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Interagency Aviation Mishap Response Plan

By Lorraine White,2014-06-17 17:53
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Interagency Aviation Mishap Response Plan ...

A Publication of the National Wildfire

    Coordinating Group

     Interagency Interagency

    Aviation Aviation

    Mishap Response Mishap Response

    Guide and Checklist Guide and Checklist

    PMS 503 January 2010 NFES 2659

    Do not waste time trying to figure out if an event is an accident, that’s not your job. If you have an event with an aircraft that results in damage or injury no matter how slight.

    REPORT IT1-888-464-7427 (888-4MISHAP).

    Then follow your Bureau / Agency procedures

Administrative Information

    This is a generic aircraft mishap response guide and checklist. It is not intended to be all encompassing but rather it

    provides the minimum essential elements that apply to most aviation mishaps. You must tailor this plan to your own organization, mission, and operational location. An electronic copy of this document can be downloaded at

    http://amd.nbc.gov/safety/library/iamrp.html. It will serve you best when used in conjunction with the Agency

    Administrator’s Guide to Critical Incident Management (available on www.nwcg.gov (PMS 926). All personnel involved in aviation operations should be familiar with the Aviation Mishap Response Guide and

    Checklist. Ensure that your plan is up-to-date. It must be verified a minimum of annually AND prior to

    operations conducted in new locations. When you review your Aviation Mishap Response Checklist ensure that all of

    the points-of-contact listed and their respective phone numbers and e-mail addresses are still valid. Change Symbols. Revised text is indicated by a black vertical bar in the right margin of the page, adjacent to the

    affected text, like the one printed next to this paragraph. The change symbol identifies the addition of either new

    information, changed procedure, the correction of an error, or a rephrasing of the previous material. Priority of Actions. As soon as you are aware of the accident START A LOG OF ALL ACTIONS AND CALLS, then refer to the expanded subsections of this plan. The subsections are listed in order of priority.

    a. Protect people (Tab A). Life saving operations take first priority.

    b. Protect property (Tab B). Property should be protected from unnecessary additional damage.

    c. Preserve evidence (Tab C). Treat the area as if it were a crime scene and provide 24-hour security until the

    investigation team arrives. Identify witnesses, get their addresses and phone numbers.

    d. Notify and investigate (Tab D). Report the accident using your organization’s chain-of-command and policies.

    Do not delay reporting if detailed information is not immediately available.

    e. Recovery operations (Tab E). Everything at the site is under the control of the NTSB until released. Practice -- The absolute best way to be prepared for the unexpected is to periodically practice your Aviation Mishap

    Response Plan. Coordinate in advance and get as many responders as possible to participate when you conduct a training

    drill.

    Update Record

    Date of Review Signature

    Protecting People

    a. Many times in the urgency to assist accident victims the rescuers may place themselves in jeopardy and

    become victims themselves. Risk assessment and mitigation procedures should be enforced. b. Ensure ALL crew and passengers involved in an aircraft accident are cleared by medical authority prior to

    returning to duty.

    c. Aircraft wreckage attracts people like a magnet. Keep non-essential personnel well clear, and preferably upwind. d. Hazards at an aircraft accident site can include:

    1. Biological Hazards -- Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV), and many

    others. See OSHA’s 29 CFR 1910.1030 for control measures.

    2. Toxic Substances -- Fuel, oil, hydraulic fluid, and exotic aircraft materials such as beryllium, lithium,

    chromium, and mercury. You must also consider the cargo the aircraft was carrying (see the DOT

    Emergency Response Guide at http://phmsa.dot.gov/hazmat/library/erg)

    3. Pressure Vessels -- Tires (often above 90 psi), hydraulic accumulators, oleo struts, oxygen cylinders,

    and fire extinguishers. They may look OK, but they may have been damaged in the crash.

    4. Mechanical Hazards -- Metal under tension (rotor blades bent under fuselage), heavy objects,

    composite materials, and innumerable sharp edges.

    5. Fire Hazards -- Unburned fuel, hot metal (or other components), aircraft batteries, pyrotechnics, and

    the ignition of grass as a result of the accident. Be cautious of smoldering items which may re-ignite.

    6. Environmental Hazards -- Weather, terrain, and animals (snakes, spiders, scorpions, etc.) Depending

    on the location and time of year, the environment may be among the most serious hazards at the scene. e. Utilize available protective devices and clothing, and use extreme caution when working around the wreckage.

