Seal for the National Commission on Miiitary Aviation Safety. NCMAS

National Commission on Military Aviation Safety

Frequently Asked Questions About the Final Report

Click here for FAQs about the Commission


Q:  What can be done immediately to improve military aviation safety?

Impactful institutional changes need to be made with long-term sustainability, effectiveness, and efficiency in mind. It cannot be accomplished overnight. Congress and the Department of Defense (DoD) can take immediate steps to reduce aviation mishaps by focusing on four areas: Pilots should fly more; maintainers should be given the time and tools to maintain; the aviation community must take a more proactive, data-centric approach to safety that reduces risk; and the Department must provide consistent and predictable funding.


Q:  How will the proposed Joint Safety Council (JSC) be an improvement over the Defense Safety Oversight Council (DSOC)?

The Defense Safety Oversight Council (DSOC) was established in 2003 to manage DoD-wide efforts to reduce preventable injuries, non-combat accidents, and mishaps of all kinds. The Joint Safety Council (JSC) will solely address aviation safety. While DSOC was chaired by the Under Secretary of Defense for Personnel and Readiness, JSC will be chaired by military leadership, with a Senior Executive Service member providing continuity and facilitating JSC's access to the Deputy Secretary of Defense. JSC will ensure that the Services are given the visibility and platform needed to make timely, substantive contributions to improving aviation safety.


Q:  What is the difference between training a pilot for currency and proficiency?  

Training for currency is making sure that a pilot has completed all of the basic pilot training and is meeting his or her ongoing safety requirements and flight hour minimums. Training for proficiency is allowing a pilot the time and opportunity to become an expert, both for the purposes of instructing junior pilots and for completing future missions in a near-peer fight. The problem with training only for currency—due to a lack of aircraft, instructors, or flight hours—is that pilots are doing the bare minimum to remain functional without mastering the crucial warfighting skills they must learn and maintain. Inexperience in the cockpit leads to aviation mishaps, and combat losses.


Q:  What data and resources did the Commission utilize to gather information for its report?

The Commission made learning about the flight line experience a priority, and visited more than 200 organizations and military aviation units. In addition, the Commission analyzed more than 6,000 mishap reports, as well as additional data on flight hours, staffing levels, training syllabi, and DoD budgets. Literature and document reviews were done on an abundance of studies, as well as DoD directives and instructions, covering military aviation safety over the past 25 years. These studies were conducted by government offices and agencies, federally funded research and development centers, think tanks, and academia. A bibliography is included in Appendix E of the report.


Q:  What actions did the Commission take when it saw something particularly alarming during a base visit?

The safety of our servicemembers is paramount. When the Commission witnessed unsafe practices or conditions while on base visits, commissioners privately brought it to the local command's attention. Often, the commanders were already aware of the issue and were simply awaiting additional funding or approval to correct it. The Commission will also be presenting the report to leadership of each Service individually, so they are free to discuss any issues specific to that Service. The goal is not to single out any command, base, or Service for criticism, but to bring to light any aviation safety issues.


Q:  What problems are caused when aircraft are cannibalized for parts?

Cannibalization is taking working parts off of one aircraft to fix another. It is often the result of a lack of parts in maintenance units, particularly parts for legacy aircraft that are no longer being manufactured. While cannibalization may seem an effective stop-gap solution, it is also a drain on already-taxed resources. When parts are taken from a working aircraft, there are now two aircraft being worked on and—at least temporarily—unavailable. Twice as much labor is involved. Parts may need to be modified to accommodate changes in technology, even within the same aircraft platform.


Q:  How can DoD improve its collection and use of data to reduce aviation mishap risk?

The Commission sees two distinct data deficiencies: some types of critical data—such as pilot metrics in the cockpit—are not being consistently collected, and the data currently collected is not standardized in a manner to allow for thorough analysis and trend identification.

The proposed JSC could oversee the implementation of programs providing the necessary data, such as MFOQA (Military Flight Operations Quality Assurance), LOSA (Line Operations Safety Assessment), HUMS (Health and Usage Monitoring System), and CVFDR (Cockpit Voice and Image Flight Data Recorders). Once these programs are more widely employed, the Services could establish baseline procedural standards for collection and analysis of this data. Data does not serve any purpose if it cannot be ultimately be analyzed in a purposeful way.

The Services also need to establish and enforce more consistent mishap reporting and investigation, particularly with Class C mishaps, in order to generate data that is more accurate and better equipped to highlight future issues and risks.


Q:  What roles do technology and generational differences play in training?

The Commission heard repeatedly that while students from this generation are more adept at learning and using new technologies, such as simulators or virtual reality, they are less experienced in hands-on mechanical skills. Conversely, previous generations often exhibit the opposite. It may be a challenge to bridge that gap in training, but it also is an opportunity for each generation to both learn from, and teach, those with different experiences and skills. New technologies are most effective when they are accessible, up-to-date, and used to supplement tactile skills learned through hands-on training.


