BY ORDER OF THE AIR FORCE INSTRUCTION 91-204 SECRETARY OF

472 Pages·2000·3.03 MB·English

BY ORDER OF THE AIR FORCE INSTRUCTION 91-204
SECRETARY OF THE AIR FORCE
29 NOVEMBER 1999
Safety
SAFETY INVESTIGATIONS AND REPORTS
COMPLIANCE WITH THIS PUBLICATION IS MANDATORY
NOTICE: This publication is available digitally on the SAF/AAD WWW site at: http://afpubs.hq.af.mil.
If you lack access, contact your Publishing Distribution Office (PDO).
OPR: HQ AFSC/SEP (Lt Col Jay Johnson) Certified by: HQ USAF/SEP (Col David Capotosti)
Supersedes AFI 91-204, 1 October 1999. Pages: 472
Distribution: F
This instruction gives procedures for investigating and reporting all US Air Force mishaps and exchang-
ing F-16 mishap information with European Participating Air Forces (EPAF). It implements 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, and those persons who
handle such reports. This instruction provides guidance regarding the control and use of privileged safety
reports. Failure to observe the prohibitions and mandatory provisions of this instruction in Chapter 2 by
active duty Air Force members, USAFR members on active duty or inactive duty for training, and ANG
members in federal, is a violation of Article 92, Uniform Code of Military Justice (UCMJ). Violations by
civilian employees may result in administrative disciplinary actions without regard to otherwise applica-
ble criminal or civil sanctions for violations of related laws. This regulation implements NATO Standard-
ization Agreements (STANAG) 3101, Exchange of Accident/Incident Information concerning Aircraft
and Missiles; 3102, Flight Safety Cooperation; 3531, Safety investigation and Reporting of Accident/Inci-
dents Involving Military Aircraft and/or Missiles; and 3750, Reporting and Investigation of Airmiss Inci-
dents. Maintain and dispose of all records created by processes prescribed in this publication IAW
AFMAN 37-139, Records Disposition Schedule.
Send major command (MAJCOM) supplements to HQ USAF/SE, 9700 G Avenue SE, Suite 240, Kirtland
AFB NM 87117-5670, for approval before publication.
See Attachment 1 for a Glossary of References and Supporting Information.
SUMMARY OF REVISIONS
This document is substantially revised and must be completely reviewed.
This revision incorporates IC 99-1 and includes substantive changes and numerous additions. It redefines
nearest Air Force Base responsibilities after a Class A Flight mishap (paragraph 1.1.7.1.); defines host and
tenant investigative responsibilities (paragraph 1.3.1.5.); defines ARC convening authority (paragraph
1.5.1.2.); deletes paragraph 1.5.1.3.; redefines disclosure of privileged information to outside agencies
2 AFI91-204 29 NOVEMBER 1999
(paragraph 1.11.1.1.); redefines administrative hospitalization (paragraph 1.15.1.3.); redefines component
parts (paragraph 1.15.1.7.); redefines jettison of non-essential equipment (paragraph 1.15.1.14.). Adds
additional privileged release authority for mishap report information (all added or changed paragraphs).
Redefines aircraft ground operations (paragraph 3.1.3.1.3.); redefines government motor vehicle (para-
graph 3.1.3.4.1.); adds new definition of fire (paragraph 3.1.3.9.); redefines Class J mishap (paragraph
3.2.3.1.); standardizes definition of HAP (paragraph 3.2.4.4.); deleted paragraph 3.4.1.3.; clarifies costing
methods in paragraphs 3.4. and 3.5. Redefines role of AIB investigators (paragraph 4.1.2.4.); adds single
investigator (paragraph 4.4.1.1.). Expands identifying involved personnel (paragraph 5.6.2.1.); redefines
role of SIB or single investigator and OPR action agencies for the AF Form 847 process (paragraph
5.10.3.1.); redefines how to inform causal individuals (paragraph 5.10.5.1.). Defines what type of
changes the MAJCOM/DRU/FOAs can make on Class C, D, E, HAP, and HATR messages (paragraph
6.1.5.3.); clarifies which reports are MOFE’d (paragraph 6.2.1.1.); requires reporting status on all recom-
mendations (paragraph 6.3.2.1.). Redefines Class E Event reporting criteria and adds exception (para-
graph 7.2.3.1.); expands on the use of a Single Investigator (paragraph 7.3.1.4.); adds CMR format for
Class E Events (Figure 7.5.); updates address tables for messages and formal reports (Tables 7.1. to 7.4.).
