Chapter 16
FLIGHT SURGEON IN FLIGHT SAFETY
revised by Louis D. Eldridge, M.D., M.P.H. and David M. O’Brien, M.D., M.P.H.
INTRODUCTION
"The flight surgeon's role in flight safety is of paramount importance. Indeed, the flight surgeon's rating and flying status are justified, to a great degree, by his contribution to flight safety..." This opening statement published 20 years ago is as true today as it was then. The roots of the flight surgeon are founded in the need to produce qualified individuals to fly. During World War I, Great Britain discovered that out of every 100 fliers killed, only two died in combat and eight died due to defective aircraft. Ninety of those killed, died due to the individual causes, with 60 of these being physical defects. With the institution of an aviation medical program, deaths due to physical defects were reduced to 12% in 3 years. However, with increasing technology advances, the "machine" has become more reliable, and accidents due to parts failure significantly reduced. In the latter 20th century, a renewed emphasis on the "human" has occurred. As USAF aircraft and missions become more complex, aircrews have increasingly become more tasked to "stay ahead" of the machine. While computers have removed some of the manual and mental tasks aviators performed in the past, they have also imposed new taskings. In light of these ongoing changes, the flight surgeon must stay at the forefront of flight safety to assure as smooth a "human-machine" interaction as possible. To this end, the flight surgeon must stay active in several areas pertaining to safety. These areas will be discussed in this chapter.
USAF Program
"Safety is everyone's business" is an old saw. In the Air Force this is true to the point that directions for policy formulation begin at the level of the Secretary of the Air Force. The Air Force Inspection and Safety Center (AFISC) implements these orders and directives. It performs the safety and nuclear surety responsibilities of the USAF Chief of Safety Inspector General. These responsibilities are divided among three operational divisions, Aviation Safety, Ground Safety and Weapons Safety. This, in turn, is divided into the Directorate of Aerospace Safety and Directorate of Nuclear Surety.
When flight surgeons consider safety issues, they are usually referring to the responsibilities under the Director of AviationAerospace Safety. Areas of responsibility include: managing mishap prevention information, education, and training; conducting or taking part in mishap investigations; and conducting studies to predict, identify causes, and prevent future mishaps. Insuring human factor and life sciences considerations are incorporated into aerospace safety programs is also the responsibility of AFISC. The repository for all mishap investigation reports is at AFISC.
Specific safety disciplines are flight safety, weapons safety, ground safety and system safety. Weapons safety deals with handling of conventional and nuclear weapons including the training of personnel. The flight surgeon's involvement in such a program will depend on the local mission. In weapons management, the flight surgeon should be concerned with the occupational hazards encountered in weapons handling, as well as the stresses encountered by missile crews.
Ground safety is concerned with occupational illness and injury as well as traffic safety. System safety applies engineering and management principles, criteria, and techniques to optimize safety in specific systems. System safety is in force throughout the life of a system and is incorporated into acquisition of new systems. Flying safety will be discussed further in this chapter. The major command (MAJCOM) is responsible for disseminating information to units in its command as well as monitoring corrective actions taken. It also develops and carries out education and training to meet the needs of the command.
Local Programs
At the local level, from commander to supervisor, each individual is responsible for implementing safe practices and policies to prevent mishaps. Each installation has a safety council, run by the host unit, supporting all tenants. The Safety Council may have subcommittees if needed. This council functions as a forum to discuss solutions to safety problems. A member of the medical services, potentially a flight surgeon, should be an active participant. Other committees include the Occupational Safety and Health Council and Traffic Safety Committee. The flight surgeon should, if not a member, be aware of these various committees and their functions. Safety of flight is not limited just to the aircrew and flying but includes all those areas that must mesh together to form a fully functional, mission ready unit. The health and safety of support personnel should not be neglected.
The host base safety office is also responsible for conducting the base flight safety program when a flight safety officer (FSO) position is authorized. Otherwise, the largest tenant with a FSO authorization is responsible to conduction the base flight safety program. The FSO monitors and inspects all areas pertaining to the flying program including facilities, procedures, and environmental factors. This individual is also responsible for maintaining a list of people qualified to participate on mishap investigation boards.
