ARMS Inspections and U.S. Army Aviation Accident Rates

Introduction

As the United States continues the fight in the Global War on Terror, military resources remain a defining factor. The use of military resources and their continued demand has placed defense spending on an upward trend. This spending is nowhere more consequential than in military aviation accidents, and is especially significant within United States Army aviation.

United States Army aviation resources are an expensive, finite element of the federal budget. The number of helicopters required in warfighting deployments has a direct impact on peacekeeping missions and the conduct of global conflicts. The loss of United States Army helicopters directly affects the mission, capability, and effectiveness of Army aviation in deployments and support missions to ground forces. The expenditure of these valuable assets — including the loss of life — directly impacts the strategy of the United States Army. If present aviation accident trends continue, coupled with combat losses, the cost of United States Army aviation accidents (Class A through C) could exceed one billion dollars. This downward spiral in aviation safety must be reversed.

The purpose of the Aviation Resource Management Survey (ARMS) is to identify and recommend corrections for deficiencies in Operations, Flight Standardization, Supply, Aviation Maintenance, Safety, Petroleum, Aviation Life Support Equipment, Aviation Medicine, Air Traffic Services, Training, Tactical Operations, and Night Vision systems within aviation organizations from brigade down to detachment level. ARMS accomplishes this through an independent and unbiased appraisal of all aspects of an aviation unit's operations, personnel, and facilities. Results are then reported to the unit and Major Army Command (MACOM) for consideration and action. Currently there are twenty-three active duty Army and one National Guard MACOM organized within the United States Army.

ARMS is the tool by which MACOMs assess an aviation unit's ability to conduct its wartime and contingency mission. The survey is comprised of 12 different functional areas that exist within each aviation unit: Operations, Flight Standardization, Supply, Aviation Maintenance, Safety, Petroleum, Aviation Life Support Equipment, Aviation Medicine, Air Traffic Services, Training, Tactical Operations, and Night Vision systems.

To conduct these inspections, each MACOM has a dedicated team of functional area experts who travel to different installations on a normally two-year rotational cycle. Checklists have been developed for each functional area; every subject addressed in the checklist is based on an Army standard derived from Army Regulations (ARs), Field Manuals (FMs), Department of the Army Pamphlets (DA PAMs), Training Circulars (TCs), and Standard Operating Procedures (SOPs). Within United States Army Europe and Seventh Army (USAREUR), the USAREUR Aviation Safety and Standardization Detachment (UASSD) holds that responsibility. The UASSD schedules and conducts an ARMS of each USAREUR aviation unit on a 24-month cycle (AE Reg 95-1).

As of 31 December 2006, USAREUR had experienced twenty-five fatalities and an estimated loss of $164,583,907 due to Class A–C accidents within a four-year period (ASMIS Aviation Accident Database).

United States Army aviation accident rates continue on a costly upward trend that negatively impacts future military budgets. During a four-year period (Fiscal Years 2003 through 2006), the cost of Class A through C aviation accidents exceeded $164 million within USAREUR (ASMIS Aviation Accident Database).

The researcher spent twenty-four years in the United States Army working as an Army Aviation Operations Non-Commissioned Officer and retired as an Aviation Sergeant Major. The researcher served as the senior Aviation Operations Advisor to the Commanding General, Third United States Army, Army Central Command, and Coalition Forces Land Component Command during combat operations in Afghanistan and Iraq. The researcher also previously served as the Theater Aviation Sergeant Major for United States Army Europe and Seventh Army in Heidelberg, Germany. While serving in the Army, the researcher assisted and participated in numerous Army Aviation accident and incident investigations.

In 1954, Army Aviation Training — an echelon of the Artillery School at Fort Sill, Oklahoma — established the Army Accident Review Board, whose mission was to review Army aviation accidents. By 1957, the mission of the Review Board had expanded, and it was renamed the U.S. Army Board for Aviation Accident Research. Its mission included not only aircraft accident review but also crash-site investigation and research into aviation safety matters involving aircraft design, operations, and training, as well as supervision, maintenance, inspection, and human factors (United States Army Combat Readiness/Safety Center). Combat effectiveness is decreased and loss of Army aircraft and personnel is increased when aircraft have not been properly inspected. Failure to inspect — or insufficiently thorough inspections — creates high risk for Army aircraft, personnel, and ultimately the ability to conduct successful combat missions.

