Congressional Hearings
[H.A.S.C. No. 115-68] ADDRESSING PHYSIOLOGICAL EPISODES IN FIGHTER, ATTACK, AND TRAINING AIRCRAFT
Congressional Hearings
SuDoc ClassNumber: Y 4.AR 5/2
Congress: House of Representatives
CHRG-115hhrg28971
| AUTHORITYID | CHAMBER | TYPE | COMMITTEENAME |
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| hsas00 | H | S | Committee on Armed Services |
[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 115-68]
ADDRESSING PHYSIOLOGICAL EPISODES
IN FIGHTER, ATTACK, AND
TRAINING AIRCRAFT
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON TACTICAL AIR AND LAND FORCES
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
FEBRUARY 6, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
28-971 WASHINGTON : 2019
SUBCOMMITTEE ON TACTICAL AIR AND LAND FORCES
MICHAEL R. TURNER, Ohio, Chairman
FRANK A. LoBIONDO, New Jersey NIKI TSONGAS, Massachusetts
PAUL COOK, California, Vice Chair JAMES R. LANGEVIN, Rhode Island
SAM GRAVES, Missouri JIM COOPER, Tennessee
MARTHA McSALLY, Arizona MARC A. VEASEY, Texas
STEPHEN KNIGHT, California RUBEN GALLEGO, Arizona
TRENT KELLY, Mississippi JACKY ROSEN, Nevada
MATT GAETZ, Florida SALUD O. CARBAJAL, California
DON BACON, Nebraska ANTHONY G. BROWN, Maryland
JIM BANKS, Indiana TOM O'HALLERAN, Arizona
WALTER B. JONES, North Carolina THOMAS R. SUOZZI, New York
ROB BISHOP, Utah JIMMY PANETTA, California
ROBERT J. WITTMAN, Virginia
MO BROOKS, Alabama
John Sullivan, Professional Staff Member
Doug Bush, Professional Staff Member
Neve Schadler, Clerk
C O N T E N T S
----------
Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Tsongas, Hon. Niki, a Representative from Massachusetts, Ranking
Member, Subcommittee on Tactical Air and Land Forces........... 3
Turner, Hon. Michael R., a Representative from Ohio, Chairman,
Subcommittee on Tactical Air and Land Forces................... 1
WITNESSES
Cragg, Clinton H., Principal Engineer, NASA Engineering and
Safety Center.................................................. 4
Joyner, RDML Sara A., USN, Navy Physiological Events Action Team
Lead, U.S. Navy................................................ 6
Nowland, Lt Gen Mark C., USAF, Deputy Chief of Staff for
Operations, U.S. Air Force..................................... 8
APPENDIX
Prepared Statements:
Cragg, Clinton H............................................. 32
Joyner, RDML Sara A.......................................... 39
Nowland, Lt Gen Mark C....................................... 52
Turner, Hon. Michael R....................................... 29
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
[There were no Questions submitted during the hearing.]
Questions Submitted by Members Post Hearing:
Mr. Gaetz.................................................... 75
Ms. Tsongas.................................................. 73
Mr. Turner................................................... 67
ADDRESSING PHYSIOLOGICAL EPISODES IN FIGHTER, ATTACK, AND TRAINING
AIRCRAFT
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Tactical Air and Land Forces,
Washington, DC, Tuesday, February 6, 2018.
The subcommittee met, pursuant to call, at 3:30 p.m., in
Room 2118, Rayburn House Office Building, Hon. Michael R.
Turner (chairman of the subcommittee) presiding.
STATEMENT OF HON. MICHAEL R. TURNER, A REPRESENTATIVE FROM
OHIO, CHAIRMAN, SUBCOMMITTEE ON TACTICAL AIR AND LAND FORCES
Mr. Turner. Everyone, take a seat. We are under the
pressure of votes. They are going to happen sometime around
4:00, 4:15, so we are going to try to make certain we get
through everybody's statements and maybe some initial comments.
So beginning with my opening comments, the subcommittee
meets today to receive an update on how the Departments of the
Navy and the Air Force are addressing physiological episodes
[PE] in tactical and training aircraft. I would like to welcome
our distinguished panel of witnesses. We have Mr. Clint Cragg--
is that correct? Okay--Principal Engineer from the NASA
[National Aeronautics and Space Administration] Engineering and
Safety Center [NESC]; Rear Admiral Sara Joyner, Physiological
Episodes Action Team Lead for the U.S. Navy; and Lieutenant
General Mark Nowland, Air Force Deputy Chief of Staff for
Operations. I want to thank each of you for your service and
for your important testimony today.
For over 2 years now, this subcommittee has held briefings,
hearings, and conducted site visits regarding the occurrences
of physiological episodes, or PEs, in tactical and training
aircraft. As I stated before, I believe Navy leadership was
initially slow to respond to this issue that is having a direct
effect on overall readiness and affecting the confidence of our
pilots, as well as their ability to perform their missions.
