Hearing Loss Prevention: Improvements to DOD Hearing Conservation Programs Could Lead to Better Outcomes
Published: 2011-01-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Exposure to hazardous noise can have negative implications for both servicemember health and readiness. Moreover, in fiscal year 2009, some of the most common impairments for veterans receiving Veterans Affairs (VA) disability benefits were hearing related, as annual payments for such conditions exceeded $1.1 billion. To examine Department of Defense (DOD) efforts to prevent hearing loss, GAO is reporting on (1) how well the DOD and armed services identify and mitigate hazardous noise; (2) how well the military evaluates hearing conservation program performance; and (3) the status of DOD's Hearing Center of Excellence and the extent that DOD and VA are sharing information to inform this and other efforts. GAO reviewed DOD and services' policies and guidance, reviewed DOD performance data, interviewed officials and servicemembers, and conducted site visits to nine military bases.
section_title: What GAO Found
paragraphs: Each of the armed services is taking steps to monitor hazardous noise, but inconsistencies in some hearing protection strategies and limited training weaken mitigation efforts. Services monitor noise periodically, depending on the level of risk servicemembers have in being exposed to hazardous noise (for example, annually for firing ranges and flight decks, and every 5 years for administrative offices). However, they lack a reliable system for detecting changes in noise levels that may occur outside the scheduled review cycle. Although DOD requires that noise be controlled by setting exposure limits and requiring the use of hearing protection, these strategies are not consistently used. For example, servicemembers told us that they do not always wear hearing protection, citing concerns with comfort and communication. Annual hearing-related training is required for at-risk servicemembers, but services are not able to fully determine who has completed annual training, and many servicemembers told GAO that training is not necessarily well timed. DOD's evaluation of services' hearing conservation programs has key weaknesses, but some services have taken steps to review and improve their own programs. First, DOD performance indicators are not sufficiently comprehensive. One key indicator--the rate of hearing loss among servicemembers in the hearing conservation programs--only measures program performance after hearing loss has occurred. Second, evaluation is limited by weaknesses in the processes used to capture, track, and use performance data. For example, the data may not accurately capture the number of servicemembers enrolled in the respective programs--a number required to calculate compliance rate. Third, audiologists, and other key stakeholders do not, on some bases GAO visited, routinely coordinate to share and evaluate hearing loss data to identify and mitigate noise hazards. Individual services have, at times, conducted reviews of their own programs and made some improvements. For example, once the Army decided that soldiers would not be deployed if the individual had not completed a required hearing test, the number of hearing tests rose significantly. DOD has developed, though not yet finalized, a plan for a Hearing Center of Excellence to improve hearing loss prevention and treatment as well as a plan for its registry to track and share information with VA on injured military personnel and veterans. Neither Congress nor the DOD set a date for when planning should be formally approved to implement the center, but a key DOD official estimated that plans may receive final DOD approval in the near future. In the meantime, an interim director for the center has begun to lay the groundwork for implementation of both the center and the registry. While data sharing between DOD and VA has been very limited to date, military and VA officials said the registry should ultimately facilitate sharing and development of best practices.
section_title: What GAO Recommends
paragraphs: GAO recommends that to improve hearing conservation programs, DOD should address issues with the type, timing, and tracking of training and education; develop an appropriate set of performance indicators; improve processes to collect and use performance data; and examine services' reviews to identify opportunities for program improvement. In reviewing a draft of this report, DOD concurred with GAO's recommendations. DOD and VA provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: Military service can expose soldiers to hazardous levels of noise, ranging  from gunfire to military aircraft, all of which can lead to a loss or damage  in hearing if protective equipment and measures to reduce exposure are  not employed in advance. Well before retirement, such damage can reduce  servicemembers’ ability to communicate and affect the quality of their  professional and personal lives. Moreover, it can create additional costs to  the government and taxpayers by decreasing troop readiness and  increasing the need for medical services and disability compensation. To  protect servicemembers’ hearing, the Department of Defense (DOD) and  the armed services have established hearing conservation policies and  programs. Nevertheless, U.S. Department of Veterans Affairs (VA) has  reported that tinnitus (ringing in the ears) and hearing loss remain some of  the most common service-connected disabilities. Approximately $1.1  billion in disability compensation was paid out for these two conditions in  fiscal year 2009.
Many have raised concerns about the need to protect servicemembers’  hearing, including DOD, VA, Congress, and national organizations  dedicated to protecting hearing. Such concern on hearing-related  disabilities prompted Congress in October 2008 to require that DOD  establish a center dedicated to the prevention and rehabilitation of  servicemembers and veterans with auditory disabilities. Congress has  mandated GAO to review DOD’s hearing protection efforts and report on  the status of the hearing center. Specifically, to respond to this mandate  and gain insight into DOD’s efforts to prevent hearing loss, we determined  (1) how well the DOD and armed services identify and mitigate hazardous  noise; (2) how well the military evaluates hearing conservation program  performance; and (3) the status of DOD’s Hearing Center of Excellence  and the extent to which DOD and VA are sharing information to inform  this undertaking and generally protect servicemembers. To address  objectives one and two, we reviewed DOD and armed services hearing  conservation policies and guidance, reviewed other federal agencies that  set standards and policy for hearing conservation, and interviewed  cognizant military officers from DOD, Army, Navy, Air Force, and Marines,  as well as stakeholders. We reviewed past evaluations of DOD hearing  conservation programs, including a study conducted by the Institute of  Medicine (IOM). We conducted site visits to nine military installations.  During these site visits, we interviewed senior officials, audiologists,  industrial hygienists, servicemembers, safety officers, and other officials  who assess, measure, and mitigate occupational health hazards. We  selected these site visits based on a number of factors, including the  military branch, size of the installation, presence of different types of  hazardous noise, and geographic location. To determine how DOD and the  armed services monitor program performance, we also interviewed  cognizant officials, reviewed hearing conservation performance measures  and program data and reviewed documentation for DOD’s Defense  Occupational and Environmental Health Readiness System (DOEHRS),  and analyzed key system reports for each of the armed services. To  address objective three, we interviewed the DOD Hearing Center of  Excellence program manager, the interim director of the Hearing Center of  Excellence, as well as representatives from the VA involved with the  center’s development.
We conducted our overall performance audit from November 2009 to  January 2011 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient and appropriate evidence to provide a reasonable basis  for our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives. For additional information  on our scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: Noise is one of the most common occupational health hazards faced by  military servicemembers. Servicemembers may be exposed to high- intensity noise of various types during their training and when performing  general job duties or combat operations. Without proper protection, this  exposure can cause or contribute to tinnitus and hearing loss. The effects  of tinnitus, a ringing in the ears significantly associated with unprotected  exposure to hazardous noise and noise-induced hearing loss, can range  from minor to debilitating and can be permanent. Noise-induced hearing  loss, and occasionally tinnitus, can be rehabilitated with a hearing aid, but  they are permanent disabilities.
