"Supplement Number or Change Number" \* MERGEFORMAT

15 June 1994 "Short Title of Publication Supplemented, i.e., AFI 37-167" \* MERGEFORMAT

"Date of Supplement - Spell Month Out Completely"

Safety "Series Title"

"Long Title - Type In All Capital Letters"MISHAP REVIEW PANEL

This headquarters operating instruction (HOI) establishes concepts, functions, responsibilities, and procedures for the Air Force Space Command (AFSPC) Mishap Review Panel (MRP). Directsactions and assigns responsibilities to assure fully coordinated staff actions on Class A and B flight and aircraft involvement mishap report recommendations, as well as selected Class C and High Accident Potential (HAP)recommendations. Implements requirements of AFR 127-4, Chapter 14 (soon to be AFI 91-204, Chapter 6). This HOI applies to HQ AFSPC.

Section A - General

1. Fundamental Concepts:

1.1. The AFSPC Chief of Safety (SE) is responsible for tracking follow-up actions to correct deficiencies documented in all Class A and B flight mishap reports and selected Class C and HAP recommendations. All Directors and special staff agencies will provide support or initiate actions necessary for recommendations in their functional areas.

1.2. The purpose of this HOI is:

1.2.1. To ensure coordination of staff efforts to track and/or implement corrective actions following mishaps or HAPS.

1.2.2. To validate the requirement for staff actions and determine the extent and priority of action needed.

1.2.3. To expedite coordination and facilitate normal functional staff actions.

1.2.4. To provide a method to reconcile differences among staff positions.

1.2.5. To ensure adequacy of corrective actions by agencies outside AFSPC.

1.2.6. To keep Commander AFSPC informed of the status of corrective actions.

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1.2.7. To inform Commander AFSPC when a response to a mishap recommendation is inadequate.

2. Definitions:

2.1. Cause: In a mishap sequence of events, a single deficient act or circumstance which directly results in continuation of a mishap sequence, loss of life, injury, or reportable property loss or damage. The test of whether a finding is causal is to remove it from the mishap sequence; if the sequence does not then logically continue or result in any of the types of losses described, the finding is causal. See AFR 127-4 (AFI 91-204) for amplification.

2.2. Recommendation: A recommendation developed by a safety investigation board or investigating officer IAW AFR 127-4 (AFI 91-204), which is directly related to a cause or causes of the mishap. For Class A and B mishaps, these are recommendations validated by the Air Force Safety Agency (AFSA) and approved by the Chief of Safety, Headquarters USAF, in the Letter of Final Evaluation. AFSA tracks major command actions toward resolving all primary recommendations and receives semiannual progress updates IAW AFR 127-4 (AFI 91-204).

2.3. Other Recommendation of Significance: A recommendation developed by a safety investigation board or investigating officer as a result of deficiencies uncovered during investigations, but not directly related to a cause ofthe mishap. Major commands are responsible for identifying, acting upon and closing other recommendations of significance.

2.4. Open Recommendation: An action item which is being actively worked by HQ AFSPC agencies, Air LogisticsCenters, or other agencies outside the command.

2.5. Closed Recommendation: An action item which is completely resolved, either with definitive action or a deliberate decision that further action is impractical or undesirable.

2.6. Monitor Recommendation: A fully staffed action item for which routine action towards satisfactory closing is inprogress. To be placed in monitor status, a recommendation must meet two tests:

2.6.1. All "decision" actions must be satisfactorily completed; that is, funds must be obligated, final approval/concurrence with modification programs or publications must be obtained, etc.

2.6.2. No further action can be taken by the HQ AFSPC Office of Primary Responsibility (OPR) to accelerate or otherwise influence the ultimate action desired, which is to be taken by an agency outside the command.

NOTE: In select cases, long-term programs which require lengthy preliminary actions prior to AFSPC becoming actively involved may be conditionally placed in monitor status until ready for consideration in "open" status.

3. Organizational Concepts:

3.1. MRP management actions are separate from other staff actions. Directorates and staff agencies retain functional responsibility to make and defend decisions.

3.2. MRP Membership:

3.2.1. Executive Chairperson: Chief of Safety.

AFSPCHOI91-1 15 Jun 1994 3

3.2.2. Primary Members. These are voting members who endorse ongoing corrective actions and recommend closure to the Vice Commander AFSPC (AFSPC/CV) when actions are complete, partially complete and deemed adequate, or found unfeasible. In the latter case, primary members will approve a specific assessment of risk assumed as a resultof choosing not to take action on a given recommendation. Chief of Safety (HQ AFSPC/SE). Maintenance Division (HQ AFSPC/LGMA). Chief of Aerospace Medicine (HQ AFSPC/SGPA). Chief of Airfield Operations Branch (HQ AFSPC/DOGH). Chief of Flight Safety (HQ AFSPC/SEF).