FLIGHT SAFETY
Flight safety is the area that most flight surgeons are intimately aware of and deal with on a day-to-day basis. Flight safety for the operational flight surgeon begins the day an individual presents for their initial flying class I physical. The flight surgeon is tasked with applying the standards set forth in AFI 48-123 (Medical Examination and Medical Standards) to screen out aviator candidates with potentially compromising aeromedical conditions. Though no one desires to be the bearer of bad tidings, it is wiser to deny entry into flying training, than to remove the individual during training or prior to completing a full flying career. Reducing human factor incidents and accidents began with the physical in World War I and is no less pertinent today.
Annual preventive health appraisals (PHA)physical examinations and routine medical care are designed to both monitor and maintain the health of the crew, and should include clinical preventive medicine in key areas (e.g., cardiovascular disease). Illness or injury must be evaluated in light of their impact on flight safety and mission completion, as well as potential exacerbation of the condition by the abnormal environment of flight. Unfortunately, fliers often fear their wings will fall off if they walk into the flight surgeon's office. This notion can only be overcome by building rapport with the air crew and maintaining an air of unscrupulous professionalism and fairness. A level of trust and respect must be developed with crewmembers to encourage early reporting of illnesses. The flight surgeon must prove knowledgeable in areas of flight medicine and is also encouraged to follow the popular literature on the latest medical fads and remedies. These topics will come up during social activities, providing an opportunity to demonstrate professional competence (which builds confidence in the crew) and educate the aviation community. Formal aeromedical education during Commander’s Calls and Flying Safety Meetings should be ongoing.
FLYING SAFETY PARTICIPATION
The flight surgeon's involvement in flying and flying safety activities is one of the most important aspects of the position. Through flying, the flight surgeon experiences those psycho- physiologic stresses that aircrew experience. An attempt should always be made to participate in all flight profiles of the mission. The flight surgeon should become thoroughly familiar with all life support equipment. The experience and knowledge of these activities helps provide the good judgment required to make DNIF (duties not involving flying) and return to flying recommendations for aircrew. Remember, the flight surgeon makes the final determination on return to flying when aircrew are treated by other medical specialties. (Clearance for return to duty by general surgery does not necessarily equate to fully functional in the cockpit). The flight surgeon should make regular visits to the flight line, both formal and informal. This provides further opportunity to build rapport and learn the "personality" of the squadron. Participation in social events and squadron activities is encouraged, particularly for squadron medical elements. As a respected and involved squadron member, your expert observations of safety, morale, and personnel issues are of interest and importance to the squadron leadership.
A relationship should be established with the wing level FSO and each squadron level FSO. Squadron level flight surgeons should participate in squadron level safety meetings as much as possible. The flight surgeon's office should be in the loop to review all mishap reports and summaries (e.g., Blue Four News) received in the unit to look for incidents with human factor elements pertinent to the flying mission of the unit. The flight surgeon should have a recurring list of briefings to be presented at unit flying safety meetings. This can be built into the yearly calendar of the flight surgeon office activities. These should be relevant to the mission, brief and timely (e.g., heat injury during the summer). Briefing packages are available through the local audio-visual services, but avoid canned, scripted presentations. Use local scenes, personnel and incidents to keep interest. Follow available publications such as the TIG Brief and MAJCOM newsletters for ideas and topics. Above all be knowledgeable and creative. Aviators are an intelligent group and many will have heard these topics several times during their career. Topics generally covered on a recurrent basis include self medication, environmental stresses, cardiovascular risk factors, and self imposed stresses.
Involvement with squadron safety activities allows the flight surgeon to observe first hand those areas that are potentially hazardous to safety of flight. The previously established relationship allows the flight surgeon to express these concerns with the supervisors and individuals involved with greater ease. More formal procedures exist for those areas which are not satisfactorily resolved or which require input from outside agencies. The AF Form 457, USAF Hazard Report, is generally used for those areas not covered by other programs such as the Hazardous Air Traffic Report (HATR) Program (AFIR 91-202127-3). The HATR is more specific to air traffic flow and air space management and is an important part of the Midair Collision Avoidance Program.
MISHAP INVESTIGATION
Participation of the flight surgeon in all aspects of the flying mission is key to the further reduction of mishaps due to human factors. The flight surgeon is in a prime position to see "human-machine" mismatch (flying and nonflying) and pass this information to the research and development elements of the USAF and to directorates and major commands responsible for implementing changes. Unfortunately, despite best efforts, incidents and mishaps still occur. The flight surgeon must be prepared for the eventuality, whether it occurs during his or her career or not. Mishaps can be categorized as Class A, B, C, or D according to total dollar cost, levels of injury, or loss of work-days. These categories apply whether the mishap is an aircraft or ground mishap.
