 

HOURS

FY10 F-16 84.3 52.5

FY18 F-16 56.2 68

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National Commission on Military Aviation Safety

are not reporting to the unit adequately prepared for 

their first assignment. As a result, operational units must 

dedicate limited training hours to basic flying skills, 

reducing the hours preparing for combat missions. 

Combat capability decreased as instructors were forced 

to teach new pilots basic flight skills instead of more 

advanced combat tactics, techniques, and procedures. “I 

get guys struggling to get qualified,” said a Navy pilot and 

department head while discussing the quality of graduates 

coming from a flight training program. In his view, the 

program has the primary goal of “just get them out of 

the door. And it’s a snowball effect. I’m doing final check 

rides, and I’m appalled: they’ve gotten that far without 

learning basic stuff?”

FINDING

Pilot training is intended to provide military aviation 

professionals with their basic flying skills. Across the 

Services, the flying skills of pilots graduating from 

the schoolhouses are deficient. 

The Commission heard from commanders who 

were frustrated with not having the requisite number of 

instructor pilots or senior personnel to provide sufficient 

training for new pilots and aircrew. One Air Force training 

unit conducting aircraft-specific training was authorized 

114 instructor pilot billets, but filled only 82 despite 

lowering the IP qualification from 500 hours to 400 hours.

The pressure to get people qualified is not limited 

to the schoolhouses. Instructor pilots reported feeling 

pressure to quickly advance new aviators to higher 

qualifications to offset personnel shortages. “I had seven 

progression flights quickly,” a junior Army aviator told 

the Commission. “The demand for aviators is so high 

that there’s pressure to push people into positions that 

their experience doesn’t support.” Said a junior Marine 

aviator, “We just need pilots so desperately” that pilots 

are getting “qualifications that they don’t deserve because 

we have to have them.” This pressure to quickly progress 

and qualify aviators is also extending to more advanced 

credentials such as instructor pilots.

FINDING

Unit instructor pilots are conducting basic skills 

training to make up for deficiencies at the 

schoolhouse. Operational units are not resourced to 

provide basic flight training. 

Flight Hours

Flight time is the lifeblood of military aviation safety 

and readiness. More flight hours lead to more proficient 

aircrews. Too little flight time leads to a lack of 

proficiency and the experience necessary to accomplish 

operational missions.

Studies have shown a relationship between career 

flight hours and increased pilot mishap causal factors. 

A 2009 CNA study found that P-3 Orion pilots with 

low career flight hours tended to have greater numbers 

of pilot error mishaps. A second 2009 CNA study of 

Marine Corps aviators reported that junior F/A-18, AV8B, CH-46E, and AH-1W/UH-1N pilots had greater 

numbers of pilot error mishaps than their more senior 

counterparts. A 2010 CNA study described a “wellestablished relationship between low pilot career flight 

hours and higher mishap frequency.”

The Commission heard multiple comments that total 

career flight hours have decreased. Across the Services, 

mid-career pilots reported having as many as 200 fewer 

career flight hours than previous generations. 

Other CNA studies also found a relationship 

between more frequent pilot error mishaps and lower 

recent hours. A 2007 study found that an operational 

strike fighter pilot with 10 or less flight hours in the 

BREAKS IN TRAINING

Many aviators described long breaks in their training, 

either during a course because of aircraft or instructor 

pilot shortages or between assignments because of 

backlogs. 

One student reportedly took a year to complete a 

27-week training syllabus. “You get good training, but 

there were a lot of breaks,” a student pilot at a training 

wing told the Commission. “Some of us were only 

flying every two weeks.” 

Some students reported as much as a six-month gap 

between initial pilot training and advanced training. 

During that time, there’s no requirement to fly. Air 

Force aircrew also have to wait for an opening to 

attend the Survival, Evasion, Resistance, and Escape 

(SERE) school at Fairchild Air Force Base, Washington. 

“When I get to my unit, it will be six months since I’ve 

flown,” said an advanced pilot training student. 
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Chapter 10: Protecting Investment in Aircrews

previous 30 days was three to four times more likely than 

a pilot with 16 or more hours to have an “unsafe flight 

incident.” CNA’s further studies concluded that the trend 

held regardless of career experience level. 

FINDING

Decreased flight hours, inexperience, and failure to 

sustain currency and proficiency are contributors to 

aviation mishaps. Sustained investment in the flying 

hour program is necessary to ensure aviation safety 

and readiness.

Many aviators told the Commission that they are not 

getting the flight hours they need. Servicemembers across 

all four Services spoke about the challenge of getting at 

least 15 flight hours per month. Army aviators say they are 

flying just short of 15 hours per month. Air Force airlift 

squadrons are not getting the flight hours for training. 

Navy aviators said they are not getting 11 hours per 

month unless they are preparing to deploy. Although the 

Marine Corps’ goal for CH-53E pilots is 15 flight hours 

per month, one pilot said, “We too often are in the single 

digits for flight hours per pilot per month, a dangerously 

low number of flight hours to be decent at a very difficult 

trade.” Many Marine Corps aviators said they averaged 

about five hours per month. The Commission recognizes 

the importance of sustained investment in the flying hour 

program.

Waivers

With fewer flight hours, pilots risk losing currency. 

The Commission found evidence that the Services have 

increased their reliance on waivers to operate despite 

currency and proficiency shortcomings. The Commission 

often heard that commanders are relying on waivers to 

qualify instructor pilots, conduct operations, and train 

during deployments. An Army pilot told the Commission 

that “except for the trainers and evaluators, everyone in my 

flight company had minimums waived.”

Reserve Component units have relied on waivers 

to overcome challenges in meeting flight hour 

requirements. “Last year, of our 78 pilots, 26 got 

waivers,” said a Navy Reserve aviator. “One-third of 

our folks didn’t meet the minimum number of flying 

hours.” Army and Marine Reserve Component pilots 

echoed similar concerns, with a Marine telling the 

Commission that he had not flown at night for two 

months, despite being an instructor pilot.

FEEDBACK FROM THE FIELD

A Chief Warrant Officer 4 and Aviation Safety Officer 

for his unit, who attended a roundtable discussion, 

shared the following with the Commission. 

One big thing that was noted is the lack of 

sufficiently trained pilots from flight school. As 

we get more and more junior pilots and keep 

up with the OPTEMPO of training deployments, 

field exercises, operational deployments, etc., 

these pilots end up stagnating and waiting for 

long periods of time before they are available to 

use on missions. Some even wait long periods 

to start flying at all at a unit. Here alone, we 

have had an influx of junior aviators: 18 Warrant 

Officer 1s and five second lieutenants. These will 

all take the Instructor Pilots away from their own 

continuation training. This will end up burning 

out the IPs as they fly non-stop RL Progressions 

[readiness-level progressions continuation 

training]. This lends itself to mistakes, cut 

corners, close-calls, and things of that nature, 

all of which can change the seconds and inches 

that separate a non-event from an accident. This 

also puts the senior guys at the back of the line 

when they come in and need local training before 

they can get up to an operational level, further 

removing them from the normal consistency of 

flying their aircraft.

Another thing we have to deal with, that runs 

along with the mass influx of junior pilots, is 

the lack of flight hours. When manned at or 

near 100 percent, some units do not have the 

required flight hours for all personnel to make 

their minimum required flight times, let alone 

provide hours for the progression of junior pilots, 

retraining of regressed pilots, or any contingency 

that may come up. If this is allowed to continue, 

either the minimums will have to be lowered or 

flight hours increased. The cost for adding flight 

hours would be a thing that will be considered 

over most; however, if we continue to lower the 

standards, we continue to get sub-par products. 

Sub-par products require more time and effort 

to bring to an operational level and will end up 

costing more time and money.
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National Commission on Military Aviation Safety

The Commission noted that waivers have shown up 

among causal factors in mishap reports, including fatal 

Class A mishaps. Yet, the Commission found there was 

no centralized tracking of waivers across the Services or 

Department of Defense that leaders could use to identify 

and research this risk. The proliferation of waivers represents 

a new normal and acceptance of degraded standards.

The Commission found senior leaders and safety officials 

unaware to what appears to be an erosion of safety. This 

vulnerability must be addressed. 

FINDING

In many units, the minimum flight hour requirements 

for currency are not being met, leading to flight 

waivers that are increasing risks and impacting the 

safety culture of military aviation.

The Right Training Medium

For years, aviation has used simulators to supplement real 

flight training and experience in a safe, nonthreatening 

environment. Modern simulators are effective mediums 

for teaching core skills, enhancing mission techniques, 

practicing emergency procedures, and providing 

orientation to specialized operational skills. Simulator 

hours cost considerably less than actual flight hours, as 

Figure 10-4 shows.

Constrained budgets, decreased aircraft availability, 

instructor pilot shortages, and reduced training range 

availability have led to greater simulator usage. The 

Commission heard concerns from pilots in all the 

Services about the increased use of simulation in 

lieu of actual flying. Recognizing that simulation is a 

cost-effective flight training tool, it is a supplement 

or enhancement, not a replacement, for actual flight 

training. There is great value in both. 

Simulators cannot replicate carrier landings or 

simulate G-forces, but they do provide the safest 

environment for training on emergency procedures and 

aircrew coordination. Achieving the proper balance 

between actual flight and simulator training is crucial for 

both safety and readiness.

For simulators to be effective, they must mirror 

the specifications of the aircraft they simulate. In many 

cases, units lack simulators with the same configurations 

and flight characteristics as the actual aircraft. Several 

units reported that contracts limit simulator availability 

and do not provide the engineering support necessary 

to keep their simulators operating and up to date. This 

results in “negative training,” pilots practicing skills 

contrary to how they would employ them in actual 

flight. 

The units with the worst simulator support are those 

flying legacy aircraft, such as the F-16, AV-8B, KC-135, 

and T-38. These aircraft receive inadequate funding 

as resources are invested in new aircraft. Nonetheless, 

history shows that these older aircraft will remain mission 

essential and in the operational inventory for years. The 

KC-135, for example, continues carrying the bulk of 

refueling missions as the KC-46 encounters delays in 

becoming fully operational. In anticipation of a faster 

transition to the KC-46, the Air Force removed the KC135 simulator at McConnell Air Force Base, Kansas, in 

2017. Those KC-135 aircrews must now travel to other 

air bases to get simulator time. The 509th Bomb Wing 

at Whiteman Air Force Base, Missouri, operates T-38As, 

but has no T-38A simulator. 

The Federal Aviation Administration, which oversees 

civilian simulator certification, requires regular software 

updates so that training facilities and flight simulators 

continue to meet strict standards of performance and 

operations.

FINDING

Simulators are an essential tool for training military 

aviation professionals. Installations have outdated 

and out-of-service simulators. 

Figure 10-4:

Examples of Cost Comparison of Actual Flight Hours 

to Simulators, Fiscal Year 2019

AIRCRAFT COST OF 

FLYING HOUR1

COST OF 

SIMULATOR HOUR2

F-16 $14,000–$16,000 $900 

F/A-18 

(A-F) $11,000–$22,000 $875 

AH-64 $5,000–$7,000 $300 

KC-135 $13,000 $650 

C-130 $5,000–$14,000 $650 

C-17 $15,000 $650

F-35 $17,000–$23,000 $340–$600

Source: 1Office of the Secretary of Defense Comptroller; 2Aircraft Program Offices
63

Chapter 10: Protecting Investment in Aircrews

Retaining Experience

Retaining experienced personnel, especially seasoned 

instructors and supervisors, is imperative to sustaining 

the training pipelines for aircrew. A 2019 report from 

the Department of Defense to the Congressional Armed 

Services committees warned that flooding units with 

untrained pilots would have a cascading effect, when 

too few experienced pilots are available to train the new 

aircrews: “[A]bsorption models show a typical fighter 

squadron should be comprised of 55 percent experienced 

pilots. As that percentage decreases, it lengthens the 

time it takes for junior pilots to gain the experience they 

need to be fully mission capable, as inexperienced pilots 

require experienced pilots to lead them in training.” 

The report states that increasing pilot production to 

mitigate a pilot shortage results in units “saturated with 

inexperienced pilots.”

Accordingly, the Commission sees an urgent need to 

invest in retaining experienced military pilots. Demand 

from the airlines for military pilots will continue in 

the future. Notwithstanding the current pandemic, the 

Services need to be prepared for when that demand 

resumes. 

A decrease in retention affects not only readiness 

and safety, it also ineffectively utilizes resources. As 

many mid-level aviators leave the Services looking for 

greater stability, higher pay, or improved quality of life, 

an increased workload will fall on the less experienced 

personnel left behind. 

A 2019 Report to Congress on Initiatives for 

Mitigating Military Pilot Shortfalls explained that 

“replacing an experienced pilot at the end of his or her 

initial obligated service commitment (10–12 years of 

service) will take a minimum of 6–8 years of training and 

experience and millions of dollars for every pilot lost.” A 

2019 RAND study estimated the total costs of training 

a basic qualified Air Force pilot is expensive. The study 

concluded,

The cost of training a basic qualified 

fighter pilot ranges from $5.6 million for 

an F-16 pilot to $10.9 million for an F-22 

pilot. Bomber pilot training cost is also high, 

ranging from $7.3 million for a B-1 pilot 

to $9.7 million for a B-52 pilot. Costs for 

training transport pilots and mobility pilots 

are somewhat lower, but still considerable, 

ranging from $1.1 million for a C-17 pilot to 

$2.5 million for a C-130J pilot. Training cost 

per pilot for command, control, intelligence, 

surveillance, and reconnaissance operations 

(e.g., the RC-135) is about $5.5 million. 

Notably, these cost estimates only cover initial 

training and not the subsequent years of continuous 

investment as aircrew hone their skills and accumulate 

experience. 

In other words, increasing aircrew experience by 

increasing retention saves money and improves safety 

and readiness. To maximize efficiency, safety, and 

readiness, the Services must have the flexibility to adjust 

retention incentives. Because it costs millions of dollars 

to train a replacement pilot, the Services must be able to 

offer competitive compensation. Granting the Services 

standing authority to increase their annual aviation 

retention bonuses up to $100,000 would allow the 

Services to respond to retention challenges in a dynamic 

environment. See 37 U.S.C. § 334.

