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National Guard Helicopters: Additional Actions Needed to Prevent Accidents and Improve Safety

GAO-23-105219 Published: Mar 14, 2023. Publicly Released: Apr 12, 2023.
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Fast Facts

The National Guard is comprised of Army and Air Force components. Both components fly helicopters to perform domestic and overseas missions. Together, they reported 298 accidents—mostly due to human errors—for certain helicopters during non-combat flights between FYs 2012-2021.

We found that the Army and Air National Guard could improve how they promote safety. For example, safety officers have limited time to focus on safety issues—such as leading safety briefings—because they are often responsible for a variety of other duties.

We recommended, among other things, that the National Guard components reassess their safety officer workload.

Army National Guard’s Black Hawk Helicopter

helicopter in air surrounded by blue sky

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Highlights

What GAO Found

Army and Air National Guard reported 298 helicopter accidents during non-combat flight operations from fiscal years 2012 through 2021. Approximately 45 of those were considered serious helicopter accidents in that they involved death, permanent disability, extensive hospitalization, property damages of $500,000 or more, or a destroyed helicopter (see figure). These non-combat helicopter accidents fluctuated over time and were mainly due to human errors such as not following training standards, overconfidence, poor communication, and lack of awareness, according to GAO's analysis of Department of Defense data.

Reported Army and Air National Guard Serious Helicopter Accidents, Fiscal Years 2012 through 2021

Reported Army and Air National Guard Serious Helicopter Accidents, Fiscal Years 2012 through 2021

Note: Serious helicopter accidents include those that involved death, permanent disability, extensive hospitalization, property damages of $500,000 or more, or a destroyed helicopter. GAO analyzed non-combat helicopter accidents for four Army National Guard and one Air National Guard helicopter types, which were the primary helicopters used by the National Guard in fiscal years 2012 through 2021.

The Army and Air National Guard use a variety of processes to promote safety and reduce risks during helicopter training, but the effectiveness of their respective flight safety training programs can be improved. National Guard helicopter units use risk management processes during aviation operations, but GAO found each component did not continuously evaluate and update unit level risk management worksheets to incorporate relevant safety information such as accident data and unit culture surveys. By evaluating these worksheets on a routine and recurring basis, Army and Air National Guard helicopter units will ensure those units have cyclical feedback and evaluation of this key risk management process to help ensure risk management procedures are effective.

The Army and Air National Guard established flying hour goals, but pilots did not fly enough on average to meet them due to lack of aircrew availability, maintenance issues, and simulator access. For example, having too few maintenance personnel limited the number of helicopters available for training. The Army and Air Force, including their National Guard components, have taken steps to mitigate these challenges, such as conducting formal studies, but these steps have not fully addressed the identified challenges. By developing comprehensive strategies, the Army and Air Force would be better positioned to fully address the identified challenges that have hindered National Guard helicopter pilot training.

Why GAO Did This Study

National Guard helicopter units perform a range of federal and state missions, including combat search and rescue, medical evacuations, and disaster relief. The Army and Air National Guard experienced helicopter accidents that resulted in the deaths of 28 National Guard personnel during fiscal years 2012 through 2021, based on reported data.

GAO was asked to review issues related to National Guard helicopter accidents. This report examines (1) the trends from fiscal years 2012 through 2021 in reported Army and Air National Guard helicopter accidents in non-combat scenarios and reported causes; and evaluates the extent to which (2) the Army and Air National Guard used existing processes to promote safety and reduce risks during helicopter training; and (3) the Army and Air Force have addressed challenges, if any, that hindered National Guard helicopter pilot training.

GAO analyzed accident data from fiscal years 2012 through 2021; reviewed documents; and interviewed officials from a non-generalizable sample of units selected based on factors such as locations where accidents occurred.