Redefines missile mishaps (Paragraphs 8.1.1. through 8.1.2.4.8.2. and Table 8.5.). Deletes requirement
for submission of preliminary/status reports for Class D mishaps and HAPs (Table 8.1.). Redefines
explosives and chemical agent mishaps (Paragraphs 10.1.2. through 10.1.2.4.6.3. and Table 10.4.).
Deletes requirement for submission of preliminary/status reports for Class D mishaps and HAPs (Table
10.1). Fire mishaps include the reporting of both injury and damage as of the result of a fire (paragraph
11.1.1.1. and 11.5.5.1.); Ground and Industrial Mishaps involving Aircraft damage is limited to the air-
craft being a commodity or cargo (paragraph 11.5.2.1.); redefines the GMV and PMV Mishap sub-catego-
ries (paragraph 11.5.1.2. and 11.5.1.4.); Establishes reporting requirements of on- and off-duty Sports and
Recreation Mishaps (paragraph 11.5.2.5. and 11.5.4.4.); Loss of Air Force resources aboard non-DoD
Aircraft (commercial, foreign, civil, and Aero Club) with intent for flight are reported as Miscellaneous
Air Operations Mishaps (paragraph 11.5.2.4.); adds Class L events for optional use by local safety staffs
(paragraph 11.6.6.1.); deletes Abbreviated CMR Report format (Figure 11.4.); adds military off-duty
injury recording requirements for the Occupational Illness and Injury Log (paragraph 11.9.3.1.). Corrects
figures to ensure sequence numbers are based on a fiscal versus a calendar year (Figures 12.1 and 12.2).
Reclassifies all Engine Confined Incidents as Mishaps (Class J) and consolidated reporting guidance.
Deletes all “Class M” references. Replaces Chapter 13 in its entirety. Reformats Table 14.1 and updates
addresses in Table 14.2. Redefines reporting procedures, report formats and reporting categories.
Replaces Attachment 2 in its entirety. The entire text of IC 99-1 is at Attachment 7.
Chapter 1—RESPONSIBILITIES 11
1.1. Responsibilities for Air Force Mishaps. .................................................................... 11
1.2. Assigning Mishap Accountability. ............................................................................ 16
1.3. Determining Who Investigates. ................................................................................. 16
1.4. Acting on Critical Safety Information. ...................................................................... 18
1.5. Investigating ARC Mishaps: ...................................................................................... 18
1.6. Investigating Mishaps Involving Multiple Services. ................................................. 18
1.7. Investigating Mishaps Involving NATO Aircraft, Explosive, ................................... 19
1.8. Investigating Mishaps Involving Foreign Military Aircraft, Explosives, .................. 20
AFI91-204 29 NOVEMBER 1999 3
1.9. Contractor Involvement in Mishaps. ......................................................................... 21
1.10. Investigating Mishaps Involving Civil Aviation. ...................................................... 22
1.11. Investigating Potential Criminal Acts. ....................................................................... 23
1.12. Investigating Mishaps Involving Research and Development (R&D) Programs. ... 24
1.13. Using Test Organizations in Investigations. .............................................................. 24
1.14. When to Obtain Legal Representation. ...................................................................... 24
1.15. Non-Reportable Mishaps. .......................................................................................... 25
Chapter 2—PRIVILEGE GUIDELINES 28
2.1. Defining Types and Limiting Use of Safety Reports. ............................................... 28
2.2. Transmitting Safety Messages over Electronic Mail. ................................................ 30
2.3. Disclosing Privileged Reports. .................................................................................. 31
2.4. Handling and Disclosing of Non-Privileged Reports (Ground and Explo ................ 37
2.5. Dispose of Records According to AFMAN 37-139. ................................................. 38
Figure 2.1. Contractor Statement of Understanding. ................................................................... 38
Figure 2.2. Letter for Contractor Representatives to Safety Investigations. ................................ 39
Figure 2.3. Sample Privileged Witness Statement. ...................................................................... 40
Figure 2.4. Sample Non-Privileged Witness Statement. .............................................................. 41
Figure 2.5. Sample Privileged WARNING Statement. ................................................................ 41
Chapter 3—MISHAP CATEGORY, CLASS, AND COSTS 42
3.1. Mishap Category. ....................................................................................................... 42
3.2. Defining Mishap and Event Classifications. .............................................................. 44
3.3. Mishap Class or Category Changes. .......................................................................... 46
3.4. Determining Mishap Costs. ....................................................................................... 46
3.5. Damage To Air Force Property. ................................................................................ 47
3.6. Damage to Non-Air Force Property. .......................................................................... 49
3.7. Standard Injury, Illness, and Fatality Costs. .............................................................. 49