Because it is not just that these events are occurring; it
is also the anxiety that these events occur in succession. As a
result of the subcommittee's activity, the National Defense
Authorization Act [NDAA] for fiscal year [FY] 2017 included
legislation that required an independent report of the Navy's
efforts to resolve these issues. That report was delivered to
the subcommittee in mid-December, and a copy has been provided
to members' offices.
According to the report, the Navy was addressing the PE
problem as an aircraft problem, not a human problem. We have to
acknowledge that physiological episodes happen to people, not
aircraft. I was just talking to the Secretary of the Air Force,
and the human body as a sensor is perhaps different than just
our technological sensors and can give us a gap in the
information or data that we are receiving, but we have to trust
those pilots, those human responses and reports that we are
having of these issues.
The report also concludes that the F/A-18 systems that
support human health are ``complex, dynamic, and interactive.''
As a result, the more complex, dynamic, and interactive a
system is, the more important it is to have a well-coordinated
systems approach to design and operations.
Finally, the report notes that the physiological episodes
will persist in the F/A-18, and all high-performance aircraft,
if there is a piecemeal approach to human systems integration.
Our witness, Mr. Cragg, was the primary author of this report,
and he is prepared to provide the subcommittee with a summary
of the report's findings and recommendations.
On September 15th of last year, Ms. Tsongas and I visited
the Naval Air Station Pax [Patuxent] River to receive briefings
on the root cause and corrective action processes from members
of the Navy's Physiological Episodes Action Team [PEAT]. We
spoke with engineers and pilots and learned about the Navy's
process to find the root cause of these events. We were also
briefed on the Navy's attempts to alert and protect the aircrew
and monitor the system.
Additionally, we spoke with engineers at some of the labs
who are analyzing specific portions of the primary systems that
make up the Environmental Control System, ECS, and the On-Board
Oxygen Generating System, OBOGS. I believe the Navy has taken a
step in the right direction by establishing a formal action
team directly responsible for addressing physiological
episodes. The team is led by our Navy witness today, Rear
Admiral Joyner.
However, despite these efforts, pilots are continuing to
experience physiological episodes, and I am concerned about the
increased frequency. For example, since the subcommittee's last
event in May of last year, the Navy as well as the Air Force
have continued to report incidences of PE in aircraft.
This past summer, the Navy made the decision to ground T-45
training aircraft due to increasing occurrences of pilots
experiencing hypoxia symptoms in the aircraft. The decision was
made after a significant number of instructor pilots at all
three T-45 training locations refused to fly the aircraft due
to safety concerns with the oxygen systems. It is an incident
that we were very concerned about in this committee that would
have to go to the level of the pilots themselves intervening
and refusing to fly, prior to leadership understanding the need
to intervene.
The Air Force grounded F-35 Joint Strike Fighters [JSF] at
Luke Air Force Base in June of last year due to oxygen
problems, and the F-35 fleet has experienced 29 physiological
episodes to date.
In early December of last year, the subcommittee was
informed that 13 A-10 aircraft at Davis-Monthan Air Force Base
have been grounded due to problems with the oxygen systems. And
just last week, the Air Force grounded all T-6 training
aircraft at six operating locations due to an increasing rate
of unexplained physiological episodes in the T-6 aircraft.
There is no doubt this remains a complex problem to solve
that requires a well-coordinated systems approach to include
all factors, such as the aircraft, the pilot, and the
environment. So in closing, we need to be reassured that this
remains a top priority for the Navy and the Air Force and that
the two services are coordinating efforts and that such a
systems approach to solve this problem is being taken.
The increasing frequency of these physiological episodes is
having a direct effect on overall readiness, and as such we
expect to receive your professional assessments on what we as
members of this subcommittee can do to help you address this
critical problem. In addition to effects on readiness, this has
a direct correlation and effect on morale.
Before we begin with witnesses' opening statements, I would
like to turn to my good friend from Massachusetts, Ms. Niki
Tsongas, for any comments that she may want to make.
[The prepared statement of Mr. Turner can be found in the
Appendix on page 29.]
STATEMENT OF HON. NIKI TSONGAS, A REPRESENTATIVE FROM
MASSACHUSETTS, RANKING MEMBER, SUBCOMMITTEE ON TACTICAL AIR AND
LAND FORCES
Ms. Tsongas. Thank you, Mr. Chairman, and good afternoon to
our witnesses. It is good to have you here. And I want to thank
Chairman Turner for holding this hearing and continuing the
subcommittee's focus on this really important issue.
One of the reasons for today's hearing is a completion of
the independent review of the Navy's efforts to address
persistently high rates of physiological episodes experienced
by aviators in F/A-18 aircraft, a critical issue since these
episodes can put a pilot's life at risk.
The review was mandated by the fiscal year 2017 NDAA and
conducted by the NASA Engineering and Safety Center under the
leadership of Mr. Clinton Cragg, who is here with us today, and
I would like to thank you, Mr. Cragg, and your entire team for
your diligent work on the report.