    Protective measures include:

    1. Minimize the number of personnel allowed to enter the accident site.

    2. Ensure exposed personnel use appropriate personal protective equipment (PPE) such as boots, long

    pants, long-sleeved shirts, leather gloves (use surgical gloves as inserts if blood or bodily fluids are

    present), and appropriate respirators if toxic vapors or composite material pose respiratory hazards. f. Do whatever is necessary to extricate victims and to extinguish fires, but keep in mind the need to protect and

    preserve evidence. Document and/or photograph the location of any debris, which must be disturbed in

    order to carry out rescues or fire suppression activities.

    REMEMBER, it’s already a bad day; don’t make it worse by letting someone else get hurt!

    Emergency Actions Tab A (Protect People)

Protecting Property

     NTSB Sec. 831.12 Access to and release of wreckage, records, mail, and cargo.

    a. Only the Board's accident investigation personnel, and persons authorized by the

    investigator-in-charge to participate in any particular investigation, examination or

    testing shall be permitted access to wreckage, records, mail, or cargo in the Board's

    custody.

    b. Wreckage, records, mail, and cargo in the Board's custody shall be released by an

    authorized representative of the Board when it is determined that the Board has no

    further need of such wreckage, mail, cargo, or records. When such material is

    released, Form 6120.15, “Release of Wreckage,'' will be completed, acknowledging

    receipt.

Treat the accident site like a crime scene. Wreckage, cargo, and debris should not be disturbed or moved

    except to the extent necessary:

    a. To remove victims.

    b. To protect the wreckage from further damage.

    c. To protect the public.

    In addition to the authority explicit in NTSB 831.12 another (very good) argument for restricting access is for the

    protection of the public from the hazards of the accident site (Tab A).

Initially the accident site should be protected by either your own people (e.g. if the accident occurred at a fire) or by

    agency and local law enforcement officers. The investigation team may request extended security until the investigation

    is complete.

    Emergency Actions Tab B ) (Protect Property

Preserving Evidence

    NTSB Sec. 830.10 Preservation of aircraft wreckage, mail, cargo, and records. a. The operator of an aircraft involved in an accident or incident for which notification must be given is

    responsible for preserving to the extent possible any aircraft wreckage, cargo, and mail aboard the

    aircraft, and all records, including all recording mediums of flight, maintenance, and voice recorders,

    pertaining to the operation and maintenance of the aircraft and to the airmen until the Board takes

    custody thereof or a release is granted pursuant to Sec. 831.12(b) of this chapter. b. Prior to the time the Board or its authorized representative takes custody of aircraft wreckage, mail, or

    cargo, such wreckage, mail, or cargo may not be disturbed or moved except to the extent necessary:

     1. To remove persons injured or trapped;

     2. To protect the wreckage from further damage; or

     3. To protect the public from injury.

    c. Where it is necessary to move aircraft wreckage, mail or cargo, sketches, descriptive notes, and

    photographs shall be made, if possible, of the original positions and condition of the wreckage and any

    significant impact marks.

    d. The operator of an aircraft involved in an accident or incident shall retain all records, reports, internal

    documents, and memoranda dealing with the event, until authorized by the Board to the contrary.

In addition to those items required by law (above) you should also:

    Control access to the site by cordoning off the area and contact the agency aviation safety investigator to determine who needs access. Request agency or local law enforcement to immediately secure the site for the accident investigation

    team. Establishing a pass system to identify authorized personnel is an excellent technique for serious accidents.

    Everyone who enters should be briefed on the known or suspected hazards and cautioned to avoid disturbing the

    evidence (flipping switches and souvenir hunting).

    Photograph everything. Film is cheap (digital photos are OK) and some evidence may be easily destroyed prior to the arrival of the accident investigators. Photograph switch positions, ground scars, and other perishable evidence. Collect copies of all photos and videos taken by witnesses, participants, and rescuers.

    Identify witnesses and request statements. Request witnesses to write out their statements as soon as possible (before

    witnesses can compare notes). Be sure to GET WITNESSES’ NAMES, ADDRESSES AND PHONE NUMBERS. Supervisors must ensure that personnel with information pertinent to the investigation are made available to the

    investigators in a timely manner. If possible, coordinate with the accident investigator(s) PRIOR to de-mobilizing personnel with information pertinent to the accident.

    Secure equipment and records. Crew items (i.e. helmets, survival equipment (if used), notes, charts, etc.) as well as

    dispatch logs and records should be controlled and provided to the IIC/investigation team upon arrival. Emergency Actions Tab C (Preserve Evidence)

Notify and Investigate

    If you see something…SAY SOMETHING !!

    Do not try to “classify” events as accidents or incidents, that’s the job of the

    National Transportation Safety Board (NTSB). If you have an event with an

    aircraft that results in damage or injury, REPORT IT.