After leaving the military, servicemembers who sustain tinnitus or hearing  loss during service may qualify for compensation from the VA. VA’s  disability compensation program compensates veterans for the average  loss in civilian earning capacity that results from injuries or diseases  incurred or aggravated during military service, regardless of current  employment status or income. In fiscal year 2009, VA compensated 1.2  million claims for veterans with either tinnitus or hearing loss injuries,  representing an annual federal expenditure exceeding $1.1 billion for  disability compensation payments. In 2005, auditory impairments, which  include hearing loss and tinnitus, became the most common service- connected disabilities compensated by VA. Since 2005, VA has reported  that the numbers of veterans who have begun receiving compensation  each year for these disabilities have continued to grow, contributing to  VA’s increasing annual expenditure on disability claims (see fig. 1).
Beyond the cash benefits VA provides to veterans with hearing-related  disabilities, there are other expenditures by both VA and DOD to  rehabilitate, treat, or correct auditory injuries. For example, VA purchased  almost 382,000 hearing assistive devices in fiscal year 2008, for an  expenditure of approximately $154 million.
Both noise-induced hearing loss and noise-induced tinnitus may be  avoided through auditory injury prevention, referred to as hearing  conservation. Due to the introduction of the jet engine to military  environments and the number of World War II veterans who sustained  hearing loss during combat, hearing conservation became a concern of the  armed services in the late 1940s. According to a recent IOM study, in 1948,  the armed services began developing hearing conservation programs and,  in 1978, DOD issued the first departmentwide hearing conservation  directive that provided guidelines to unify the implementation and goals of  hearing conservation programs (HCP) throughout the armed services.
According to DOD policy, the goal of hearing conservation is to protect all  servicemembers and other personnel from hearing loss resulting from  occupational noise exposure. The policy states that each armed service is  to implement a hearing conservation program, including the Air Force, the  Army, the Marine Corps, and the Navy, and that these programs are to be  implemented when personnel are exposed to a certain level of noise. All  the services have policies that include the enrollment of personnel  working in areas with noise at or above levels that can be hazardous when  performing their general job duties. Though military operations are not  subject to federal civilian health and safety regulations, DOD’s hearing  conservation instructions direct that the armed services’ HCPs comply  with federal standards whenever practicable.
DOD policy incorporates the following key elements into its hearing  conservation programs: noise hazard identification, safety signs and labels,  noise mitigation, education and training, audiometric surveillance, and  program evaluation (see table 1). Each armed service branch must submit  a written plan to DOD that outlines its program, including the strategies  for implementing these elements.
DOD instructions require services to reduce noise to safer levels, where  possible, using three strategies: engineering controls, hearing protection,  and administrative controls. DOD policy requires that engineering controls  be the primary means of eliminating exposure of personnel to potentially  hazardous noise. To implement engineering controls, services should  design their work environment to reduce noise below hazardous levels  and purchase equipment with the lower sound emissions. The use of  hearing protection is considered an interim measure, but if services  determine that engineering controls are not possible, DOD policy allows  them to use personal hearing protection as a permanent measure to  mitigate noise. Furthermore, if additional protection is needed,  administrative controls, such as modifying work schedules or procedures  should be used to limit exposure to hazardous noise.
In recent years, studies have addressed hearing loss and tinnitus in the  military. For example, in 2002, Congress directed that VA contract with the  National Academy of Sciences to conduct a study on noise exposure with  respect to hearing loss and tinnitus in the military. The National  Academies’ IOM study examined the sources of hazardous noise exposure  in the military, levels of noise exposure necessary to cause hearing loss or  tinnitus, the course of hearing loss following noise exposure, risk factors,  and compliance by the military services with requirements for audiometric  testing and the adequacy of their hearing conservation programs. The  study found that military hearing conservation programs were not  adequate to protect servicemembers’ hearing. This conclusion was  supported by findings that the annual audiometric testing of  servicemembers enrolled in hearing conservation programs showed that  10 percent to 18 percent had a significant shift in their threshold, which  was estimated to be two to five times higher than rates considered  appropriate in industrial hearing conservation programs. The study also  found that the military programs may not perform the required annual  audiometric testing on all servicemembers exposed to hazardous noise  and that overall testing was not sufficient to evaluate changes in hearing  associated with military service for the majority of servicemembers.  Furthermore, while information was limited, the study noted that a high  proportion of servicemembers (sometimes up to 50 percent in certain  situations) may not be wearing hearing protection when needed.
Additionally, in fiscal year 2008, the Marine Corps identified hearing loss  among personnel as a risk in its annual Risk and Opportunities  Assessment and, in following up, requested that the Naval Audit Service  (NAS) conduct a review of its hearing conservation program. The  objective of the NAS audit was to determine whether the management and  implementation of the Marine Corps HCP is effective in protecting  servicemembers’ hearing.
In response to serious auditory injuries incurred by servicemembers  associated with Operation Iraqi Freedom and Operation Enduring  Freedom, Congress mandated in October 2008 that DOD create a center of  excellence in the prevention, diagnosis, mitigation, treatment, and  rehabilitation of hearing loss and auditory system injury. A key  responsibility of the Hearing Center of Excellence is to create an  electronic registry that tracks the diagnosis, treatment, and follow-up for  each case of hearing loss and auditory system injury incurred by  servicemembers on active duty. The center is required to inform VA when  any of these servicemembers transition from the armed services to VA to  help ensure the coordination and provision of auditory system  rehabilitative services.
section_title: Services Are Employing Strategies to Identify and Mitigate Hazardous Noise, but Inconsistent Practices and Limited Training Weaken Their Efforts
subsections: section_title: Services Use a Risk-Based Approach to Monitor Sites for Hazardous Noise Levels, but Lack Reliable Notification for Interim Changes
paragraphs: According to services’ policies, the services monitor noise levels at various  sites on a periodic basis according to the level of risk these sites pose to  servicemembers, but they do not provide guidance for a reliable  notification system for changes to site conditions that may occur in the  interim. DOD policy specifically requires the services to measure noise  levels, and we found that hearing conservation personnel at each of the  sites we visited use noise surveys to assess the level at which specific  work and training areas are likely to expose servicemembers to hazardous  noise. At the sites we visited, such site noise is subsequently monitored  through periodic surveys, scheduled according to their respective level of  risk. For example, at sites we visited, high-risk areas, such as firing ranges  and flight decks, thought to pose the greatest chance of exposure to  hazardous noise are surveyed annually. Medium risk areas, such as flight  hangars and light industrial areas can be surveyed every 2 years; low-risk  areas, such as administrative offices, can be surveyed up to every 5 years,  depending on the service’s policy. For example, Navy officials told us they  conduct noise surveys every 4 years for their administrative offices,  whereas Army officials conduct them every 5 years.