I am also pleased that Rear Admiral Joyner is with us
today, but I must point out that the Navy has decided to move
the Admiral out of her current position overseeing the
service's response to physiological episodes after less than a
year in the position. While I understand that the Navy is
working to find another talented officer to take over the
position, I do believe that making the change so soon sends an
unfortunate message to the entire Navy aviation community,
including their families. This important issue deserves unified
leadership and I would urge Navy leadership to prioritize
continuity in this position moving forward.
After reviewing the report, it appears its findings and
recommendations fall into three broad categories. First, it
makes several findings and recommendations related to the,
quote, ``human factors'', unquote, underlying the Navy's
physiological episode problem. The report states upfront that,
quote, ``Physiological episodes happen to people, not
aircraft'', unquote. It goes on to point out numerous areas
where human factors research, data gathering, and testing is
needed to provide a true end-to-end understanding of the
problem. I will have several questions on some of the issues
raised in the report in this area.
Second, the report points out several specific concerns
with the design and specifications of the F/A-18 aircraft
related to aircrew life support. It places particular attention
on the aircraft's oxygen generation and cabin pressure systems,
raising significant questions regarding both.
Finally, the report examines internal Navy organizational
challenges that may be making it much harder to address the PE
issue. In particular, the report focuses attention on the need
for the Navy's medical community to be more tied into the
Navy's ongoing lines of effort.
And of special concern to me, given what we learned about
the situation the Navy faced this summer in its T-45 training
community, the report also raises concerns about, quote, ``a
breakdown of trust in leadership within the pilot community,''
unquote, regarding the Navy's efforts on this issue.
I know that hundreds of dedicated people in the Navy are
working very hard to address this problem. But the report
points out that we have a long way to go and that in some areas
we can do much, much better. I am hopeful that the Navy is
carefully examining the findings of this report and acting on
them as quickly as possible and hope to learn more on this
front today.
The other reason for today's hearing is to get an update
from the Air Force on its challenges with its own physiological
episodes, most recently in F-35A, A-10s, and T-6A aircraft
fleets. In the case of the T-6A, the Air Force's fleet remains
grounded. We need to know the full story of what happened and
how the Air Force plans to stay ahead of this problem moving
forward. I look forward to today's testimony and yield back.
Mr. Turner. Thank you, Ms. Tsongas. Without objection, all
our witnesses' prepared statements will be included in the
hearing record.
Mr. Cragg will begin, followed by Admiral Joyner and
General Nowland. Mr. Cragg.
STATEMENT OF CLINTON H. CRAGG, PRINCIPAL ENGINEER, NASA
ENGINEERING AND SAFETY CENTER
Mr. Cragg. Chairman Turner, Ranking Member Tsongas, and
members of the subcommittee, thank you for this opportunity to
discuss the NASA Engineering and Safety Center's, or NESC's,
independent assessment of the Navy's efforts to understand and
mitigate the F/A-18 fleet physiological episodes.
Mr. Turner. I am sorry, sir. If I could interrupt you for a
second, if you could move that microphone to in front of you,
because we are not hearing you-- they are directional. If you
could point it at you, there you go. Thank you.
Mr. Cragg. Too complicated for me. I am honored to be
serving as the lead for this NESC team. The NESC performs
independent testing, analysis, and assessments to help address
some of NASA's tougher challenges.
We can draw upon technical experts from all 10 NASA
centers, from industry, from academia, and other governmental
agencies. This allows us to bring the country's best experts to
bear on the problems and challenges of NASA programs.
In February 2017, the U.S. Navy's Naval Air Systems Command
requested NASA's assistance in assessing the Navy's efforts to
understand the causes of physiological episodes affecting
aircrew on their F/A-18 fleet. In March of 2017, the NESC
assembled a multidisciplinary team with a broad range of
expertise that included flight surgeons, life support system
experts, engineers, and several subject matter experts.
In the course of this investigation, the team reviewed data
from a variety of sources, visited multiple manufacturing sites
and Navy commands, and held numerous discussions with
knowledgeable personnel. The NESC team's findings and
recommendations are based on this data and not an exhaustive
review of all F/A-18 documentation.
To address the complex causes of physiological episodes,
the NESC team used a multi-systems trends analysis approach and
formed the following resulting findings. First and foremost,
physiological episodes are a human phenomenon. Although the
Navy has put a significant effort into investigating the
physiological episodes, the bulk of their efforts to date have
been directed at the aircraft, rather than human physiology.
Centering our investigation on the human element revealed new
information about the character of physiological episodes.
Second, hypoxia--determined to be the most prevalent cause
of physiological episodes--is not a condition of insufficient
oxygen in the breathing gas. It is insufficient delivery of
oxygen to tissues of the body, importantly, the brain.
Third, a key reliable On-Board Oxygen Generating System
performance is uniform operating conditions, which the F/A-18
design and dynamic operating environment rarely provides.
Fourth, the F/A-18 program has a large amount of aircraft
performance data, but a shortage of evidence related to human
health and performance in an F/A-18 environment.
Fifth, the F/A-18 systems that support human health are
complex, dynamic, and interactive. This requires a well-
coordinated systems approach to design requirements,
interfaces, and operations.