Recommendations

GAO is making 8 recommendations to the Army and Air Force, including that they take steps to ensure that their National Guard helicopter units continuously evaluate and update risk management worksheets and develop comprehensive strategies to address challenges that have hindered National Guard helicopter pilot training. The department generally agreed with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of the Army The Secretary of the Army should ensure that the Director of the Army National Guard, in coordination with the Army Combat Readiness Center, establishes a system of record for tracking the status of accident investigation recommendations through implementation. (Recommendation 1)
Open
The Army concurred with this recommendation. In a corrective action plan provided to us in July 2023, Army officials shared plans to update the Army's mishap reporting system to have more comprehensive recommendation tracking. In the meantime, they are manually tracking the recommendations. The Army estimates that these actions will be completed by the end of September 2024. By taking these actions, the Army will be able to track recommendations, no matter the component, through to implementation, as GAO recommended in March 2023.
Department of the Army
Priority Rec.
The Secretary of the Army should ensure the Chief of Staff of the Army, in coordination with the Director of the Army National Guard, updates safety or operational guidance to establish a process to continuously evaluate and update operational risk management worksheets for Army National Guard helicopter units to reflect relevant safety information such as accident data, hazard reporting, and unit culture surveys. (Recommendation 2)
Open
The Army concurred with this recommendation. In a corrective action plan provided to us in July 2023, Army officials noted that they intend to update Army Regulation 385-10 "The Army Safety Program" to reflect the need for a well-defined process for continuous evaluation of operational risk management practices that is informed by relevant safety data. The Army estimates that these actions will be completed by the end of December 2024. By taking these actions, the Army will be able to ensure that risk management worksheets reflect relevant and up-to-date safety information, as GAO recommended in March 2023.
Department of the Air Force
Priority Rec.
The Secretary of the Air Force, in coordination with the Chief of Staff of the Air Force and the Director of the Air National Guard, should incorporate an evaluation of unit processes for updating risk management worksheets as a component of the Air Force's unit inspection program or other means to ensure that the worksheets reflect relevant safety information such accident data, hazard reporting, and unit culture surveys. (Recommendation 3)
Open
The Air Force partially concurred with this recommendation. In a corrective action plan provided to us in July 2023, Air Force officials shared plans to update Air Force Unit Effectiveness Inspection and Continual Evaluation worksheets to include a specific item to verify Air National Guard helicopter unit's compliance with existing risk management directives. Specifically, the plans call for adding an evaluation item to the worksheet that requires safety staff to provide accident, hazard, and culture survey information to the commander for incorporation into the risk management worksheets. Further, the plans will add an evaluation item to have helicopter wing commanders verify that their unit risk management worksheets comply with Air Force and Air Combat Command risk management guidance. The Air Force estimates that these actions will be completed by the end of September 2024. By taking these actions, the Air Force will be able to ensure that risk management worksheets reflect relevant and up-to-date safety information, as GAO recommended in March 2023.
Department of the Army
Priority Rec.
The Secretary of the Army should ensure the Army Training and Doctrine Command's Army Aviation Center of Excellence, in coordination with the Director of the Army National Guard, develops a coordinated plan and identifies the resources necessary for conducting in-flight aviation standardization program evaluations of Army National Guard helicopter unit aircrews on a regular and recurring basis. (Recommendation 4)
Open
The Army concurred with this recommendation. In a corrective action plan provided to us in July 2023, Army officials noted that a review of the resourcing requirements to support the Directorate of Evaluations and Standardizations to start re-occurring assessments for the Army National Guard helicopter units is almost complete. The Army estimates that these actions will be completed by the end of September 2023. By performing this review and identifying the resources needed for the Directorate of Evaluations and Standardizations to perform these re-occurring assessments and by developing a plan to implement those resources, the Army will be able to provide more regular assessments of Army National Guard Helicopter crew training standardization, as GAO recommended in March 2023.
Department of the Army The Secretary of Army should ensure the Director of the Army National Guard assesses the resource and workload allocations of safety personnel to determine whether helicopter units are appropriately staffed, or if any adjustments are needed to workloads or resource levels to implement operational flight safety programs. (Recommendation 5)
Open
The Army concurred with this recommendation with comment. In a corrective action plan provided to us in July 2023, Army officials noted that they intend to perform a manpower study as there is not a recent comprehensive manpower study for aviation flight facilities. The Army estimates that this study will be completed by the end of September 2028. By taking this action, the Army will have visibility on whether their aviation facilities are appropriately staffed and what an appropriate staffing level would be, which is in alignment with what GAO recommended in March 2023.
Department of the Air Force The Secretary of the Air Force should ensure the Director of the Air National Guard assesses the resource and workload allocations of safety personnel to determine whether helicopter units are appropriately staffed, or if any adjustments are needed to workloads or resource levels to implement operational flight safety programs. (Recommendation 6)
Closed – Implemented
The Air Force concurred with this recommendation. In a corrective action plan provided to us in July 2023, Air Force officials stated that, based on a March 2023 review, all three Air National Guard helicopter units were verified as funded appropriately for full time safety manning for a flying wing as stated in Air Force Instruction 91-202 and Air National Guard standard 11H100. This action meets the intent of our recommendation that the Air Force assess the resource and workload allocations of safety personnel to determine whether helicopter units are appropriately staffed to implement operational flight safety programs.
Department of the Army
Priority Rec.
The Secretary of the Army should ensure that the Chief of Staff of the Army, in coordination with the Director of the Army National Guard, develops a comprehensive strategy that includes goals, priorities, and performance measures to address the challenges that hinder Army National Guard helicopter pilot training. (Recommendation 7)
Open
The Army concurred with this recommendation. In a corrective action plan provided to us in July 2023, Army National Guard officials recommended the Army establish a working group to identify challenges and develop a strategy with the Army Aviation Enterprise and the Combat Readiness Center to meet the challenges which are currently hindering pilot training and determine the trends and solutions which will address pilot training friction points in the future. The Army estimates that establishing the working group and developing recommendations will take until the end of April 2024. By taking this action, the Army will have a comprehensive approach to address the training challenges facing Army National Guard helicopter pilots, as GAO recommended in March 2023.
Department of the Air Force
Priority Rec.
The Secretary of the Air Force should ensure that the Chief of Staff of the Air Force, in coordination with the Director of the Air National Guard, develops a comprehensive strategy that includes goals, priorities, and performance measures to address the challenges that hinder Air National Guard helicopter pilot training. (Recommendation 8)
Open
The Air Force concurred with this recommendation. In a corrective action plan provided to us in July 2023, Air Force officials shared plans to develop an actionable and comprehensive strategy to update its Ready Aircrew Flying Hour Program goals to reflect the information in our report. Additionally, the Air National Guard will require an initial and midyear comparative review of personnel funding and the flying hour program for each unit to ensure units are adequately resourced to achieve the goals set by the Ready Aircrew Program. Further, Air Force Unit Effectiveness Inspection and Continual Evaluation worksheets will include a specific item to verify Air National Guard helicopter unit's compliance with existing risk management directives. The Air Force estimates that these actions will be completed by the end of September 2024. By taking these actions, the Air Force will be better able to identify and mitigate the training challenges faced by Air National Guard helicopter units, as GAO recommended in March 2023.

Full Report

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Topics

Accident investigationsData collectionHelicopter pilot trainingHelicoptersMilitary aviationNational GuardRisk managementSafetyMilitary forcesNaval aviation