Feb. 6, 2013 —
What We Did
Our objective was to review the United States Air Force (USAF) Aircraft Accident Investigation Board (AIB) report on the F-22A mishap of November 16, 2010, for adherence to the procedures set forth in Air Force Instruction (AFI) 51-503, “Aerospace Accident Investigations.” We assessed whether the AIB’s conclusions were supported by facts consistent with the standards of proof established by AFI 51-503.
What We Found
The AIB Statement of Opinion regarding the cause of the mishap was not supported by the facts within the AIB report consistent with the clear and convincing standard of proof established by AFI 51-503.
The AIB report contains the following deficiencies.
- The AIB report cites three causal factors (channelized attention, breakdown of visual scan, and unrecognized spatial disorientation) as the cause of the F-22 mishap. However, these three factors are separate, distinct, and conflicting. The AIB report does not clearly explain their interrelationship and how it is possible that all three factors concurrently caused the mishap. Failure to adequately explain this interrelationship calls into question the AIB Statement of Opinion regarding the cause of the mishap.
- The AIB report’s determination that the mishap pilot’s mask was in the full up position throughout the mishap sequence was not adequately supported by the Summary of Facts or by the analysis cited in the TABs. This determination directly affected several conclusions of the AIB and precluded the analysis of other potential causes of the mishap. Failure to provide adequate facts or analysis to support this determination calls into question the AIB finding.
- The AIB report’s Non-Contributory portion of the Human Factors section inadequately analyzes the human factors listed, such as hypoxia, gravity-induced loss of consciousness, and sudden incapacitation and does not contain any references and/or supporting documentation. Without detailed analysis and proper documentation, it is unclear how the AIB determined that these factors did not contribute to the mishap.
- The AIB report lacked detailed analysis of several areas, such as the Emergency Oxygen System activation as well as the physiological reactions to lack of oxygen.
- Of the 109 references in the AIB report’s Summary of Facts, 60 of those references were either incorrect or did not direct the reader of the AIB report to the information cited in the paragraph.
What We Recommend
We recommend that the Judge Advocate General of the Air Force reevaluate the AIB report and take appropriate action in light of the findings in this report regarding the AIB report Statement of Opinion and other deficiencies.
Air Force Comments
The Air Force concurs that aspects of the AIB report could have been more clearly written. However, the Air Force found that the AIB President’s Statement of Opinion regarding the cause of the mishap was supported by clear and convincing evidence and he exhausted all available investigative leads. To conclude that the AIB’s President’s opinion was supportable, the Air Force relied upon the findings of a special Task Force that was convened to review and respond to DoD Inspector General (IG) draft report. The Air Force acknowledged that remedial actions would be taken to address the following deficiencies in the AIB report: the lack of detailed analysis of the non-causal or non-contributory factors; insufficient details regarding conclusions concerning Emergency Oxygen Activation and blood oxygen levels; and, inaccurate references within the AIB report.
DoD IG Response
The DoD IG does not concur with the Air Force response that the AIB President exhausted all investigative leads and that the AIB President’s Statement of Opinion is sufficiently supported by clear and convincing evidence, as reflected in the AIB report, consistent with the requirements of AFI 51-503. In reaching our conclusion, we note that AFI 51-503 states that AIB Summary of Facts must present a thorough discussion of the facts relevant to the accident; be fully supported by documentary evidence; and should be self-contained. Furthermore, AFI 51-503 mandates that a Statement of Opinion regarding the cause of an accident “must be supported by facts stated in the Summary of Facts, which must be supported by evidence included in the Tabs [of the AIB report], unless otherwise restricted.” With respect to clear and convincing evidence, AFI 51-503 states that the AIB President’s opinion “must be supported by credible evidence that shows it is highly probable that the conclusion is correct.” Based on the deficiencies we identified in the AIB report, we conclude that the AIB report did not meet the requirements of AFI 51-503.
The Air Force stated that remedial actions would be taken to address Findings C, D, and E; however, the Air Force did not provide a description as to what those actions will be or entail. Without a sufficient description of these actions, the DoD IG cannot determine if these actions will adequately address the AIB report deficiencies. Moreover, we believe a sufficiently detailed action plan will also be especially useful to identify and implement appropriate departmental-wide AIB process improvements. Additionally, the Air Force did not indicate if any actions will be taken to address Findings A and B; even though the Air Force acknowledged those sections could have been more clearly written. Therefore, the DoD IG requests the Air Force provide a detailed description of the remedial action to be taken by February 28, 2013.
This report is a result of Project No. D2012-DTOTAD-0006.000.