ARMS inspections result in a decrease in Army aviation accidents.

The loss of any Army aviation combat asset, whether an aircraft or a flight crew member, constitutes a significant loss and decreases combat effectiveness. Success on the battlefield depends largely on the ability to reduce losses through decreased Army aviation accident rates. During the period 2003 through 2006, USAREUR experienced a total of 57 aviation accidents (Class A through Class C) resulting in 25 deaths and the loss of 14 aircraft.

This study was limited to one MACOM — USAREUR, headquartered at Heidelberg, Germany — and includes Class A through Class C aviation accidents only. All Army aviation assets assigned to USAREUR were included. All accident data, without regard to type of airframe, were included. Ground accident statistics were not included. All aviation accident data were collected from the Army Safety Management Information System (ASMIS) database located at the United States Army Safety Center, Fort Rucker, Alabama. The time frame was narrowed to four fiscal years, 2003–2006. There are twenty-eight MACOMs in the Army; limiting the research to one MACOM allowed for a more manageable population sample without too many confounding variables, enabling the researcher to complete the research in an adequate time.

(1) Limiting the research to Class A through Class C accidents enables straightforward sampling of Army aircraft data across the three major accident classifications.

(2) Analyzing all accident data without regard to airframe type provides an easy sampling approach and reduces potential bias toward fixed-wing versus rotary-wing aircraft.

(3) Excluding ground accidents allows the research to focus solely on aviation accidents.

(4) Limiting the research to a four-year period (2003–2006) provides an adequate data sample without constraining the results.

First Assumption: The accident data used will be an adequate sample of Class A through Class C accidents within the USAREUR area of operations.

Second Assumption: ARMS inspection dates derived from official USAREUR publications and historical data files will reflect the actual dates of ARMS inspections.

History of Aviation Safety Oversight

Third Assumption: Current ARMS inspections continue to incorporate comprehensive checklists used to evaluate resource management and assist in improving operational readiness and safety for USAREUR aviation.

ARMS Team — Comprised of subject matter experts within each aviation functional area, including: aircraft armament, airfield and heliport operations, aviation life-support systems (ALSSs), aviation maintenance, aviation night vision goggle (NVG) maintenance, aviation safety, flight operations, petroleum, oils and lubricants (POL) operations, and standardization and aircrew training program (ATP).

Class A Accident — An Army accident in which the resulting total cost of property damage is $1,000,000 or more; an Army aircraft or missile is destroyed, missing, or abandoned; or an injury and/or occupational illness results in a fatality or permanent total disability. (Department of the Army Regulation 385-40, 1 November 1994)

Class B Accident — An Army accident in which the resulting total cost of property damage is $200,000 or more but less than $1,000,000; an injury and/or occupational illness results in permanent partial disability; or five or more personnel are hospitalized as inpatients as the result of a single occurrence. (Department of the Army Pamphlet 385-40, 1 November 1994)

Class C Accident — An Army accident in which the resulting total cost of property damage is $10,000 or more but less than $200,000; a nonfatal injury that causes any loss of time from work beyond the day or shift on which it occurred; or a nonfatal occupational illness that causes loss of time from work or disability at any time (lost-time case). (Department of the Army Pamphlet 385-40, 1 November 1994)

Hansen, McAndrews, and Berkeley (2005), in their work "History of Aviation Safety Oversight in the United States," relate that federal aviation safety began with the Air Mail Service, which featured a safety program with "strict selection criteria for pilots and rigorous maintenance" (p. v). This program's value was demonstrated through lower fatality rates "compared with unregulated itinerant commercial fliers" (p. v). Industry leaders subsequently called for regulation of civil aviation, resulting in the Air Commerce Act being passed in 1926, which established the Aeronautics Branch (AB) in the Department of Commerce and made it responsible for "licensing and ensuring the airworthiness of aircraft and certifying airmen" (p. v).