Improving Career Management

Many aviators told the Commission that assignments to 

nonaviation billets diminished their aviation proficiency 

just as they were gaining experience. 

Most pilots have fairly structured career paths and 

important developmental experiences that must be met 

along the way. These assignments are designed to create 

well-rounded officers, but they can also be a detour on 

the road to making good aviators. “We spend a lot of 

time training pilots,” said a Navy senior NCO crew 

chief. “We get them good at flying and then they go fly 

a desk. Their next assignment is coming back to fly and 

they aren’t good.” The degradation in proficiency during 

the time away from the cockpit diminishes the Services’ 

return on investment.

Similarly, aircrews believe the current promotion and 

evaluation systems do not sufficiently take into account 

their aviation skills. “We are told from day one in flight 

school, when you get to the fleet, they tell you that your 

ground job is what gets you promoted,” said a Marine 

aviator. 

The overall failure to address problems with pilot 

training and experience results in an aggregation of risks 

over time: a cohort of aviators who have inadaquate 

training and lack the skills and experience they will need 

as they advance through their careers. The Commission 

learned of students who completed a rushed initial 

training program, who were pushed through their 

follow-on training by less-experienced instructors, and 

then became instructors and leaders themselves. They 

are at higher risk of making costly mistakes and lack the 

experience to train the next generation. Without action, 

military aviators will not be exposed to what “right” 

looks like. Inexperience will become institutionalized and 

jeopardize the safety of a future generation of aviators. 
64

National Commission on Military Aviation Safety

RECOMMENDATIONS

Because of the significant investment in time and resources required to train and sustain fully qualified military 

aviation personnel, and a commercial marketplace competing for such high-demand talent, Congress, the 

Department of Defense, and the Services must regard and manage aircrews as a specialty and their training 

as a career-long pursuit. The Services must develop personnel management processes that account for the 

complexities of aviation and support aviation safety, readiness, and the demands of OPTEMPO. Congress and 

the Services must execute the following measures to focus aviation professionals on their flying duties, sustain 

their skills, and promote advancement of their proficiencies.

The Commission recommends: 

10.1 The Services mandate and enforce 

assignments and performance evaluation 

guidance that focus aircrews primarily 

on areas of performing, sustaining, and 

advancing their aviation professional 

skills, knowledge, and experience. The 

Services must discourage using aircrews 

for assignments and additional duties 

unrelated to their aviation-related 

warfighting fitness, skills requirements, 

or essential supervisory responsibilities. 

DoD and the Services should reduce 

nonaviation-related ancillary training to 

the minimum. 

10.2 The Services restore flight hours to 

not less than fiscal year 2010 levels for 

schoolhouse and operational units. 

10.3 The Services centrally track waivers, create 

a baseline, and monitor them to identify 

trends, assess risk, and predict potential 

problems and resource shortfalls. 

10.4 Congress grant the Services standing 

authority to increase the aviation bonuses 

from up to $35,000 to up to $100,000 

per year to retain pilots in exchange 

for a commensurate additional service 

commitment.

10.5 The Services upgrade data collection to 

improve training programs and training 

tool selections that better measure student 

learning. Data collection must include 

classroom, pilot task training, full-motion 

simulators, and flying training plus 

feedback from the field as a measure of 

training efficacy.

10.6 The Services link simulator sustainment 

to aircraft production, upgrades, and 

modifications and have the same 

operational flight plan as the aircraft. The 

Department of Defense and the Services 

must eliminate software and system 

upgrade lags that hamper simulator 

training.
65

Chapter 10: Protecting Investment in Aircrews
F/A-18 Super Hornets from Strike Fighter Squadron (VFA) 31, VFA-32, VFA-87, and 

VFA-105 honor the late Sen. John McCain with a missing man formation flyover of 

the U.S. Naval Academy during his burial service, Sept. 2, 2018. (U.S. Navy photo by 

Mass Communication Specialist 2nd Class Nathan Burke.)
67

The National Commission on Military Aviation Safety honors the military aviation professionals and other 

servicemembers, civilians, and contractors who paid the ultimate sacrifice in U.S. military aviation mishaps 

during the period of this Commission’s study. The following are the released names of those individuals as provided by the 

military Departments.

Second Lieutenant David Samuel Albandoz, Puerto Rico 

Air National Guard

First Lieutenant Kenneth Allen, U.S. Air Force

Mr. Ruslan Alymkulov, Civilian

Master Sergeant Jean M. Audiffred-Rivera, Puerto Rico 

Air National Guard

First Lieutenant Kathryn M. Bailey, U.S. Army

Corporal Daniel E. Baker, U.S. Marine Corps

Corporal Daniel I. Baldassare, U.S. Marine Corps

Captain Paul J. Barbour, U.S. Air Force

Lance Corporal Joshua E. Barron, U.S. Marine Corps

Staff Sergeant Marcus S. Bawol, U.S. Marine Corps

Captain Andrew Christopher Becker, U.S. Air Force

Staff Sergeant Lance Jacob Bergeron, Louisiana Army 

National Guard

Technical Sergeant Marty B. Bettelyoun, U.S. Air Force

Staff Sergeant Steven P. Blass, U.S. Army

Staff Sergeant Trevor P. Blaylock, U.S. Marine Corps

Master Sergeant Mario Braña-Ortega, Puerto Rico Air 

National Guard

Captain Travis W. Brannon, U.S. Marine Corps

Staff Sergeant Dashan J. Briggs, U.S. Air Force

Major James M. Brophy, U.S. Marine Corps 

Chief Warrant Officer 2 Kevin F. Burke, U.S. Army

Mr. William Burnette, Contractor

Sergeant Dwight W. Burns, U.S. Army 

Major Shawn M. Campbell, U.S. Marine Corps

Chief Warrant Officer 2 Stephen Travis Cantrell, 

U.S. Army

Chief Warrant Officer 2 Alex Caraballo-Leon, U.S. Army

Captain Clayton Carpenter, U.S. Army

Mr. Carlos J. Carrasco, Contractor 

Chief Warrant Officer 2 James J. Casadona, U.S. Army

Sergeant First Class Toby A. Childers, U.S. Army

Master Sergeant Eric Circuns, Puerto Rico Air National 

Guard

Corporal Justin R. Clouse, U.S. Army

Aircrewman Helicopter 3 Brian A. Collins, U.S. Navy

Master Sergeant Victor J. Colon, Puerto Rico Air 

National Guard

Staff Sergeant Cole Condiff, U.S. Air Force

Chief Warrant Officer 3 Ryan Connelly, U.S. Army

Chief Warrant Officer 3 Stephen B. Cooley, U.S. Army

First Lieutenant Clayton R. Cullen, U.S. Army

Captain Sara M. (Knutson) Cullen, U.S. Army

Captain Brandon Lee Cyr, U.S. Air Force

Captain Kenneth Stephen Dalga, U.S. Air Force

Major Stephen Del Bagno, U.S. Air Force

Lieutenant Junior Grade Valerie C. Delaney, U.S. Navy

First Lieutenant Frederick Drew Dellecker, U.S. Air 

Force

Lance Corporal Matthew J. Determan, U.S. Marine 

Corps

Staff Sergeant Sean Samuel Devoy, U.S. Army

Staff Sergeant Richard A. Dickson, U.S. Air Force

IN MEMORIAM
68

National Commission on Military Aviation Safety

Mr. Ralph Dietz, Contractor

Corporal Matthew R. Drown, U.S. Marine Corps

Captain William H. Dubois Jr., U.S. Air Force

Lieutenant Colonel Ira S. Eadie, U.S. Air Force

Captain Sean E. Elliott, U.S. Marine Corps

Staff Sergeant Carl P. Enis, U.S. Air Force

Staff Sergeant Adam Erickson, U.S. Air Force 

Senior Airman Roberto A. Espada-Gali, Puerto Rico Air 

National Guard

Staff Sergeant Daniel N. Fannin, U.S. Air Force

Staff Sergeant Maximo A. Flores, U.S. Marine Corps

Staff Sergeant Thomas C. Florich III, Louisiana Army 

National Guard

Staff Sergeant Liam A. Flynn, U.S. Marine Corps

Lieutenant Colonel Morris M. Fontenot Jr., 

Massachusetts Air National Guard

Captain James E. Frederick, U.S. Marine Corps

Chief Warrant Officer 2 Kirk T. Fuchigami Jr., U.S. 

Army

Chief Warrant Officer 3 Taylor J. Galvin, U.S. Army

Master Sergeant Joshua M. Gavulic, U.S. Air Force

Chief Warrant Officer 4 Stien P. Gearhart, Idaho Army 

National Guard

Chief Warrant Officer 3 Jonathan S. Gibson, U.S. Navy 

Captain Jonathan Joseph Golden, U.S. Air Force

Master Sergeant Martin Gonzales, U.S. Air Force

Major Caine M. Goyette, U.S. Marine Corps

Captain John Francis Snavely Graziano, U.S. Air Force

Chief Warrant Officer 4 G. George Wayne Griffin Jr., 

Louisiana Army National Guard

Chief Warrant Officer 3 James E Groves III, U.S. Army

Major Lucas F. Gruenther, U.S. Air Force

Staff Sergeant Ryan David Hammond, U.S. Air Force

Lance Corporal Steven M. Hancock, U.S. Marine Corps

Lance Corporal Ty L. Hart, U.S. Marine Corps

Chief Warrant Officer 4 Jon L. Hartway, Idaho Army 

National Guard

Sergeant Justin R. Helton, U.S. Army

Chief Warrant Officer 2 Bryan J. Henderson, U.S. Army

Lieutenant Colonel Kevin R. Herrmann, U.S. Marine 

Corps

Lance Corporal Jacob A. Hug, U.S. Marine Corps

Corporal Thomas J. Jardas, U.S. Marine Corps

Sergeant Ward M. Johnson IV, U.S. Marine Corps

Senior Airman Quinn Lamar Johnson-Harris, U.S. Air 

Force

Lieutenant Commander Landon L. Jones, U.S. Navy

Captain Elizabeth R. Kealey, U.S. Marine Corps

Staff Sergeant Kerry M. Kemp, U.S. Marine Corps 

Captain Brian T. Kennedy, U.S. Marine Corps

Lieutenant Colonel John M. Kincade, U.S. Air Force 

Chief Warrant Officer 2 David C. Knadle, U.S. Army

Mr. Shane Krogen, Civilian

Master Sergeant Gregory T. Kuhse, U.S. Air Force

Captain Jeff M. Kuss, U.S. Marine Corps

Mr. Matthew LaCourse, GS-13

Staff Sergeant Jonathan E. Lewis, U.S. Marine Corps

Chief Warrant Officer 2 Lucas M. Lowe, Texas Army 

National Guard

Captain Dustin R. Lukasiewicz, U.S. Marine Corps

Technical Sergeant Herman Mackey III, U.S. Air Force

Mr. Alberto Marin, Contractor

Staff Sergeant Vincent P. Marketta, U.S. Army

Mr. Kevin A. Mason, Contractor

Technical Sergeant Dale E. Mathews, U.S. Air Force

Chief Warrant Officer 3 Andrew L McAdams, U.S. Army

Chief Warrant Officer 4 Jason W. McCormack, U.S. 

Army

Staff Sergeant Jason A. McDonald, U.S. Army

Lieutenant Junior Grade William B. McIlvaine III, U.S. 

Navy

Corporal Sara A. Medina, U.S. Marine Corps

Staff Sergeant Abigail R. Milam, U.S. Army

Chief Warrant Officer 3 Dustin L. Mortenson, Texas 

Army National Guard

Captain Reid B. Nannen, U.S. Marine Corps

Sergeant Michael L. Nelson, U.S. Army

Captain Reid Kijiro Nishizuka, U.S. Air Force

Mr. Kristopher L. Noble, Contractor

Chief Warrant Officer 2 Charles P. Nord, Minnesota 

Army National Guard

Captain Christopher L. Norgren, U.S. Marine Corps
69

In Memoriam

Major Richard S. Norton, U.S. Marine Corps

Technical Sergeant Timothy A. Officer Jr., U.S. Air Force

Captain Andreas B. O’Keeffe, U.S. Air Force

Corporal Christopher J. Orlando, U.S. Marine Corps

Senior Master Sergeant Jan A. Paravisini-Ruiz, Puerto 

Rico Air National Guard

Lieutenant Commander Alan A. Patterson, U.S. Navy

Major Phyllis J. Pelky, U.S. Air Force

Major Carlos Perez-Serra, Puerto Rico Air National 

Guard

Captain Ryan S. Phaneuf, U.S. Air Force

Captain Jordan Pierson, U.S. Air Force

Captain Victoria A. Pinckney, U.S. Air Force

Sergeant Kort M. Plantenberg, Minnesota Army National 

Guard

Lieutenant Nathan Poloski, U.S. Marine Corps 

Sergeant Afton M. Ponce, U.S. Air Force

Master Sergeant William R. Posch, U.S. Air Force

Master Sergeant Christopher J. Raguso, U.S. Air Force

Chief Warrant Officer 4 Paul J. Reidy, U.S. Army

Captain Jahmar F. Resilard, U.S. Marine Corps

Staff Sergeant Emil Rivera-Lopez, U.S. Army

Captain Kevin T. Roche, U.S. Marine Corps

Chief Warrant Officer 2 James A. Rogers Jr., Minnesota 

Army National Guard

Major José R. Román-Rosado, Puerto Rico Air National 

Guard

Corporal William C. Ross, U.S. Marine Corps

Captain Sean M. Ruane, U.S. Air Force

Chief Warrant Officer 3 Matthew P. Ruffner, 

Pennsylvania Army National Guard

Mr. Christopher J. Ruiz, Contractor

Airman First Class Kcey Elena Ruiz, U.S. Air Force

Major Taj Sareen, U.S. Marine Corps 

Senior Airman Nathan Cole Sartain, U.S. Air Force

First Lieutenant Adam C. Satterfield, U.S. Marine Corps

Master Sergeant Thomas Arthur Vaughan Saunders, U.S. 