    Initial Notification. DOI’s National Business Center - Aviation Management (NBC-AMD) or the USDA-Forest Service (USFS) will be contacted by calling 1-888-464-7427 (1-888-4MISHAP) and providing the information on the Aircraft Accident Checklist AMD Form 77/ FS 5700-28.

     **DO NOT DELAY the initial notification by trying to complete all of the blanks on the form. Call in the accident as

    soon as possible and call back as more information becomes available.

    The NBC-AMD or USFS Investigator will review your procedures taken and advise you of any additional actions you should be taking, or reports you need to make. The NBC-AMD / USFS investigator will notify the NTSB as appropriate.

    Field personnel should not make initial notification to the FAA or the NTSB. If contacted by the FAA or the NTSB you

    should refer them to the NBC-AMD or USFS Aviation Safety Manager and answer those questions that you can. **If you have enough people you should conduct the notification process at the same time as you are conducting other

    aspects of the immediate response.

    Investigation:

    a. Aircraft accidents (fatality, serious injury, or substantial damage) will usually be investigated by NTSB

    personnel (PL 106-181). NBC-AMD/USFS personnel will generally be a “party” to the NTSB investigation.

    b. Aircraft incidents-with-potential will be investigated by Air Safety Investigators from NBC-AMD or USFS.

    c. Aircraft incidents will usually require the local Aviation Manager or Aviation Safety Manager to investigate the

    event and report the facts and circumstances to NBC-AMD/USFS. No report is required by the NTSB unless

    specifically requested (Part 830.15)

    d. All aviation-related events that impact aviation safety (for either NBC-AMD or USFS), must be reported using

    the SAFECOM (http://www.safecom.gov) reporting system.

    Emergency Actions Tab D (Notify and Investigate)

Recovery Operations

    NTSB Sec. 831.12 Access to and release of wreckage, records, mail, and cargo.

    a. Only the Board's accident investigation personnel, and persons authorized by the

    Investigator-In-Charge to participate in any particular investigation, examination or testing

    shall be permitted access to wreckage, records, mail, or cargo in the Board's custody.

    b. Wreckage, records, mail, and cargo in the Board's custody shall be released by an

    authorized representative of the Board when it is determined that the Board has no further

    need of such wreckage, mail, cargo, or records. When such material is released, Form

    6120.15, “Release of Wreckage,'' will be completed, acknowledging receipt.

If an accident is investigated by NBC-AMD or USFS investigators, they are responsible for notification of the

    NTSB and compliance with section 831.12 prior to releasing the wreckage.

    Actual recovery (and the associated costs) is usually the responsibility of the owner (or the owner’s insurer).

    Before committing the Government to unnecessary costs, check with the appropriate Contracting Officer. Use extreme caution when removing or recovering aircraft wreckage (Tab A). Normally, salvage personnel

    are aware of, and take appropriate precautions for, hazards at accident sites. Your people may not! Release of wreckage from the NTSB should go to the USFS or NBC-AMD investigation team, and they will release it to the contractor through the contracting officer.

    Emergency Actions Tab E (Recovery Operations)

    Anyone who has ever been involved in the immediate response to an aircraft accident will agree that the

    first few minutes (and hours) are chaotic. Developing and practicing your Aviation Mishap Response

    Checklist today is your best defense against the chaos of tomorrow. Time is an extremely critical factor

     and immediate positive action is necessary; delay may affect someone’s survival.

    Conduct of Aircraft Accident Investigations. All U.S. Department of the Interior (DOI) and U.S. Department of

    Agriculture - Forest Service (USDA-FS) aircraft mishaps are investigated under the authority of the National

    Transportation Safety Board (NTSB) as defined in:

    a. 49 Code of Federal Regulations (CFR) Parts 830 and 831

    b. Public Law (PL) 110-181, and Federal Management Regulation (FMR) 102-33.185. ** This means that regardless of severity, all aircraft mishaps (accidents or incidents) are the domain of the NTSB. If the

    NTSB elects to not visit the site and the field investigation is conducted by DOI or USDA-FS personnel, it is still an NTSB investigation and investigative efforts must comply with their rules and standards. Tips and Techniques

    a. Who’s in charge -- Although the investigation is the responsibility of the NTSB you need to determine in

    advance who your organization wants to be responsible for the initial actions at the accident site

    b. Notification of Next-of-Kin -- See Agency Administrator’s Guide to Critical Incident Management

    (http://www.nwcg.gov/pms/pubs/pubs.htm) for guidance. As a minimum, all supervisors should have a plan on

    how to contact their employee’s next-of-kin.

    c. Start a journal -- Write down everything regarding events, actions, points of contact (who, what, when, where,

    why).

