AIR FORCE AF M91-223 CHANGE 1-2006 AVIATION SAFETY INVESTIGATIONS AND REPORTS《飞行安全调查和报告》.pdf

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1、BY ORDER OF THESECRETARY OF THE AIR FORCE AIR FORCE MANUAL 91-2236 JULY 2004Incorporating Change 1, 9 August 2006SafetyAVIATION SAFETY INVESTIGATIONSAND REPORTSCOMPLIANCE WITH THIS PUBLICATION IS MANDATORYACCESSIBILITY: Publications and forms are available on the e-Publishing website at www.e-publis

2、hing.af.mil for downloading or ordering.RELEASABILITY: There are no releasability restrictions on this publication.OPR: HQ AFSC/SEFM Certified by: HQ AFSC/SEF (Col Corso)Pages: 59This manual provides aviation unique guidance to support AFI 91-204, Safety Investigation and Reports.It directs procedur

3、es specific to investigating and reporting USAF aviation mishaps and events. It imple-ments Air Force Policy Directive (AFPD) 91-2, Safety Programs. It applies to commanders, managers,supervisors, and safety staffs at all levels, all persons who investigate and report Air Force mishaps, andthose per

4、sons who handle such reports. Ensure that all records created by this AFI are maintained inaccordance with AFMAN 37-123, Management of Records, and disposed of in accordance with AFMAN37-139, Records Disposition Schedule. Send major command (MAJCOM) supplements to HQ USAF/SE, 9700 G Avenue SE, Kirtl

5、and AFB NM87117-5670, for approval before publication. Reference AFI 91-204, Attachment 1 for a Glossary of References and Supporting Information. SUMMARY OF CHANGESThis change incorporates Interim Change (IC) 2006-1, which modifies the investigation membership min-imum requirements. Specific change

6、s include: revised Table 5.1. and associated notes; incorporation ofparagraphs 5.1.1. and 5.1.2. into Table 5.1. and paragraph 5.1., respectively; and new terms forengine-confined mishaps and foreign object damage. A bar ( | ) indicates a revision from the previous edi-tion. Chapter 1 GENERAL INFORM

7、ATION 41.1. Overview. .41.2. Non-reportable mishaps. 41.3. Aviation Events that Require Safety Investigations and Reports. . 41.4. UAV Mishaps. . 71.5. Parachute Recovered RPV Costs. 8Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-2 AFMAN91-223 6 JU

8、LY 2004Chapter 2 RESPONSIBILITIES 92.1. Responsibilities of the Interim Safety Board (ISB) President. 92.2. Deployed Unit Safety Operations. . 9Chapter 3 PRIVILEGED SAFETY INFORMATION 113.1. General Information. 11Chapter 4 DETERMINING INVESTIGATIVE RESPONSIBILITY 124.1. Mishap Ownership. 124.2. Mis

9、haps Involving Civil Aviation and/or Federal Air Traffic Services. . 12Chapter 5 SAFETY INVESTIGATIONS 135.1. General Guidelines. . 13Table 5.1. Investigation Membership Minimum Requirements. . 135.2. Safety Investigation Board Member Roles. . 145.3. SIB/SIO Requirements and Restrictions. . 165.4. I

10、nvestigative Evidence. 185.5. Deficiency Reporting Procedures. . 215.6. Coordinating with an AIB. . 22Chapter 6 REPORTS AND BRIEFINGS 246.1. General Information. 246.2. Class E HATR and CMA Violation Reporting Procedures. 25Table 6.1. FAA AFREP and Regional Boundaries By State. 286.3. Life Sciences

11、Safety Reporting. . 296.4. Documenting the Investigation and Analysis. . 296.5. Formal Reports. . 30Figure 6.1. Formal Report Distribution Memorandum. 33Table 6.2. Example Certificate of Damage. . 37Figure 6.2. Tab T Outline. . 406.6. Briefing Investigation Results. 44Chapter 7 FOLLOW-UP ACTIONS 457