Finally, an unacceptable number of physiological episodes
will persist in the F/A-18 program if there continues to be a
piecemeal approach to the human systems integration.
The NESC team made the following observations regarding the
Navy processes. Until recently, the absence of a single leader
to coordinate and prioritize the Navy's physiological episodes
efforts resulted in organizational stove-piping and exclusion
of key stakeholders. Investigations have been structured as if
the physiological episodes were isolated events, rather than a
series of related events.
Furthermore, troubleshooting efforts used a top-down
approach that emphasized component-level behaviors instead of
evaluating the performance of the system as a whole. In this
case, the system means the aircraft, the pilot, and the
environment.
The NESC team asserts that a dedicated, coordinated, cross-
organizational, and cross-discipline program--under the
direction of a single leader with clearly defined authority--
would improve the U.S. Navy's effectiveness in finding and
fixing the causes of physiological episodes.
The NESC team has identified a number of near- and long-
term recommendations. Near-term tasks are focused on gathering
key evidence about human health and performance and
understanding hypoxia in the F/A-18 flight environment. Long-
term tasks which may provide substantial benefit include
utilizing a data-driven causal analysis effort, updating the F/
A-18 to conform to MIL-STD-3050 [Military Standard], and
developing a systems-level understanding of bleed air
management systems.
In conclusion, and although key data is lacking, the NESC
believes that the majority of F/A-18 physiological episodes are
a result of hypoxia. This hypoxia, it is believed, is caused by
a combination of issues affecting the various stages of oxygen
delivery process, including those stages within the human.
We applaud the Navy's efforts to gather the necessary data
to resolve these issues. The NESC report has provided a
conceptual framework to view the issue of physiological
episodes in a new light and offers recommendations that may
guide future processes and technological improvements.
I thank you for the opportunity to testify before the
subcommittee and look forward to your questions.
[The prepared statement of Mr. Cragg can be found in the
Appendix on page 32.]
Mr. Turner. Admiral Joyner.
STATEMENT OF RDML SARA A. JOYNER, USN, NAVY PHYSIOLOGICAL
EVENTS ACTION TEAM LEAD, U.S. NAVY
Admiral Joyner. Mr. Chairman, Representative Tsongas, and
distinguished members of the subcommittee, thank you for the
opportunity to appear before you today to discuss the
Department of the Navy's ongoing efforts to address
physiological episodes, or PEs, in fighter and attack and
training aircraft.
Addressing PEs remains the Navy's number one safety
priority and encompasses naval and Marine Corps aviation
communities. We have implemented numerous technical and
operational measures to mitigate the risk to our aircrew.
Utilizing every resource available to resolve these issues, the
Department of the Navy has engaged a broad spectrum of internal
and external partners, including subject matter experts from
the United States Air Force, National Aeronautics and Space
Administration, Federal Aviation Administration, industry,
academia, medical communities, and the Navy's dive communities.
In addition, we have established regular fleet communication to
share all data and progress related to PEs.
I would like to first focus on the efforts of the
Physiological Episodes Action Team, or PEAT. In April 2017, the
Chief of Naval Operations directed a comprehensive review of
PEs be conducted. As a result, the PEAT was formed to serve as
a single-source Navy and Marine Corps entity which unites both
Department of Defense [DOD] and non-DOD entities as a cohesive
force to combat PEs.
The PEAT follows three lines of effort: Warn the aircrew,
fix the machine, protect and prevent. Our efforts rely on
understanding of an inherently challenging environment
encountered at altitude and its effects on the human body.
The PEAT has served to synchronize efforts to resolve
physiological episodes between NAVAIR [Naval Air Systems
Command], Commander Naval Air Forces, Bureau of Medicine and
Surgery, the Naval Safety Center, our industry partners, and
academia.
Coordinating multiple agencies, the PEAT's focus is on
finding the root causes of PEs, correcting deficiencies that
they are identified, and equipping existing agencies with long-
term resources to address PE issues effectively.
Additionally, the PEAT is responsible for providing timely
information to aircrew and maintainers regarding past PEs,
present research, ongoing mitigation efforts, and future plans.
Direct fleet engagement has been established where
representatives from the PEAT, NAVAIR, and the Naval Safety
Center are available for frank and direct dialogue with
aircrew, providing an open forum between warfighters and
leadership.
We provide a response triage reports to aircrew to improve
feedback and communication. These efforts combined have made a
great impact in restoring aircrew confidence in their equipment
and the efforts to resolve the PE problem.
Why haven't we solved the issue yet? Our incredibly
talented engineers at NAVAIR have worked diligently to ensure
the aircraft are operating according to required specifications
and that material solutions met engineering requirements. As
our aircraft capabilities have advanced, we have encountered
challenges in how to best support the human in the cockpit in
an ever more dynamic environment.
Today, we benefit from oxygen systems that no longer limits
prolonged operations. Rather it is limited only by the
constraints of fuel, ordnance, and human endurance. Routinely
operating for 8 hours or longer on a combat mission, by flying
higher, faster, and longer, we have come to realize that there
are aspects of our operational environment that need to be more
fully understood.