Marine Corps

First Lieutenant David John Schmitz, U.S. Air Force

Sergeant Adam C. Schoeller, U.S. Marine Corps

Lieutenant Colonel Eric Schultz, U.S. Air Force

Staff Sergeant Marc A. Scialdo, U.S. Army

Sergeant Drew M. Scobie, U.S. Army

Sergeant Eric M. Seaman, U.S. Marine Corps 

Staff Sergeant Andrew C. Seif, U.S. Marine Corps

Sergeant Dillon J. Semolina, U.S. Marine Corps

Sergeant Jeffrey A. Sempler, U.S. Marine Corps

Specialist Zachary L. Shannon, U.S. Army

Major Stanford H. Shaw III, U.S. Marine Corps

Sergeant Tyler M. Shelton, U.S. Army

Lieutenant Christopher C. Short, U.S. Navy

Chief Warrant Officer 3 Jacob M. Sims, U.S. Army

Chief Warrant Officer 3 Brandon A. Smith, U.S. Army

Sergeant First Class Jason M. Smith, U.S. Army

Technical Sergeant Mark A. Smith, U.S. Air Force

Lieutenant Sean C. Snyder, U.S. Navy 

Corporal Jordan L. Spears, U.S. Marine Corps

Captain James Michael Steel, U.S. Air Force

Captain Christopher S. Stover, U.S. Air Force

Chief Warrant Officer 4 George David Strother, 

Louisiana Army National Guard

Staff Sergeant Scott R. Studenmund, U.S. Army

Chief Warrant Officer 3 Michael F. Tharp, U.S. Army

Specialist Jeremy D. Tomlin, U.S. Army

Private Second Class Andrew Toppen, U.S. Army

Captain Steven R. Torbert, U.S. Marine Corps

Sergeant William J. Turner, U.S. Marine Corps

Lieutenant J. Wesley Van Dorn, U.S. Navy

Captain Mark T. Voss, U.S. Air Force

Lieutenant Colonel Paul K. Voss, U.S. Air Force

Lieutenant Charles Z. Walker, U.S. Navy

Captain Mark K. Weber, U.S. Air Force

Chief Warrant Officer 2 Kevin M. Weiss, U.S. Army

Major Matthew M. Wiegand, U.S. Marine Corps

Second Lieutenant Travis B. Wilkie, U.S. Air Force

Chief Warrant Officer 3 Brian Marshall Woeber, U.S. 

Army

Chief Warrant Officer 2 Jarett M. Yoder, Pennsylvania 

Army National Guard

Captain Christopher T. Zanetis, U.S. Air Force
70

National Commission on Military Aviation Safety

An Air Force F-22 Raptor from the 95th Fighter Squadron, 

Tyndall Air Force Base, Florida, flies over Tallinn, Estonia. 

(U.S. Air Force photo by TSgt. Jason Robertson.)
A-1

John S. McCain National Defense Authorization Act for Fiscal Year 2019

SEC. 1087. NATIONAL COMMISSION ON MILITARY AVIATION SAFETY.

(a) ESTABLISHMENT; PURPOSE.—

(1) ESTABLISHMENT.—There is established the National Commission on Military Aviation Safety (in this section 

referred to as the ‘‘Commission’’). The Commission shall be considered an independent establishment of the 

Federal Government as defined by section 104 of title 5, United States Code, and a temporary organization under 

section 3161 of such title.

(2) PURPOSE.—The purpose of the Commission is to examine and make recommendations with respect to certain 

United States military aviation mishaps.

(b) MEMBERSHIP.—

(1) COMPOSITION.—The Commission shall be composed of eight members, of whom— 

(A) four shall be appointed by the President;

(B) one shall be appointed by the Chairman of the Committee on Armed Services of the Senate;

(C) one shall be appointed by the Ranking Member of the Committee on Armed Services of the Senate;

(D) one shall be appointed by the Chairman of the Committee on Armed Services of the House of Representatives; 

and

(E) one shall be appointed by the Ranking Member of the Committee on Armed Services of the House of 

Representatives.

(2) APPOINTMENT DATE.—The appointments of the members of the Commission shall be made not later than 

90 days after the date of the enactment of this Act.

(3) EFFECT OF LACK OF APPOINTMENT BY APPOINTMENT DATE. — If one or more appointments under 

subparagraph (A) of paragraph (1) is not made by the appointment date specified in paragraph (2), the authority 

to make such appointment or appointments shall expire, and the number of members of the Commission shall be 

Appendix A: 

CONGRESSIONAL CHARTER 

FOR THE NATIONAL 

COMMISSION ON MILITARY 

AVIATION SAFETY 
A-2

National Commission on Military Aviation Safety

reduced by the number equal to the number of appointments so not made. If an appointment under subparagraph 

(B), (C), (D), or (E) of paragraph (1) is not made by the appointment date specified in paragraph (2), the authority 

to make an appointment under such subparagraph shall expire, and the number of members of the Commission 

shall be reduced by the number equal to the number otherwise appointable under such subparagraph.

(4) EXPERTISE.—In making appointments under this subsection, consideration should be given to individuals with 

expertise in military aviation training, aviation technology, military aviation operations, aircraft sustainment and 

repair, aviation personnel policy, aerospace physiology, and reserve component policy.

(5) PERIOD OF APPOINTMENT; VACANCIES.— Members shall be appointed for the life of the Commission. 

Any vacancy in the Commission shall not affect its powers but shall be filled in the same manner as the original 

appointment.

(6) CHAIR AND VICE CHAIR.—The Commission shall select a Chair and Vice Chair from among its members. 

The Chair may not be a Federal officer or employee.

(7) STATUS AS FEDERAL EMPLOYEES.—Notwithstanding the requirements of section 2105 of title 5, United 

States Code, including the required supervision under subsection (a)(3) of such section, the members of the 

Commission shall be deemed to be Federal employees.

(8) PAY FOR MEMBERS.—

(A) IN GENERAL.—Except for the Chair, each member of the Commission who is not an officer or employee 

of the Federal government shall be paid at a rate equal to the daily equivalent of the annual rate of basic pay 

payable for level IV of the Executive Schedule under section 5315 of title 5, United States Code, for each day 

(including travel time) during which the member is engaged in the actual performance of duties vested in the 

Commission. All members of the Commission who are officers or employees of the United States shall serve 

without compensation in addition to that received for their services as officers or employees of the United 

States.

(B) CHAIR.—The Chair of the Commission shall be paid at a rate equal to the daily equivalent of the annual rate 

of basic pay payable for level III of the Executive Schedule under section 5314, of title 5, United States Code, 

for each day (including travel time) during which the member is engaged in the actual performance of duties 

vested in the Commission.

(C) TRAVEL EXPENSES.—The members of the Commission shall be allowed travel expenses, including per diem 

in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, 

United States Code, while away from their homes or regular places of business in the performance of services 

for the Commission.

(c) ADDITIONAL STAFF.—

(1) EXECUTIVE DIRECTOR.—

(A) APPOINTMENT.—The Commission shall appoint and fix the rate of basic pay for an Executive Director in 

accordance with section 3161 of title 5, United States Code.

(B) LIMITATIONS.—The individual appointed to serve as Executive Director may not have served on active 

duty in the Armed Forces or as a civilian employee of the Department of Defense during the one-year period 

preceding the date of such appointment.

(2) COMMISSION STAFF.—The Executive Director, with the approval of the Commission, may appoint and fix 

the rate of basic pay for additional personnel as staff of the Commission in accordance with section 3161 of title 5, 

United States Code.

(3) DETAILEES.—Not more than half of the personnel employed by or detailed to the Commission may be on detail 

from the Department of Defense and other Federal departments or agencies.
A-3

Appendix A: Congressional Charter for the National Commission on Military Aviation Safety

(d) MEETINGS.—

(1) IN GENERAL.—The Commission shall meet at the call of the Chair.

(2) INITIAL MEETING. — Not later than 30 days after the date on which all members of the Commission are 

required to have been appointed under subsection (b)(2), the Commission shall hold its initial meeting.

(3) QUORUM.—A majority of the members of the Commission shall constitute a quorum, but a lesser number of 

members may hold hearings.

(e) SPACE FOR COMMISSION.—Not later than 90 days after the date of the enactment of this Act, the Administrator 

of General Services, in consultation with the Secretary of Defense, shall identify and make available suitable excess space 

within the Federal space inventory to house the operations of the Commission. If the Administrator is not able to make 

such suitable excess space available within such 90-day period, the Commission may lease space to the extent that funds 

are available for such purpose.

(f) CONTRACTING AUTHORITY.—The Commission may enter into contracts for the acquisition of administrative 

supplies and equipment for use by the Commission, to the extent that funds are available for such purpose.

(g) PROCUREMENT OF TEMPORARY AND INTERMITTENT SERVICES.—The Chair of the Commission 

may procure temporary and intermittent services under section 3109(b) of title 5, United States Code, at rates for 

individuals which do not exceed the daily equivalent of the annual rate of basic pay prescribed for level V of the 

Executive Schedule under section 5316 of such title.

(h) DUTIES.— 

(1) STUDY ON MILITARY AVIATION SAFETY.— The Commission shall undertake a comprehensive study of 

United States military aviation mishaps that occurred between fiscal years 2013 and 2018 in order—

(A) to assess the rates of military aviation mishaps between fiscal years 2013 and 2018 compared to historic 

aviation mishap rates;

(B) to make an assessment of the underlying causes contributing to the unexplained physiological effects;

(C) to make an assessment of causes contributing to delays in aviation maintenance and limiting operational 

availability of aircraft;

(D) to make an assessment of the causes contributing to military aviation mishaps; and

(E) to make recommendations on the modifications, if any, of safety, training, maintenance, personnel, or other 

policies related to military aviation safety.

(2) REPORT.—Not later than March 1, 2020, the Commission shall submit to the President and the congressional 

defense committees a report setting forth a detailed statement of the findings and conclusions of the Commission 

as a result of the study required by paragraph (1), together with the recommendations of the Commission for such 

legislative and administrative actions as the Commission considers appropriate in light of the results of the study.

(i) POWERS.—

(1) HEARINGS.—The Commission may hold such hearings, sit and act at such times and places, take such testimony, 

and receive such evidence as the Commission considers advisable to carry out its duties under this subtitle.

(2) INFORMATION FROM DEPARTMENT.—The Commission may secure directly from any element of the 

Department of Defense such information as the Commission considers necessary to carry out its duties under this 

subtitle. Upon request of the Chair of the Commission, the head of such element shall furnish such information to 

the Commission.
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National Commission on Military Aviation Safety

(j) PROTECTION OF PRIVILEGED SAFETY INFORMATION.—

(1) REQUEST OF INFORMATION.—The Commission may request privileged safety information from the 

Department of Defense.

(2) TREATMENT OF INFORMATION.—Any privileged safety information provided to the Commission by the 

Department of Defense shall be handled by the Commission as though the Commission were a non-Department 

of Defense Federal Government agency under Enclosure 5, Section 8, of Department of Defense Instruction 

6055.07, Mishap Notification, Investigation, Reporting, and Record Keeping.

(3) PROHIBITION ON USE OF INFORMATION IN PUBLIC HEARINGS.—No privileged safety information 

shall be allowed in any public hearing of the Commission. The Commission may only consider privileged safety 

information in camera, and no record of the proceedings of the Commission may include privileged safety 

information.

(4) PROHIBITION ON PUBLICATION.—Any privileged safety information secured by the Commission from the 

Department of Defense—

(A) may not be published or revealed to anyone outside the Commission;

(B) may not be retained but shall be returned to the originating Department of Defense organization; and

(C) may not be included in any Commission report.

(5) USE OF AGGREGATED DATA.—Aggregated data based on privileged safety information or information that 

has been completely sanitized in accordance with Department of Defense Instruction 6055.07, such that individual 

mishaps are not identifiable, may be included in the report produced by the Commission.

(6) DEFINITION OF PRIVILEGED SAFETY INFORMATION.—In this subsection, the term ‘‘privileged safety 

information’’ has the meaning given it in Department of Defense Instruction 6055.07, dated June 6, 2011.

(k) TERMINATION.—The Commission shall terminate 90 days after the date on which the Commission submits the 

report required under subsection (h)(2).

(l) AUTHORIZATION OF APPROPRIATIONS.—Of the amounts authorized to be appropriated for fiscal year 2019, 

as identified in division D of this Act, $5,000,000 shall be available for the National Commission on Aviation Safety.
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Appendix A: Congressional Charter for the National Commission on Military Aviation Safety

National Defense Authorization Act for Fiscal Year 2020

SEC. 1738. NATIONAL COMMISSION ON MILITARY AVIATION SAFETY.

(a) Extension of Deadline for Report.—Subsection (h)(2) of section 1087 of the John S. McCain National Defense 

Authorization Act for Fiscal Year 2019 (Public Law 115-232) is amended by striking “March 1, 2020’’ and inserting 

“December 1, 2020’’.

(b) Secretary of Defense Report.—Such section is further amended by adding at the end the following new subsection:

“(m) Report to Congress.—Not later than 120 days after the date of the submittal of the 

report under subsection (h)(2), the Secretary of Defense, in coordination with the Secretary 

of each of the military departments, shall submit to the Committees on Armed Services of 

the Senate and House of Representatives a report that includes each of the following:

(1) An assessment of the findings and conclusions of the Commission.

(2) The plan of the Secretaries for implementing the recommendations of the Commission.

(3) Any other actions taken or planned by the Secretary of Defense or the Secretary of any 

of the military departments to improve military aviation safety.’’

(c) Authorization of Appropriations.—In addition to any other amounts authorized to be appropriated for the National 

Commission on Military Aviation Safety established under section 1087 of the John S. McCain National Defense 

Authorization Act for Fiscal Year 2019 (Public Law 115-232), of the amounts authorized to be appropriated for 

Operation and Maintenance, Defense-wide for fiscal year 2020, as specified in the funding table in section 4301, 

$3,000,000 shall be available for the National Commission on Aviation Safety.
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National Commission on Military Aviation Safety
B-1

Appendix B: 

RECOMMENDATIONS

Chapter 4: The Joint Safety Council

The Department of Defense must establish aviation safety responsibilities within the Office of the Secretary of Defense 

to ensure sufficient status, experienced and highly qualified personnel, and adequate funding to be effective in preventing 

injury, death, and damage. The following recommendations will create a coordinated, robust, proactive, data-driven aviation 

safety program that incorporates the best aviation safety practices from all relevant sources to become effectively predictive 

and preventive instead of reactive. 