12、.1. Overview. .457.2. Acting upon Recommendations. 45Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-AFMAN91-223 6 JULY 2004 3Figure 7.1. Sample Final Review Comments. . 477.3. Forms Adopted. . 47Attachment 1 GLOSSARY OF REFERENCES AND SUPPORTING INF

13、ORMATION 49Attachment 2 SAFETY MESSAGE FORMATS 54Attachment 3 DMS RELEASE OF SAFETY MESSAGES AND FORMAL REPORT ROUTING 55Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-4 AFMAN91-223 6 JULY 2004Chapter 1 GENERAL INFORMATION 1.1. Overview. This manual

14、 provides aviation unique guidance to support AFI 91-204, Safety Investiga-tion and Reports. It directs procedures specific to investigating and reporting USAF aviation mishaps andevents. 1.2. Non-reportable mishaps. Do not report Aviation Mishaps meeting Class D dollar cost or injury cri-teria as d

15、efined in AFI 91-204, paragraph 1.8.4. 1.3. Aviation Events that Require Safety Investigations and Reports. 1.3.1. Class E Events. Events that do not meet reportable mishap classification criteria described inAFI 91-204, paragraph 1.8. and have a high potential for causing injury, occupational illne

16、ss, or dam-age if they recur (high potential for becoming a mishap). Class E events are deemed important toinvestigate and trend for mishap prevention. Unless noted, report all events whether intent for flight isestablished or not. In most cases, events do not require reporting if they occur as desc

17、ribed in the air-craft flight manuals and are expected responses to crews actions or flight regime. For example, do notreport the loss of pitot-static instrument indications if the loss is the result of crew failure to activatethe pitot heat. If the circumstances of an event meet two or more criteri

18、a, such as an in-flight firewhich results in a physiological episode, report the event utilizing the following hierarchy: Physiolog-ical, Propulsion, Flight Control, Instrument, Miscellaneous, High Accident Potential (HAP). Hazard-ous Air Traffic Report (HATR), Controlled Movement Area (CMA) Violati

19、on, Bird/Wildlife AircraftStrike Hazard (BASH). 1.3.1.1. Physiological Events. Report episodes of abnormal physical, mental, or behavioral condi-tions or symptoms which occur during or after flight. For assistance in determining reportability ofphysiological events, contact the owning MAJCOM SEF, SG

20、P, or HQ AFSC/SEFL, DSN246-0830/0880, commercial (505) 846-0830/0880. The following events must be reported: 1.3.1.1.1. Aircrew or passenger decompression sickness from evolved gas (bends, chokes,skin, neurological, or neurocirculatory manifestations). 1.3.1.1.2. Aircrew loss of consciousness or inc

21、apacitation in-flight. 1.3.1.1.3. Aircrew hypoxic (altitude) hypoxia (suspected, probable, or definite). 1.3.1.1.4. Aircrew trapped gas disorders (ear, sinus, teeth, or abdominal). 1.3.1.1.5. Aircrew or passenger symptoms or health effects caused by toxic, noxious, or irri-tating materials such as s

22、moke, fumes (including carbon monoxide) or liquids. 1.3.1.1.6. Aircrew G-induced loss of consciousness. 1.3.1.1.7. Aircrew spatial disorientation of any type (including visual illusion) resulting in anunusual aircraft attitude. 1.3.1.1.8. Any medical condition, event or physical injury directly resu

23、lting from performanceof flight activities that an aeromedical professional determines is significant to the health ofthe aircrew. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-AFMAN91-223 6 JULY 2004 51.3.1.1.9. Aircrew degraded operational capabi

24、lities or retinal damage caused by military orcommercial lasers. 1.3.1.2. Propulsion-Related Events. Report the following propulsion related events: 1.3.1.2.1. Loss of thrust sufficient to prevent maintaining level flight at a safe altitude orwhich requires the pilot to jettison stores. 1.3.1.2.2. E