According to the policies from most services, responsibility for measuring  and reporting noise levels is delegated to experts in noise abatement, such  as industrial hygienists, who employ a number of measuring devices, such  as sound level meters and noise dosimeters, to determine how loud the  noise is and how long servicemembers are exposed (see fig. 2 for  examples of measuring devices). At the sites we visited, the results of the  measurements were recorded on noise survey forms that were used as the  basis for reports that were sent to safety offices, individual military units,  work sites and base leadership, depending on local base procedures.
At the sites we visited, while the frequency at which the services monitor  site noise depended on an initial determination of the site’s risk level, it  did not appear that changes to a site that alter its noise levels are always  promptly and systematically reported. DOD policy requires that noise be  measured within 30 days of any change in operations affecting noise  levels; however, several noise abatement experts at the sites we visited  told us they are not always informed of changes in noise. Instead, they  more often encounter the changes in noise levels during a scheduled noise  survey. Some of these experts suggested that servicemembers could be  exposed to more hazardous noise levels for a prolonged period of time if  no one informs them of changes to noise levels between scheduled  surveys; some of which are conducted only once every several years.
section_title: Services Employ Strategies to Mitigate Noise, but Some Practices Are Inconsistent
paragraphs: In accordance with DOD policy for those in the hearing conservation  program, the services employ a number of strategies to control the amount  of exposure to hazardous noise. These strategies include engineering noise  to safer levels, setting time limits on noise exposure, and requiring the use  of protective equipment; however they are not consistently practiced.
subsections: section_title: Engineering Controls
paragraphs: Mitigating noise thorough engineering controls can be carried out by  improving noise reduction technology, building barriers to deflect noise,  and through procurement of quieter equipment and technology. Under  DOD policy, the services are required to use engineering controls as the  primary means of eliminating personnel exposure to potentially hazardous  noise. During our site visits, we observed examples of how the services  have implemented such controls. For example, at an Air Force base  maintenance shop we visited, we observed a “muff” being used to reduce  the noise for a newly acquired water drill. At a Navy base we visited, a  separate building was constructed apart from the maintenance shop to  house a loud piece of equipment to reduce servicemembers’ noise  exposure. Services are also required to review equipment being  considered for procurement to determine if they produce hazardous noise  and consider methods for limiting the noise when technologically and  economically feasible. In the Air Force, when designing weapons and  facilities such as firing ranges, procurement decisions are not made at the  base level, but are decided centrally by the Air Force Civil Engineering  Support Agency (AFCESA). AFCESA attempts to strike a balance between  operational effectiveness and worker protection when making  procurement decisions. During this decision-making process,  bioenvironmental engineers and other staff are involved in examining  safety, fire, and occupational health issues—including hazardous noise.  For example, AFCESA’s involvement in the procurement of the new F-22  fighter jet led to considerations in how bases could redesign hangars to  reduce the impact of noise from this plane. Officials from the Army Office  of the Surgeon General said noise abatement experts are usually included  in the procurement process for weapons systems, though not necessarily  for non-weapon system procurements. Also several Navy officers from the  Office of the Surgeon General told us the Navy has recently started to  include industrial hygienists in the procurement of weapon systems  though, to date, this has involved only one such procurement. Navy  officials also added they are attempting to update their own procurement  guidance to include noise abatement experts. However, at a number of  sites we visited, several noise abatement experts told us they are not  involved in the procurement process.
section_title: Setting Time Limits
paragraphs: In accordance with DOD policy, all the services have established guidance  detailing how long servicemembers can be exposed to certain hazardous  noise levels without the use of hearing protection—also known as  administrative controls. For example, the DOD allows servicemembers to  be exposed to 85 decibels of noise, a more stringent threshold than the  Occupational Safety and Health Administration (OSHA) considers  hazardous, for up to 8 hours without the use of hearing protection  equipment. However, according to a number of hearing conservation  personnel, controlling the amount of time that servicemembers are  exposed to noise is often more practical for military personnel who work  in civilian or industrial style, non-military operations. By comparison, for  servicemembers engaging in military operations, abiding by specific time  limits is more difficult because their duties may require them to stay at  their station beyond recommended limits. For example, hearing  conservation personnel aboard an aircraft carrier we visited told us that  personnel who work on the flight deck have flight operations lasting as  long as 16 hours. Reflecting a similar point, an audiologist told us that  controlling the amount of time Marines are exposed to hazardous noise in  battle is unrealistic, as Marines cannot stop fighting because they have  exceeded their allotted exposure time to noise.
section_title: Personal Protective Equipment
paragraphs: DOD policy requires servicemembers to wear personal protective  equipment, such as earplugs, when engineering controls are not sufficient  to reduce noise levels. Based on our interviews with servicemembers and  audiologists, we found that the services largely make such equipment  available. More specifically, some servicemembers at the sites we visited  told us they were able to obtain hearing protection primarily from their  units or from hearing testing centers and from work or training areas (see  fig. 3 for examples of hearing protection devices). However, according to  several hearing conservation personnel we spoke with, some of the  services do not have an up-to-date list of approved equipment that units  can choose from when purchasing hearing protection. They also said  purchasers have little to no experience with hearing protection and we  were told of a unit that, as a result, had purchased personal protective  equipment without determining whether it would be effective. Hearing  conservation personnel at one of the Army bases we visited recounted a  story where one unit deployed using untested hearing protection that was  later rejected. In addition, senior DOD officials also told us that some  servicemembers bought their own hearing protection equipment that was  below the required standards. Finally, we observed that servicemembers  themselves are not necessarily using equipment provided to them or are  not using the hearing protection equipment properly.
To assure that the correct personal protective equipment is used, DOD’s  policy requires that all hazardous noise areas and industrial and military  equipment have signs or labels that identify them as producing hazardous  noise. The signs and labels are also expected to communicate the level of  protective devices (i.e., single or double hearing protection) that should be  worn to prevent hearing loss while working in or around the hazardous  noise. However, at many of the sites we visited, we observed signs and  labels indicating hazardous noise equipment or areas, although not all of  the signs included the protective measures required. (See fig. 4 for an  example of a hazardous noise sign that does not include the level of  hearing protection needed.) In some limited instances, a sign was not  posted in an area that the safety officer guiding our walk-through noted  should have had proper signage.
Also, some of the servicemembers at the sites we visited maintained that  enforcement of the wearing of protective equipment is limited. These  servicemembers said their superiors did not consistently check for  equipment usage, and there is little to no discipline for members who are  not using them. Some services also placed the responsibility for reminding  their members about the importance of hearing protection with  servicemembers who are often of lower rank and thus lack the authority  to enforce adherence to the requirements. Army Hearing Program  personnel described to us a program that assigned specific soldiers to  disseminate information on hearing conservation issues and remind  individuals to wear hearing protection. However, according to some Army  Hearing Program staff these assigned soldiers were of low-rank with  limited authority to ensure their peers and superior officers were educated  on hearing conservation or wore appropriate hearing protective  equipment.
