Report of National Commission on Military Aviation Safety on Aviation Mishaps from 2013 to 2020

December 3, 2020 11:04 AM

The following is Dec. 1, 2020 report from the National Commission on Military Aviation Safety. Congress created the National Commission on Military Aviation Safety in the John S. McCain National Defense Authorization Act (NDAA) for Fiscal Year 2019. The Commission’s purpose is to examine past mishaps and make recommendations to the President, Congress, and the Defense Department for improving aviation safety and readiness in the military.

From the report

The National Commission on Military Aviation Safety asked thousands of pilots and maintainers this question during visits to military flight lines. Across the country, certain answers were consistently repeated, regardless of Service, rank, or airframe: insufficient flight hours, decreasing proficiency levels, inadequate training programs, excessive administrative duties, inconsistent funding, risky maintenance practices, and a relentless operations tempo.

The Commission also independently assessed this same question. The Commission reviewed thousands of mishap reports, consulted volumes of secondary research, and conducted data analysis to determine why mishap rates have increased. The Commission also utilized its resident knowledge and experience: two retired four-star military aviators; a former member of the National Transportation Safety Board and Director of Safety and Survivability for the Navy; a former Secretary of the Army who had previously served as Acting Secretary of the Air Force and as a member of Congress; an engineer turned CEO for major aircraft manufacturers; a White House Deputy Chief of Staff for Operations who served four presidents; and a former Navy helicopter pilot who oversaw Air Force One and Marine One while director of the White House Military Office.

This report shares critical perspectives from the flight line and addresses the safety concerns that so many aviators and maintainers candidly shared. This report also covers broader topics in the Commission’s statutory charter, such as aviation mishap rates, unexplained physiological episodes, and aviation maintenance delays. The complete list of the Commission’s recommendations is provided in Appendix B.

During its study, the Commission realized that many aviation safety issues are uniquely interconnected and require collaborative, cross-cutting solutions. For example, increasing spare parts inventories does little good if there are not enough experienced maintainers to install them. Fixing one issue may require fixing several related issues, and all solutions must be crafted to work in concert. In this report, the Commission took special care to balance competing and sometimes conflicting priorities, and its recommendations are proposed with an understanding of the importance of harmonization.

Our findings and recommendations focus on four areas where Congress and the Department of Defense can take immediate steps to reduce aviation mishaps: Pilots should fly; maintainers should maintain; data can save lives; and funding should be consistent.

Aircrews and Maintainers

The Commission found that aviation and maintenance experience, the key to doing a job safely and efficiently, is declining. Newly trained pilots and maintainers are reporting to operational units without basic skills. Flight hours are being replaced with simulator hours, yet the simulators are often outdated, out of service, or unavailable. Aircrews and maintainers are saddled with additional nonaviation duties that are more valued than their primary duties for purposes of promotion. Furthermore, on top of their experience gaps, some aircrews are experiencing physiological episodes when an aircraft’s environmental systems fail to meet the needs of the pilot.

This report addresses these issues in detail. Two chapters address the shortcomings in initial training, follow-on training, and personnel management of aircrews and maintainers. One chapter examines the effects of a relentless pace on military aviation for both machine and personnel. Another chapter discusses the human-machine interface and recommends changes in the acquisition process to better meet the needs of the pilot during aircraft design and modification.

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