The Commission recommends:

4.1 Congress mandate, authorize, and fund the creation of a Joint Safety Council that reports to the Deputy 

Secretary of Defense. The Joint Safety Council would support and coordinate the capability of the Services’ 

safety centers to identify and mitigate safety risks to reduce the number of aviation mishaps. The Joint Safety 

Council must be fully funded, staffed, and charged with developing and overseeing Defense-wide safety policies 

for the Secretary of Defense. It must have funding as a program element and unlimited access to the requisite 

databases. 

4.2 The Joint Safety Council oversee the Services’ implementation of robust Safety Management Systems that 

include programs such as MFOQA (military flight operations quality assurance), LOSA (line operations safety 

assessment), HUMS (health and usage monitoring system), and CVFDR (cockpit voice and image flight data 

recorders) from aircraft; SOQA (simulator operational quality assurance) from simulators; in-flight physiological 

data from aviators; and ASAP (aviation safety action programs) from aviators and maintainers. These programs 

should be based on best practices from commercial and military enterprises.

4.3 The Joint Safety Council set the requirements for mishap investigations in each of the Services to include the 

same Human Factors Analysis and Classification System (HFACS) codes for all Class A, B, and C mishaps. The 

Secretary of Defense will mandate that Class C mishap investigations use DoD reporting standards and data 

collection fields including HFACS codes. 

4.4 That members of the Joint Safety Council will be the military Departments’ chiefs of safety, all of whom should 

be the grade of O-8, and an additional representative from each of the military Services. The chair, selected 

among the military Departments’ chiefs of safety every two years, would serve in a dual-hatted role as the 

Department of Defense’s Director of Aviation Safety. The vice chair should be a career Senior Executive Service 

position appointed by the Secretary of Defense. The vice chair’s responsibilities should be focused entirely on the 

mission and activities of the Joint Safety Council. The vice chair will report to the chair.
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National Commission on Military Aviation Safety

Chapter 5: The Human/Machine Interface

With modern aviation machines placing unprecedented stress on human physiology, the Department of Defense and 

the Services must adopt an aggressive, proactive approach to understanding the physiological needs of aviators and to 

developing additional capabilities that improve the human-machine interface, including aircraft and cockpit design, testing, 

and subsequent modifications. 

The Commission recommends:

5.1 The Joint Safety Council (Commission recommendation on page 27) lead a robust review into the effects on 

humans in aviation operational environments, including physiological episodes. The JSC shall have a program 

element to conduct further research into determining and mitigating unexplained physiological episodes. 

5.2 Program offices address human physiology concerns and analyze physiological effects throughout the aircraft 

testing phases for T-7, B-21, Future Vertical Lift, and other next-generation platforms early in the initial aircraft 

and cockpit design and with any materiel modification of the aircraft. 

5.3 The Department of Defense and the Services develop physiological standards for each airframe to use in 

screening and training to ensure that the pilot/operator is able to successfully perform at optimal levels across the 

spectrum of the weapon system’s capabilities.

5.4 The Department of Defense, with input from each of the safety centers, update and modify the Force Protection 

key performance parameters (KPP) to better incorporate Aviation Human Systems Safety. 

5.5 That the Force Protection Functional Capability Board include representative capabilities such as ground and 

other aircraft collision avoidance; cockpit voice and flight data recording; biometric sensing for aircrew; and a 

spatial disorientation recovery system used for instrument meteorological conditions and brownout.

Chapter 6: Sustaining the Machine

The Department of Defense and Services must improve their planning, contracting, and program management processes to 

ensure timely availability of spare parts, improve maintenance efficiency, increase mission capable rates, and better sustain 

the investment made in aircraft. The Services should improve sustainment management systems, particularly for legacy 

aircraft and service life extensions, to provide the necessary visibility on expiring parts and production upgrades. 

Chapter 7: The Need for Consistent Predictable Funding

Congress and the administration must recognize that consistent, reliable, and timely funding is key to sustaining military 

aviation readiness and safety. 

The Commission recommends:

7.1 Congress and the administration ensure predictable and reliable funding for military aviation and stop using 

continuing resolutions to fund national security, military readiness, and aviation safety. 

7.2 Congress task the Congressional Budget Office to study and report on the negative impacts of continuing 

resolutions on military aviation readiness and safety. 
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Appendix B: Recommendations

Chapter 8: The Demand Environment

Policy at all levels must reflect that aviation is a high-demand, low-density specialty with routinely insufficient capacity to 

satisfy all of the demand placed on it. This has overextended the aviation force beyond sustainable levels, resulting in chronic 

fatigue and burnout, which negatively impacts retention. The current high demand is forcing the Services to shortchange 

safety to accomplish current missions. The Services must increase aviator and maintainer capacity, reduce additional duties, 

and focus on proficiency to mitigate the risk.

The Commission recommends:

8.1 The Services ensure aviation units have sufficient administrative personnel to allow aviators and maintainers to 

concentrate on their primary mission, sustain currency and proficiency, and meet the unit’s mission readiness rates.

8.2 The Department of Defense and the Services report aviation unit’s personnel experience levels and member 

PERSTEMPO.

8.3 The Department of Defense and the Services require that proper policies, practices, staffing, and all other 

necessary resources are in place to ensure that the military’s high demand/low density aviation units always are 

fully prepared and standing ready to perform at levels commensurate with the critical and unique role they 

perform in securing and maintaining our nation’s security. 

Chapter 9: Maintainers as Aviation Professionals

Because of the significant investment in time and resources required to train and sustain fully qualified military aviation 

maintainers, and a commercial marketplace competing for such high-demand talent, Congress, the Department of Defense, 

and the Services must regard and manage aviation maintainers as a specialty and their training as a career-long pursuit. 

The Services must develop personnel management processes and career paths that account for the complexities of aviation 

and support aviation safety, readiness, and OPTEMPO. DoD and the Services must execute the following measures to 

recognize achievement and enable aviation professionals to focus on their flight line duties, sustain their skills, and promote 

advancement of their proficiencies. 

The Commission recommends:

9.1 The Services mandate and enforce assignments and performance evaluation guidance that focus aviation 

maintainers primarily on areas of performing, sustaining, and advancing their aviation professional skills, 

knowledge, and experience. The Services must discourage using aviation professionals for assignments and 

additional duties unrelated to their aviation-related warfighting fitness, skills requirements, or essential 

supervisory responsibilities. DoD and the Services should reduce mandated, nonaviation-related ancillary 

training to the minimum. 

9.2 The Services experiment with technical specialty enlisted ranks for aviation maintenance personnel that include 

unique career paths to ensure that maintenance personnel achieve and are able to sustain the highest level of 

proficiency and professionalism.

9.3 The Services reward and incentivize the professional achievements of aviation maintainers with recognition and 

professional development throughout their careers. 

a. The Services should establish aviation maintenance proficiency badges or credentials that would recognize 

and incentivize excellence in aviation maintainers and empower supervisors with support from leaders at 

the unit level to keep aviation maintainers focused on their primary flight line responsibilities. 

b. The Services should institute a tuition-paid A&P (Airframe and Powerplant) license option in return for 

an extended enlisted commitment meeting a cost/benefit threshold.
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National Commission on Military Aviation Safety

9.4 The Services implement policies and training for transitioning maintainers among platforms that require and 

certify proficiency, promote retention, and leverage experience for both legacy and new platforms. 

Chapter 10: Protecting Investment in Aircrews

Because of the significant investment in time and resources required to train and sustain fully qualified military aviation 

personnel, and a commercial marketplace competing for such high-demand talent, Congress, the Department of Defense, 

and the Services must regard and manage aircrews as a specialty and their training as a career-long pursuit. The Services 

must develop personnel management processes that account for the complexities of aviation and support aviation safety, 

readiness, and the demands of OPTEMPO. Congress and the Services must execute the following measures to focus 

aviation professionals on their flying duties, sustain their skills, and promote advancement of their proficiencies.

The Commission recommends: 

10.1 The Services mandate and enforce assignments and performance evaluation guidance that focus aircrews 

primarily on areas of performing, sustaining, and advancing their aviation professional skills, knowledge, and 

experience. The Services must discourage using aircrews for assignments and additional duties unrelated to their 

aviation-related warfighting fitness, skills requirements, or essential supervisory responsibilities. DoD and the 

Services should reduce nonaviation-related ancillary training to the minimum. 

10.2 The Services restore flight hours to not less than fiscal year 2010 levels for schoolhouse and operational units. 

10.3 The Services centrally track waivers, create a baseline, and monitor them to identify trends, assess risk, and 

predict potential problems and resource shortfalls. 

10.4 Congress grant the Services standing authority to increase the aviation bonuses from up to $35,000 to up to 

$100,000 per year to retain pilots in exchange for a commensurate additional service commitment.

10.5 The Services upgrade data collection to improve training programs and training tool selections that better 

measure student learning. Data collection must include classroom, pilot task training, full-motion simulators, 

and flying training plus feedback from the field as a measure of training efficacy.

10.6 The Services link simulator sustainment to aircraft production, upgrades, and modifications and have the same 

operational flight plan as the aircraft. The Department of Defense and the Services must eliminate software and 

system upgrade lags that hamper simulator training.
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Appendix C: 

COMMISSIONERS AND STAFF

Commissioners

General Richard A. Cody (USA, Retired)

Chairman, National Commission on Military Aviation Safety

General Richard Cody recently retired from L3 Technologies, which he joined in 2008 after concluding a 36-year U.S. 

Army career with four years as Vice Chief of Staff of the Army. 

A Master Aviator with over 5,000 hours of flight time, General Cody served in several command and staff assignments, 

including Deputy Chief of Staff for Operations (G-3); Commanding General of the 101st Airborne Division (Air Assault); 

Director of Operations, Readiness, and Mobilization in the Office of the Deputy Chief of Staff for Operations and Plans, 

Department of the Army; Deputy Commanding General of Task Force Hawk in Tirana, Albania; Commander of the 

160th Special Operations Aviation Regiment; Commander of 4th Brigade, 1st Cavalry Division; Aide-de-Camp to the 

Commanding General of the Combined Field Army, Korea; and Director of Flight Concepts Division. 

He is Chairman of the Board for Homes For Our Troops, which builds mortgage-free custom homes for severely 

wounded war veterans.

A graduate of the Military Academy at West Point, General Cody’s professional military education includes the 

Transportation Corps Officer Basic and Advanced Courses; the Aviation Maintenance Officer Course; AH-1, AH-64, 

AH-64D, UH-60, and MH-60K Aircraft Qualification Courses; Command and General Staff College; and the Army War 

College.

The Honorable Richard F. Healing

Vice Chairman, National Commission on Military Aviation Safety

Mr. Richard Healing is a professional engineer and internationally recognized transportation safety expert who founded Air 

Safety Engineering LLC in 2015, a company that provides safety analysis and solutions in general, military, and commercial 

aviation.

He served as a Board Member of the National Transportation Safety Board, holding the Safety Engineering position and 

providing technical inputs on several transportation accident investigations from 2003 to 2005. As Director of Safety and 

Survivability for the Department of the Navy from 1985 to 2002, he worked on aviation safety and developed initiatives to 

rapidly bring state-of-the-art safety and survivability technology into the Navy and Marine Corps. 

Mr. Healing retired as a captain from the U.S. Coast Guard Reserve in 1993. During his 32-year combined active and 

reserve Coast Guard career, he held four commands, including a coastal patrol boat on combat missions in Vietnam from 

1966 to 1967 and, prior to his retirement, the Secretary of Defense Crisis Coordination Center Joint Reserve Unit in the 

Pentagon during Operations Desert Shield and Desert Storm. 

Mr. Healing attended the U.S. Coast Guard Academy and graduated from Worcester Polytechnic Institute. He 

graduated from the Naval War College and was a Senior Executive Fellow at Harvard University.
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National Commission on Military Aviation Safety

The Honorable Scott C. Donnelly

Commissioner, National Commission on Military Aviation Safety

Mr. Scott Donnelly is the Chairman, Chief Executive Officer, and President of Textron Inc. He has more than two decades 

of business experience in innovation, manufacturing, sales and marketing, business processes, research and development, 

design engineering, and industrial systems control. 

Mr. Donnelly joined General Electric and spent 20 years leading the design and development of GE products in 

aerospace, industrial systems, health care, and aircraft engines. He started his career in the aerospace and semiconductor 

industries as a design engineer developing advanced computer architectures and devices for special-purpose processors 

and systems. In 1995, he moved to GE’s Industrial Control Systems business as Manager of Technology and System 

Development. He advanced through management positions across GE’s divisions, including Vice President of Global 

Technology Operations for GE Medical Systems, Senior Vice President and Director of Global Research, and President and 

Chief Executive Officer for GE Aviation. 

Mr. Donnelly joined Textron in 2008, serving as the Chief Operating Officer prior to becoming the company’s CEO. 

Mr. Donnelly has been active in many industry associations. In 2010, he served as chairman of the Aerospace Industries 

Association’s board of governors.

Mr. Donnelly attended the University of Colorado and graduated with a bachelor’s degree in electrical and computer 

engineering in 1984.

The Honorable Preston Geren

Commissioner, National Commission on Military Aviation Safety

Mr. Preston “Pete” Geren, who served in the U.S. Congress and at the highest levels of the Department of Defense, is 

president of the Sid W. Richardson Foundation, which provides grants to educational, health, human service, and cultural 

nonprofit organizations in Texas. He assumed that position in 2011.

Mr. Geren’s Department of Defense career included several senior positions from 2001 to 2009, including Special 

Assistant to the Secretary of Defense, Acting Secretary of the Air Force, Under Secretary of the Army, and Secretary of the 

Army. In recognition of his service, he was twice awarded the Distinguished Civilian Service Award, the Department of 

Defense’s highest civilian award.

The 12th District of Texas elected Mr. Geren to four terms in the U.S. House of Representatives from 1989 to 1997. 

He was also an assistant to U.S. Senator Lloyd Bentsen. As a lawyer and former business executive, he has held leadership 

positions in numerous civic, educational, business, and philanthropic organizations in Texas. 

He earned his Doctor of Jurisprudence at the University of Texas Law School and his Bachelor of Arts in history at the 

University of Texas at Austin. He studied architecture at Georgia Tech before transferring to the University of Texas.