During our interviews with DOD officials and servicemembers, we heard  that in some cases, servicemembers do not wear required hearing  protection. During our site visits, many servicemembers expressed a  number of reasons why they chose not to wear the required hearing  protection. Some servicemembers said the protective equipment was  uncomfortable. At the sites we visited we spoke with a number of  servicemembers working on a flight line in close proximity to fighter jets  who are required to wear double hearing protection. While they were  generally aware that they were required to wear double protection, each  was wearing single protection and many cited comfort as a reason for their  non-compliance. (See fig. 5 for an example of the proximity of flight line  personnel to jet airplanes.) At other locations we visited, servicemembers  cited the impact of hearing protection on communication. They said that  the protection can interfere with the need to communicate with their  colleagues and to hear orders from superiors. Still others said they  perceived that wearing hearing protection in combat can put them in  harm’s way because they cannot hear an enemy approach or determine  where enemy gunfire is coming from. Finally, many servicemembers  expressed the view that hearing loss is part of the military experience and  many accepted this as a fact of a military career. For those that used  hearing protection equipment, we heard of a number of instances where  hearing protection equipment was not worn properly. Across many of the  military sites we visited, servicemembers told us of hearing protection  either falling out of their ears or getting dirty to the point of being  unsanitary to wear.
section_title: Educating Servicemembers on Hearing Conservation Is Not Necessarily Tracked or Well Timed
paragraphs: In accordance with DOD policy for the armed services’ hearing  conservation programs, participating servicemembers should be educated  and trained annually with regard to hearing conservation requirements.  Per DOD policy, servicemembers should be educated on topics such as the  effects of noise on hearing and the purpose of hearing protection. The  policy allows services to design their own specific training. Among the  sites we visited, servicemembers told us they received education on  hearing conservation through a variety of training methods, including  Safety Stand Downs, videos, posters, and supervisor initiatives.
Although services have a number of training options for educating  servicemembers on hearing conservation, officials from some of the  services reported they were unable to verify whether servicemembers  have taken any training. For example, Army Hearing Program personnel  noted that the Army has no method for tracking whether soldiers have  received such training. Also, Navy hearing conservation personnel told us  the Navy operates systems for tracking individual training activities, but  servicemembers are not required to record their training in the system.  However, Air Force officials require that workplace supervisors document  a servicemember’s annual training on hazardous noise exposures and  equipment on an Air Force Record of Training form.
We also found that educating servicemembers on hearing conservation is  not necessarily conducted prior to servicemembers’ first exposure to  hazardous noise or during hearing tests, when they are interfacing with  audiologists or audiometric technicians with hearing conservation  expertise. At many of the sites we visited, we were told that  servicemembers, as new recruits, were given very little education on  hearing conservation prior to the first time they fire weapons during basic  training in these locations. The education generally consisted of  instructors telling new recruits to simply use hearing protection in their  ears, but not explaining its importance or the proper technique to insert  such equipment. A few servicemembers stated they were told not to wear  hearing protection during training, with the justification that training  should be conducted under the same conditions as combat, which does  not include hearing protection. Also, at the sites we visited, a number of  servicemembers added that educating new recruits on hearing  conservation may be difficult during basic training because there is little  time for any additional education. Despite these observations, a number of  hearing conservation personnel told us that even a single exposure to  hazardous noise can trigger some level of hearing loss and believe that  educating new recruits on hearing conservation during basic training  would help underscore the importance of hearing protection.
Lastly, several audiologists and audiometric technicians—hearing testing  personnel—at sites we visited told us there is no formal training in  conjunction with the hearing examination process for those  servicemembers in a hearing conservation program. Similarly, a number of  servicemembers we spoke with noted that the training they receive from  hearing testing personnel primarily consists of reminding them to wear  hearing protection. That stated, several hearing conservation personnel at  the sites we visited told us they provided more in-depth informal training  to servicemembers who fail their hearing examinations, consisting of an  explanation of test results, a demonstration on the proper fitting of  hearing protection, and a reminder to wear hearing protection.
section_title: DOD’s Approach to Evaluating Hearing Conservation Has Key Weaknesses, While Some Services Have Taken Steps to Review and Improve Their Own Programs
subsections: section_title: DOD Lacks Adequate Performance Indicators
paragraphs: DOD delegates most program evaluation to the services, but lacks  adequate performance indicators to proactively assess how well services  are reducing hearing loss among servicemembers. At the time of our  review, DOD policy required that services evaluate their hearing  conservation programs on an annual basis based on two annual  performance indicators both targeted for servicemembers enrolled in a  hearing conservation program—(1) the percentage of servicemembers that  take a required annual hearing test and (2) the rate of significant hearing  loss. Several senior service-level hearing program managers expressed  concern about the adequacy of the indicators. More specifically, they told  us that the current performance indicators are not sufficiently  comprehensive and that the rate of significant hearing loss only provides a  measure of performance after damage has occurred. In general, key  officials in the services we spoke with expressed a desire for more leading  indicators that could signal to program managers that targeted  interventions are needed before hearing loss has occurred. Moreover,  some Army officials told us that they would like to see indicators that are  more closely aligned with their readiness—which is a basic measure to  assess each servicemember’s ability to deploy. A senior-level DOD official  told us they convened two working group sessions—which involved  representatives from across the services—since spring 2010 to discuss  amending existing performance indicators. According to another senior- level DOD official, additional indicators were put in place in December  2010 when DOD released its updated hearing program guidance. This  guidance includes indicators designed to be more proactive in hazard  evaluation and intervention prior to measurable hearing loss, such as the  percentage of noise hazardous workplace characterizations completed and  an index of unacceptable noise exposures. The guidance also encourages  services to develop additional measures of program effectiveness.
section_title: Limitations in Information System Processes Hinder Program Evaluation Efforts
paragraphs: Program evaluation is also hindered by limitations in the processes used to  capture, track, and use hearing-related performance data. DOD has  multiple information systems related to its hearing conservation program,  including one that tracks servicemember hearing test results and another  that tracks servicemembers’ exposure to occupational noise hazards. But  officials we spoke with identified limitations in the processes designed to  support these systems that, collectively, compromise the reliability or  usefulness of performance data that they generate.