3.2.3. Supplementary Membership. Other headquarters staff directors or special assistants may become supplementary members of the MRP when requested by the presiding chairperson. Supplementary members have the same responsibilities as primary members. A Plans (XPP) representative will normally be asked to attend MRP meetings to provide current status of initiatives with safety involvement.

3.2.4. Alternates. Primary and supplementary MRP members will have alternates. Alternate members will present their respective directors' positions if the primary member is absent.

3.2.5. Subcommittee Membership. At the discretion of the presiding chairperson, a subcommittee of appropriate representatives may be appointed to review specific mishap reports. The subcommittee chairperson conducts meetings and provides recommendations to the MRP suggesting corrective actions for deficiencies. The subcommittee meets as required until deficiencies are corrected.

3.2.6. Recorder. MRP actions are tracked by SEF. SEF distributes and collects status updates, publishes meeting minutes, keeps the agenda, facilitates MRP meetings, and performs staff actions required when presentations to the command section are to be made for direction or endorsement.

3.3. The MRP meets quarterly or as directed by the presiding chairperson.

Section B - Functions and Responsibilities

4. Responsibilities: The MRP is responsible for reviewing and evaluating recommendations and corrective actions from all AFSPC Class A and B flight and aircraft-involvement mishap reports, selected Class C and HAPS, and other mishaps at SE or Commander AFSPC's direction.

5. Meetings, Records and Reporting:

5.1. Thirty days before each meeting, the chairperson forwards a review package to all voting members. This package contains individual pages with identifying information, the text of each recommendation, OPR/Office of Collateral Responsibilty (OCR), and the most recent MRP status l (see attachment 1 for format). New items will show an initial status report based on the AFSPC position on the recommendation. Voting members obtain the most current status information and briefly summarize it on each individual recommendation page. The entire update package is returned to SEF not later than 10 days prior to the scheduled meeting. New items and open recommendations constitute the agenda for the meeting.

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5.2. At the meeting, the panel reviews all items in "open" status. In cases where multiple OPRs work different issues related to a single recommendation, their respective inputs are discussed and continued direction agreed upon by the corporate voting membership. Members evaluate adequacy and timeliness of corrective actions and recommend whether each item should remain open, be closed, or be placed in "monitor" status as defined above. In cases where a primary recommendation (related to a cause of the mishap) is to be closed administratively due to fiscal unfeasibility, impracticality, or other limiting factors, the recorder prepares a summary of actions taken and a recommendation for closure. This package is coordinated with all voting members and their respective Director and then presented to the Vice Commander AFSPC for approval. AFSA is then advised of administrative closing. "Other recommendations of significance'' may be closed via a corporate decision of the voting members with the concurrence of the Vice Commander AFSPC.

5.3. After the meeting, the executive chairperson works with the Chief Executive Services (ES) to identify items for briefing to Commander AFSPC as necessary. The recorder consolidates updates plus additional information presented at the meeting into a review package. Each member reviews and concurs with or corrects the summary position andreturns their coordinated copy to SEF. The recorder adds the coordinated updates to the ongoing MRP record, then duplicates and distributes the final package. Copies of the complete package, with all prior status's and current updates, are distributed to AFSPC Numbered Air Forces, and wing and group safety offices (with flying missions). Informational copies are sent to HQ AFSA, and Air Force Materiel Command for redistribution at their discretion.

5.4. An information copy of the final package will be forwarded to the command section. A summary briefing on MRP actions and recommendation status's will be presented to Commander AFSPC within 30 days of the MRP meeting.

5.5. AFR 127-4 (AFI 91-204) requires major commands to submit semiannual updates to AFSA on all open recommendations related to mishap causes for which they are OPR. One copy of the March and September MRP minutes is sent to HQ AFSA/ SEFM to satisfy this requirement. If the March or September MRP meeting is postponed or canceled, SEF will collect current update information on AFSA-tracked recommendations and forward it to HQ AFSA/SEFM.

Director of Safety\* mergeformat

1. Action Item Format

HOI 91-1 Attachment 1 15 June 1994 5


Aircraft TypeLocation of Mishap Date of Mishap

Recommendation number and complete written recommendation. (One recommendation per page.)

Current Status: Should include background on corrective actions and list dates when closing action is expected. Status updates are used to prepare the meeting agenda, the Commander AFSPC update briefing, and the required semiannual mishap review to the Air Force Safety Agency.

Recommendation Status: (Open), (Closed), (Monitor).


Note: Add the following statement to each page containing mishap information.


This is privileged, limited use information. Unauthorized disclosure is a criminal offense punishable under Article 92, Uniform Code of Military Justice. See AFR 127-4, para 1-8 and 1-9 (soon to be AFI 91-204) for restrictions. \* mergeformat