    d. Control of Records -- Under the provisions of NTSB Part 831.12 (Tab B) the records pertaining to the aircraft

    and the flight become a part of the investigation and “belong” to the NTSB until released. Gather and control the

    appropriate records until they can be turned over to the NTSB (or other authorized investigator). Required

    records include (but are not limited to) aircraft operating and maintenance documents, crew records (flight and

    medical), flight plans, weather briefings, weight and balance forms, and load calculations.

    e. Conduct after-action review (AAR) -- After the dust has settled and the professional investigators have taken

    charge it is time to review what happened, what worked, and what needs to be improved. Conduct the AAR

    while issues and events are fresh in everyone’s mind. Share your lessons learned with your Regional / Bureau /

    National Aviation and Safety Managers. Update your Aviation Plan with the lessons learned.

    (page 1) General Information

    Definitions (See 49 CFR (NTSB) 830/831)

    a. Aircraft Accident -- an occurrence associated with the operation of an aircraft, which takes place between the

    time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in

    which any person suffers death or serious injury, or in which the aircraft receives substantial damage. b. Substantial Damage -- damage or failure which adversely affects the structural strength, performance, or flight

    characteristics of the aircraft, and which would normally require major repair or replacement of the affected

    component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or

    cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and

    damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered

    “substantial damage” for the purpose of this part.

    * Incident with Potential (IWP)-- an incident that narrowly misses being an accident and in which the

    circumstances indicate significant potential for substantial damage or serious injury. The USDA-FS

    National Aviation Safety and Training Manager or the NBC-AMD Aviation Safety Manager, as

    appropriate, will determine final classification. (The concept “IWP” is unique to USDA-FS and DOI.) c. Aircraft Incident -- an occurrence other than an accident, associated with the operation of an aircraft, which

    affects or could affect the safety of operations.

    d. Investigator In Charge -- the designated Investigator-In-Charge (IIC) organizes, conducts, controls, and

    manages the field phase of the investigation. The IIC has the responsibility and authority to supervise and

    coordinate all resources and activities of all personnel, both Board and non-Board, involved in the on-site

    investigation. The IIC continues to have considerable organizational and management responsibilities throughout

    later phases of the investigation, up to and including Board consideration and adoption of a report or brief of

    probable cause(s).

    e. Serious Injury -- any injury which:

    1. Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was

    received;

    2. Results in a fracture of any bone (except simple fractures of fingers, toes, or nose);

    3. Causes severe hemorrhages, nerve, muscle, or tendon damage;

    4. Involves any internal organ; or

    5. Involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. * In-flight damage to rotor blades or propellers may also involve less obvious damage to internal structures/systems

    (i.e. drivetrain) that might fit into the definition of “Substantial Damage.” If you have damage to the main or tail

    rotor blades, or to the propeller, the chances are good that you have at least an incident with potential…report it

    immediately! 1 888 464-7427 (888-4MISHAP).

    ** Managers may also need to record employee injuries in their Department/Agency’s Safety Reporting System,

    DOI: Safety Management Information System (SMIS)/ USFS: Safety Health Information Portal System (SHIPS).

     (page 2) General Information

    Media Relations

     NTSB Sec. 831.13 Flow and dissemination of accident or incident information.

    a. Release of information during the field investigation, particularly at the accident

    scene, shall be limited to factual developments, and shall be made only through

    the Board Member present at the accident scene, the representative of the

    Board's Office of Public Affairs, or the Investigator-In-Charge.

    b. All information concerning the accident or incident obtained by any person or

    organization participating in the investigation shall be passed to the IIC through

    appropriate channels before being provided to any individual outside the

    investigation. Parties to the investigation may relay to their respective organizations

    information necessary for purposes of prevention or remedial action. However, no

    information concerning the accident or incident may be released to any person not a

    party representative to the investigation (including non-party representative

    employees of the party organization) before initial release by the Safety Board

    without prior consultation and approval of the IIC.

    When the field investigation is conducted by NBC-AMD / USFS personnel they will comply with the law by referring all

    questions, requests for interviews, etc. to the NTSB IIC or to the appropriate NTSB office.

    Tips and techniques when working with the media:

    a. You can acknowledge an accident has occurred, but do not speculate on what caused it or release any names.

    Advise the media that the investigation of this accident is under the jurisdiction of the NTSB and any questions

    must be directed to them.

    b. Don’t aggravate the media and don’t get aggravated by the media; they’re just doing their job. Even aircraft

    accidents don’t stay in the headlines forever… unless the reporter thinks you’re hiding something.

    c. Most reporters have prior experience at accident sites. Remind them of the hazards, to avoid disturbing the

    wreckage, and ask them to be respectful of the victims.

    Media Relations

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