The NASA report was valuable in reminding us that we need
to consider not just what we were most comfortable with
addressing--the engineering elements--but also the human
performance element of the aviation environment.
The effects of pressure and breathing gas composition on
the human body. It became apparent that in order to discover
physiological episode root causes, we needed to start with the
human, the aviator, and the cockpit. The close relationship
between our aeromedical specialists and our engineers had
atrophied, and we are working actively to restore this
relationship in combatting PEs.
Today we acknowledge that there is more we need to learn
about human physiology in a pressurized environment and
incorporate that into our engineering design. We are moving
forward to close our knowledge gap through research and
instrumentation on humans in flight and to develop a thorough
and holistic understanding of environmental challenges in the
flight regime that results in PEs.
I would like to thank Congress for supporting the Navy's
and our efforts to address PEs. We were able to combine
congressional funding with other resources to immediately put
into motion research and material solutions to address
physiological episodes, as well as expedite longer-term
solutions.
We are moving forward in optimizing the cockpit environment
with measurable improvements, providing our aviators with every
tactical advantage in a dynamic environment in which they
operate. It is appropriate that I appear today with our Air
Force partners. Not present today are our international
partners who continue to assist us in gathering data and
providing solutions to the PE issue.
Right now, the Royal Australian Air Force and the Swiss Air
Force fly with instrumentation to gather further data in
support of our efforts. I have no doubt that through our
coordinated efforts we will be successful in resolving this
issue for the U.S. Navy, the Marine Corps, the Air Force, and
our international partners.
Thank you for the opportunity to present our progress
today. I look forward to your questions.
[The prepared statement of Admiral Joyner can be found in
the Appendix on page 39.]
Mr. Turner. General Nowland.
STATEMENT OF LT GEN MARK C. NOWLAND, USAF, DEPUTY CHIEF OF
STAFF FOR OPERATIONS, U.S. AIR FORCE
General Nowland. Chairman Turner, Ranking Member Tsongas,
and distinguished members of the subcommittee, thank you for
the opportunity to provide an update on our physiologic events
within your United States Air Force.
Today I will address some of the risk our airmen face
defending our Nation, as well as multiple initiatives underway
to address physiological events. Operating high-performance
aircraft is fundamental to air superiority. Inherently, the
nature of our profession means there will always be risk to the
human body. It can be caused by unforeseen mechanical issues in
our increasingly complex aircraft or by overstressing our
bodies when we are max performing those aircraft to their
combat capability.
As the Deputy Chief of Staff for Operations, I believe that
training our pilots is the critical factor between life and
death. Whether it is executing the right procedures during in-
flight emergency or the maneuvers necessary to defeat an
adversary in combat, training is paramount. Therefore, we make
sure it goes hand-in-hand with material solutions when we
implement recommendations for physiologic events.
The Air Force tracks and provides historical data on
physiological events. And even though the probability that Air
Force pilots will experience a physiological event remains much
less than 1 percent per year, the Air Force takes flight safety
very serious. The service investigates every incident that may
impact our most valuable asset, our people.
And we are in complete agreement with actually the NASA
report. This is really about people, as we have discovered over
our incidents over time. The Air Force increased the budget of
our 711th Human Performance Wing nearly by $60 million over the
past 10 years, which goes back to the F-22 incidents we had,
because we recognized we needed to look at the human element
here. This funding has supported multiple research vectors into
hypoxia, biomechanics, and toxicology studies.
Additionally, the Air Force was able to add five pilot
physicians last year. I have Dr. Bill Mueller behind me who is
an example of those. He is a rated Air Force pilot, but he is
also a physician, so he flies the airplanes that were actually
out there and able to talk to the aviators. This unique
critical program qualifies aerospace physicians to fly the
airplane and then care for the airmen.
We have also made organizational changes to the
Headquarters Air Force Operations staff. I have appointed a
general officer to be the singular point of contact for
physiologic events. We learned from the Navy essentially.
Brigadier General Bobbi Doorenbos will integrate the flow of
information during physiological event investigations. She
couldn't be here today because she has something with her
family, her father, but she is hand-in-hand with Admiral
Joyner.
General Doorenbos provides a single nexus to pass
information from aircrew to senior leaders and across multiple
stakeholders. We continuously strive to improve our processes
which we share information between multiple agencies and our
joint partners during these events. The Air Force stood up an
investigative team called the Characterizing and Optimizing the
Physiological Environment in Fighters. Typical, we have a five-
letter name as opposed to the Navy's four. We call it COPE
Fighter. This multiple service interagency team identifies
solutions to optimize human performance and minimize
unexplained physiologic events in our high-performance
aircraft.
But they are not always high-performance aircraft. So I
would like to provide a quick update on our T-6, which is our
primary trainer, which is critical to United States Air Force.
The trainer fleet experienced multiple unexplained
physiological events since the beginning of 2018. The first one
happened at Columbus on the 19th of January, and I happened to
be there on the day when it happened. It was an extremely cold
day.