25、ngines which do not restart normally after an intentional in-flight engine shutdownfor training, functional check flight (FCF) or other non-emergency purposes. A normal restartis one that occurs at the planned and expected time and altitude using routine restart proce-dures. 1.3.1.2.3. Emergency or

26、precautionary landing of a single engine or rotary wing aircraft, withimminent engine or rotor drive system failure confirmed after landing. 1.3.1.2.4. Any unselected or inadvertent propeller or thrust reversal event. 1.3.1.2.5. Turbine engine flameout, failure, or emergency shutdown after completin

27、g normalengine start sequence until normal engine shutdown at mission conclusion. This applies to allsingle engine and multiple-engine aircraft. Do not report: 1.3.1.2.5.1. Flameouts or emergency engine shutdowns occurring during maintenanceengine runs 1.3.1.2.5.2. Intentional inflight engine shutdo

28、wns for training or FCF. 1.3.1.2.6. All F-16 engine stalls, when operating outside of Region 1 (except F100-PW-200engine stalls). Do not report stalls occurring during maintenance engine runs. 1.3.1.2.7. All F-15 engine stalls, occurring during afterburner operation that involves maneu-vering flight

29、 (except F100-PW-100 engine stalls). Do not report stalls occurring during main-tenance engine runs. 1.3.1.3. Flight Control-Related Events. 1.3.1.3.1. Unintentional departure from controlled flight for any reason. 1.3.1.3.2. All uncommanded inputs to the flight controls (including stability augment

30、er, auto-pilot, or trim systems) whether it results in a dangerous situation or not. Report autopilot faultsif, in the opinion of the investigator, the autopilot would have put the aircraft in a dangeroussituation. 1.3.1.3.3. All uncommanded reversions to a backup mode for any safety critical flight

31、 controlsystem. 1.3.1.3.4. Aircraft side stick controller interference from any source or for any reason. 1.3.1.4. Instrument-Related Events. 1.3.1.4.1. In-flight loss of all pitot-static instrument indications. 1.3.1.4.2. In-flight loss of both primary and standby attitude indicators. 1.3.1.4.3. Si

32、multaneous loss of more than one electronic display (i.e.; Multi-function Display/CRT) showing attitude, altitude, airspeed or heading. Report regardless of duration of event orability to fly the aircraft on standby instruments. Provided by IHSNot for ResaleNo reproduction or networking permitted wi

33、thout license from IHS-,-,-6 AFMAN91-223 6 JULY 20041.3.1.5. Miscellaneous Aircraft Events. 1.3.1.5.1. In-flight fires. 1.3.1.5.2. Massive fuel leakage in an engine bay. 1.3.1.5.3. All gear up landings. 1.3.1.5.4. Unintended departure from takeoff or landing surfaces, (e.g. runway, helipad, land-ing

34、 zone, etc.) onto adjacent surfaces. Includes landing short of the landing surface. For thepurposes of this manual, the overrun is considered part of the takeoff or landing surface. 1.3.1.5.5. Spillage or leakage of radioactive, toxic, corrosive, or flammable material from air-craft stores or cargo

35、that creates a hazardous condition or an airborne emergency divert. Iden-tify in the message which agency or unit prepared the shipment. If cargo is shipped under awaiver, tell which agency (MAJCOM, Numbered Air Force, etc.) granted the waiver. 1.3.1.5.6. Explosive/missile releases impacting outside

36、 of the impact area. If a malfunction ofthe explosive or missile is involved, report as explosive/missile mishap. 1.3.1.5.7. Any unintentional strike by an aircraft or UAV to another object. 1.3.1.5.8. All events where a member of the crew executed any portion of an emergencychecklist in response to

