```
Military Training Deaths: Need to Ensure That Safety Lessons Are Learned
and Implemented (Letter Report, 05/05/94, GAO/NSIAD-94-82).

Not all training deaths are investigated by the military services, with
some fatalities attributed to natural causes even when training may have
been a factor.  Meanwhile, weaknesses in the services' controls for
investigating training fatalities increase the risk of biased
investigations and ignored recommendations. Current legal investigative
procedures do not guarantee that the officials who appoint the
investigators and the investigators themselves are independent of the
unit that experienced the mishap or that report recommendations are
monitored until resolution.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-94-82
     TITLE:  Military Training Deaths: Need to Ensure That Safety 
             Lessons Are Learned and Implemented
      DATE:  05/05/94
   SUBJECT:  Military training
             Safety regulation
             Investigations by federal agencies
             Accidents
             Occupational safety
             Accident prevention
             Internal controls
             Military personnel
             Safety standards
             Working conditions

             
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Cover
================================================================ COVER

Report to the Honorable
Dave Durenberger, U.S.  Senate

May 1994

MILITARY TRAINING DEATHS - NEED TO
ENSURE THAT SAFETY LESSONS ARE
LEARNED AND IMPLEMENTED

GAO/NSIAD-94-82

Military Training Deaths

Abbreviations
=============================================================== ABBREV

  DOD - Department of Defense
  NVG - night vision goggles

Letter
=============================================================== LETTER

B-255834

May 5, 1994

The Honorable Dave Durenberger
United States Senate

Dear Senator Durenberger: 

During peacetime, the military services train their personnel on an
ongoing basis in formal schools to develop their individual skills
and in unit operational exercises to maintain war-fighting readiness. 
Due to the combat missions of the military services, some of the
training includes phases and activities that pose risks to the safety
of both trainers and trainees and military personnel sometimes lose
their lives in training mishaps. 

We previously reported to you the numbers and types of fatalities
resulting from mishaps involving military training activities during
fiscal years 1988 to 1991.\1 At your request, we focused our present
effort on determining whether (1) all training-related deaths are
being identified and investigated, (2) the services' regulations and
procedures provide adequate independence of investigations, and (3)
the services have systems in place to ensure that corrective action
is taken where appropriate.  We did not attempt to assess the quality
of the specific investigations.  We also updated our information to
include fiscal year 1992 cases. 

--------------------
\1 Military Training:  DOD Training Fatalities for Fiscal Years 1988
to 1991 (GAO/NSIAD-92-213FS, July 22, 1992). 

   BACKGROUND
------------------------------------------------------------ Letter :1

In fiscal years 1989 through 1992, at least 700 uniformed personnel
lost their lives in accidents while engaged in training activities
such as swimming, parachuting, weapons training, and physical fitness
exercises.  The services consider deaths that occur during training
activities as "Class A"\2 accidents, which they classify as either
aviation or non-aviation\3 mishaps.  The Department of Defense (DOD)
requires the military services to investigate such fatal training
mishaps by conducting both a safety investigation (to identify the
causes and to help prevent recurrence) and a separate legal
investigation (primarily for use in litigation, claims, and
disciplinary or adverse administrative actions). 

We reviewed the safety and legal investigation files of a
non-projectable sample of 37 of the over 400 training fatality
mishaps that occurred in fiscal years 1989 to 1992.  These 37
mishaps--19 aviation and 18 non-aviation--involved 61 deaths.  A more
detailed description of our case selection process appears in the
scope and methodology section of this report. 

--------------------
\2 Class A mishaps are those where the cost of the reported damage is
at least $1 million; an aircraft, missile, or spacecraft is
destroyed; or an injury and/or occupational illness results in a
fatality or permanent disability. 

\3 The military services define "non-aviation" mishaps as those which
occur on the ground and do not directly involve damage or destruction
of aircraft or other specified items. 

   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

The military is not doing enough to ensure that safety lessons from
training-related deaths are learned and implemented.  The services
have not investigated all training-related deaths because (1) they
have characterized some training-related fatalities as attributable
to natural causes, even when training may have been a contributing
factor, and (2) even where natural causes are not a factor, they have
not always conducted both safety and legal investigations of fatal
aviation and non-aviation training mishaps. 