Table 3.1. Standard Injury, Illness, and Fatality Costs. .............................................................. 50
Chapter 4—SAFETY INVESTIGATIONS 51
4.1. General Guidelines. ................................................................................................... 51
4.2. Investigation Funding. ............................................................................................... 51
4.3. Mishap Investigation Timeline. ................................................................................. 52
4 AFI91-204 29 NOVEMBER 1999
4.4. Safety Investigation Boards. ...................................................................................... 52
4.5. Investigative Evidence: .............................................................................................. 53
4.6. Recovering and Disposing of Wreckage. .................................................................. 56
4.7. Technical Assistance. ................................................................................................. 58
Figure 4.1. Technical or Engineering Evaluation of Physical Evidence and Factual Information. 61
Chapter 5—SAFETY REPORTS AND SUMMARIES 62
5.1. General Information. .................................................................................................. 62
5.2. Determining Mishap Event Number. ......................................................................... 62
5.3. OPREP-3 Reports. ..................................................................................................... 63
5.4. Message Reports. ....................................................................................................... 64
5.5. Formal Reports. ......................................................................................................... 65
5.6. Writing the Narrative. ................................................................................................ 67
5.7. Documenting the Investigation and Analysis. ........................................................... 68
5.8. Determining Findings. ............................................................................................... 69
5.9. Determining Causes. .................................................................................................. 70
5.10. Determining Recommendations. .............................................................................. 71
Figure 5.1. Opportunity To Submit an Additional Witness Statement. ....................................... 75
Figure 5.2. Sample Memorandum of Transmittal. ....................................................................... 76
Table 5.1. Causal Finding Analysis. ........................................................................................... 77
Chapter 6—FOLLOW-UP ACTIONS 78
6.1. Review Process. ......................................................................................................... 78
6.2. Memorandum of Final Evaluation (MOFE). ............................................................. 81
6.3. Managing Preventive Action after the MOFE. .......................................................... 82
6.4. Managing Preventive Action for Mishaps w/o Formal Safety Reports. .................... 84
Figure 6.1. Sample Command Endorsement. ............................................................................... 85
Chapter 7—AIRCRAFT MISHAPS AND EVENTS 86
7.1. Aircraft Mishap and Event Categories. ...................................................................... 86
7.2. Classifying Aircraft Mishaps and Events. ................................................................. 87
7.3. Investigating Aircraft Mishaps. ................................................................................. 91
7.4. Aircraft Mishap and Event Reporting Requirements. ............................................... 95
7.5. Disclosing Mishap Information to News Media and Next of Kin (NOK). ................ 101
AFI91-204 29 NOVEMBER 1999 5
7.6. Aircraft Safety Message Reports. .............................................................................. 101
7.7. Preparing Message Reports for Aircraft Mishaps. ..................................................... 101
7.8. Preparing Aircraft Mishap Formal Reports. .............................................................. 102
7.9. Aircraft Mishap Rates and Accountability. ............................................................... 104
Figure 7.1. Format for Preliminary and Initial Status (72 Hour) Message Reports for Aircraft Class A,
B, or C Mishaps and Class E or HAP Events. ........................................................... 106
Figure 7.2. Format for Aircraft Mishap and Event Consolidated Message Report. .................... 108
Figure 7.3. Aircraft Class E Propulsion–Related Event Summary Report. ................................. 115
Figure 7.4. Aircraft Class E Physiological Event Summary Report. ........................................... 117
Figure 7.5. Added. Aircraft Class E Event Summary Report. .................................................... 120
Table 7.1. Reporting Schedule for Aircraft Mishaps and Events. .............................................. 122
Table 7.2. Addresses for Aircraft Mishap and Event Message Reports. .................................... 124
Table 7.3. Aircraft, Engine, SPD, and Common Service Information. ...................................... 128