Physiological Incidents
According to AFI 91-204 a physiologic episode is defined as "in-flight events of a physical, physiological, medical, pathological, psychological, pharmacological, or toxicological nature which compromises performance, confuse, disorient, dull, distract, pain, endanger or incapacitate." This is a Class C Mishap even when no damage or lost workdays occurs. Within this category are subdivisions requiring standard reports (complete AF Form 711gC, Life Sciences Report of a Class C Physiologic Mishap and a 72 hour history) and those requiring an abbreviated version. Those requiring a standard report include such things as hypoxic hypoxia, decompression sickness, and G-induced loss of consciousness. An abbreviated report may be submitted for such things as hyperventilation, spatial disorientation, and toxic substances in the cockpit. This is not an all-inclusive list. The AFI 91-204 should be consulted and, when there is doubt, Air Force Safety CenterAgency, Life Sciences BranchDivision (HQ AFSCA/SEFL), MAJCOM or the Aerospace Medicine Division of the Surgeon General's office (AFMOAUSAF/SGOPA) should be contacted.
Aircraft Mishap Investigation
The investigation of a downed aircraft with fatalities is one of the least desirable aspects of the job of flight surgeon. It is a grim task which on the surface may appear unrewarding, yet it is essential that each mishap be investigated thoroughly to determine what the cause is and what measures can be undertaken to prevent its recurrence. Investigating a mishap is in some ways, similar to diagnosing an illness. A thorough history and physical must be performed to determine the most probable cause. Unfortunately, in mishap investigation, the history (what happened) must sometimes is determined from what remains of the physical (the wreckage).
Pre-response preparation. Just as no physician can respond and diagnose illness without certain skills and tools, neither can a flight surgeon respond to a mishap without preparation. Response begins with a well organized disaster response. Each installation must have a Disaster Preparedness Operations Plan (OP 32-1355-1) in accordance with AFI 32-4001R 355-1 and an Aircraft Mishap Response Plan (OP 127-1) in accordance with AFI 91-202R 127-3. The Director of Base Medical Services (DBMS) is responsible for the Medical Annex of the OP 32-1355-1. Each flight surgeon should be thoroughly familiar with these. They should outline procedures for each contingency and the equipment required. The chain of command at various stages of a response should be understood. For example, the Fire Chief is usually in command until the area is deemed safe, then the on-scene commander takes over. The personnel who need to be there should be delineated by position.
Realistic training is needed to ensure safe proceedings during contingencies. Chaos cannot always be avoided in real situations but it can be minimized through preparation. The flight surgeon is usually part of the initial response team. All technicians should be thoroughly familiar with all procedures and policies. As the medical officer of the day (MOD) and emergency room (ER) technicians are the initial responders during off duty hours, training with these individuals must not be neglected. Coordination of supply locations, ambulance configurations, and procedures can smooth the interaction between the various groups. All personnel involved should be familiar with the equipment and capabilities of the crash ambulances. Training should not be limited to equipment usage but include personal conduct at crash sites. Individuals responding to a crash site must have it emphasized not to disturb any of the wreckage or to move any remains until cleared to do so by someone in authority. Who the authority is should be clearly understood before proceeding to a site. The general plan of action should be understood before any mishap ever occurs. Specialized training in mishap investigation is also available at the School of Aerospace Medicine (Aircraft Mishap Investigation and Prevention Course), the Safety Center at Kirtland AFB, and other resources.
The flight surgeon should have a crash response kit prepacked and available. The content will be influenced by the nature of the mission and the aircraft that frequent the air field. A primarily single seater response will vary from a multiplace aircraft response. The nature of the terrain will also influence the needs. (A sample kit may be found in the aviation pathology chapter of this publication.)
The question of jurisdiction should be established before any mishap occurs. Authority over any deceased will vary depending on whether the land is federal, state, or county land. All military facilities are not necessarily federal reservations. A close working relationship with the local coroner should be established and letters of agreement should be drawn with the assistance of the local staff judge advocate (SJA). Investigations conducted in foreign countries must be conducted under both AFI 91-204 and NATO Standardization Agreement (STANAG) 3531. The convening authority and local SJA should be consulted for any special requirements.