37、 smoke or fumes. The intent is to report those noxious fumes and/orvisible particulate matter that the crew has decided constituted a safety hazard versus anannoying odor. If the event meets the reporting criteria in paragraph 1.3.1.1., report as a “Phys-iological Event.” 1.3.1.5.9. In-flight malfun

38、ction of an air refueling drogue, hose, hose reel assembly, or refuel-ing pod. 1.3.1.5.10. Structural failure of critical landing gear components. A critical landing gear com-ponent is defined as any component that could cause landing gear collapse upon failure. 1.3.1.5.11. In-flight hoist malfuncti

39、ons involving inadvertent separation of the hoist cablefrom the hoist (i.e., inadvertent cable shear or cable unwrapping from the drum). 1.3.1.6. High Accident Potential (HAP) Events. Report any hazardous occurrence that has a highpotential for becoming a mishap as a HAP event. This includes emergen

40、cy conditions arising fromaircraft operation or from the failure or malfunction of systems or components essential for safeflight. 1.3.1.7. Hazardous Air Traffic Report (HATR) Events. Report any air traffic or movement areahazardous occurrence that endangers the safety of an aircraft or UAV. The int

41、ent of the HATR pro-gram is to identify potentially hazardous aviation practices or procedures based on a particularevent and to disseminate information that might prevent similar hazardous conditions at otherUSAF locations or operations. See paragraph 6.2. for specific HATR reporting guidance. Repo

42、rtthe following: 1.3.1.7.1. Near Mid Air Collision (NMAC): Aircrew took abrupt evasive action to avoid acollision or would have taken evasive action if circumstances allowed. 1.3.1.7.2. TCAS Resolution Advisories (RA): TCAS RAs (involving USAF aircraft/UAV)that require the aircraft/UAV to deviate fr

43、om an assigned clearance. This includes USAF air-craft/UAV triggering TCAS RA aboard civil or other DOD aircraft. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-AFMAN91-223 6 JULY 2004 71.3.1.7.3. Air Traffic Control (ATC) Services: Any ATC service

44、that contributed to a hazard-ous air traffic condition. Example: Failure by ATC to maintain required separation betweenaircraft under their control. 1.3.1.7.4. Pilot Procedures: Any aircrew actions that contributed to a hazardous condition. 1.3.1.7.5. Navigational Aid (NAVAID): An equipment indicati

45、on/malfunction that contrib-uted to a hazardous air traffic condition. 1.3.1.7.6. Flight Information Publication (FLIP)/ Notice to Airman (NOTAM): Any occur-rence with the FLIP/NOTAM publications that contributed to a hazardous condition 1.3.1.7.7. Ground Events: Any occurrence caused by an aircraft

46、, vehicle, or pedestrian in themovement area (e.g. taxiway/ramp/parking area) that endangers an airborne aircraft or an air-craft operation on the ground. 1.3.1.7.8. Runway Intrusions: Unauthorized entry of a runway or other surface used for take-off and landing of aircraft that results in aircraft

47、endangerment. 1.3.1.7.9. Publications/Directives: Errors in air traffic publications/directives that contributedto a hazardous air traffic condition. 1.3.1.7.10. Communications: Any communications, or lack thereof, that contributed to a haz-ardous air traffic condition. 1.3.1.8. Controlled Movement

48、Area (CMA) Violation Events. Reference AFI 91-204, Attachment1, for CMA definition. Report airfield infractions caused by aircraft, vehicles, or pedestriansentering the CMA without specific control tower approval. See paragraph 6.2. for specific CMAViolation event reporting guidance. If the violatio

49、n resulted in the endangerment of an aircraft,report as a Class E HATR event. 1.3.1.9. Bird/Wildlife Aircraft Strike Hazard (BASH) Events. Bird/wildlife strikes (damaging andnon-damaging) with less than Class C damage thresholds. Bird/wildlife strikes to captive or livemunitions (explosive/missiles) are reported as aviation events. A message is not required for strikeevents if no other Class E criteri