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Military Training Deaths: Need to Ensure That Safety Lessons Are Learned and Implemented

NSIAD-94-82 Published: May 05, 1994. Publicly Released: May 05, 1994.
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Highlights

Pursuant to a congressional request, GAO reviewed the military services' investigations of training-related deaths, focusing on whether the services: (1) identified and investigated all training-related deaths; (2) ensured adequate independence of investigations; and (3) had systems for ensuring that corrective actions are taken.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should formally define what constitutes a training-related death and include in that definition deaths due to natural causes that occur during or shortly after a training activity.
Closed – Implemented
DOD has developed a definition of "training-related" death which will be included in the revised accident reporting instruction, scheduled for issuance by the end of 1994.
Department of Defense The Secretary of Defense should direct the services to amend their regulations to include the common definition for training-related death and require that all training-related deaths be investigated.
Closed – Implemented
The DOD revised accident reporting instruction now includes a common definition for "training-related" death and requires that all such deaths be investigated.
Department of Defense The Secretary of Defense should direct the services to enforce the Department of Defense's requirement to conduct safety and legal investigations on all training-related deaths, both aviation and non-aviation.
Closed – Implemented
DOD will now use the "training-related" death definition to ensure that required safety investigations are conducted.
Department of Defense The Secretary of Defense should direct the services to ensure the independence of legal investigations by requiring that the: (1) convening authority come from a higher level than the unit that experienced the mishap; and (2) senior investigative member also be independent of that unit.
Closed – Implemented
DOD will direct the services to ensure the independence of legal investigations of homicides, suicides, and accidents associated with military training by requiring that the: (1) convening authority come from a higher level than the unit that experienced the training fatality; and (2) senior investigative member also be independent of that unit.
Department of Defense The Secretary of Defense should direct the services to establish systems to track safety recommendations made in legal investigative reports to ensure that appropriate actions have been taken.
Closed – Implemented
DOD revision of the accident investigation instruction requires that safety recommendations contained in any type of investigation be tracked using the existing safety tracking system.

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Topics

Accident preventionAccidentsInternal controlsInvestigations by federal agenciesMilitary personnelMilitary trainingOccupational safetySafety regulationSafety standardsWorking conditions