Table 7.4. Routing of Aircraft Formal Reports. .......................................................................... 129
Chapter 8—MISSILE MISHAPS 133
8.1. General Information. .................................................................................................. 133
8.2. Determining Missile Mishap Accountability. ............................................................ 134
8.3. Determining Missile Mishap Category. ..................................................................... 134
8.4. Determining Classification of Missile Mishaps. ........................................................ 134
8.5. Change in Mishap Class. ........................................................................................... 135
8.6. Investigating Missile Mishaps. .................................................................................. 136
8.7. Reporting Missile Mishaps. ....................................................................................... 137
8.8. Message Reports. ....................................................................................................... 138
8.9. Determining Mishap Event Number. ......................................................................... 139
8.10. Formal Reports. ......................................................................................................... 140
8.11. Review of Final Report. ............................................................................................. 141
8.12. Follow-up Actions. .................................................................................................... 142
Figure 8.1. Privileged Warning. ................................................................................................... 142
Figure 8.2. Format for Preliminary Class A, B, C, D, or HAP Missile Mishaps. ........................ 143
Figure 8.3. Format for Missile Consolidated Mishap Report (CMR). ......................................... 145
Table 8.1. Reporting/Recording Schedule for Class A, B, C, D, and HAP Events. ................... 149
6 AFI91-204 29 NOVEMBER 1999
Table 8.2. Addressees for Missile Mishap Message Reports (see note 9). ................................. 151
Table 8.3. Missile Common to Other Services. .......................................................................... 154
Table 8.4. Routing of Missile Formal Safety Reports (see note 4). ............................................ 155
Table 8.5. Added. Missile Mishap Category Flow Chart. ......................................................... 160
Chapter 9—SPACE MISHAPS 161
9.1. General Information. .................................................................................................. 161
9.2. Assigning Space Mishap Accountability. .................................................................. 161
9.3. Classifying Space Mishaps. ....................................................................................... 161
Table 9.1. Orbital Mishap Determination Matrix. ...................................................................... 163
9.4. Other Events. ............................................................................................................. 163
9.5. Mishap Category. ....................................................................................................... 163
9.6. Investigation. .............................................................................................................. 165
9.7. Messages, Reports, and Logs. .................................................................................... 166
9.8. Follow-up Actions. .................................................................................................... 170
Figure 9.1. Privileged Warning. ................................................................................................... 170
Figure 9.2. Format for Preliminary Class A, B, C, or HAP Space Mishap Message. .................. 171
Figure 9.3. Format for Consolidated Mishap Report (CMR) Space Mishap. .............................. 173
Table 9.2. Reporting/Recording Schedule for Class A, B, C, and HAP Events. ........................ 177
Table 9.3. Addresses for Space Mishap Message Reporting. ..................................................... 179
Table 9.4. Routing of Formal Space Mishap Reports. ................................................................ 181
Chapter 10—EXPLOSIVE AND CHEMICAL AGENT MISHAPS 185
10.1. General Information. .................................................................................................. 185
10.2. Assigning Explosive and Chemical Agent Mishap Accountability. .......................... 186
10.3. Determining Explosives or Chemical Agent Mishap Category. ................................ 186
10.4. Determining Classification of Explosives or Chemical Agent Mishaps.. ................. 186
10.5. Change In Mishap Class. ........................................................................................... 187
10.6. Safety Investigation Boards for Explosives or Chemical Agent Mishaps. ................ 188
10.7. Message Reports for Explosive and Chemical Agent Mishaps. ................................ 190
10.8. Formal Reports. ......................................................................................................... 191
10.9. Follow-up Actions. .................................................................................................... 192
AFI91-204 29 NOVEMBER 1999 7
Figure 10.1. Format for Preliminary Class A, B, C, D, or HAP Explosive or Chemical Agent Mishaps.