Response. Response can vary depending on whether it is an on base or off base response. The organization is slightly different in the two cases.
a.) On or near base. Notification of a crash generally comes over two networks. The primary network links members of the initial response team: the control tower, flight medicine, fire/crash rescue, operations, and security. The secondary network will include the command post, the safety office, and support organizations. The primary network is usually activated by the control tower. A crash message is disseminated to include: 1) type of aircraft, 2) nature of the emergency, 3) location of crash or landing runway, 4) expected arrival time, 5) number of souls on board, 6) hazardous cargo, 7) other pertinent information. The crash ambulance, with the flight surgeon and technicians, should assemble at a point previously designated in the Disaster Response Plan or as directed by the Fire Chief and remain there until cleared to enter the area. The location is generally 2000 feet or more away. If there are survivors, avoid the urge to charge in to take them. Rescue will bring them to a safe area or will clear the medical team into the area when it is safe. When there are survivors, the medical team's primary responsibility is to them. Where multiple casualties are involved a system of triage may be needed. Specific areas for casualty management should be designated with standard nomenclature (minimal, delayed, etc.,) used. If more medical support is needed this should be conveyed to the medical command post. The responding flight surgeon becomes the on scene medical representative and must act as liaison between the medical treatment facility and crash scene. It is this individual's responsibility to keep the medical command post abreast of numbers and types of casualties, need for additional support and any facts the command post needs to make decisions. Once all survivors have been treated and transported from the scene, the flight surgeon provides medical support for the disaster response team and begins the on scene investigation and recovery procedures.
b.) Off base (remote). An off base response will generally come as a notification through the command post. All responding personnel will proceed to a prearranged assembly point for convoy to the area, especially if no air lift is available. Again, medical personnel should enter the area, once reached, only when it is declared safe. If survivors have been rescued by local personnel, a flight surgeon should contact the receiving hospital and arrange for the performance of laboratory studies necessary for the investigation to follow. This should be done in conjunction with all the other preparations for departing the base especially when there will be a delay in reaching the site and the survivors. Equipment and supplies appropriate to the area should be carried. In some cases, backpacks may be the only feasible way. The flight surgeon must also care for all individuals at a remote site, therefore first aid supplies must be on hand for emergencies. Consider where the nearest available medical support is, terrain, climate, and physical condition of the response team members. Personal survival kits are a must. Remember, the flight surgeon may be there for the duration. As on base, once survivors' needs are taken care of attention can be turned to the deceased.
Post Response. Once the survivors have been taken care and the remains of the deceased secured or removed, the investigation is turned over to the interim investing board, of which the responding flight surgeon may be a member. The responding team may return to normal duties but an assessment of the adequacy of response should be made as soon as possible to include supplies and equipment evaluations (too little, inappropriate, not available) and personnel (adequately trained, management). These evaluations should be used to make changes in the disaster response plan and improve future response.
Another aspect which is neglected in evaluating personnel is the psychological impact of the mishap on the response team members and the community. Opportunity should be made for individuals to express feelings about what was witnessed at the scene. Remember that most responding personnel, including the flight surgeon, may have never been involved in something of this nature before. A Critical Incident Debriefing or other intervention by mental health workers should be considered responding or on-site workers. Other interventions must be considered for family, friends, and squadron members of the persons involved in the mishap. Because of the rapport developed between the flight surgeon and the squadron, the flight surgeon is more accepted and able to intervene in the flying community. In consultation with experienced mental health professionals, the squadron flight surgeon can plan where, when and how this intervention should occur.
Safety Investigation Board
The safety investigation board (SIB) can be divided into two categories: an interim investigation board and a permanent investigation board. Depending upon the availability of personnel, the initial response flight surgeon may also serve as the board flight surgeon for both of these categories. However, it is usually preferred that a flight surgeon not associated with either the mishap unit or its base, perform the SIB medical officer duties of the permanent board.
Interim Safety Board. The functions of the interim safety board are to secure the area and gather initial perishable data for the permanent safety board. This phase begins when the disaster response ends. Materials to be secured include voice recordings, flight plans, passenger manifests, aircraft documents, fuel samples, both at the site and at the refueling sites. Names of witnesses with addresses should be obtained as soon as possible. The interim board also arranges support for the permanent board, issues the required preliminary reports, and interacts with the media.