Controls to ensure the credibility of safety investigations and the
implementation of resulting recommendations generally appear to be
adequate.  However, weaknesses exist in the services' internal
controls for conducting legal investigations of fatal training
mishaps, thereby increasing the risk of biased investigations and
ineffective recommendation resolution.  Current legal investigative
procedures do not ensure that (1) the officials who appoint the
investigators and the investigators themselves are independent of the
unit that experienced the mishap or (2) report recommendations are
monitored until resolution. 

   INVESTIGATING FATALITIES
------------------------------------------------------------ Letter :3

Service regulations require each of the military services to conduct
a safety investigation of serious mishaps in order to improve safety
and reduce the risks of property damage, injuries, and deaths.  In
addition, each service conducts other investigations to determine
whether mishap deaths resulted from negligent or criminal activities. 

Each of the services has a central safety center\4 that establishes
and implements safety policies.  These safety centers monitor and
review investigation reports on fatal and other serious mishaps. 
They also follow up on report recommendations to ensure that they are
implemented.  In addition, the safety units enter relevant
information from the reports into their data banks to use in trend
analysis for identifying safety hazards and providing safety
statistics. 

Safety investigations result in one of two types of reports--limited
use and general use reports.  Limited use reports are restricted,
internal reports done for the sole purpose of preventing subsequent
mishaps.  This type of report is required on all aviation mishaps and
is authorized for use in certain other mishaps.  Witnesses may be
given a promise of confidentiality that protects them from having the
information they provide used against them for disciplinary purposes. 
If a pledge of confidentiality is given, DOD will resist efforts to
require disclosure of the information under the Freedom of
Information Act. 

General use reports, on the other hand, are prepared on all
reportable mishaps not covered by a limited use report.  Although the
primary purpose of this type of report is to prevent future mishaps,
its use for other purposes for reasons of economy is not specifically
prohibited.  Witnesses may be promised that their statements will not
be used against them for disciplinary purposes, but no promises are
made regarding exemption from Freedom of Information Act requests. 

The primary purpose of a legal investigation is to determine the
facts of the accident and to obtain and preserve available evidence
for claims, litigation, and disciplinary and administrative actions. 
Each of the services, with the exception of the Air Force, makes
recommendations in their legal investigation reports that are often
aimed at improving training safety.  For example, we examined a case
in which a Marine was shot and killed during a live-fire exercise. 
The legal investigation concluded that the accidental shooting of the
Marine would have been avoidable had personnel of the training unit
followed the safety procedures called for in specific service
regulations.  It recommended that Marine Corps orders and guidelines
be clarified and revised to include specific requirements to improve
safety during live-fire exercises. 

Lastly, according to service officials, criminal investigations are
conducted on all noncombat and non-aviation deaths that are
considered "medically unattended"\5 to determine if any criminal
misconduct was involved.  These investigation reports do not contain
any recommendations. 

--------------------
\4 These units are the Army Safety Center, Air Force Safety Agency,
Naval Safety Center, and Marine Corps Safety Office.  The Marine
Corps Safety Office monitors only those investigations involving
mishaps on the ground.  The Naval Safety Center monitors
investigations into Marine Corps aviation mishaps. 

\5 Service officials defined a medically unattended death as a death
that occurs outside a hospital or without a physician in attendance. 

   REQUIRED INVESTIGATIONS OF
   TRAINING-RELATED DEATHS NOT
   ALWAYS PERFORMED
------------------------------------------------------------ Letter :4

The military services did not perform all required investigations of
all training-related fatal mishaps.  Specifically, the services
classified a number of deaths as being due to natural causes
unrelated to the work environment, even though the deaths occurred
during or shortly after physical conditioning training.  Also, the
Navy, Marine Corps, and Air Force did not comply with DOD's policy
requiring both safety and legal investigations of all fatal
non-aviation training mishaps.  In addition, the Army was unable to
provide evidence that legal investigations were performed on some of
the aviation and non-aviation mishap fatalities in our sample. 