We found limitations in the process to identify whether hearing loss for an  individual may have occurred. Typically, immediately prior to  administering a hearing test, an audiometric technician will query the  hearing test system to retrieve a servicemember’s prior test results, which  are used as a baseline with which to establish whether a loss has occurred.  However, on some occasions, prior hearing test data cannot be located in  the system and must be entered manually by audiometric technicians  before they administer the hearing test. For example, at one base we  visited, if a servicemember did not bring their original paper examination  to the test, technicians told us they would sometimes have to categorize  the test as a “non-hearing conservation” hearing test or have to re-establish  the baseline hearing test, making it difficult to assess whether a significant  hearing loss has occurred because there would not be two comparison  points. Audiometric technicians must also manually enter into the hearing  test system whether a servicemember is receiving an initial or follow-up  hearing test. However, Navy researchers conducting system reliability  tests told us they have found anomalies in how initial and subsequent  hearing tests were categorized, making it difficult to tell whether tests  were given in the proper sequence. They attributed many of these  problems to technicians’ manual data entry errors and the lack of a  consistent review process to ensure these entries are accurate, which  undermine the accuracy of the test data.
We also found limitations in the process to establish that hearing loss for  an individual has actually occurred. If a hearing loss is detected during an  annual examination, it is generally considered temporary until the hearing  loss is confirmed in at least two additional follow-up examinations.  According to DOD officials, servicemembers must appear for the follow-up  examinations within 90 days of an annual test. However, we found that  when servicemembers who fail their annual tests do not appear for follow- up examinations within the required period, the system will automatically  count their temporary hearing loss as permanent. To the extent this  occurs, the rate of permanent hearing loss could be inflated. Without a  reliable rate for hearing loss, services are unable to properly assess the  effectiveness of their program or properly target prevention efforts.
Finally, in reference to hearing tests, we found limitations in the process  used to identify the number of servicemembers enrolled in the services’  respective hearing conservation programs—which is essential to  calculating the hearing test compliance rate. Because the system designed  to track hearing tests does not automatically capture the number of  enrollees, each service must estimate its number from other data sources.  For example, Air Force hearing program enrollment information is  maintained in a separate database that does not link to the hearing test  system. Consequently, Air Force officials resort to using an often time- consuming manual process to tally the number of servicemembers  enrolled in the hearing conservation program. Similarly, Navy and Marines  officials told us that at some locations, officials must construct enrollment  information from multiple sources, including paper files. Compiling  enrollment numbers from multiple sources can lead to errors in  calculating the compliance rate. For example, we found that the Army  reported a compliance rate that exceeded 100 percent in 2007.
In reference to the system that tracks hazard exposure information— including the time, place, and amount of servicemembers’ exposure to  hazardous noise—we identified some limitations with the current  usefulness of the system. This system is designed to track  servicemembers’ occupational exposure to noise and other hazards over  the course of a military career. However, based on the information we  received, the system is not yet fully implemented at some installations.  Moreover, Army industrial hygiene officials at one installation told us that  they had been trained on the system, but did not have the staff resources  to upload exposure information into the system from individual files. In  discussing this issue, Army officials told us that 300 new industrial hygiene  personnel they expect to hire over the next 3 years will aid systems  implementation. A senior-level Air Force official told us that the Air Force  has fully implemented the hazard tracking system across all installations.  However, Air Force industrial hygiene officials expressed concern to us  about the system’s capacity to generate reports in a format that provides  useful performance information. More specifically, they noted that to get  critical information about the hazards that exist in each Air Force work  site, the new system generates a 14-page report. To overcome the system’s  limitations, the Air Force developed a reporting process that could  produce the same information in 2 pages. A senior-level Air Force official  told us it is necessary for them to upload hazard information twice daily  from the new system into an existing Air Force form to get the  performance information needed to effectively mitigate noise hazards on  base and meet DOD requirements, respectively. Moreover, the hazard  exposure tracking system is not currently integrated with the hearing test  system. DOD initially designed these systems with the intent to integrate  data from both systems to identify the impact of each servicemember’s  individual exposure to noise and other occupational hazards. Although the  DOD hearing test system has been active since 1999 and the hazard  exposure system was initiated in 2006, to date, these systems have not  been linked. As a result, hearing conservation managers told us it is  difficult to systematically analyze the causes of hearing loss and  effectiveness of mitigation measures. According to DOD officials, DOD has  not determined when they plan to integrate the two systems.
section_title: Program Stakeholders Do Not Appear to Routinely Coordinate to Evaluate Program Performance
paragraphs: Evaluating an installation’s implementation of the hearing conservation  program requires information that often resides across various  departments on base. This information includes noise hazard data; steps  actually taken to mitigate hazards; and hearing tests results. As indicated  by DOD guidance and supported in principle by many of the stakeholders  we spoke with, it is necessary for various stakeholders, including  workplace supervisors, industrial hygienists, audiologists, and safety  officials, to communicate and share information about potential noise  hazards and hearing loss trends in order to effectively manage and  evaluate the hearing conservation program. However, based on interviews  with senior-level officials and our site visits, coordination does not appear  to routinely occur at some bases. For example, at a Navy and Marine base  we visited, industrial hygienists were responsible for identifying hazardous  noise at work sites and making recommendations on how to mitigate these  hazards, but they had no authority to oversee the implementation of their  recommendations. Across all the services, officials, who reside in a  separate department from industrial hygienists, are responsible for  monitoring hearing loss and following up and enforcing industrial hygiene  recommendations, but we were told on some bases these two departments  rarely coordinate. At one base we visited, industrial hygiene and audiology  officials had never met one another prior to our visit. However, we did  document one instance of effective coordination at one Army installation,  whereby an audiologist responsible for hearing testing identified an  increase in hearing loss among servicemembers at a particular work site.  In order to prevent further hearing loss, the audiologist shared this  information with the industrial hygiene officials on base and they were  able to conduct an assessment of potential noise hazards and make  recommendations to mitigate these hazards.
section_title: Services Have Made Efforts to Review and Improve Their Own Hearing Programs
paragraphs: Each service has taken some steps to review their own hearing  conservation programs and identify opportunities for improvement. These  include scheduled reviews of hearing loss data and hearing test audits,  among other efforts.
subsections: section_title: Air Force Occupational and Environmental Health Working Group
paragraphs: The Air Force developed a mechanism to aid coordination across multiple  departments by requiring each base to establish an Occupational and  Environmental Health Working Group to review data on a wide range of  health hazards and indicators. At one site we visited, the working group  had members from multiple departments, including Flight Medicine,  Safety, Bioenvironmental Engineering, Aerospace Physiology, Public  Health, and Audiology. Members of the working group told us they review  hearing loss data each month for each unit on base to determine if there  are incidences of significant hearing loss. If significant loss is identified,  the working group will conduct a site visit to determine its cause and  make recommendations for noise mitigation.