We took an operational pause last Friday after we had
multiple events across the fleet, to include Sheppard and
Vance--and if you remember, Vance had had previous events. We
did it because we needed to think about the safety of our
student pilots and the instructors. This pause will remain in
effect until we are certain that aircraft and procedures ensure
flight safety.
Major General Patrick Doherty, the commander of the 19th
Air Force and our Air Education and Training Command, and his
wing leaders are actively meeting in person with T-6
instructors and student pilots to discuss the current situation
and to listen to their concerns. We have learned this from our
F-22 Raptor, our F-15, and our F-35. Direct interface with the
leadership to the pilots is critical.
But it is also critical that they meet with the spouses,
because we need to ensure the family members that we put safety
first and to explain what actions we are undertaking to repair
and return the fleet to flying status. The key is trust. If the
aircrew doesn't trust their system, the family doesn't trust
the Air Force, we lose. That is why training is critical to
this whole as we move forward.
In our experience, we have studied the OBOGS, the onboard
generating systems, and for the most part, we have not really
discovered anything that is not working properly. We had some
A-10 issues, which was a maintenance issue. We think we are
discovering in the T-6 it is a maintenance issue right now. The
system and the way the systems work is sound. Maintaining it is
the critical factor.
Your Air Force T-6s have flown 2.1 million hours with a
physiological rate of 1.95. That means 1.95 incidents for every
100,000 hours flown. But in 2018, the rate is soaring. So what
is going on? That is why we paused to look at it. But we also
need to get in the training, and we totally agree with the
Navy--I mean with the NASA. We need to instrument our pilots.
We are looking into that as we move forward.
I thank you for the opportunity to provide you an update,
and I appreciate the opportunity to answer any questions.
[The prepared statement of General Nowland can be found in
the Appendix on page 52.]
Mr. Turner. General Nowland, I got to tell you, I could not
be more disappointed by your presentation. I mean, we have
hearing after hearing after hearing on this, and we have this
report in front of us, and the report and the presentation that
we have is that the human factor is not being taken into
consideration and your answer is training.
Now, I got to tell you, what I have in front of me--and I
just had the Secretary of the Air Force in my office, and she
does not agree with you. And I am glad, because you didn't
ground your aircraft, your T-6 aircraft, just last week because
of training. And this is a significant issue, and it is not
just listen and talk. This is pure safety.
Now, when we first started having hearings on this, the
issue that individuals who are testifying before us came forth
with was the difficulty to replicate the conditions in which
the physiological episode happened. No one ever came to us and
tried to blame the pilots and say it is just an issue of
training. There is something wrong with the systems that these
pilots are relying on for their lives and that we are asking
them to rely on.
Now, I was just telling the Secretary--and I mentioned this
in the very first hearing that we had on this--I had this issue
when I was a mayor, and it was with my firefighters and their
breathing apparatus and equipment. And we, too, could not
replicate anything that was happening with their equipment
except situation after situation they found themselves in where
their breathing apparatus was failing. And it had an impact of
morale on the entire fire department.
And what I am stunned by is that here I am--and I don't
even know how many hearings we have had on this--and I still
have someone who is representing one of the most important
service branches for our pilots come and say this is an issue
of training and listening and we need to talk to spouses. I
mean, I have this report in front of me, and one of the
headlines on this report is ``No Physiological Monitoring of
the Pilot's Breathing Air Has Been Conducted.'' This isn't an
issue of talking.
I mean, the Secretary of the Air Force is concerned that
the T-6 training aircraft are grounded not because somebody
doesn't have training. Now, I realize what they have done in
the past, but I realize what they are doing now. And I realize
the problem that we had in the failure of the leadership in the
Navy because we had pilots that refused to fly because the
leadership of the Navy continued to treat this as if it was not
a physiological episode that was happening to people, but that
it was something that, because they were not able to replicate
it, didn't need to be addressed.
Now, we asked for this report and to move forward with
this, because we didn't feel like we were getting the right
answers. But if you continue to come before us and say this is
just an issue of training the pilots, I mean, you know,
General, should we start doing hearing training where we ask
you to come before us and then let's have you hold your breath
for a minute during the first hearing, and the second hearing
we will have you hold your breath for the second for 2 minutes
during the second hearing? It makes no sense.
Mr. Cragg, give us some sense here. I know the OBOGS system
has been tested. There are certainly concerns of maintenance.
There are certainly concerns of where to identify this. But
clearly something is wrong for these number of pilots to have
these incidences and these planes to be grounded versus just we
just have to train them to understand what happened when the
incidents happen.
What should be happening to try to fix this so our planes
fly again and people can get the training and our pilots have
the confidence in their equipment?
Mr. Cragg. Well, sir, as we looked at the situation, we
tried to come up with some hypotheses on what was causing the
problems with the pilots. And we went through and looked--at
least on the Navy side, we went through and looked at all the
cases and our flight surgeons came up with a consensus that
over 80 percent of those cases were due to hypoxia.