      SERVICES DO NOT IDENTIFY AND
      INVESTIGATE ALL
      TRAINING-RELATED DEATHS
---------------------------------------------------------- Letter :4.1

DOD and the services classify the deaths of service members in a
number of categories, such as hostile action, accident, and so forth. 
Only the Marine Corps has a "training-related death" category, and it
did not include all deaths we consider to be training-related. 
Therefore, we manually reviewed data obtained from DOD and the
services' casualty offices and safety centers to identify
training-related incidents.  With basic agreement from the Army and
the Navy surgeons general,\6 we developed and used the following
definition for "training-related" circumstances to extract
information from the various databases: 

     A training-related death is one that results from a peacetime
     military exercise or training activity that is designed to
     develop a military member's physical ability, maintain or
     increase individual or collective tactical skills, or maintain
     or increase a member's proficiency in a specific activity or
     environment.  This includes deaths that occur after the training
     event but where the exercise or activity could be a contributing
     factor. 

Our analysis revealed that six deaths categorized by the services as
resulting from natural causes occurred under circumstances that could
be related to training activities.  These were primarily cardiac
arrests that occurred during or shortly after the service members had
performed required physical training exercises.  A typical example of
these was a Marine who died from cardiac arrest after completing a
required physical fitness regimen.  Although he had just completed 5
pull-ups, 80 sit-ups, and a 3-mile run, his death was not considered
to be a training death, but rather was classified as a natural cause
death. 

DOD Instruction 6055.7, governing mishap investigation and reporting,
does not require deaths from "natural causes unrelated to the work
environment" (emphasis added) to be investigated as a mishap.  Since
the services are classifying these deaths as being due to natural
causes rather than training, they are not investigating them and,
consequently, are unable to make a definitive determination regarding
the impact of the work environment on the death. 

Officials in both the Army and the Navy surgeons general offices said
they believe that cardiac arrest cases should be treated as mishaps
and investigated to determine whether physical training was a
contributing cause.  This could allow the safety centers to identify
and monitor potentially dangerous physical training practices and
procedures so they can take appropriate actions where necessary. 
Also, the Marine Corps essentially adopted this policy in its 1993
version of its safety investigation regulation.\7

An example in our 1989 review of Navy training safety illustrates how
lessons learned from apparent natural cause deaths can be used to
improve safety.\8 We found that the Navy had identified a number of
cases of heat exhaustion deaths that were complicated by the
sickle-cell trait.  Navy officials told us that recognition of the
sickle-cell trait as an increased risk factor in heat injuries led
them to improve safety by routinely testing sailors for the
sickle-cell trait and requiring those who possessed the trait to wear
identifying armbands during physical fitness training so that their
condition could be monitored more closely. 

--------------------
\6 The Air Force Surgeon General's office did not concur with the
GAO-developed definition, but did agree with the goal of developing
such a definition. 

\7 Marine Corps Order P5102.1, "Marine Corps Ground Mishap
Reporting," March 3, 1993. 

\8 Navy Training:  Safety Has Been Improved, but More Still Needs to
Be Done (GAO/NSIAD-89-119, Mar.  7, 1989). 

      REQUIRED SAFETY AND LEGAL
      INVESTIGATIONS OF FATAL
      AVIATION AND NON-AVIATION
      TRAINING MISHAPS NOT ALWAYS
      CONDUCTED
---------------------------------------------------------- Letter :4.2

Although required by DOD, the services had not conducted safety and
legal investigations of all 37 mishaps in our sample.  Aside from not
conducting safety investigations of any of the 6 deaths attributed to
natural causes, the services had conducted safety investigations of
only
9 of the other 12 fatal non-aviation training mishaps we reviewed. 
The Army and the Air Force conducted safety investigations on all
such mishaps--six Army and three Air Force.  The three mishaps for
which no safety investigations were conducted involved

  a Marine who was shot while training to maneuver with support fire
     from a rifle squad,

  a Marine who was left out in the desert following a field exercise,
     and

  a sailor who drowned in a pond during Emergency Service Team
     training. 