In the early days of airline safety, AB leaders held an objective that was "not so much to regulate as to promote" (Hansen, McAndrews & Berkeley, 2005, p. v). The intention was safety improvement without excessive regulations that dramatically increased costs. During this period, AB leaders generally consulted with business leaders before issuing rules and setting regulations in order to "accommodate industry" (Hansen, McAndrews & Berkeley, 2005, p. v). Aircraft were even granted temporary certificates by the AB, allowing time to correct noted deficiencies, while the AB worked "constantly to modify the rules in the face of experience and rapid development of the aviation industry" (p. v).

In 1930, "certification requirements were extended to business enterprises engaged in aviation, such as airlines and flight schools" (Hansen, McAndrews & Berkeley, 2005, p. v). From the very start, the oversight system "employed inspectors who were assigned to districts around the U.S." (p. vi). In 1938, the Civil Aeronautics Act was passed, "motivated in part by the accident of the TWA plane in 1935 that resulted in the death of Senator Bronson Cutting" (p. vi). Under the Civil Aeronautics Act, responsibilities for aviation oversight were divided among "a five-member Civil Aeronautics Authority Board, a three-member Air Safety Board, and an Administrator" (p. vi).

Policies were set by the Civil Aeronautics Authority Board, which was responsible for promulgating safety rules, while the Air Safety Board held responsibility for accident investigation. However, "this structure proved unworkable, and in 1939 it was changed to include a Civil Aeronautics Board with responsibility for accident investigation and economic regulation, and a CAA, back again in the Department of Commerce, with responsibility for safety regulation" (Hansen, McAndrews & Berkeley, 2005, p. vi). The CAA Office for Safety Regulations held the responsibility for oversight, with "divisions devoted to general aviation, airlines, aircraft design, and flight testing and factory inspection" (p. vi).

Challenges cited by the CAA inspector workforce included not only a heavy workload but also "being forced to play the role of instructors when checking ill-prepared pilots" (Hansen, McAndrews & Berkeley, 2005, p. vi). Complaints were made about inspectors "cutting corners in testing and reporting, discourteousness, and large work backlogs." The safety record was improving by 1939, and in 1940 more than a year passed with no fatal incident involving a single commercial airline. While accidents eventually "became the exception rather than the rule," when they did occur — especially "several in a short time period" — heightened public attention led to excessive rules, "causing rule adherence to supplant safety as the primary goal" (p. vi).

In 1959, the Federal Aviation Agency was assigned responsibility for safety oversight, with the Bureau of Flight Standards absorbing the Office of Flight Operations and Airworthiness while "also absorbing the safety rulemaking authority that had previously belonged to the CAB" (Hansen, McAndrews & Berkeley, 2005, p. vii). The FAA was charged with the capacity for quick diagnosis and solution, though political challenges remained in implementing those solutions. In 1966, the FAA "was absorbed into the newly created Department of Transportation. Accident investigation responsibility was also shifted from the CAB to the newly created National Transportation Safety Board" (p. x).

In 1978, the Airline Deregulation Act (ADA) was passed by Congress. This Act liberalized the economic regulation of airline fares and routes and "curtailed the authority of the Civil Aeronautics Board (CAB), the agency that administered the economic regulations, until it was finally abolished in 1985" (Hansen, McAndrews & Berkeley, 2005, p. x). Economic deregulation dramatically changed the structure, conduct, and performance of the aviation industry. In 1984, the Department of Transportation Secretary "initiated the National Air Transportation Inspection (NATI) effort" (p. x) — "both a broad and deep surveillance effort in which all major and commuter airlines received additional inspections" (p. xi). This represented the "first comprehensive audit of the surveillance element of the safety oversight program, and it provided data that could be used to change the safety oversight system" (p. xi). A subsequent review by the Safety Activity Functional Evaluation (SAFE) extended the NATI program's efforts and "called for increased standardization in safety oversight" (p. xi).

The FAA responded by creating the National Work Program Guidelines, which focused on standardization of the "inspection process while taking into account risk precursors" (Hansen, McAndrews & Berkeley, 2005, p. vi). Additionally, the FAA and stakeholders collaborated, and new requirements were issued addressing the structural integrity of older aircraft. The increasing complexity of the oversight system — as new data collection and information technology systems were introduced — resulted in "more complex analysis, training, data collection, and administration" (p. xi). Problems with implementing new databases and the challenges associated with systems design raised questions about whether the information needed to assess compliance and make safety determinations was actually being captured.