Then we looked at the systems onboard the aircraft, and
they have what is called an OBOGS degrade light, which comes on
when the percentage of oxygen gets below certain values. So
what we--we did a little further digging and found out that
many or most of the physiological episodes that occurred
happened without this OBOGS degrade light on. So in other
words, they were getting enough proper oxygen in the cockpit.
And so when we went to look further, what we found was
there is hardly any information on the human in the cockpit. We
don't have the amount of oxygen in his mask, the amount of
CO2 [carbon dioxide] in his mask, the kind of
pressure that you would want to know about in the cockpit, the
breathing rates, those kind of things where we could do some
kind of physiological assessment of what is happening to the
pilot.
CO
Now, in our report, you may have noticed we had an oxygen
diagram that showed how oxygen was--how we think oxygen is
being taken away in little certain steps by different
circumstances like an aircrew vest that is too tight, maybe
they didn't have enough water to drink before they went on a
flight, some things like that. But what we really need is to
get a picture of the pilot, and we don't have that yet.
Mr. Turner. Do you have any sense that that step is being
taken? I mean, because as we try to do the data, pulling just
off of these systems that are producing the oxygen, and being
unable to replicate it, do you see any steps that are occurring
to be able to get that data of what the human is experiencing?
Mr. Cragg. Absolutely. As a matter of fact, I get a weekly
summary from the Navy on what they are doing to assist in the
physiological episodes. And the one I got end of last week,
they have made some remarkable progress on getting those type
of instruments in the cockpit that are going to measure just
those things we talked about.
Mr. Turner. What is the data saying?
Mr. Cragg. Well, I haven't seen the data, but what they
have is they are out testing it with the VX-23, I guess it is,
so--I mean, it is a heck of a lot further on than it was when
we delivered our report.
Mr. Turner. Admiral, what are you finding?
Admiral Joyner. So where we are today is, we went to what
was easy in T-45. We put in a system that could do cockpit
pressure and oxygen delivered at the regulator outside of the
OBOGS system to the pilot, because we could do that. And when
we did that on the T-45, we had the discovery that we had a
flow problem in that aircraft, and that was able to give us
that.
But that was an easier solution than what we are pursuing
right now. What he is speaking of is something called an AMS--
it used to be called AMS, now it is called VigilOX--which is an
attempt to measure breathing gas at the pilot. And we have
tried several systems so far, and there are a lot of
difficulties. It is probably one of the most difficult aspects
of this problem. We are working closely with the Air Force to
do this, and we are leveraging a lot of their early findings in
F-22.
So we are--these systems come forward. They are not
perfect, but we have flown three flights now with the VigilOX
system. We are just starting to collect the data. And it is
really early with the three flights. Right now we don't see a
lot of problems with the oxygen----
Mr. Turner. I know you can't tell us anything that is
conclusive, but are you at least being able to capture
something that indicates that there is a problem?
Admiral Joyner. We are able to capture the information of
what is being delivered at the pilot level. Right now it will
take those medical professionals and those researchers for us
to better understand the data that is being delivered--because
it is not apparent from the data that we are seeing what the
shortfall would be, but it is three flights in, so it is very
immature at this point. We are taking those steps. Those steps
were brought forward by the 711th Human Performance Wing, some
of their early work with the system, and through NASA prompting
and also the oxygen labs at NAVAIR, there is a lot of work to
make these systems work and make the data actually speak to us.
Mr. Turner. So speak to us about the F-35. Apparently 29
physiological episodes have occurred. What can we learn from
what you are doing now? And how does that apply to the F-35?
Admiral Joyner. I would say with the F-35, I talk to them
constantly. A through C. I am sure the general also is
collecting that data, as well. They enjoy an airframe that
speaks to you more clearly than any other airframe we have ever
had. So if I take my legacy Hornet, you are looking at my 1978
Corvette. If I go to a Super Hornet, I am looking at maybe a
2016 Lincoln Navigator. And I am in a JSF, I am flying the
newest and greatest, and it is telling us more data than we
have ever had.
So they are actually accelerating a lot of their learning,
and they just finished testing their OBOGS system, and they
have a good understanding of that system. And it was a very
positive outcome. But obviously we have issues that we have to
pull apart that are not--we haven't discovered yet at this
point.
Mr. Turner. Ms. Tsongas.
Ms. Tsongas. Thank you. I would like to talk about the role
of the medical community, as you have wrestled with these very
troubling episodes. And I think one of the--obviously the
finding that we are all most taken by from the independent
report is that this is so much about people.
So I am going to quote again from it, just to sort of
restate that. So chapter 12 states the following. Quote, ``PEs
happen to people, not to aircraft. The U.S. Navy is addressing
the PE problem as an aircraft, not a human problem. Remembering
that PEs afflict people and not aircraft may help focus
activities on better understanding human systems, human system
requirements, and human system impacts caused by conditions of
flight.''
Later, in Appendix A of the report, it goes further and
says, quote, ``The naval medical community as a whole has not
been involved with attempting to solve the PE issue.'' From the
beginning, PEs have been viewed as an engineering issue. And
you have even referenced that, Admiral Joyner. ``Therefore, a
proactive investigative U.S. Navy medicine effort never really
got underway,'' unquote.