section_title: Audit of Marine Corps Hearing Tests
paragraphs: After the Headquarters Marine Corps Safety Division designated hearing  loss as a high risk issue for the Marines in fiscal year 2008, the Marines  requested that the Naval Audit Service conduct an audit of its program.  The audit focused on audiometric testing and reviewed a representative  sample of Marines discharged in 2007 to determine how many had  received hearing tests both at the beginning and end of their military  service. Additionally, the review included an assessment of the reliability  and consistency of hearing test data and a survey of senior leadership on  who is responsible for the hearing conservation program, how often the  program has been evaluated, and the effectiveness of these evaluations,  action plans, performance measures, and standard operating procedures.  The audit found that the Marine Corps had not effectively protected the  hearing of Marine Corps personnel and noted that 6,300 Marines from 2001  to 2008 had hearing loss or hearing-related injuries. NAS also found that 84  percent of the medical records of Marines who left the service in fiscal  year 2007 did not have an entrance or exit audiogram within 60 days of  their entry or exit from the service. The report makes several  recommendations to improve the effectiveness of the Marine Corps  hearing conservation program, including performing a one-time review to  identify all current Marines who are due for an audiogram and establishing  controls to ensure that Marines receive timely access to care for required  audiograms.
section_title: Navy Survey of Hearing Protection Equipment aboard Aircraft Carriers
paragraphs: In 2005, the Naval Air Systems Command published a survey of sailors  aboard six aircraft carriers assessing the extent to which hearing  protection equipment was being appropriately fitted, used, and  maintained. The study included interviews with flight deck personnel on  their duties, noise exposure, and their perceptions about the adequacy and  comfort of their equipment. The reviewers reported that almost 50 percent  of the sailors surveyed reported never wearing earplugs and only 7 percent  had inserted the earplugs deeply enough to achieve the recommended  protection. Moreover, they found that, for flight deck personnel studied, 79  percent received noise reduction of only 0 to 6 decibels from their  equipment—this despite working in conditions that required double  hearing protection. Although helmets were found to be properly fitted for  90 percent of those surveyed, some were found to be in poor condition, or  to have been shared among sailors or worn over hats or scarves. The  report recommended the following actions: (1) improve the effectiveness  of hearing protection equipment, including helmets, earplugs, and muffs;  (2) instruct servicemembers on how to select the proper size and correctly  wear and maintain hearing protective equipment; (3) make hearing  protection part of the uniform; and (4) set penalties for noncompliance  with the appropriate use of hearing protection.
section_title: Army Program Review
paragraphs: Concerned about the high rate of hearing-related injuries incurred during  the early stages of Operation Iraqi Freedom, the Army released in 2005 a  broad-based review of its hearing conservation program with regard to  training, base, and combat environments. The reviewers concluded that  the Army’s hearing conservation program was more suitable for industrial  rather than military conditions. For example, military audiologists were  serving in Iraq but their role was largely limited to evaluating—not  preventing—hearing loss. In addition, the review found that the Army’s  readiness requirements were not specific enough to reflect the critical  importance of hearing to soldiers in combat. The reviewers recommended  a number of policy changes to make hearing protection policies more  effective for active duty soldiers, such as requiring that, in order to meet  combat readiness standards, soldiers must be up to date on their periodic  hearing tests and be fitted with combat arms earplugs. Subsequently, the  Army instituted a policy that soldiers who did not meet the hearing  readiness standard could not be deployed. Army officials we spoke with  told us that implementing this enhanced readiness standard has improved  compliance with hearing tests, and have given individual soldiers and unit  commanders clear accountability for taking steps to protect soldier  hearing. The Army reported that audiograms increased from 168,000 in  2003 to almost 440,000 in 2006; officials attributed this increase to the new  hearing readiness standard. Several Navy and Marine officials with whom  we discussed the Army’s hearing readiness standard expressed interest in  considering a similar approach for their respective services.
The same report also recommended that military audiologists be assigned  broader responsibility for hearing conservation, given their combination of  medical skills, military training, and knowledge of protective and  communication equipment designed for combat. In response, the Army  reports that it plans to increase the number of Army military audiologists  from 25 to 45. In addition, to determine whether the Army’s staffing policy  would effectively support military audiologists’ expanded role in hearing  conservation, the Army conducted a pilot study in 2008 at Fort Carson,  Colorado. The Army found that an increase from one to two military  audiologists at the base allowed them to spend time performing  preventative services, such as training medics and noise-exposed soldiers  on proper earplug use, giving briefings on hearing conservation, and  inspecting noise-hazardous areas, in addition to their clinical work. At  Fort Carson we observed a military audiologist and medic meeting with  soldiers on the firing range, assessing earplug fit and answering questions,  as well as providing individually-fitted combat arms earplugs and  distributing boxes of foam earplugs in different sizes.
section_title: Plans Are Almost Complete for Both the Hearing Center of Excellence and a System to Facilitate DOD and VA Data Sharing
subsections: section_title: A Plan for the Center Has Been Submitted for Final Department Approval
paragraphs: DOD has developed, but not yet finalized, its planning for the DOD Hearing  Center of Excellence that Congress mandated in October 2008 to be  established. While DOD maintains final authority on decisions for the  center, it is coordinating the planning effort with the VA and has assigned  the Air Force responsibility to draft plans for the center. The Air Force, in  turn, designated an interim director for the center in November 2009.  Subsequently, the center’s interim director completed basic logistical  planning, such as identifying space and budgeting for the center, along  with developing proposals to hire staff and purchase equipment. He also  led the internal workgroup that included representatives from all the  armed services and VA that jointly developed early drafts of the concept of  operation for the center to delineate its mission, goals and structure. As of  September 2010, each of the armed services had reviewed the current  draft. The draft was awaiting approval by the DOD Assistant Secretary of  Defense of Health Affairs before it could be sent to the VA for approval.  Neither Congress nor DOD set a date for when planning should be  formally approved to implement the center, but a key DOD official  estimated that the concept of operations may get final DOD approval in  the near future.
As described by the center’s interim director and Air Force Surgeon  General, the current plan envisions a “hub-and-spoke concept”----the  center’s headquarters as the hub and selected DOD and VA regional  medical centers and research sites as spokes—to integrate, facilitate, and  coordinate clinical care and research for servicemembers and veterans  with the latest treatment and research on hearing loss, tinnitus, and  auditory system injury. The Lackland Air Force Base in San Antonio,  Texas, will serve as headquarters, while the regional sites have yet to be  named. The director told us that the plan also describes the center as  facilitating the sharing of information between DOD and VA on clinical  advances related to the management and rehabilitation of hearing loss and  injury. This arrangement is intended to optimize clinical care and research  and avoid unnecessary duplication. DOD also has planned for possible  consolidation of common support functions, such as administrative  support and contract support, for all the DOD centers of excellence to  help ensure operational economy and efficiency.