The FAA began in the early 1990s to "pursue system safety strategies for the safety oversight systems" (Hansen, McAndrews & Berkeley, 2005, p. xii). One of the "pivotal events in the history of FAA's oversight was the crash of ValuJet Flight 592 in May 1996," which illustrates "how combinations of factors such as a new-entrant carrier, outsourced maintenance, and rapid growth create complex systems that are difficult to survey" (p. xii). Following this crash, a series of corrective actions "converged to a system safety strategy for safety oversight" (p. xii).

United States Army aviation accidents cost taxpayers millions of dollars. The price tag for personnel deaths, aircraft replacements, and the repair of aircraft and components continues to rise. Military budgets are approaching one billion dollars at a time the United States is engaged in both overt and covert warfare. This trend must stop.

Currently, the United States Army Safety Center, located at Fort Rucker, Alabama, collects and analyzes information for all United States Army accidents. These accidents, with date and time of occurrence, are investigated and reported through the chain of command. During each investigation, the monetary damage from the accident is assessed through Estimated Cost of Damage (ECOD) reports and injury reports. (Department of the Army Pamphlet 385-40). The cost of repair for aviation accidents is calculated in accordance with Department of the Army Pamphlet 738-751, and the cost of personal injury or death is calculated using Department of the Army Pamphlet 385-40. Based on the cost, accidents are categorized into a specific class. All aviation accidents are classified as Class A through F based on the following criteria:

Class A — Army accident in which the resulting total cost of property damage is $1,000,000 or more; an Army aircraft or missile is destroyed, missing, or abandoned; or an injury and/or occupational illness results in a fatality or permanent total disability.

Army Accident Classification and Rates

Class B — Army accident in which the resulting total cost of property damage is $200,000 or more but less than $1,000,000; an injury and/or occupational illness results in permanent partial disability; or three or more personnel are hospitalized as inpatients as the result of a single occurrence.

Class C — Army accident in which the resulting total cost of property damage is $10,000 or more but less than $200,000; a nonfatal injury causing any loss of time from work beyond the day or shift on which it occurred; or a nonfatal occupational illness that causes loss of time from work or disability at any time (lost-time case).

Class D — Army accident in which the resulting total cost of property damage is $2,000 or more but less than $10,000.

Class E — Army incident in which the resulting damage cost and injury severity do not meet the criteria for a Class A–D accident. A Class E aviation incident is recordable when the mission (either operational or maintenance) is interrupted or not completed. Intent for flight may or may not exist. An example of a recordable Class E incident is: during a maintenance operational check (MOC) the engine quits. Examples of nonrecordable Class E incidents are: chip detector light illumination where the component is not replaced; mission interrupted or aborted because of weather unless the mission is canceled; failure of Fair Wear and Tear (FWT) items found on pre- or post-flight inspection; radio failure where radio is replaced; closing a door found open in flight.

Class F — Foreign Object Damage (FOD) aviation incident. Recordable incidents confined to aircraft turbine engine damage (not including installed aircraft Auxiliary Power Units) as a result of internal or external FOD, where that is the only damage.

Note. From Department of the Army PAM 385-40, Army Accident Investigation and Reporting, 1 November 1994.

Once an accident is classified, proper reports are prepared and required administrative procedures are followed through completion of the investigation. The report is forwarded to Fort Rucker for inclusion in the Army Safety Management Information System (ASMIS) database. This database allows comparison of past accident history by classification and airframe type at any time, and supports computer queries on variables such as time of day and pilot rank. United States Army officials use this data to assess the health of the aviation safety program.

The current Army standard for comparing aviation accidents is calculated as one aircraft accident per 100,000 flight hours (1:100,000). Ground accident statistics are calculated as one accident per 1,000 soldiers (1:1,000). Civilian aviation accident rates are calculated using passengers carried rather than hours flown. The tables below present USAREUR flying hours and accident results for fiscal years 2003–2006.

Table 2 — USAREUR Flying Hours

FY 2003: 81,404 hours | FY 2004: 93,277 hours | FY 2005: 73,426 hours | FY 2006: 53,085 hours

Note. From USAREUR G3 Aviation Division Historical Files.