Q:  What kind of onboard technology could DoD be utilizing more effectively?

While the investigation of past mishaps is invaluable in determining their causes, and in mitigating future risk, DoD is not taking full advantage of predictive technologies. These programs, including MFOQA (Military Flight Operations Quality Assurance), LOSA (Line Operations Safety Assessment), HUMS (Health and Usage Monitoring System), and CVFDR (Cockpit Voice and Image Flight Data Recorders) can all provide data regarding the status of both the aircrew and the aircraft throughout the flight. Monitoring the aircrew's real-time physiological state in flight, as well as the aircraft's mechanical soundness, can provide vital data on each flight as it occurs. Every effort should be made to identify and proactively address issues that may contribute to a future mishap.


Q:  What can be done to improve transition planning from legacy aircraft to fifth-generation platforms and lessen the need for excessive service life extensions of legacies?

Many legacy aircraft are seen as a reliable and known quantity, providing steady—if not cutting edge—performance when called upon. However, if they are utilized far beyond their original service life, their ages and lack of technological capabilities can be cause for concern. When fifth-generation platforms do not meet their goals for deliverability and mission readiness, legacy aircraft must pick up the slack. It can be exceedingly difficult to procure replacement parts for legacies, and provide personnel who have proficiency with the older aircraft.

The Services have experienced these scenarios countless times in the past, and they still experience them today. There is ample data on the many fifth-generation delays, and how they have necessitated the continued use of legacy aircraft. Improvements must be made in the planning, contracting, sustainment, and program management processes for aircraft acquisition and service life extensions.


Q:  How are the issues faced by the aviation community different from the rest of DoD?

In aviation, almost all mishaps have the potential for significant loss of life and materiel. On a daily basis, the aviation community utilizes some of the military's most expensive and complex equipment, operated and maintained by personnel who are extensively trained, and—even with mitigation—subject to a high degree of unavoidable risk. The skills of pilots and maintainers are perishable, and must be continually honed and developed. If a pilot is not able to get sufficient flying hours, or a maintainer doesn't have an opportunity to regularly work on aircraft, their skills are diminished and readiness levels suffer.


Q:  Congress appropriates substantial amounts for DoD's budget. Why are there still shortfalls in staffing, equipment, facilities upkeep, etc.?

The lack of timely and consistent funding resulting from numerous continuing resolutions (CR) is one of the biggest budget obstacles that DoD and the Services face. It is impossible for the Services and their units to plan effectively when they do not know what their budget will be, cannot take advantage of long-term planning and funding tools, and often do not receive funds until it is too late to address their most pressing needs. DoD and the Services are in a seemingly endless cycle of having to do more with less for the majority of the year, and then receiving funds that they must quickly spend before the end of the fiscal year. Leadership struggles to make the best possible, fiscally sound decisions.


Q:  Isn't asking Congress to cease using CR's just unrealistic?

The use of CRs is intended to be a last resort to keep the government operating; it has become the default condition under which DoD has been forced to operate. Thirteeb of the past 18 fiscal years have begun under a CR, indicating that its use has gone from stop-gap spending measure to business as usual. A comprehensive study has not been done to analyze the immediate and long-term effects that CRs have on the military, much less on military aviation safety. The Commission recommends that Congress utilize the Congressional Budget Office to study and report on the issue. If members of Congress and their constituents have access to concrete data and analysis on the ongoing impacts of CRs, they may demand a more sound solution.


Q:  Who have you briefed on Capitol Hill, and what kind of reaction have they had to your report?

The Commission has offered briefings to both the House and Senate Armed Services Committees. Our Chairman and Vice Chairman have testified before the House Subcommittee on Military Readiness. We have also offered briefings on the findings and recommendations to each of the Services, as well as their Safety Centers.


Q:  Is the Human Factors Analysis and Classification System (HFACS) effective in categorizing mishap causes and assisting in mishap mitigation? If not, what improvements can be made?

HFACS codes are used to classify the human factors present before and during a mishap. The system's goal is not to attribute blame, but to understand the underlying causal operational or cultural factors. A single mishap may include codes from various HFACS categories, and the inclusion of second- and third-level causes is key to identifying trends and allowing for proactive prevention and mitigation efforts. HFACS is only as accurate as the detailed codes assigned to a mishap. The Commission found a lack of consistent and standardized reporting at all levels of mishaps, from Class A to Class C. Greater uniformity in safety investigations, including more accurate and thorough use of HFACS codes, will help the Services make better use of data that is readily available to them.


Q:  What are waivers? Why do they increase aviation risk?

Waivers are given to pilots when they have not met the flying hour requirements mandated for advancement in their position. Pilots have increasingly been given waivers exempting them from completing requirements such as a minimum number of night flights. This is cause for concern. Quality flight hours and experienced instruction are crucial to the development of proficient pilots. As waivers are given at the local command's discretion, there is both a lack of consistency and insufficient evaluation of their long-term effects on performance.