194
Figure 10.2. Format for Explosive or Chemical Agent Consolidated Mishap Report (CMR). ..... 196
Table 10.1. Reporting/Recording Schedule for Class A, B, C, D, and HAP Events. ................... 200
Table 10.2. Addressees for Explosive Mishap Message Reports. ................................................ 202
Table 10.3. Routing of Explosive Formal Safety Reports. ........................................................... 206
Table 10.4. Added. Explosives or Chemical Agent Mishap Category Flow Chart. .................... 209
Chapter 11—GROUND MISHAPS 210
11.1. General Information. .................................................................................................. 210
11.2. Assigning Mishap Accountability. ............................................................................ 210
11.3. NON-REPORTABLE MISHAPS. ............................................................................. 211
11.4. Duty Status. .............................................................................................................. 211
11.5. MISHAP CATEGORIES.. ...................................................................................... 212
11.6. Mishap Classification. ............................................................................................... 214
11.7. Reporting Ground Safety Mishaps. ........................................................................... 216
11.8. Determining Mishap Costs. ....................................................................................... 218
11.9. Standard Injury, Illness, and Fatality Costs. .............................................................. 219
11.10.Class A, B, C or HAP Mishaps with Aircraft Involvement. ...................................... 219
11.11.Formal Reports. ......................................................................................................... 219
11.12.On-Duty Ground Mishaps: ........................................................................................ 222
11.13.Waiving the Formal Report. ...................................................................................... 223
11.14.Class C Ground Mishaps: .......................................................................................... 223
11.15.Class D Ground Mishaps. .......................................................................................... 223
11.16.Reporting Motor Vehicle Mishaps. ........................................................................... 223
11.17.Reporting Off-Duty Ground Mishaps. ....................................................................... 224
11.18.HAP Events. ............................................................................................................... 224
11.19.Reporting and Logging Occupational Illnesses and Injuries. .................................... 224
11.20.Additional Reporting by the Nearest Installation. ..................................................... 226
Figure 11.1. Privileged Warning. ................................................................................................... 227
Figure 11.2. Format for Preliminary Class A, B, C, or HAP Ground Mishap Messages. ............. 228
Figure 11.3. Format for Consolidated Mishap Report (CMR) Ground Messages. ........................ 230
8 AFI91-204 29 NOVEMBER 1999
Figure 11.4. Abbreviated CMR Format. ........................................................................................ 235
Figure 11.5. Format for Class C Off-Duty Sports and Recreation Summary Mishap Report (SMR) Messages.