Furthermore, the interim director told us that the focus of the center will  be to  research and support field testing of the best available protection and  communication devices currently available, as well as developing  improved hearing protection, along with better education and training on  its use;   create best practice guidelines for improving hearing outcomes after injury  and explore new lines of therapy to protect or restore hearing loss or  injury;   determine how many hazardous noise exposures are too many for a  servicemember and the level of hearing needed for selected jobs to  facilitate appropriate job assignments;   develop and implement better restorative and rehabilitative devices;    promote standards for implementing hearing awareness and treatment  into medical air evacuations for injured troops; and   collaborate with academic centers and industry in all these pursuits to  mitigate or restore hearing loss.
section_title: Data Sharing between DOD and VA Is Expected to Increase with Implementation of a New Electronic System
paragraphs: While attempts have been made by DOD and VA to share data, officials  from both departments told us that a new data sharing system is needed so  that sufficient information is available to address hearing injuries and loss,  such as assessing the effectiveness of the DOD and armed service hearing  conservation programs, providing and assessing treatment, and making  disability compensation decisions. A recent data sharing experience  between the two departments demonstrates some of the current  weaknesses that may be resolved by the pending implementation of a new  data system. In January 2010, VA responded to the hearing center’s interim  director’s request for data to help evaluate the scope and rate of hearing  loss specific to each service. VA was able to provide much of the  information requested, such as the number of new VA approved claims for  hearing loss and tinnitus grouped by each military branch of service and  the disability rating, for each year from 2004 through 2009. However, VA’s  system, developed to process claims and make disability payments, was  not able to provide the other data requested in a format to meet DOD’s  needs for information on all claimants with hearing loss, such as date of  separation from the military, period of military service, and military job.  Without this additional information, the center’s interim director reported  to us that he could not sufficiently evaluate the military’s hearing  conservation programs, in part, because he could not determine the rate or  trends of unique claims that could be attributable to the current conflict,  specific at-risk locations or duties, or prevention efforts.
Although not yet finished, the plan for a comprehensive “registry”—for  tracking and exchanging data between DOD and the VA on hearing loss,  injury, treatment, and outcomes—is close to completion. While the  concept of operations for the registry was initially expected to be  developed for final review by the Assistant Secretary of Defense by July  2010, it was still under preliminary review by the armed services and the  VA as of late 2010. According to the center’s interim director and a  working group member, the development of the registry’s plan will be  facilitated by borrowing from the design of the Vision Center of  Excellence’s registry, such as using some of the same data fields and data  sources for both registries. The interim director also told us that the  hearing center’s registry would use data from the existing DOD and VA  systems. Pending DOD approval of the registry plan, the interim director  anticipates launching a pilot registry in the summer of 2012.
A key DOD official, armed services officials, and VA officials told us they  expect the registry to provide a wealth of information to assess techniques  for hearing protection and to develop best practices for treatment of those  with hearing loss and injury. They expect the registry data to contain  information on hearing loss and injury incurred during active duty, by  virtue of tracking servicemembers’ injuries, interventions, and outcomes.  According to the center’s interim director, this information will enable the  armed services to better assess their hearing conservation programs,  hearing protective efforts, therapies and procedures for auditory injury,  and rehabilitation. The center’s efforts could, he noted, reduce hearing  impairments and with it, the cost of VA compensation for hearing loss.
section_title: The Center’s Interim Director Has Been Laying the Groundwork to Facilitate the Implementation of the Center and Data System
paragraphs: In preparation for implementation, the center’s interim director has taken  a number of steps to build alliances with academic institutions to address  prevention, clinical care, rehabilitation, and research gaps. For example,  to establish visibility for the center and build relationships with academic  institutions, the director has contacted the Deafness Research Foundation,  which has an alliance of 10 laboratories that conduct stem cell, metabolic,  and other types of restoration research for hearing injuries and loss.  According to the center’s interim director, this alliance is needed because  DOD and VA lack resources and expertise in this area. In February 2010,  the interim director facilitated a symposium of academics and officials  from DOD and VA on addressing war fighter injuries. The group identified  23 relevant research projects and several areas of focus for the center’s  research.
Additional steps taken to prioritize and facilitate research on prevention  and treatment include (1) spearheading the formulation of a white paper  to identify gaps and propose solutions to coordinate and link research  efforts across DOD and VA hearing research labs and clinical sites and (2)  initiating discussions to create within DOD a centralized and independent  Institutional Review Board to be linked with VA’s centralized Institutional  Review Board. The center’s interim director envisions that such a board  would not only meet the standard research requirement for an  independent body to protect patients and patient data, but would also  shorten the time it takes for any of DOD’s Centers of Excellence to get  board approval for research and access to data.
With regard to the data sharing network that includes the registry, the  center’s interim director has taken a number of steps to develop its  capacity. To move forward with data sharing, he has requested a military- wide health system certification of auditory software that is needed to  allow DOD and VA to collect and share hearing test results. The hearing  center registry has also been developed so that it can linked with other  registries and centers, to help integrate servicemember data on hearing  with other sensory deficits, as well as traumatic brain injury. He has also  assisted with the development of a module to include auditory data  collection in DOD’s front-line medical treatment information registry.
section_title: Conclusions
paragraphs: Good hearing is critical to a servicemember’s performance and well-being,  whether in combat or in carrying out peaceful operations. The U.S.  military system has, in recent years, undertaken measures to preserve the  hearing of military personnel and alter the assumption that military duty  must inevitably lead to a loss in hearing capacity. Nevertheless, hearing  loss and tinnitus remain conditions that most often require disability  compensation for veterans. Yet both are largely preventable.
The inconsistencies that we found in the various military strategies for  hearing protection and the lack of good monitoring and oversight suggests  that these programs are not realizing their full potential. The fact that new  servicemembers do not necessarily receive instruction on using protective  equipment before they are exposed to hazardous noise in basic training,  for example, undermines the first stage of any defense, which is  prevention. Moreover, servicemembers enrolled in a hearing protection  program that do not necessarily receive more education and training when  they appear for their periodic exams represent another lost opportunity  for hearing loss prevention. Aside from the lack of more thorough and  carefully timed training programs, the services and DOD have no uniform  system for tracking who has received training on hearing loss prevention.  The services and DOD must ensure that service personnel are cognizant of  the immediate and long term risks to hearing posed by exposure to  hazardous noise.
In terms of strategy, DOD itself is not in a position to assess the adequacy  of the programs and practices it now requires of the services for hearing  preservation without a full set of performance indicators. Additionally,  without more reliable data and reporting capability, and an integrated  system of records that relate hearing injuries to work sites, DOD will  further lack the ability to approach the problem of hearing loss more  strategically—by capitalizing on areas of success and targeting areas of  weakness.