The Honorable Joseph W. Hagin

Commissioner, National Commission on Military Aviation Safety

Mr. Joseph Hagin was Deputy Chief of Staff for Operations for President Donald Trump from 2017 to 2018 and for 

President George W. Bush from 2001 to 2008. He served in that role longer than any other member of the White House 

senior staff. 

Among his many duties was responsibility for White House communications, logistics, Air Force One operations, and 

security for President George W. Bush and President George H.W. Bush. He oversaw the activities of 4,000 civilian and 

military personnel. As Deputy Chief of Staff, Mr. Hagin traveled with the president and has interacted with world and 

business leaders around the globe. 

Mr. Hagin was Chief Executive Officer at Jet Support Services Inc. from 2008 to 2009 and has held senior management 

positions at Chiquita Brands and Federated Department Stores. He has been chairman of SMobile International Advisory 

Board since August 2008 and was chairman of SMobile Corporation from 2008 to 2010. 

Mr. Hagin serves on the Board of Directors of SMobile Systems, Jet Support Services Inc., The Franklin Mint, and 

Fox Factory Inc. He was a director of Fox Factory Holding Corp from 2013 to 2016. He holds a Bachelor of Arts degree in 

economics from Kenyon College.
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Appendix C: Commissioners and Staff

General Raymond E. Johns (USAF, Retired)

Commissioner, National Commission on Military Aviation Safety

General Ray Johns recently retired from FlightSafety International serving as Co-CEO and President of Government and 

Manufacturing following a 36-year career in the U.S. Air Force. A test pilot, including chief test pilot and test program 

manager for the VC-25 Air Force One, he has over 5,000 hours in more than 83 different aircraft.  

He concluded his military career as Commander of Air Mobility Command, overseeing 135,000 personnel, 1,300 

aircraft, and an annual operating budget of $20 billion. Previously, he was Air Force Deputy Chief of Staff for Strategic 

Plans and Programs, developing, integrating, and analyzing the Air Force’s annual $120 billion budget, the Future Years 

Defense Program, and Air Force Long-Range Plan.

General Johns has served in senior strategy, planning, and fiscal policy positions at U.S. European 

Command and U.S. Pacific Command. He was a White House Fellow in the Office of National Service working on the 

Points of Light initiative for President George H.W. Bush. 

General Johns received a Bachelor of Science degree in aeronautical engineering from the Air Force Academy and 

a Master of Science degree in administration from Central Michigan University. He is a graduate of the U.S. Air Force 

Test Pilot School, the Industrial College of the Armed Forces, and the John F. Kennedy School of Government at Harvard 

University. 

The Honorable Dabney Kern

Commissioner, National Commission on Military Aviation Safety

Mr. Dab Kern is Senior Vice President for Corporate Homeland and National Defense at CACI International Inc. He 

served 20 years in the U.S. Navy as a pilot with a space subspecialty, a career that led to several government posts. 

He served as Director of the White House Military Office and Deputy Assistant to the President from 2014 to 2017, 

combining nearly 3,000 personnel in over 20 commands and directorates, including the White House Communications 

Agency, Presidential Airlift Group (which operates Air Force One and other associated platforms), Marine Helicopter 

Squadron One (with 22 rotary platforms including the V-22 Osprey and Marine One), the White House Medical Unit, 

and Camp David. He was Senior Director for Response and Recovery Policy at the National Security Council from 2009 to 

2011. 

He spent the last seven years of his Navy career in national security appointments in the White House and the 

Department of Homeland Security, including Director of Homeland Security’s Mt. Weather Emergency Operations Center 

from 2005 to 2009. 

Mr. Kern studied information systems management, computer, and military science at Jacksonville University. He has 

degrees in information technology management from the Naval Postgraduate School and maritime security from the Naval 

War College.
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National Commission on Military Aviation Safety

National Commission on Military Aviation Safety Staff

Major General Gregory A. Feest (USAF, Retired)

Executive Director, National Commission on Military Aviation Safety

Major General Greg Feest concluded his 34-year U.S. Air Force career as Commander of the Air Force Safety Center and Air 

Force Chief of Safety. He since has worked at L3 Technologies as Vice President of USAF Programs and at Lockheed Martin’s 

Advanced Development Programs (Skunk Works) as Deputy Director of Operations, Business, and Strategy Development.

A command pilot with over 5,600 flying hours, more than 800 in combat operations, Major General Feest has 

commanded at all levels, including an F-117A stealth fighter squadron, the 379th Air Expeditionary Wing in Southwest 

Asia, and 19th Air Force, the largest numbered Air Force with over 38,000 personnel, 1,500 aircraft, and 27 bases. 

With Air Education and Training Command, he served as Director of Logistics, Installations, and Mission Support and 

as Deputy Director of Operations for all Air Force flying training.

He graduated from the University of Wisconsin, Madison, with a Business Administration degree in finance and 

management. He has an MBA in management and a Master of Science in national security strategy from the National 

War College. He attended the Systems Acquisition Management General Officer Course, the Syracuse University National 

Security Management Course, and Harvard University’s John F. Kennedy School of Government. 

Carvell Akuffo Research Assistant

Destini Berry Operations Analyst

Michael J. Blaine Executive Assistant

Corey Bradley Deputy General 

Counsel

Cody Cheek Deputy General 

Counsel

Amy Grace P. Donohue Deputy Editor

Clark D. Frederick Research Analyst

Jamie Hammon Finance and Budget 

Administrator

Denise Jade Hlavaty Public Outreach 

Specialist

Madison Ianniello Research Assistant

Kevin D. Mickie Human Resources

Eric Minton Editor

Laurel Prucha Moran Graphic Designer

Charles Risio Research Analyst

Chad Schumacher Congressional Liaison

Ray B. Shepherd Director of Research 

and Analysis

Leslie H. Smith Staff Director, 

Director of Operations

Marian Veld Librarian

Bryan G. Whitman Director of Government

and Public Engagement

Stefan R. Wolfe General Counsel
D-1

Military Organizations

1/25th Aviation Regiment, Fort Wainwright, Alaska

1/52nd Aviation Regiment, Fort Wainwright, Alaska

101st Airborne Division, Fort Campbell, Kentucky

104th Fighter Wing, Massachusetts Air National 

Guard, Barnes Air National Guard Base, Westfield, 

Massachusetts

108th Wing, New Jersey Air National Guard, Joint Base 

McGuire-Dix-Lakehurst, New Jersey

110th Aviation Brigade, Fort Rucker, Alabama

115th Fighter Wing, Wisconsin Air National Guard, 

Madison, Wisconsin

11th Air Force, Joint Base Elmendorf-Richardson, Alaska

126th Airlift Wing, U.S. Air Force Reserve, Scott Air 

Force Base, Illinois

128th Air Refueling Wing, Wisconsin Air National 

Guard, Milwaukee, Wisconsin 

128th Aviation Brigade, Fort Eustis, Virginia (U.S. Army 

Aviation Maintenance Training)

133rd Airlift Wing, Minnesota Air National Guard, 

Minneapolis, Minnesota

139th Air Wing Advanced Airlift Tactics Training Center, 

San Antonio, Texas

143rd Airlift Wing, Rhode Island Air National Guard, 

Providence, Rhode Island

150th Special Operations Wing, New Mexico Air 

National Guard, Kirtland Air Force Base, New Mexico

154th Wing, Hawaii Air National Guard, Joint Base 

Pearl Harbor-Hickam, Hawaii

157th Air Refueling Wing, New Hampshire Air National 

Guard, Portsmouth, New Hampshire

15th Fighter Wing, Joint Base Pearl Harbor-Hickam, 

Hawaii

160th Special Operations Aviation Regiment, Fort 

Campbell, Kentucky; Joint Base Lewis-McChord, 

Washington

16th Combat Aviation Brigade, Joint Base LewisMcChord, Washington

173rd Fighter Wing, Oregon Air National Guard, 

Kingsley Field, Klamath Falls, Oregon

176th Wing, Alaska Air National Guard, Joint Base 

Elmendorf-Richardson, Alaska

19th Air Force, Joint Base San Antonio, Texas

1st Armored Division Combat Aviation Brigade, Fort 

Bliss, Texas

1st Fighter Wing, Langley Air Force Base, Virginia

20th Fighter Wing, Shaw Air Force Base, South Carolina

Appendix D: 

COMMISSION ENGAGEMENTS 
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National Commission on Military Aviation Safety

22nd Air Force, U.S. Air Force Reserve, Dobbins Air 

Reserve Base, Georgia

22nd Air Refueling Wing, McConnell Air Force Base, 

Kansas

23rd Flying Training Squadron, Fort Rucker, Alabama

244th Expeditionary Combat Aviation Brigade, Joint 

Base McGuire-Dix-Lakehurst, New Jersey

25th Combat Aviation Brigade, Wheeler Army Airfield, 

Hawaii

2nd Air Force, 81st Training Wing, Keesler Air Force 

Base, Mississippi

2nd Marine Air Wing, Marine Corps Air Station Cherry 

Point, North Carolina 

2nd Operations Group, Barksdale Air Force Base, 

Louisiana

305th Air Mobility Wing, Joint Base McGuire-DixLakehurst, New Jersey

306th Flying Training Group, Colorado Springs, 

Colorado

309th Aerospace Maintenance and Regeneration Group, 

Davis-Monthan Air Force Base, Arizona

310th Fighter Squadron, Luke Air Force Base, Arizona

33rd Fighter Wing, Eglin Air Force Base, Florida

355th Fighter Wing, Davis-Monthan Air Force Base, 

Arizona

375th Air Mobility Wing, U.S. Air Force Reserve, Scott 

Air Force Base, Illinois

388th Fighter Wing, Hill Air Force Base, Utah

3rd Marine Air Wing, Marine Corps Air Station 

Miramar, California

4/160th Special Operations Aviation Regiment, Joint 

Base Lewis-McChord, Washington

419th Fighter Wing, U.S. Air Force Reserve, Hill Air 

Force Base, Utah

422nd Test and Evaluation Squadron, Nellis Air Force 

Base, Nevada

433rd Airlift Wing, U.S. Air Force Reserve, Joint Base 

San Antonio, Texas

436th Airlift Wing, Dover Air Force Base

439th Airlift Wing, U.S. Air Force Reserve, Westover Air 

Reserve Base, Massachusetts

442nd Fighter Wing, U.S. Air Force Reserve, Whiteman 

Air Force Base Missouri

446th Airlift Wing, U.S. Air Force Reserve, Joint Base 

Lewis-McChord, Washington

46th Aviation Support Battalion, Joint Base LewisMcChord, Washington

477th Fighter Group, Joint Base Elmendorf-Richardson, 

Alaska 

479th Flying Training Group, Naval Air Station 

Pensacola, Florida

49th Wing, Holloman Air Force Base, New Mexico

4th Combat Aviation Brigade, Fort Carson, Colorado

4th Fighter Wing, Seymour Johnson Air Force Base, 

North Carolina

509th Bomb Wing, Whiteman Air Force Base, Missouri

512th Airlift Wing, Dover Air Force Base

552nd Air Control Wing, Tinker Air Force Base, 

Oklahoma

55th Electronic Combat Group, Davis-Monthan Air 

Force Base, Arizona

56th Fighter Wing, Luke Air Force Base, Arizona

57th Wing Maintenance Group, Nellis Air Force Base, 

Nevada

58th Special Operations Wing, Kirtland Air Force Base, 

New Mexico

62nd Airlift Wing, Joint Base Lewis-McChord, 

Washington

645th Aeronautical Systems Group, Wright-Patterson Air 

Force Base, Ohio

711th Human Performance Wing, Wright-Patterson Air 

Force Base, Ohio
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Appendix D: Commission Engagements

80th Flying Training Wing, Sheppard Air Force Base, 

Texas

82nd Training Wing, Sheppard Air Force Base, Texas

916th Air Refueling Wing, Seymour Johnson Air Force 

Base, North Carolina

931st Air Refueling Wing, U.S. Air Force Reserve, 

McConnell Air Force Base, Kansas

932nd Airlift Wing, U.S. Air Force Reserve, Scott Air 

Force Base, Illinois

940th Air Refuel Wing, Beale Air Force Base, California

94th Airlift Wing, U.S. Air Force Reserve, Dobbins Air 

Reserve Base, Georgia

97th Air Mobility Wing, Altus Air Force Base, Oklahoma

9th Reconnaissance Wing, Beale Air Force Base, 

California

Air Combat Command, Langley Air Force Base, Virginia

Air Education and Training Command, Joint Base San 

Antonio, Texas

Air Force Acquisition Safety Systems Personnel, The 

Pentagon, Virginia

Air Force Agency for Modeling and Simulation, Orlando, 

Florida

Air Force Air National Guard, National Guard Bureau, 

The Pentagon, Virginia

Air Force Aircrew Crisis Task Force, The Pentagon, 

Virginia

Air Force Airworthiness Office, Wright-Patterson Air 

Force Base, Ohio

Air Force Central Command, Shaw Air Force Base, 

South Carolina

Air Force Directorate of Plans and Integration Force 

Support Career Field Management and Readiness 

Division, The Pentagon, Virginia

Air Force Global Strike Command, Barksdale Air Force 

Base, Louisiana 

Air Force Initial Flight Training, Pueblo, Colorado

Air Force Life Cycle Management Center, Hill Air Force 

Base, Utah

Air Force Lifecycle Management Center, WrightPatterson Air Force Base, Ohio

Air Force Maintenance Next, Kelly Field, Texas

Air Force Program Executive Office Simulation, WrightPatterson Air Force Base, Ohio

Air Force Recruiting Service, Joint Base San Antonio, 

Texas

Air Force Research Lab, Wright-Patterson Air Force Base, 

Ohio

Air Force Reserve Command, Robins Air Force Base, 

Georgia

Air Force Safety Center, Kirtland Air Force Base, New 

Mexico

Air Force Safety School, Kirtland Air Force Base, New 

Mexico

Air Force Sustainment Center, Tinker Air Force Base, 

Oklahoma

Air Force Warfare Center, Nellis Air Force Base, Nevada

Air Force Weapons School, Nellis Air Force Base, Nevada

Air Mobility Command, Scott Air Force Base, Illinois 

Air National Guard Air Force Reserve Test Center, DavisMonthan Air Force Base, Arizona

