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

U.S. Government Accountability Office

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.

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Recommendations for Executive Action

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

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

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

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

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