237
Table 11.1. Reporting/Recording Schedule for Ground Mishaps. ................................................ 239
Table 11.2. Addressees for Ground Message Reports. ................................................................. 241
Table 11.3. Routing Class A and B Ground Formal Safety Reports. ........................................... 244
Chapter 12—NUCLEAR MISHAPS 247
12.1. Scope and Objectives. ................................................................................................ 247
12.2. Safety Investigations: ................................................................................................. 247
12.3. Statistical Comparisons: ........................................................................................... 248
12.4. Release of Information. .............................................................................................. 249
12.5. General Reporting Requirements and Procedures: .................................................... 249
12.6. Nuclear Weapon System Reporting Criteria: ............................................................ 251
12.7. Nuclear Weapon System Mishap and Safety Deficiency Reports: ............................ 255
12.8. Nuclear Weapon System OPREP-3 Reports: ............................................................ 257
12.9. Nuclear Weapon System Mishap Formal Reports: .................................................... 257
12.10.Nuclear Reactor System and Radiological Reporting Criteria: ................................. 257
12.11.Nuclear Reactor System and Radiological Mishap Reports. ..................................... 259
12.12.Nuclear Reactor System and Radiological Safety Deficiency Reports. .................... 260
12.13.Preparing Nuclear Reactor System and Radiological Safety Deficiency Re ............. 260
12.14.Nuclear Reactor System and Radiological OPREP-3 Reports: ................................. 260
12.15.Nuclear Reactor System and Radiological Mishap Formal Reports. ........................ 260
Figure 12.1. Format for Nuclear Weapon System Mishap Reports. .............................................. 262
Figure 12.2. Format for Nuclear Weapon System Safety Deficiency Reports. ............................. 265
Figure 12.3. Format for AF Form 711F, USAF Nuclear Accident/Incident Report. ..................... 267
Figure 12.4. Format for Nuclear Reactor System and Radiological Mishap Reports. ................... 269
Figure 12.5. Format for Nuclear Reactor System/Radiological Safety Deficiency Reports. ......... 273
Figure 12.6. Format for Nuclear Reactor System and Radiological Mishap Formal Reports. ...... 274
Table 12.1. Addressees for Nuclear Weapon System Reports. .................................................... 275
Table 12.2. Reporting Schedule for Nuclear Weapon System Mishap Reports. .......................... 279
Table 12.3. Reporting Schedule for Nuclear Weapon System Safety Deficiency Reports. ......... 280
AFI91-204 29 NOVEMBER 1999 9
Table 12.4. Addressees forN uclearR eactorS ystem andR adiologicalM ishapa ndS afetyD eficiencyR eports.
281
Table 12.5. Reporting Schedule for Nuclear Reactor System and Radiological Mishap Reporting. 282
Table 12.6. Reporting Schedule for Nuclear Reactor System and Radiological Safety Deficiency Reports.
283
Chapter 13—ENGINE-CONFINED INCIDENTS 284
13.1. General Information. .................................................................................................. 284
13.2. Classification. ............................................................................................................ 285
13.3. Investigation. .............................................................................................................. 285
13.4. Reporting. .................................................................................................................. 285
13.5. Follow-up Actions. .................................................................................................... 285
Chapter 14—MISCELLANEOUS AIR OPERATION MISHAPS 286
14.1. General Information. .................................................................................................. 286
14.2. Accountability. ........................................................................................................... 286
14.3. Mishap Classification. ............................................................................................... 286
14.4. Investigation Responsibility. ..................................................................................... 286
14.5. Aero Club Mishap Investigation Procedure. .............................................................. 287
14.6. Reporting. .................................................................................................................. 287
14.7. Follow-up Actions. .................................................................................................... 287
14.8. Using or Releasing Mishap Reports Without Authorization. .................................... 288
Table 14.1. Mishap Reporting Schedule for Miscellaneous Air Operations. ............................... 288
Table 14.2. Miscellaneous Air Operations Message Addressees. ................................................ 289
Figure 14.1. Preliminary Message Format. .................................................................................... 290
Figure 14.2. Abbreviated CMR Format. ........................................................................................ 292
Chapter 15—UNMANNED AERIAL VEHICLE MISHAPS 295
15.1. UAV Mishap Categories. ........................................................................................... 295
15.2. Definitions. ................................................................................................................ 295
15.3. Classifying UAV Mishaps. ........................................................................................ 296
15.4. Investigating and Reporting UAV Mishaps. .............................................................. 296
15.5. Critical Profile RPV Missions. ................................................................................ 298
15.6. Forms prescribed. ....................................................................................................... 299
10 AFI91-204 29 NOVEMBER 1999
Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 300
Attachment 2—DESIRED SIB SUPPORT REQUIREMENTS LIST 320
Attachment 3—FORMAL SAFETY REPORTS AND BRIEFINGS 323
Attachment 4—CAUSAL-AGENT-AREA-REASON (CAR) DEFINITIONS 337
Attachment 5—CMR LOOK-UP TABLE 342
Attachment 6—DELETED 354
Attachment 7—TEXT OF IC 99-1 355