Technical Assessment Report
02-06-2013 |
What We Did Our objective was to review the United States Air Force (USAF) Aircraft Accident Investigation Board (AIB) report on the F-22A mishap of November 16, 2010, for adherence to the procedures set forth in Air Force Instruction (AFI) 51-503, “Aerospace Accident Investigations.” We assessed whether the AIB’s conclusions were supported by facts consistent with the standards of proof established by AFI 51-503. What We Found The AIB Statement of Opinion regarding the cause of the mishap was not supported by the facts within the AIB report consistent with the clear and convincing standard of proof established by AFI 51-503. The AIB report contains the following deficiencies.
What We Recommend We recommend that the Judge Advocate General of the Air Force reevaluate the AIB report and take appropriate action in light of the findings in this report regarding the AIB report Statement of Opinion and other deficiencies. Air Force Comments The Air Force concurs that aspects of the AIB report could have been more clearly written. However, the Air Force found that the AIB President’s Statement of Opinion regarding the cause of the mishap was supported by clear and convincing evidence and he exhausted all available investigative leads. To conclude that the AIB’s President’s opinion was supportable, the Air Force relied upon the findings of a special Task Force that was convened to review and respond to DoD Inspector General (IG) draft report. The Air Force acknowledged that remedial actions would be taken to address the following deficiencies in the AIB report: the lack of detailed analysis of the non-causal or non-contributory factors; insufficient details regarding conclusions concerning Emergency Oxygen Activation and blood oxygen levels; and, inaccurate references within the AIB report. DoD IG Response The DoD IG does not concur with the Air Force response that the AIB President exhausted all investigative leads and that the AIB President’s Statement of Opinion is sufficiently supported by clear and convincing evidence, as reflected in the AIB report, consistent with the requirements of AFI 51-503. In reaching our conclusion, we note that AFI 51-503 states that AIB Summary of Facts must present a thorough discussion of the facts relevant to the accident; be fully supported by documentary evidence; and should be self-contained. Furthermore, AFI 51-503 mandates that a Statement of Opinion regarding the cause of an accident “must be supported by facts stated in the Summary of Facts, which must be supported by evidence included in the Tabs [of the AIB report], unless otherwise restricted.” With respect to clear and convincing evidence, AFI 51-503 states that the AIB President’s opinion “must be supported by credible evidence that shows it is highly probable that the conclusion is correct.” Based on the deficiencies we identified in the AIB report, we conclude that the AIB report did not meet the requirements of AFI 51-503. The Air Force stated that remedial actions would be taken to address Findings C, D, and E; however, the Air Force did not provide a description as to what those actions will be or entail. Without a sufficient description of these actions, the DoD IG cannot determine if these actions will adequately address the AIB report deficiencies. Moreover, we believe a sufficiently detailed action plan will also be especially useful to identify and implement appropriate departmental-wide AIB process improvements. Additionally, the Air Force did not indicate if any actions will be taken to address Findings A and B; even though the Air Force acknowledged those sections could have been more clearly written. Therefore, the DoD IG requests the Air Force provide a detailed description of the remedial action to be taken by February 28, 2013. |
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