While each of the services has made some effort to review and improve its  hearing loss prevention practices, weaknesses remain in DOD efforts to  identify and mitigate hazardous noise. Some of these individual initiatives,  if expanded across each of the services, likely hold promise for addressing  these issues. Without efforts to expand these initiatives, new insights and  improvements could be lost—to the detriment of the services and  servicemembers.
section_title: Recommendations for Executive Action
paragraphs: To position DOD and the services to better protect servicemembers from  hearing loss, we recommend that the Under Secretary for Personnel and  Readiness work with the Assistant Secretary for Health Affairs and take  the following four actions to ensure that:    DOD and the services improve upon the type, timing, and tracking of  training and education provided to servicemembers on hearing protection,  by providing information that is more comprehensive and training that is  more frequent and possibly earlier in servicemembers’ careers.
DOD work with the services to develop an appropriate set of performance  indicators that assess how well services are reducing hearing loss among  servicemembers.
DOD and the services address limitations in the processes used to capture,  track, and use performance data. This effort should address issues with  data reliability, data entry, reporting capability, and integration across  relevant databases.
DOD work with the services to examine the appropriateness and  feasibility of expanding those service-level initiatives that hold promise of  improving—-on a DOD-wide basis—-the military hearing conservation  programs. Particular attention should be focused on those efforts that  already appear to have either increased compliance with program  requirements or have demonstrated the potential to reduce hearing loss  among servicemembers, such as establishing hearing loss as a readiness  issue, improving the comfort and design of hearing protection, and  including noise experts more consistently in the procurement process.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DOD and VA for review and  comment. DOD provided written comments and agreed with our  recommendations. DOD’s comments have been reproduced in appendix II.  VA did not provide formal written comments, but both DOD and VA  submitted technical changes to the draft of the report, which we  incorporated into the report as appropriate.
In its comments, DOD stated the agency’s ongoing and planned actions in  response to our recommendations. Specifically, to improve upon the type,  timing and tracking of hearing conservation training provided to  servicemembers, DOD plans to monitor the progress of the services in  their efforts to implement improvements, encourage the sharing of lessons  learned, and standardize improvements across services as appropriate.  DOD agreed with our recommendation to more proactively assess how  well services are reducing servicemembers’ hearing loss. As noted in our  report, in December 2010, DOD issued updated guidance that included  new performance indicators designed to be more proactive in hazard  evaluation and intervention prior to measurable hearing loss. The services  also plan to review these indicators and develop additional indicators as  needed. DOD also stated that it plans to address limitations in the  processes used to capture, track, and use performance data. In addition,  DOD agreed to work with the services to examine the appropriateness and  feasibility of expanding DOD-wide those service-level initiatives that hold  promise of improving the military hearing conservation programs. To this  end, DOD stated that it will continue to use its annual Safety and  Occupational Health In-Progress Review and the DOD Hearing  Conservation Work Group as mechanisms of sharing service-level  improvement initiatives. Our review of the department’s new guidance and  its planned actions indicate that DOD is taking steps in the right direction.  If the department follows through with its efforts, we believe that it will be  responsive to our recommendations.
We are sending copies of this report to the Secretaries of Defense and  Veterans Affairs, interested congressional committees, and other  interested parties. The report also is available at no charge on the GAO  Web site at http://www.gao.gov.
Please contact me on (202) 512-7215 if you or your staff have any  questions about this report. Contact point for our offices of Congressional  Relations and Public Affairs may be found on the last page of this report.  Key contributors to this report are listed in appendix III.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: To address the objectives of this study, we used a variety of methods  including:  reviewed professional journal articles and studies on audiology, military  audiology, and hearing conservation; researched relevant federal laws, regulations, standards, and Department  of Defense (DOD) and armed services’ guidance; interviewed 12 military and civilian audiologists, 5 audiology technicians,  30 representatives of professions who assess, measure, and mitigate  occupational health hazards such as industrial hygienists and safety  officials, and 123 servicemembers across each of the armed services; and interviewed senior-level officials from DOD, Veterans’ Affairs (VA), and  the armed services, including the Army, the Navy, the Air Force and the  Marines. We also conducted informational interviews with officials at the  National Institute of Occupational Safety and Health (NIOSH), the  Occupational Safety and Health Administration (OSHA), and the Institute  of Medicine.
To review how well the services identify and mitigate hazardous noise and  evaluate their hearing conservation programs, we visited nine military  installations across the country—with at least two locations for each of  the armed services, to review hearing conservation activities and  interviewed officials both responsible for and participating in each base’s  hearing conservation program. (See table 2.) We selected sites to visit  based on the size of the installation, the presence of hazardous noise, and  geographic location. During our site visits, we met with senior officials  from the installation and public health commands and interviewed  audiologists, audiometric technicians, industrial hygienists, other  occupational safety personnel as well as servicemembers with experience  in combat or other missions with hazardous noise. We visited various  installation work sites, including maintenance shops, a firing range, and an  aircraft carrier to observe signs and labels designating hazardous noise  areas or equipment; the availability of hearing protection equipment in or  around such areas; and the use of personal hearing protection. We also  observed audiologists and technicians conduct hearing conservation  activities, including performing hearing tests, interviewing and educating  servicemembers about hearing protection, and assessing appropriate fit  and use of hearing protection equipment at noise hazardous sites.
To further review DOD and the services’ program evaluation efforts, we  discussed performance goals, measures, and information systems at the  leadership and the installation levels. We interviewed officials from NIOSH  and OSHA—organizations responsible for creating hearing conservation  program review standards for civilian workers, as well as DOD and armed  services officials responsible for oversight of military hearing conservation  programs. More specifically, we interviewed DOD officials and reviewed  documentation related to the armed services’ program evaluation  activities, such as setting targets and reviewing performance trends. To  determine the availability and usefulness of information to support  program evaluation, we interviewed officials responsible for managing  DOD’s hearing conservation data system as well as officials who are  familiar with and use the system, including installation hearing  conservation program managers and technicians. We reviewed data  dictionaries and other technical documentation for the Defense  Occupational and Environmental Health System (DOEHRS), DOD’s  database for tracking servicemembers’ hearing test results and their  occupational exposure to noise and other hazards. After an internal review  of standard data reports provided by the services, we determined that it  would not be feasible to validate data consistent with GAO’s reliability  standards within our planned time frames.
To determine the status of the DOD Hearing Center of Excellence and its  registry and efforts to share information to improve hearing protection, we  interviewed officials from DOD, including the center’s interim director and  the representatives of the armed services and VA involved in these efforts.  We also reviewed planning documents for the center and registry and data  shared between DOD and VA.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Brett Fallavollita (Assistant Director) and Michelle Bracy (Analyst-in- Charge) managed all aspects of the assignment. Julie DeVault, David  Forgosh, Suzanne Rubins, and Melissa Baker made significant  contributions to all aspects of this report. In addition, Walter Vance and  Beverly Ross provided technical support in the design and methodology;  James Rebbe provided legal support; Susan Bernstein and Mimi Nguyen  assisted in the message and report development; and Sara Edmondson,  Jessica Gray, Jonathan McMurray, and Ronni Schwartz assisted with  quality assurance.