Military Training Deaths:

Need to Ensure That Safety Lessons Are Learned and Implemented

NSIAD-94-82: Published: May 5, 1994. Publicly Released: May 5, 1994.

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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.

GAO found that: (1) between fiscal years 1989 and 1992, at least 700 uniformed personnel died while engaged in such training activities as swimming, parachuting, weapons training, and physical fitness exercises; (2) each of the services has regulations requiring it to conduct safety investigations of serious mishaps and each of the services has a central safety center that establishes and implements safety policies; (3) the services have not performed all required investigations of all training-related deaths because they do not investigate deaths due to natural causes, even if the deaths occurred during training; (4) the services have not conducted all required safety and legal investigations of fatal aviation and non-aviation training mishaps; (5) the services have adequate controls to ensure credible investigations and effective tracking of recommendations for corrective actions; and (6) the services do not have adequate procedures to ensure that legal investigations of training mishaps are independent and that recommendations are monitored until corrective action is complete.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: The DOD revised accident reporting instruction now includes a common definition for "training-related" death and requires that all such deaths be investigated.

    Recommendation: 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.

    Agency Affected: Department of Defense

  3. Status: Closed - Implemented

    Comments: DOD will now use the "training-related" death definition to ensure that required safety investigations are conducted.

    Recommendation: 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.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Defense

  5. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Defense

 

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