At the time the mishaps we reviewed occurred, Marine Corps
regulations did not incorporate the DOD requirement that safety
investigations be conducted for all fatal non-aviation training
mishaps.  The Marine Corps has since revised its regulations to
require investigations of such mishaps.  Although Navy regulations
required safety investigations of non-aviation deaths, Navy officials
acknowledged that they had not always been conducting these
investigations.  However, Navy officials told us that they are now
enforcing the requirement and that all future non-aviation deaths
should be subject to a safety investigation. 

Additionally, the services were not conducting legal investigations
of all aviation and non-aviation training fatalities at the time of
our review.  The services had conducted legal investigations of only
8 of the 12 non-aviation mishaps in our sample that were not
attributed to natural causes.  Three of the four non-aviation mishaps
that did not receive legal investigations were from the Air Force,
and one was from the Army.  The Air Force mishaps involved

  an Air National Guard driver who fell out of his vehicle and was
     run over during a training exercise,

  an airman who was shot in the back of the head on an Army firing
     range during an Air Force training exercise, and

  an Air Force security policewoman who was fatally injured by a
     grenade during a live-fire training exercise. 

The Army mishap involved a soldier who drowned when a boat
unexpectedly entered the water due to failed truck brakes. 

According to Air Force officials, they were not aware of DOD's
requirement and had not incorporated it into their regulations. 

Except for the Army, the services had conducted legal investigations
on all the aviation mishaps in our sample.  The Army did not have any
record of whether legal investigations were conducted on some of its
aviation training fatalities.  Army legal officials said they did not
know whether legal investigations were ever performed on these deaths
since such investigations are performed and retained at the local
installation level with no centralized reporting. 

The Army was unable to produce legal investigation reports on three
of its four aviation mishaps in our sample.  All three mishaps
involved the use of night vision goggles (NVG).  The mishaps involved

  an OH-58 helicopter that hit a power line during NVG flight;

  a UH-1 helicopter in a NVG-related, mid-air collision; and

  an OH-58C helicopter that crashed during a low-level NVG training
     mission. 

Army officials cited the fact that one of the training mishaps
occurred in a combat zone (during Operation Desert Shield) as a
possible reason it did not conduct a legal investigation.  However,
Army regulations governing legal investigations do not cite combat
zone location as an exemption to the requirement to conduct a legal
investigation. 

   INTERNAL CONTROLS IN
   INVESTIGATIVE PROCESSES
------------------------------------------------------------ Letter :5

We identified minimal criteria that should be met to provide adequate
assurance that the findings of the various investigations will be
credible and useful in reducing the likelihood of future mishaps. 
The criteria we used to assess the investigative processes are (1)
the existence of procedures to either ensure the independence of the
convening authority and the senior investigative member from the unit
that experienced the mishap or provide a reviewing authority outside
the mishap unit's chain of command and (2) the existence of a system
to monitor the implementation of recommendations. 

      SAFETY INVESTIGATION
      CONTROLS APPEAR ADEQUATE
---------------------------------------------------------- Letter :5.1

With regard to safety investigations, service procedures generally
provide reasonable assurance of credible investigations and effective
tracking of recommendations. 

In the Army and the Marine Corps, the commander of the unit in which
the fatal mishap occurred initiates the safety investigation.  In the
Air Force, the commander of the Numbered Air Force or major command
to which the mishap unit belongs initiates the safety investigation. 
In the Navy, safety investigations are initiated by standing aircraft
mishap boards (for aviation-related mishaps) or by the immediate
superior of the mishap unit commander (for non-aviation fatalities). 
In each of the services, depending upon the complexity of the mishap,
an officer or board of officers may be appointed to conduct the
investigation.  A safety investigation board is generally headed by a
senior officer and consists of at least one safety, investigative,
and technical expert.  The services' regulations require the
investigating officer to submit a report upon the completion of the
investigation to the commander.  A copy of the investigative report
also goes to the service's central safety center.  Although the
convening authority and the senior investigative member are typically
from the mishap unit, the independent review by the central safety
center provides a reasonable check on the credibility of
investigations. 

With the exception of the Army Safety Center, central safety center
personnel generally do not conduct safety investigations themselves. 