Those initial actions specific to the medical member include impounding medical and dental records of crewmembers and other individuals who may have played a role in the mishap, assuring that proper laboratory studies have been performed on survivors, coordination with Mortuary Affairs and the local coroner, if necessary, for recovery of remains and notification of Armed Forces Institute of Pathology (AFIP) of any fatalities. Upon arrival at the scene of the mishap, the interim flight surgeon should make a walk-through with the purpose of getting a general idea of the layout of the mishap area. This ideally should begin before the impact site. Notes of the location of life support equipment should be made. Care should be made not to destroy fragile evidence such as ground scars before they can be documented by photography or can be reviewed by the formal Safety Investigation Board (SIB). Documentation of the condition of remains must be done before removal; therefore, a photographer and perhaps a recorder should accompany the flight surgeon. The flight surgeon should have photographic support available either through the base audiovisual services or possess a camera as part of the crash investigation kit. The interim medical officer must emphasize to the on-scene commander the need not to hurriedly remove remains until all documentation, including diagramming, has been performed. All remains and life support equipment should be photographed in place and in all aspects. Remember, however, that life support equipment can be dangerous. If in doubt have an explosive ordinance disposal (EOD) person, in coordination with a life support expert examine such things as ejection seat rockets for safety. Personal effects and life support equipment should not be removed from the remains at the site.
Search and recovery of remains is the responsibility of the mortuary affairs officer and methods for systematically performing a search and recovery procedure are detailed in AFR 143-1 and AFP 127-1 (Vol I). Removal of remains must be coordinated with the on-scene commander and the flight surgeon. As a medical/ safety expert, the flight surgeon should ensure recovery efforts are conducted without unnecessary risk and with the appropriate personal protective equipment. This includes disposable gloves, and possibly masks, eye shields, and fluid impermeable outer garments. Removal of remains is on the approval of the safety board president; however, this aspect of the investigation is usually delegated to the investigating flight surgeon. Once remains have been removed, life support equipment should be taken to a place for examination by individuals specializing in the equipment in question.
Once all remains and equipment have been removed from the site, the process of definite identification begins. Specific requirements exist for documentation of death and identity. These are outlined in AFR 143-1. Autopsies are required on all crewmembers involved in the operation of the aircraft (AFI 48-125). They may also be performed on individuals who may have contributed to the mishap and on others as needed to establish identity and patterns of injury. If assistance is needed, it can be provided by the Air Force Mortuary Affairs (HQ AFSVA/SVOM), identification specialists. When two or more fragmented bodies are involved they should be called. Items of particular interest in performing autopsies is looking for evidence of pre-existing disease, toxicological factors, and patterns of injury. Specifics of aviation pathology, including toxicology and patterns of injury, are detailed elsewhere in this publication. AFIP can be requested to provide assistance through the MAJCOM or by contacting the technical assistance unit at AFSCA. All toxicological specimens must be sent to AFIP for examination. It is advisable to draw dual samples, those for AFIP and those to be performed locally, the results of which may be more quickly available. A copy of the autopsy should be sent to AFIP along with tissue specimens, X- rays, autopsy photos, and a narrative summary of the accident sequence. In addition, a copy of the autopsy must be submitted to HQ AFSCA/SEFL. This may be part of copy 1 of the formal report.
Life support equipment, specifically garments removed during the autopsy, should be stored in a large, ventilated, secure room. They can be sprayed with Lysolâ and should be allowed to dry. Preservation of all life support equipment may be critical to accident reconstruction. Expert consultation is available on life support equipment by the Mr. Michael Grost, Life Sciences Equipment Lab, HSC/YADTL, Bldg 323183, 514 Shop Lane 450 Quentin Rd, Kelly AFB, TX 78241-643416 (DSN 945-4999, Comm 210-925-4999).
Once all autopsies are complete and laboratory analyses performed, an analysis of "what happened?" begins. Part of this analysis is derived from interviewing witnesses. Interviewees must be advised of the nature and purpose of the investigation and the use of these interviews. They must understand the purpose is prevention of future mishaps and not punitive. Survivors, commanders, bereaved spouses, and friends must be interviewed as well as the farmer who was standing in the field at the time of the incident. Interviews with survivors and witnesses must be performed as soon as possible after the event. This is one of the most perishable pieces of evidence of all. Memory of events becomes more unreliable the further away from the event the interview becomes. Aids to enhance recall are; to place the witness back in the situation if at all possible; to return to the farmer's field; and sit in the cockpit of a simulator of the aircraft. Whatever will help the witness recall the facts as accurately as possible should be attempted if feasible. The flight surgeon will generally focus on interviews pertinent to human factors elements; however, any facts of a nonhuman factors nature uncovered during these interviews should be communicated to the board members in aiding their portion of the investigation. Ideally interviews should be recorded on tape. Coordination with other board members helps prevent confusion.
Permanent Safety Investigation Board...
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