Q:  How do retention issues uniquely impact aviation professionals, from pilots and aircrew to maintainers? How can retention rates be improved?

Aviation professionals are highly trained and skilled, and the precise execution of their tasks has life-or-death consequences. The amount of time and money required to train them to the level of proficiency is substantial, and that investment is lost when servicemembers leave the military. They cannot just be replaced, much less in a matter of weeks or months. It takes years to train someone before they acquire the experience and expertise needed to fill that role. Mid-level aircrew and maintainers are particularly valuable; they are not only using their skills to perform advanced tasks, but they also are responsible for passing those skills on to junior personnel.

The Services have to create an environment that is a sustainable and preferable alternative to civilian employment. Despite unique institutional limitations, they must do their best to offer comparable salaries, opportunities, work/life balance, job satisfaction, and recognition. Monetary bonuses may motivate some servicemembers to stay; others will insist on better quality-of-life conditions for their families, with greater stability and predictability. Improving retention will require focusing on all of these personnel issues.


Q:  What lessons learned can be adapted from commercial aviation, and adapted for military aviation?

Following a rash of commercial air disasters in 1994, the commercial aviation industry sharpened its focus on improving safety. Over the past 25 years, it has succeeded in meeting impressive benchmarks to reach and exceed its goals. One of the industry's innovations has been the Commercial Aviation Safety Team (CAST), a government-industry partnership that developed an integrated, data-driven strategy to reduce aviation risk. CAST proactively identifies safety risks, develops mitigation strategies, and monitors the implementation of those strategies. Its collaborative nature is a framework that the Commission feels can also be successfully adapted to the JSC.

Commercial aviation enjoys far greater freedom in prioritizing safety, maintaining an accountable safety culture, and establishing a vastly superior supply system. Military aviation's structure is much more restrictive, from compliance with federal acquisition and requirement regulations, to the added responsibility of conducting combat missions. Despite these differences, the Services can still benefit from examining commercial practices. When it comes to the investment made in military aviation, even an incremental improvement in aircraft availability or more efficient staffing can be significant.


Q:  What factors affect the amount of flight hours pilots are getting?

While factors like weather conditions or hours of daylight are beyond the Services' control, there are many factors that can be actively improved upon. The lack of aircraft availability —whether as the result of downtime for maintenance, lack of parts or personnel to complete the work, or OPTEMPO—severely limits flying hours. Even if aircraft are available, the lack of qualified instructors hampers the training and missions that can be completed. Pilots with minimal flight hours are often just trying to keep their existing skills from deteriorating, and don't have the time to learn and perfect new ones. In addition, both pilots and maintainers are frequently assigned non-aviation tasks and training; these demands often interfere with the primary jobs that they are trained to do.


Q:  Which class of mishaps has increased the most during the time from 2013–2018? Why?

Class C mishaps—those with at least $50,000 but less than $500,000 in damages, and/or nonfatal injuries requiring time off from work—have increased the most during this time period. Class C mishaps are investigated at the local level, so standards for reporting and investigating mishaps have been found to be inconsistent. Although these mishaps are not as severe as Class A or B, they are still a point of concern. Class C mishaps signal that a larger issue may be beneath the surface. More uniformity in the treatment of Class C mishaps would provide the data needed to accurately evaluate trends and mitigate risks.


Q:  What are physiological episodes (PE), and what causes them? How many PEs are considered unexplained, and what is being done to further research those? 

A physiological episode occurs when a pilot experiences a loss in performance related to insufficient oxygen ("hypoxia"), depressurization, or other factors during flight. Symptoms arising from these episodes, in addition to hypoxia-like symptoms, can include dehydration, temporal distortion, mental exhaustion, spatial disorientation and hyperventilation. PEs are unpredictable and inconsistent—the same pilot flying the same aircraft and executing the same maneuvers may experience a PE during one flight, but not the next.

The Services, aided by the Navy and Air Force Physiological Episodes Action Teams (PEAT), have now been able to explain approximately 94 percent of reported PEs. Research on unexplained PEs are ongoing, with data analytics being used to evaluate various components of the aircraft, as well as pilots' gear and equipment. Human factors, such as fatigue, distraction, and other stressors, are also being assessed in order to mitigate risk.


Q:  How confident are you that the Commission's recommendations will be fully implemented?

The Commission is confident that its recommendations will be endorsed by Congress, and implemented by the Services. Congress first recognized the need for this Commission, and the Services have provided us with unlimited access, personnel, and data for the duration of our study. We all have the same goal: improving military aviation safety, and, thereby, increasing operational and Service-wide readiness. During the course of our study, military aviation has lost another 26 personnel and 25 aircraft, at a cost of $2.25 billion. The time to act is now.