The Army Safety Center conducts investigations of major mishaps
involving fatalities and extensive equipment damage.  All of the
services' safety centers may provide assistance to unit investigators
as requested. 

The safety centers in each service track the systemic recommendations
made in safety investigations.  The Army Safety Center, however, does
not track unit-specific recommendations.  According to Army Safety
Center officials, they do not track unit level recommendations
because doing so would exceed the center's scope of responsibility. 
Army Safety Center officials believe it is the responsibility of the
unit and the major command to track unit level recommendations since
those are the organizations affected. 

      LEGAL INVESTIGATION CONTROLS
      ARE WEAK
---------------------------------------------------------- Letter :5.2

The services do not have adequate procedures to ensure that legal
investigations of training mishaps are not compromised by lack of
independence and that recommendations are monitored until corrective
action is complete.  Our review of the 27 legal investigation reports
that had been conducted revealed that in most of the cases the
officials involved in the investigation were from the same unit that
experienced the mishap.  Also, there was no evidence that recommended
corrective actions had been monitored until resolution. 

         THE SERVICES DO NOT HAVE
         PROCEDURES TO ENSURE THE
         INDEPENDENCE OF LEGAL
         INVESTIGATIONS
-------------------------------------------------------- Letter :5.2.1

DOD Instruction 6055.7 recognizes that the independence of the
investigators is important to ensuring that conclusions and
recommendations will be impartial and credible.  It requires that
investigations be conducted by a "disinterested third party whenever
possible." However, DOD and service regulations and procedures do not
require that those who appoint investigators and those who conduct
the investigations be independent of the unit being investigated. 
Also, there is no provision for a review authority from outside the
mishap unit's chain of command. 

For the 27 legal investigation reports we reviewed, the appointing
officials were independent of the unit under investigation in only 12
cases (44 percent) and the investigators were from independent
organizations in only 11 cases (41 percent).  In one of the cases we
reviewed, the Marine Corps Commandant concluded that "when a Marine
is killed or injured while training, .  .  .  it should .  .  .  be
obvious that the investigating officer cannot be a member of the
organization being investigated nor should he be appointed by its
commander." As a result, the Marine Corps conducted a second
investigation. 

         SERVICES LACK SYSTEMS TO
         TRACK RECOMMENDATIONS
         MADE IN LEGAL
         INVESTIGATIONS
-------------------------------------------------------- Letter :5.2.2

Despite DOD's requirement that the services establish a system to
identify problem areas and ensure that corrective actions are
monitored until completion, none of the services has a system for
capturing and monitoring recommendations made in legal investigation
reports.  The
18 legal investigation reports we reviewed made a total of
120 recommendations.\10 Because there was no formal tracking
procedure, we could not determine whether all of these report
recommendations had been resolved.  Examples of these recommendations
are as follows: 

  Army officials investigating the rollover of a motor vehicle
     recommended a safety policy that all tracked vehicle crews be
     proficient in rollover drills. 

  Navy investigators who reviewed the premature detonation of a MK
     344 fuse during a training bombing run recommended that the use
     of the fuse in live weapons be discontinued and that the fuse be
     used only for training purposes in inert weapons. 

  Marine investigators who reviewed the death of an officer who was
     killed when the AV-8B aircraft he was flying crashed recommended
     that nighttime visual illusions be discussed at the next safety
     review. 

According to service officials, individual command units that
experience training mishaps are responsible for ensuring that
recommended corrective actions are acted upon.  We attempted to
contact officials at some of the units responsible for the
investigations to determine the status of the corrective actions. 
However, in most cases, the officials directly involved with the
mishap investigations had since left the units, and remaining
officials told us they had no formal procedure for either
implementing or monitoring corrective actions identified in legal
investigation reports.  Furthermore, none of the units maintained
records of whether appropriate actions were taken as a result of the
investigative recommendations. 

--------------------
\10 This does not include the nine legal investigations conducted by
the Air Force because its legal investigation reports do not contain
any recommendations. 