Alaska Army National Guard, Joint Base ElmendorfRichardson, Alaska

Army Aeromedical Research Lab, Fort Rucker, Alabama

Army Analytics Group Lab-Monterey, Monterey, 

California 

Army Aviation and Missile Command, Huntsville, 

Alabama

Army Aviation Safety School, Fort Rucker, Alabama

Army Combat Readiness Center, Fort Rucker, Alabama

Army Directorate of Training and Doctrine, Fort Rucker, 

Alabama

Army Material Command, Huntsville, Alabama
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National Commission on Military Aviation Safety

Army National Guard, National Guard Bureau, The 

Pentagon, Virginia

Army Pacific, Fort Shafter, Hawaii

Army Program Executive Office Aviation, Huntsville, 

Alabama

Army Research Office, Durham, North Carolina

Army Training and Doctrine Command, Fort Eustis, 

Virginia

Aviator Training Next, Fort Rucker, Alabama

Center for Naval Aviation Technical Training 

Detachment Lakehurst, Joint Base McGuire-DixLakehurst, New Jersey

Center for Naval Aviation Technical Training Unit 

Cherry Point, Marine Corps Air Station Cherry Point, 

North Carolina

Center for Naval Aviation Technical Training Unit 

Lemoore, Naval Air Station Lemoore, California

Center for Naval Aviation Technical Training, Naval Air 

Station Pensacola, Florida

Coast Guard Headquarters, Washington, District of 

Columbia

Corpus Christi Army Depot, Naval Air Station Corpus 

Christi, Texas

Defense Logistics Agency, Fort Belvoir, Virginia

Defense Safety Oversight Council, The Pentagon, 

Virginia

Detachment 24, Air Force Pilot Training Next, Joint Base 

San Antonio-Randolph, Texas

DoD Acquisition Environment, Safety, and Occupational 

Health Integrated Production Team, The Pentagon, 

Virginia

Electronic Attack Wing, Naval Air Station Whidbey 

Island, Washington

F-35 Joint Program Office, Arlington, Virginia

Fleet Logistics Support Squadron 1, Washington Naval 

Air Facility, Maryland

Fleet Logistics Support Squadron 30, Washington Naval 

Air Facility, Maryland

Fleet Logistics Support Squadron 53, Washington Naval 

Air Facility, Maryland

Fleet Readiness Center East Detachment, Joint Base 

McGuire-Dix-Lakehurst, New Jersey

Fleet Readiness Center East, Marine Corps Air Station 

New River, North Carolina

Helicopter Maritime Strike Squadron 41, Naval Air 

Station North Island, California

Helicopter Sea Combat Weapons School Atlantic, Naval 

Air Station Norfolk, Virginia

Joint Staff Force Structure, Resources, and Assessment 

Directorate (J8), Functional Capability Board, The 

Pentagon, Virginia

Marine Air Group 11, Marine Corps Air Station 

Miramar, California

Marine Air Group 13, Marine Corps Air Station Yuma, 

Arizona

Marine Air Group 14, Marine Corps Air Station Cherry 

Point, North Carolina

Marine Air Group 16, Marine Corps Air Station 

Miramar, California

Marine Air Group 24, Marine Corps Base Kaneohe Bay, 

Hawaii

Marine Air Group 29, Marine Corps Air Station New 

River, North Carolina

Marine Air Group 31, Marine Corps Air Station New 

River, North Carolina 

Marine Air Group 49, Joint Base McGuire-DixLakehurst, New Jersey

Marine Aviation Logistics Squadron 11, Marine Corps 

Air Station Miramar, California

Marine Aviation Weapons and Tactics Squadron 1, 

Marine Corps Air Station Yuma, Arizona

Marine Corps Forces Pacific, Camp H. M. Smith, Hawaii

Marine Wing Support Group 37, Marine Corps Air 

Station Miramar, California

Naval Air Facility Command, Washington Naval Air 

Facility, Maryland
D-5

Appendix D: Commission Engagements

Naval Air Force Reserve, San Diego, California 

Naval Air Forces, Naval Air Station North Island, 

California

Naval Air Forces Pacific, Safety Office, Naval Air Station 

North Island, California

Naval Air Systems Command, Naval Air Station Patuxent 

River, Maryland

Naval Air Warfare Center Training Systems Division, 

Orlando, Florida

Naval Aviation Enterprise Total Force Cross Functional 

Team, Naval Air Station North Island, California

Naval Aviation Safety School, Naval Air Station 

Pensacola, Florida

Naval Aviation Warfighting Development Center, Naval 

Air Station Fallon, Nevada

Naval Epidata Center, Portsmouth, Virginia

Naval Postgraduate School, Monterey, California

Naval Safety Center, Norfolk, Virginia

Navy Aeromedical Research Unit, Wright-Patterson Air 

Force Base, Ohio

Navy Physiological Episodes Action Team, Arlington 

Annex, Virginia

Navy Strike Fighter Wing Atlantic, Naval Air Station 

Oceana, Virginia

Navy Strike Fighter Wing Pacific, Naval Air Station 

Lemoore, California

Navy Training Air Wing 4, Naval Air Station Corpus 

Christi, Texas

Navy Training Air Wing 5, Naval Air Station Whiting 

Field, Florida

Navy Training Air Wing 6, Naval Air Station Pensacola, 

Florida

Office of the Assistant Secretary of Defense for 

Acquisition, The Pentagon, Virginia

Office of the Assistant Secretary of the Navy (Energy, 

Installations, and Environment), The Pentagon, Virginia 

Office of the Assistant Secretary of the Navy (Research, 

Development, and Acquisition), The Pentagon, Virginia

Office of the Secretary of the Air Force, The Pentagon, 

Virginia

Office of the Secretary of the Army, The Pentagon, 

Virginia

Office of the Under Secretary of Defense, Acquisition 

and Sustainment, The Pentagon, Virginia

Office of the Under Secretary of Defense, Personnel and 

Readiness, The Pentagon, Virginia

Office of the Under Secretary of Defense, Research and 

Engineering, The Pentagon, Virginia

Ogden Air Logistics Complex, Ogden Air Force Base, 

Utah

Oklahoma City Air Logistics Center, Tinker Air Force 

Base, Oklahoma

Pacific Air Forces, Joint Base Pearl Harbor-Hickam, 

Hawaii

Patrol and Reconnaissance Wing 10, Naval Air Station 

Whidbey Island, Washington

Patrol and Reconnaissance Wing 11, Naval Air Station 

Jacksonville, Florida

Program Executive Office Simulation, Training, and 

Instrumentation, Orlando, Florida

Program Management 202, Naval Air Station Patuxent 

River, Maryland

Program Management 209, Naval Air Station Patuxent 

River, Maryland

Program Management 265, Naval Air Station Patuxent 

River, Maryland

Program Management 275, Naval Air Station Patuxent 

River, Maryland

Program Management 299, Naval Air Station Patuxent 

River, Maryland

T-7A Program Office, Wright-Patterson Air Force Base, 

Ohio

U.S. Army Alaska, Joint Base Elmendorf-Richardson, 

Alaska
D-6

National Commission on Military Aviation Safety

U.S. Central Command, Tampa, Florida

Virtual Test and Training Center, Nellis Air Force Base, 

Nevada

Warner Robins Air Logistics Complex, Robins Air Force 

Base, Georgia

Western Army Air Training School, Arizona National 

Guard, Pinal Airpark, Red Rock, Arizona

Civilian and Academic Organizations

Air Methods (Helicopter Emergency Medical Services), 

Greenwood Village, Colorado

Airbus, Grand Prairie, Texas

American Airlines, Fort Worth, Texas

Applied Research Laboratory Head, Materials and 

Manufacturing Office, Penn State University, State 

College, Pennsylvania

Bell Helicopter, Fort Worth, Texas

Boeing Defense, St. Louis, Missouri

Center for Naval Analyses, Arlington, Virginia

Congressional Research Service, Washington, District of 

Columbia 

Dr. Mary L. Cummings, Duke University, Durham, 

North Carolina

Dr. Scott Shappell, Embry-Riddle Aeronautical 

University, Daytona Beach, Florida 

Dr. Thomas Morgan

Dr. Thomas Travis, Uniformed Services University of the 

Health Sciences, Bethesda, Maryland

DuPont Corporation, Wilmington, Delaware

Everett Smith, Spiegare Aviation Safety, Albuquerque, 

New Mexico

Federal Aviation Administration, Office of Accident 

Investigation and Prevention, Washington, District of 

Columbia 

Helicopter Association International, Alexandria, Virginia

Institute for Defense Analyses (IDA), Alexandria, 

Virginia

JetBlue Airways, Queens, New York

Leonardo DRS, Arlington, Virginia

Lockheed Martin, Grand Prairie, Texas

RAND Corporation, Santa Monica, California

Textron Aviation Wichita Service Center, Wichita, 

Kansas

Truth Data Systems, Fort Worth, Texas

U.S. House of Representatives Armed Services 

Committee Washington, District of Columbia

U.S. Senate Armed Services Committee, Washington, 

District of Columbia

United Airlines, Chicago, Illinois 

Conferences

Air Force Association Air Warfare Symposium “MultiDomain Operations from Vision to Reality,” Orlando, 

Florida

Air Force Association Air, Space, and Cyber Conference, 

National Harbor, Maryland

Air National Guard Air Force Reserve Command Test 

Center Weapons and Tactics Conference, Tucson, 

Arizona

Human Factors Analysis and Classification System 

Educational Seminar, Las Vegas, Nevada

Interservice / Industry Training, Simulation and 

Education Conference, Orlando, Florida

Joint Service Safety Chiefs Conference, Fort Rucker, 

Alabama 

Military Flight Training Conference, San Antonio, Texas

National Transportation Safety Board Symposium on 

Improving the Safety of Part 135 Safety Operations, 

Reston, Virginia

Weapons and Tactics Conference, U.S. Air Force, Nellis 

Air Force Base, Nevada
E-1

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E-5

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National Commission on Military Aviation Safety

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E-17

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F-1

This technical appendix provides more information 

beyond the mishap rates and HFACS analysis within 

Chapters 2 and 3. 

Additional Mishap Rate Information

Chapter 2 provides the Commission’s assessment of 

fiscal years 2013 through 2018 mishap rates compared 

against historical trends. Following are tables with the 

Commission’s calculated mishap rates. This section also 

presents additional information about the relationship 

between fatalities and destroyed aircraft in Class A 

mishaps and changes in the mishap classification criteria.

Figures F-1, F-2, F-3, and F-4 illustrate the mishap 

rates by class and by Service for the fiscal years 2013–

2018 study period (shaded in gray on the tables) and the 

comparative historical period of fiscal years 2007–2012.

Appendix F: 

TECHNICAL APPENDIX

Figure F-1: 

Class A Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army A 

Mishap Rate

2.47 1.54 2.01 1.84 1.18 1.61 0.90 1.56 1.45 0.93 1.03 1.31

Air Force A 

Mishap Rate

1.47 1.39 1.26 0.87 0.86 1.04 1.21 0.72 1.17 0.96 1.03 1.58

Navy A 

Mishap Rate 1.08 1.70 1.36 0.76 1.03 0.99 1.06 1.78 1.28 0.93 1.55 1.44

Marine Corps A 

Mishap Rate 2.62 2.25 1.71 1.70 3.80 2.35 2.98 2.28 3.29 3.81 5.19 2.49

All DoD A 

Mishap Rate

1.74 1.56 1.52 1.17 1.19 1.27 1.21 1.29 1.39 1.13 1.41 1.55

Note: The gray boxes emphasize data entirely from the Commission’s chartered study period, fiscal years 2013–2018.
F-2

National Commission on Military Aviation Safety

Figure F-3: 

Class C Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army C Mishap 

Rate

7.17 7.70 8.30 4.63 7.22 8.04 5.11 4.98 6.68 6.37 7.81 8.59

Air Force C 

Mishap Rate

29.91 29.60 46.44 34.64 30.62 29.90 34.00 37.90 35.05 36.13 38.77 35.31

Navy C Mishap 

Rate

10.35 7.42 10.33 8.87 10.29 9.31 11.57 12.92 15.24 19.01 21.05 19.48

Marine Corps C 

Mishap Rate

5.83 9.96 11.28 12.57 9.83 9.38 14.51 16.69 19.32 22.46 26.80 25.75

All DoD C 

Mishap Rate

18.07 17.41 25.63 19.32 18.24 18.16 19.79 22.00 22.86 24.40 26.66 24.85

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.

Figure F-2: 

Class B Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army B 

Mishap Rate 1.19 1.30 2.01 1.04 1.18 1.27 0.81 0.68 1.67 1.27 0.69 1.07

Air Force B 

Mishap Rate 4.56 5.65 7.32 2.19 3.55 2.02 2.58 3.18 2.50 2.95 2.41 2.11

Navy B 

Mishap Rate 3.13 3.50 3.03 1.62 1.75 2.30 2.12 1.54 2.09 2.43 3.33 3.49

Marine Corps B

Mishap Rate 2.92 2.57 6.15 3.06 1.90 3.35 2.23 2.66 2.88 2.54 3.03 3.32

All DoD B 

Mishap Rate 3.26 3.77 4.84 1.81 2.38 1.97 1.96 2.11 2.24 2.42 2.25 2.27

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018. 
F-3

Appendix F: Technical Appendix

Figure F-4: 

Class A–C Mishap Rates

FISCAL YEAR 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Army A-C 

Mishap Rate 10.83 10.54 12.32 7.50 9.58 10.92 6.81 7.22 9.80 8.56 9.53 10.98

Air Force A-C 

Mishap Rate 35.94 36.64 55.03 37.70 35.03 32.96 37.79 41.79 38.71 40.04 42.22 38.99

Navy A-C 

Mishap Rate 14.56 12.62 14.71 11.26 13.07 12.59 14.75 16.24 18.61 22.38 25.93 24.42

Marine 

Corps A-C 

Mishap Rate

11.37 14.78 19.14 17.33 15.54 15.08 19.73 21.62 25.48 28.81 35.02 31.56

All DoD A-C 

Mishap Rate 23.07 22.73 31.98 22.30 21.82 21.40 22.96 25.39 26.49 27.94 30.32 28.66

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018.
F-4

National Commission on Military Aviation Safety

Fatalities and Destroyed Aircraft

The Commission looked for a fuller understanding of 

the relationship between fatalities and destroyed aircraft 

and how that distinguished and characterized the types 

of Class A mishaps the Services were experiencing during 

the two comparison periods (Figure F-5). For example, 

higher numbers of fatalities and fewer destroyed aircraft 

indicate one or more mishaps with additional personnel 

on board. 