   RECOMMENDATIONS
------------------------------------------------------------ Letter :6

We recommend that the Secretary of Defense

  formally define what constitutes a "training-related" death and
     include in that definition deaths due to natural causes that
     occur during or shortly after a training activity;

  direct the services to amend their regulations to include the
     common definition for training-related death and require that
     all training-related deaths be investigated;

  direct the services to enforce DOD's requirement to conduct safety
     and legal investigations on all training-related deaths, both
     aviation and non-aviation;

  direct the services to ensure the independence of legal
     investigations by requiring that (1) the convening authority
     come from a higher level than the unit that experienced the
     mishap and (2) the senior investigative member also be
     independent of that unit; and

  direct the services to establish systems to track safety
     recommendations made in legal investigative reports to ensure
     that appropriate actions have been taken. 

   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :7

DOD reviewed a draft of this report and provided official comments,
the full text of which appears in appendix I.  DOD concurred that
some training fatalities that appeared to be the result of natural
causes should be treated as accidents and investigated.  DOD stated
that it would create a definition of "training-related" death and
include that definition in its update of DOD Instruction 6055.7,
"Mishap Investigation, Reporting, and Recordkeeping," which is
scheduled for issuance by the end of 1994. 

DOD disagreed with our conclusion that the services had not
investigated all training-related deaths.  DOD pointed out that the
deaths that received neither a safety nor a legal investigation were
classified by the services as "natural cause" deaths requiring no
investigation.  However, the regulation does not exempt all natural
cause deaths from the investigation requirement, but only deaths from
"natural causes unrelated to the work environment." We believe that
where death occurs during or shortly after physical training, the
services can not make a definitive determination ruling out a
relationship to the work environment without initiating an
investigation.  The Army and the Navy surgeons general agreed that
cardiac arrest deaths occuring during or shortly after a training
activity should be investigated to determine whether physical
training was a contributing cause. 

DOD disagreed with our recommendation aimed at ensuring the
independence of legal investigations.  DOD stated that it believes
its requirement for a "disinterested third party" and the review and
approval processes the services use ensure adequate independence. 
Since the commander of a unit that experienced a mishap would have a
natural interest in avoiding blame, we continue to believe that an
investigation conducted by a person reporting to the commander of
that unit would create at least the appearance of a conflict of
interest and the credibility of the findings would be open to
question. 

DOD acknowledged that at the time of our review, some legal
investigations were used as a substitute for safety investigations,
but stated that this practice no longer occurs.  DOD also indicated
that it believed we were misinterpreting the requirement for a legal
investigation as requiring a specific type of legal mishap
investigation that includes safety recommendations.  It said it uses
the term "legal investigation" somewhat generically to describe
actions taken to obtain and preserve available evidence for use in
litigation, claims, disciplinary action, or adverse administrative
actions. 

We have not taken the position that it is the role of legal
investigations to make safety recommendations.  However, we believe
that if the legal investigation report does make safety
recommendations, such recommendations should be monitored until they
are resolved.  It is possible that the legal investigation might
identify something that was overlooked by the safety investigation. 
For example, one of the mishaps in our sample involved the crash of a
Marine Corps helicopter during a night training mission at sea. 
Although the safety investigation report made no recommendations, the
legal investigation report did make some safety-related
recommendations.  It recommended that (1) the standard operating
procedures for shipboard operations concerning aircraft lighting be
modified to require anti-collision lights be turned on prior to
take-off and (2) that both voice and visual recording systems (Pilot
Landing Aid Television system and tower voice recorders) be installed
on all large amphibious (air capable) vessels.  We believe that the
services have an obligation to seriously consider safety-related
recommendations made in legal investigations and track them until
they have been resolved. 

   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :8

With the basic concurrence of the Army and the Navy surgeons general,
we developed a definition of what constitutes a training-related
death.  We used that definition to identify the number and types of
active duty training fatalities that occurred during fiscal years
1989 to 1992 from data provided by DOD's Directorate for Information
Operations and Reports and the military services' casualty offices
and safety centers.  We did not verify the accuracy of this data. 

We focused our review primarily on the services' legal and safety
investigations.  To evaluate the investigative processes, we reviewed
DOD and service regulations on legal and safety investigations, and
we interviewed responsible officials in each of the service safety
centers and investigative headquarters.  We analyzed the
investigations that were performed on 37 of over 400 training
fatality mishaps that occurred from fiscal years 1989 to 1992. 