The Commission compared the numbers of fatalities, 

destroyed aircraft, and also calculated the number of 

fatalities per destroyed aircraft to better understand the 

relationship and how it changed over time. The Army 

and Navy decreased their ratio of fatalities per destroyed 

aircraft during the fiscal years 2013–2018 period. The Air 

Force saw a significant increase, the Marine Corps a slight 

increase.

Figure F-5: 

Fatalities and Destroyed Aircraft by Service for Fiscal Years 2007–2018

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2007-

2012

2013-

2018

Army Fatalities 39 17 9 27 15 12 8 6 14 8 10 6 119 52

Air Force Fatalities 2 13 6 9 2 9 11 10 5 16 5 19 41 66

Navy Fatalities 14 6 7 8 2 2 5 4 0 1 1 9 39 20

Marine Corps Fatalities 9 0 7 13 7 17 0 2 19 14 20 5 53 60

All DoD Fatalities 64 36 29 57 26 40 24 22 38 39 36 39 252 198

Army Destroyed Aircraft 18 10 10 16 9 10 6 9 6 4 6 5 73 36

Air Force Destroyed 

Aircraft 14 15 8 7 8 10 14 2 7 9 7 10 62 49

Navy Destroyed Aircraft 8 13 5 7 5 8 4 11 6 7 4 3 46 35

Marine Corps Destroyed 

Aircraft 8 5 3 5 6 6 6 5 5 8 10 3 33 37

All DoD Destroyed 

Aircraft 48 43 26 35 28 34 30 27 24 28 27 21 214 157

Army Fatalities/ 

Destroyed Aircraft 2.17 1.70 0.90 1.69 1.67 1.20 1.33 0.67 2.33 2.00 1.67 1.20 1.63 1.44

Air Force Fatalities/ 

Destroyed Aircraft 0.14 0.87 0.75 1.29 0.25 0.90 0.79 5.00 0.71 1.78 0.71 1.90 0.66 1.35

Navy Fatalities/ 

Destroyed Aircraft 1.75 0.46 1.40 1.14 0.40 0.25 1.25 0.36 0.00 0.14 0.00 3.00 0.85 0.54

Marine Corps Fatalities/ 

Destroyed Aircraft 1.13 0.00 2.33 2.60 1.17 2.83 0.00 0.40 3.80 1.75 2.10 1.67 1.61 1.65

All DoD Fatalities/ 

Destroyed Aircraft 1.33 0.84 1.12 1.63 0.93 1.18 0.80 0.81 1.58 1.39 1.33 1.86 1.18 1.26

Source: Force Risk Reduction database.

Note: The gray boxes emphasize data entirely from the Commission’s assigned study period, fiscal years 2013–2018. 
F-5

Appendix F: Technical Appendix

Changes in Mishap Classification Criteria

Starting in fiscal year 2010, DoD changed the aircraft 

damage criteria for classification to “account for 

inflationary growth in the cost of military systems [since 

1989] and the resulting cost for mishaps of similar 

severity” (Figure F-6). The Commission, however, did 

not adjust or reclassify mishaps across the years of its 

assessment, consistent with mishap rate analyses in 

academic literature. 

Figure F-6: 

Mishap Classification Criteria Changes per 

DODI 6055.07, Mishap Notification, Investigation, 

Reporting, and Record Keeping 

PRE-FY2010 MISHAP 

CLASSIFICATION CRITERIA1

POST-FY2010 MISHAP 

CLASSIFICATION 

CRITERIA2

Class A 

Aviation 

Mishap 

· at least $1 million in 

damage ; 

· death or permanent 

disability; 

· and/or aircraft destroyed 

· at least $2 million 

in damage ;

· death or permanent 

disability;

· and/or aircraft 

destroyed

Class B 

Aviation 

Mishap 

· total cost of reportable 

property damage is 

$200,000 or more, but less 

than $1,000,000;

· an injury and/or 

occupational illness results 

in permanent partial 

disability; and/or 

· when three or more 

personnel are inpatient 

hospitalized. 

· more than $500,000, 

but less than $2 

million, in damages, 

· three or more people 

hospitalized;

· and/or permanent 

partial disability

Class C 

Aviation 

Mishap 

· total cost of property 

damage is $20,000 

or more, but less than 

$200,000; or 

· a nonfatal illness or 

disability that causes loss of 

time from work or disability 

at any time 

· at least $50,000, but 

less than $500,000, 

· and/or nonfatal 

injuries that caused 

loss of one or more 

days from work not 

including the day or 

shift it occurred 

1

 Department of Defense, “Mishap Notification, Investigation, Reporting, and 

Record Keeping. Incorporating Change 1, April 24, 2008”; Department of 

Defense, “Mishap Notification, Investigation, Reporting, and Record Keeping.” 

2

 Department of Defense, “Mishap Notification, Investigation, Reporting, and 

Record Keeping. Incorporating Change 1, August 31, 2018.” 
F-6

National Commission on Military Aviation Safety

Additional HFACS Analysis

The Commission determined the most frequently applied 

Human Factors Analysis and Classification System 

(HFACS) applications for each mishap class and Service 

from fiscal years 2013 through 2018 in addition to the 

HFACS analysis provided in Chapter 3. The top 10 

results are provided in the figures below.

Class A

Figure F-7: 

Army Top 10 HFACS Applications in Class A Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS A 

APPLICATIONS

PC206 Overconfidence 33

PE102 Vision Restricted by 

Meteorological Conditions

28

PC208 Complacency 20

SI001 Supervisory/Command 

Oversight Inadequate

19

PP102 Cross-Monitoring 

Performance

17

PC504 Misperception of Changing 

Environment

16

PP106 Critical Information Not 

Communicated

16

AE103 Procedure Not Followed 

Correctly

13

AE105 Breakdown in Visual Scan 13

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle11

PC101 Not Paying Attention 11

Figure F-8: 

Air Force Top 10 HFACS Applications in Class A 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS A 

APPLICATIONS

No 

Data

No Data 470

AE103 Procedure Not Followed 

Correctly

49

PC208 Complacency 47

AE201 Inadequate Real-Time Risk 

Assessment

46

AE206 Wrong Choice of Action 

During an Operation

45

PC102 Fixation 37

PC504 Misperception of Changing 

Environment

36

PE101 Environmental Conditions 

Affecting Vision

34

OP003 Provided Inadequate 

Procedural Guidance or 

Publications

31

PP108 Failed to Effectively 

Communicate

29

PC110 Inaccurate Expectation 25
F-7

Appendix F: Technical Appendix

Figure F-9: 

Navy Top 10 HFACS Applications in Class A Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS A 

APPLICATIONS

AE103 Procedure Not Followed Correctly 44

AE201 Inadequate Real Time Risk 

Assessment

43

AE104 Over-Controlled/Under-Controlled 

Aircraft/Vehicle

23

AE206 Wrong Choice of Action During an 

Operation

17

AE202 Failure to Prioritize Tasks 

Adequately

16

AE102 Checklist Not Followed Correctly 13

AE105 Breakdown in Visual Scan 13

AE107 Rushed or Delayed a Necessary 

Action

11

AV002 Commits Widespread/Routine 

Violation

9

AV003 Extreme Violation/Lack of 

Discipline

7

Figure F-10: 

Marine Corps Top 10 HFACS Applications in Class A 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS A 

APPLICATIONS

AE201 Inadequate Real Time Risk 

Assessment

21

AE103 Procedure Not Followed 

Correctly

17

AE206 Wrong Choice of Action During 

an Operation

8

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle6

AE202 Failure to Prioritize Tasks 

Adequately

5

AE102 Checklist Not Followed Correctly 4

AE105 Breakdown in Visual Scan 4

AE107 Rushed or Delayed a Necessary 

Action

3

AE205 Ignored a Caution/Warning 3

AV002 Commits Widespread/Routine 

Violation

2
F-8

National Commission on Military Aviation Safety

Class B

Figure F-11: 

Army Top 10 HFACS Applications in Class B Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS B 

APPLICATIONS

PC206 Overconfidence 21

PE102 Vision Restricted by 

Meteorological Conditions

13

PC208 Complacency 12

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle10

PP102 Cross-Monitoring Performance 10

AE103 Procedure Not Followed 

Correctly

8

PC504 Misperception of Changing 

Environment

8

PP106 Critical Information Not 

Communicated

8

PC101 Not Paying Attention 4

SI001 Supervisory/Command 

Oversight Inadequate

4

Figure F-12: 

Air Force Top 10 HFACS Applications in Class B 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS B 

APPLICATIONS

No 

Data

No Data 468

AE103 Procedure Not Followed 

Correctly

64

PC208 Complacency 53

OP003 Provided Inadequate 

Procedural Guidance or 

Publications

42

AE201 Inadequate Real-Time Risk 

Assessment

31

PC101 Not Paying Attention 30

OP007 Purchasing or Providing Poorly 

Designed or Unsuitable 

Equipment

26

PC206 Overconfidence 18

PC504 Misperception of Changing 

Environment

18

PC109 Technical or Procedural 

Knowledge Not Retained after 

Training

17

PC110 Inaccurate Expectation 17

PP108 Failed to Effectively 

Communicate

17
F-9

Appendix F: Technical Appendix

Figure F-13: 

Navy Top 10 HFACS Applications in Class B Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS B 

APPLICATIONS

AE103 Procedure Not Followed 

Correctly

62

AE201 Inadequate Real Time Risk 

Assessment

51

AE206 Wrong Choice of Action During 

an Operation

22

AE107 Rushed or Delayed a 

Necessary Action

16

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle15

AE102 Checklist Not Followed 

Correctly

11

AE105 Breakdown in Visual Scan 11

AE202 Failure to Prioritize Tasks 

Adequately

8

AE300 Perception Error 8

AV003 Extreme Violation/Lack of 

Discipline

7

Figure F-14: 

Marine Corps Top 10 HFACS Applications in Class B 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS B 

APPLICATIONS

AE103 Procedure Not Followed 

Correctly

14

AE201 Inadequate Real Time Risk 

Assessment

6

AE202 Failure to Prioritize Tasks 

Adequately

3

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle2

AE105 Breakdown in Visual Scan 2

AE206 Wrong Choice of Action During 

an Operation

2

AV001 Performs Work-Around Violation 2

AE102 Checklist Not Followed 

Correctly

1

AE107 Rushed or Delayed a 

Necessary Action

1

AE301 Error due to Misperception 1

AV003 Extreme Violation/Lack of 

Discipline

1
F-10

National Commission on Military Aviation Safety

Class C

Figure F-15: 

Army Top 10 HFACS Applications in Class C Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS C 

APPLICATIONS

PC206 Overconfidence 97

PC208 Complacency 76

PC101 Not Paying Attention 61

PP106 Critical Information Not 

Communicated

48

PP102 Cross-Monitoring Performance 44

PC504 Misperception of Changing 

Environment

43

AE103 Procedure Not Followed 

Correctly

42

PE102 Vision Restricted by 

Meteorological Conditions

40

AE105 Breakdown in Visual Scan 38

AE102 Checklist Not Followed 

Correctly

24

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle24

Figure F-16: 

Air Force Top 10 HFACS Applications in Class C 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS C 

APPLICATIONS

No Data No Data 2201

PC101 Not Paying Attention 374

AE201 Inadequate Real-Time Risk 

Assessment

371

AE103 Procedure Not Followed 

Correctly

291

AE206 Wrong Choice of Action During 

an Operation

259

PC208 Complacency 171

PC102 Fixation 143

AE107 Rushed or Delayed a 

Necessary Action

138

PP108 Failed to Effectively 

Communicate

129

PC504 Misperception of Changing 

Environment

113

AE105 Breakdown in Visual Scan 111
F-11

Appendix F: Technical Appendix

Figure F-17: 

Navy Top 10 HFACS Applications in Class C Mishaps 

for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS C 

APPLICATIONS

AE103 Procedure Not Followed 

Correctly

285

AE201 Inadequate Real Time Risk 

Assessment

225

AE206 Wrong Choice of Action During 

an Operation

112

AE105 Breakdown in Visual Scan 81

AE107 Rushed or Delayed a 

Necessary Action

66

AE202 Failure to Prioritize Tasks 

Adequately

61

AE102 Checklist Not Followed 

Correctly

60

AE104 Over-Controlled/UnderControlled Aircraft/Vehicle53

AE101 Unintended Operation of 

Equipment

52

AV001 Performs Work-Around Violation 26

Figure F-18: 

Marine Corps Top 10 HFACS Applications in Class C 

Mishaps for Fiscal Years 2013–2018

TITLE 

CODE

CODE TITLE CLASS C 

APPLICATIONS

AE103 Procedure Not Followed 

Correctly

78

AE201 Inadequate Real Time Risk 

Assessment

76

AE206 Wrong Choice of Action 

During an Operation

36

AE102 Checklist Not Followed 

Correctly

27

AE107 Rushed or Delayed a 

Necessary Action

18

AE202 Failure to Prioritize Tasks 

Adequately

15

AV001 Performs Work-Around 

Violation

15

AE105 Breakdown in Visual Scan 13

AE205 Ignored a Caution/Warning 11
F-12

National Commission on Military Aviation Safety
G-1

Department of Defense Directive (DoDD) 4715.1E, 

March 18, 2005, Updated December 30, 2019, 

Environment, Safety, and Occupational Health. This 

directive establishes policies on environment, safety, and 

occupational health to sustain and improve the DoD 

mission. This directive also establishes the Defense Safety 

Oversight Council (DSOC) and its structure. 

Department of Defense Instruction (DoDI) 6055.07, 

June 6, 2011, Mishap Notification, Investigation, 

Reporting, and Record Keeping. This instruction 

provides guidance collecting, aggregating, and analyzing 

military aviation mishaps. This instruction updates 

procedures for mishap notification, investigation, 

reporting, and record keeping. It also establishes the DoD 

Mishap Data Requirements Working Group. 