Specifically, we determined whether

  they were done according to established criteria,

  the investigations were sufficiently independent from the mishap
     unit to produce credible results, and

  the investigation reports contained recommendations to improve
     training safety and whether such recommendations were
     implemented. 

We did not attempt to assess the quality of specific investigations. 

We divided our database of fatal training mishaps into aviation and
non-aviation because about half the mishaps occurred in each of those
areas.  We then drew our sample from these two databases, randomly
selecting one aviation and one non-aviation fatality from each
service for each fiscal year from 1989 to 1992 with the exception of
the Air Force, which reported only four non-aviation fatalities
during this time period, three of which occurred in 1 fiscal year. 
We judgmentally selected another five mishaps, which included (1) the
two cases that had triggered the request, (2) the other two Air Force
non-aviation mishaps that occurred during the review period, and (3)
one case that appeared similar to another mishap we were reviewing. 
The 37 mishaps accounted for a total of 61 fatalities. 

We analyzed DOD and service regulations, policies, inspection and
audit reports, data from casualty and safety center offices, and
various materials associated with military training, mishap
reporting, and death investigations.  We also interviewed key
officials of each of the services' training commands, legal
investigation commands, safety organizations, criminal investigation
commands, and surgeon general offices.  We visited some training
bases where we observed high-risk training in progress and
interviewed training supervisors, instructors, and students. 

We conducted our review from June 1992 to March 1994 in accordance
with generally accepted government auditing standards. 

---------------------------------------------------------- Letter :8.1

We are sending copies of this report to responsible congressional
committees, the Secretaries of Defense, the Army, the Navy, and the
Air Force, and the Commandant of the Marine Corps.  We will also make
copies available to others upon request. 

Please contact me at (202) 512-5140 if you or your staff have any
questions concerning this report.  Major contributors to this report
are listed in appendix II. 

Sincerely yours,

Mark E.  Gebicke
Director, Military Operations and
 Capabilities Issues

(See figure in printed edition.)Appendix I
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
============================================================== Letter 

(See figure in printed edition.)

(See figure in printed edition.)

Now on p.  1. 

See comment 1. 

(See figure in printed edition.)

Now on pp.  2-3. 

(See figure in printed edition.)

Now on pp.  4-5. 

(See figure in printed edition.)

See comment 2. 

(See figure in printed edition.)

Now on pp.  5-7. 

(See figure in printed edition.)

See comment 3. 

(See figure in printed edition.)

Now on pp.  8-9. 

(See figure in printed edition.)

Now on p.  9. 

(See figure in printed edition.)

Now on p.  10. 

Now on p.  10. 

Now on p.  10. 

(See figure in printed edition.)

Now on p.  10. 

Now on p.  10. 

The following are GAO's comments on the Department of Defense's
letter dated February 2, 1994. 

   GAO COMMENTS
------------------------------------------------------------ Letter :9

1.  We modified the text that now presents the official definition. 

2.  We modified the text to reflect the fact that while the surgeons
general from all three services agreed that a definition of
training-related death should be developed, the Air Force surgeon
general did not concur with the definition we used. 

3.  We explicitly stated that our sample was non-projectable.  We
have not subjected our sample cases to any statistical analyses that
could be affected by the way in which the cases were selected. 

MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II

   NATIONAL SECURITY AND
   INTERNATIONAL AFFAIRS DIVISION,
   WASHINGTON, D.C. 
-------------------------------------------------------- Appendix II:1

Norman J.  Rabkin, Associate Director
William E.  Beusse, Assistant Director

   ATLANTA REGIONAL OFFICE
-------------------------------------------------------- Appendix II:2

Alphonse Davis, Regional Management Representative
James H.  Woods, Evaluator-in-Charge
Jyoti Gupta, Site Senior
Amy S.  Parrish, Evaluator
Pamela A.  Scott, Reports Analyst

   DENVER REGIONAL OFFICE
-------------------------------------------------------- Appendix II:3

Robert E.  Kigerl, Regional Assignment Manager
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