DoDI 6055.19, April 11, 2017, Aviation Hazard 

Identification and Risk Assessment Programs. This 

instruction establishes policy, assigns responsibilities, 

and provides direction for developing and implementing 

safety management systems around military flight 

operations quality assurance (MFOQA), Aviation Safety 

Action Program (ASAP), and line operations safety audit 

(LOSA). This instruction highlights quantitative and 

qualitative data collection in mitigating aviation risks.

Memorandum of Understanding (MOU) between the 

Office of the Under Secretary of Defense Personnel 

and Readiness, Personnel Risk and Resiliency, 

and Commander, U.S. Army Combat Readiness 

Center; Commander, U.S. Naval Safety Center; and 

Commander, U.S. Air Force Safety Center, August 7, 

2017, Department of Defense Safety and Occupational 

Health Data Sharing. This MOU is intended to describe 

standard practices and procedures for collecting mishap 

data. Notably, this MOU identifies 57 aviation mishap 

data elements that would be collected and shared. 

Department of Defense Human Factors Analysis 

and Classification System Guidance, May 10, 2005, 

updated 2014. Human factors describe how human 

interaction with tools, tasks, working environments, and 

other people influence human performance. Human 

factors are the leading cause of DoD mishaps. The 

Human Factors Analysis and Classification System 

guidance, initiated by Interservice MOU Policy on the 

Collection and Analysis of Mishap Human Factors Data and 

finalized by the DSOC Human Factors Working Group, 

explains how DoD mishap investigators and analysts 

can use a common human error category system to 

investigate, report, and analyze DoD mishaps. The DoD 

HFACS model presents a systematic, multidimensional 

approach to error analysis and mishap prevention. It is 

designed for use by all members of an investigation board 

in order to accurately capture and re-create the complex 

layers of human error in context with the individual, 

environment, team, and mishap or event. 

Appendix G: 

KEY MILITARY AVIATION 

SAFETY POLICY GUIDANCE
G-2

National Commission on Military Aviation Safety

Key Service Aviation Safety Directives 

Army

AR 385-10, Army Safety Program, November 27, 2013. 

AR 385–95 Army Aviation Accident Prevention, 

February 24, 2010

AR 70–62 Airworthiness Qualification of Army Aircraft 

Systems, July 7, 2000

AR 385–42 Investigation of NATO Nation Aircraft or 

Missile Accidents and Incidents, May 15, 1980

DA PAM 385-40, Army Accident Investigations and 

Reporting, March 18, 2015.

Marines

MCO 5100.29C: Marine Corps Safety Management 

System, October 19, 2020

MARADMIN 202/19, Marine Corps Aviation Safety 

Awareness Program, March 28, 2019

Navy

OPNAVINST 3750.6S, Naval Aviation Safety 

Management System, May 13, 2014.

OPNAVINST 5100.19E Navy Safety and Occupational 

Health Program Manual for Forces Afloat, May 30, 

2007.

OPNAVINST/MCO 5102.1 D Navy and Marine Corps 

Mishap and Safety Investigation, Reporting, and Record 

Keeping, January 7, 2005.

Air Force

AFI 91-202, Air Force Mishap Prevention Program, May 

25, 2017, updated March 12, 2020

AFI 91-204, Safety Investigations and Hazard Reporting, 

April 27, 2018

AFI 91-207, The Air Force Traffic Safety Program, July 

26, 2019

AFI 62-601, Air Force Airworthiness, June 11, 2010 

AFI 63-101/20-101, Integrated Life Cycle Management, 

May 9, 2017

AFMAN 91-223, Aviation Safety Investigations and 

Reports, September 14, 2018

Joint Directives 

MIL-STD-882E, Department of Defense Standard 

Practice for System Safety, May 11, 2012

NATO STANAG 3101, Exchange of Flight Safety 

Information, November 3, 2016 

NATO STANAG 3102, Flight Safety Cooperation in 

Common Ground/Air Space, March 27, 2007
G-3

Appendix G: Key Military Aviation Safety Policy Guidance

Safety Management Systems 

MFOQA

The military operations quality assurance program 

involves collecting raw recorded flight data that is 

processed to identify potential safety concerns within an 

aircraft or fleet of aircraft. Consistent data collection can 

assist an aviation group in identifying risk trends before a 

mishap. It can also be used for mishap investigation. 

ASAP

The aviation safety action program is a voluntary, 

individual reporting program used to detect safety 

hazards in flight and maintenance operations before 

a problem causes a mishap. The Federal Aviation 

Administration describes the focus of ASAP as 

encouraging voluntary reporting of safety issues and 

events that come to the attention of aircrews and 

maintenance personnel. ASAP programs share aviation 

hazards information across multiple communities, often 

displaying the report narrative, recommended actions, 

and resolutions. 

LOSA

Line operations safety audits were developed to analyze 

aircrew behavior in real time, providing the qualitative 

data of human perspective. All LOSA programs are 

designed to identify errors and measures for mitigating 

those errors as well as other hazards and threats. This 

proactive formal process uses trained observers collecting 

safety-related data on environmental conditions, 

operational complexity, and human performance on 

the flight deck. It is an ideal way to identify threats and 

understand flight crew responses, revealing how crews 

manage errors and undesired states. Notably, LOSA is 

confidential and nonpunitive and is not a compliance 

audit, a key to a proactive safety program. 

SOQA

Simulator operational quality assurance is a 

relatively new aviation data collection program using 

flight simulator-based data. Simulators can provide 

opportunities for gathering data on pilot performance, 

especially in abnormal conditions and emergency 

procedures. Using SOQA to record all simulator data 

and using artificial intelligence to sort through that data 

improves aviation safety via predictive analysis. This data 

can be correlated to the weapon system or associated with 

a single pilot over the course of his or her flying career. 
G-4

National Commission on Military Aviation Safety
H-1

Sec. __ _ Establishment of Joint Safety Council

Chapter 7 of Title 10 is amended by adding a new section immediately following section 183a as follows:

“Section 184 Joint Safety Council

(a) In general. There is established, within the Office of the Deputy Secretary of Defense, a Joint Safety Council (in this 

section referred to as the “Council”).

(b) Composition; Appointment; Compensation.

(1) The Council shall be composed of voting members as follows:

(A) the Director of Safety for the Department of the Army, appointed by the Secretary of the Army;

(B) the Director of Safety for the Department of the Air Force, appointed by the Secretary of the Air Force;

(C) the Director of Safety for the Department of the Navy, appointed by the Secretary of the Navy;

(D) a member of the Senior Executive Service, appointed by the Deputy Secretary of Defense; and

(E) one member from each military service, appointed by the Secretary concerned.

(2) Qualifications; Removal; Replacement.

(A) The Director of Safety for each military department shall be a uniformed officer in the grade of O-8. 

(B) The person appointed under paragraph (1)(D) shall be a career member of the Senior Executive Service with a 

history of successfully running programs within the Department of Defense. 

(C) Members of the Council serve at the will of the official who appointed them.

(D) Vacancies on the Council shall be filled in the same manner as the original appointment.

(3) Compensation. Members of the Council shall serve without compensation in addition to that received for their 

services as officers or employees of the United States.

(c) Chair and Vice Chair. 

(1) Chair. The Secretary of Defense, or his designee, shall select one of the uniformed members of the Council to serve 

as Chair. Unless earlier removed, the Chair shall serve for a term of two years. The Chair shall serve as the Director 

of Aviation Safety for the Department of Defense.

(2) Vice Chair. The Vice Chair shall be the person appointed under subsection (b)(1)(D). The Vice Chair shall report 

to the Chair and shall serve as Chair in his or her absence.

Appendix H: 

JOINT SAFETY COUNCIL 

PROPOSED LEGISLATION
H-2

National Commission on Military Aviation Safety

(d) Staff.

(1) Permanent Staff. The Council may appoint staff in accordance with 5 U.S.C. § 3101. 

(2) Detailees. The Council may accept persons on detail from within the Department of Defense and from other 

Federal departments or agencies on a reimbursable or non-reimbursable basis.

(e) Contract Authority.—The Council may enter into contracts for the acquisition of administrative supplies, equipment, 

and personnel services for use by the Council, to the extent that funds are available for such purposes. 

(f) Procurement of temporary and intermittent services.—The Chair may procure temporary and intermittent services under 

section 3109(b) of title 5, United States Code, at rates for individuals which do not exceed the daily equivalent of the 

annual rate of basic pay prescribed for level V of the Executive Schedule under section 5316 of such title. 

(g) Data Collection. 

(1) Under regulations issued by the Secretary of Defense, the Council shall have access to Department of Defense 

databases necessary to complete its duties and responsibilities.

(2) Under regulations issued by the Secretary of Defense, the Council may enter into agreements with the Federal 

Aviation Administration, the National Transportation Safety Board, and any other federal agency regarding the 

sharing of aviation safety data.

(3) Except as the Secretary of Defense may choose to provide, and notwithstanding any other provision of law, data 

collected by the Council under this subsection shall be privileged from disclosure or discovery to any person.

(h) Meetings.—The Council shall meet quarterly and at the call of the Chair.

(i) Duties.—The duties and responsibilities of the Council are as follows:

(1) Subject to subsection (j), be responsible for issuing, publishing, and updating regulations related to military 

aviation safety, to include regulations on the reporting and investigation of aviation mishaps.

(2) Mishap Data. The Council shall – 

(A) establish uniform data collection standards for aviation mishaps in the Department of Defense;

(B) review the compliance of each military service in adopting and using the uniform data collection standards 

required under subparagraph (A);

(C) review aviation mishap data to assess, identify, and prioritize risk mitigation efforts in military aviation.

(3) Non-Mishap Data. The Council shall – 

(A) establish standards and requirements for the collection of aircraft, simulator, airfield, and pilot data;

(B) establish requirements for each military service to collect and analyze the issuance of any waiver related to pilot 

qualifications or standards.

(4) Safety Management System. The Council shall – 

(A) establish, in consultation with the Federal Aviation Administration, a requirement for each military service to 

implement a safety management system;

(B) review for approval each military services’ safety management system proposal;

(C) review each military services’ implementation of a safety management system.

(5) Review and assess civil aviation safety programs and practices and determine their suitability for implementation in 

military aviation.

(j) Review. The decisions and recommendations of the Council are subject to review and approval by the Deputy Secretary 

of Defense. 
I-1

Appendix I: 

GLOSSARY AND 

ACRONYM LIST

Cannibalization: The extent to which mechanics and 

maintenance personnel remove serviceable parts, supplies, 

or equipment from one vehicle, vessel, or aircraft in 

order to render a different vehicle, vessel, or aircraft 

operational.

Class A: Any mishap with a fatality, permanent total 

disability, or aircraft destroyed. For fiscal years 2010–

2019, any mishap costing more than $2 million in total 

property damage was considered a Class A. For fiscal year 

2020, it was increased to any mishap costing more than 

$2.5 million.

Class B: Any mishap with a permanent partial disability 

or three or more persons hospitalized. For fiscal years 

2010–2019, any mishap costing between $500,000 and 

$2 million in total property damage was considered a 

Class B. For fiscal year 2020, it was increased to any 

mishap costing between $600,000 and $2.5 million.

Class C: Any mishap with a nonfatal injury resulting in 

loss of time from work beyond the day or shift when the 

injury occurred. For fiscal years 2010–2019, any mishap 

costing between $50,000 and $500,000 in total property 

damage was considered a Class C. For fiscal year 2020, 

it was increased to any mishap costing between $60,000 

and $600,000.

G-suit: A garment with pressurized pouches that are 

inflatable with air or fluid, worn by fighter pilots and 

astronauts to enable them to withstand high forces of 

acceleration

Mishap: An unplanned event or series of events that 

results in damage to DoD property; occupational illness 

to DoD personnel; injury to on- or off-duty DoD 

military personnel; injury to on-duty DoD civilian 

personnel; or damage to public or private property, or 

injury or illness to non-DoD personnel, caused by DoD 

activities.

Study period: Fiscal years 2013 through 2018, the 

Commission’s assigned period to assess military aviation 

mishap rates and compare them to historic rates.
I-2

National Commission on Military Aviation Safety

Acronyms

AFB Air Force base

AI artificial intelligence

AoA analysis of alternatives

AR augmented reality

ASAIS Aviation Safety Information Analysis 

and Sharing

ASAP aviation safety action program

Auto-GCAS Automatic Ground Collision Avoidance 

system

CAST Commercial Aviation Safety Team

CDD capability development document

CFIT controlled flight into terrain

CNA Center for Naval Analyses

CO2 carbon dioxide

CPD capability production document

CR continuing resolution

CVFDR cockpit voice and image flight data 

recorders

DoD Department of Defense

DODI Department of Defense Instruction

DOTMLPF doctrine, organization, training, 

materiel, leadership and education, 

personnel, facilities

DSOC Defense Safety Oversight Council

FAA Federal Aviation Administration

FR2 Force Risk Reduction database

FRCSE Fleet Readiness Center Southeast

FRCSW Fleet Readiness Center Southwest 

FY fiscal year

GAO Government Accountability Office

HFACS Human Factors Analysis and 

Classification System

HSI human systems integration

ICD initial capabilities document

IDA Institute for Defense Analyses

IP instructor pilot

J8 Joint Staff Force Structure, Resources, 

and Assessment Directorate

JSC Joint Safety Council

KPP key performance parameter

LOSA line operations safety assessment

MCB Marine Corps base

MFOQA military flight operations quality 

assurance

MIL-STD military standard

NAS Naval air station

NASA National Aeronautics and Space 

Administration

NAVAIR Naval Air Systems Command

NCO noncommissioned officer

NDAA National Defense Authorization Act

O-8 eighth officer rank or grade, Major 

General or Rear Admiral (upper half) 

OBOGS onboard oxygen generation system

OJT on-the-job training

OPTEMPO operations tempo

PE physiological episode or event

PEAT Physiological Episodes Action Team

PERSTEMPO personnel tempo

PPE personal protective equipment

RAND RAND Corporation

SES Senior Executive Service

SOQA simulator operational quality assurance

TDY temporary duty

UPE unexplained physiological episode or 

event

VR virtual reality



NAT

OI

NAL

COMMISSION ON MILITARY AVIATIO

N

SAFETY

NCMAS