As an example of a lack of U.S. Navy medical involvement,
the report points out that the decision to deploy hyperbaric
chambers to treat altitude-induced decompression illness
appears to have been taken at the operational level. That is to
say that it was made without any senior-level medical
involvement. So, Mr. Cragg, can you please elaborate on these
statements in the report and what you and your team think
should be done about it?
Mr. Cragg. Well, I think we were clear that the medical
community needed to get involved. And I am happy to say that
they currently are. One of the flight surgeons on my team
participates with this meeting of naval medical people that is
just now getting underway to help support the PE processes that
Admiral Joyner has started.
You know, it is unfortunate, but when everybody was saying
this was an engineering problem, they weren't asked, and so
they didn't participate.
Ms. Tsongas. And were you surprised to find that?
Mr. Cragg. Yes, we were actually very surprised to find
that. And----
Ms. Tsongas. So now that we found this to be a real
shortcoming, Admiral Joyner, these two findings and this
particular example, you know, are obviously quite troubling.
And I think most members would assume that the Navy's medical
community would be tightly integrated in all aspects of
addressing the PE issue. Those of us here certainly would be.
So what is the Navy currently planning to do in this area
of its overall PE response? And is there a plan going forward
for U.S. Navy medical to be involved and in some way that we
can depend upon?
Admiral Joyner. Yes, ma'am. Part of the standup of the PEAT
was to bring in the Bureau of Medicine and Surgery underneath
the PEAT in order to coordinate those efforts better. And that
is what having a single entity to try to bring this entire
fabric together has allowed us.
So what did we do? We set up something called the
Aeromedical Scientific Advisory Board, environmental advisory
board, and they are a group of professionals, both medical,
academia, oxygen specialists, our research scientists, some of
the ones from Dayton, Ohio, toxicology out of our NAMRU [Naval
Medical Research Unit] Dayton group, that are dedicated to
advising us as we move forward on the PE issue.
We also have an aeromedical team that is immediately
involved in all the responses on the flight lines and analyzing
and making sure that we are coming up with clinical practice
guidelines that are coherent and are tied in well with that
research community and with our medical community.
And then on top of that is we have the root cause
corrective analysis team who has--one of the members is an
operator who has become a flight surgeon, much like the Air
Force was talking about, General Nowland was talking about, and
we have those professionals, as well, involved in the root
cause analysis to make sure that we don't lose that human
element as we go forward to try to find the root cause of the
PE. So those are several examples.
Ms. Tsongas. Have you found that by engaging the medical
community in a more structured way, has it changed your
clinical practice guidelines? So, for example, have you
revisited the treatment you might--the ways in which you dealt
with hypoxia or dealt with decompression illness?
Admiral Joyner. I think it has standardized the response
across the flight line, and it has energized further research
in those areas that we are not as knowledgeable as we need to
be for what the type of treatment should be. We also engage
NASA, has been involved in several case reviews for us on some
of the difficult issues of what the treatment should be.
So we are extending beyond even within our internal
resources to external resources like NASA, Duke oxygen
specialists, and other people that we are bringing onboard to
better understand this problem. So I think it has increased the
scope. It has increased our consistency with the clinical
practice guidelines. And we know that the chambers themselves,
it is a do no harm. We know that they improve in conditions
under those treatments, and we are not going to stop treating
them effectively until we can find something better. But we
have a full research community dedicated to finding out better
ways to treat our aviators at this point.
Ms. Tsongas. Thank you, I yield back.
Mr. Turner. They have called votes. I think we can get to
Mr. Kelly and Mr. Langevin, and then we will take a break. Mr.
Kelly.
Mr. Kelly. Thank you, Mr. Chairman and the Ranking Member.
This is a very important issue. I think most of the people in
here have either soldiers--I mean, sailors or airmen that are
affected, airpeople, airwomen. I have Columbus Air Force Base,
and, General Nowland, we just talked beforehand. And I know
your son just graduated from there, so I know that you are
personally invested in getting this right, because you have got
skin in the game. And I think that applies to all of us who
have served.
I kind of agree--there is multiple issues. And we haven't
figured it out at any level, and we have got to figure this
out, what is causing this, whether it is maintenance, whether
it is lack of training, whether it is the improper use of
equipment, whether it is the equipment itself. We have been
going over this a long time, but it is critical that we get it
right and that we get it right quickly, but it is more
important that we get it right.
What type of--I don't see any movement in finding the
solution, and that is very, very difficult. So, I mean, you
have got to start with seeing what those are. What things do
you think or is there any indication that we are getting close
to finding at least what is causing it, whether it is the
maintenance of the system, which I heard you say, General
Nowland--and I think that is important. If we don't maintain
the system right and don't do that, then we get those episodes.
Do either of you--and this would--anybody on the board, do
we have any idea what may be causing this?
General Nowland. Congressman Kelly, thank you very much.
And, Chairman Turner and Ranking Member Tsongas, and the
distinguished members, if you got the impression from my
testimony that we are blaming pilots, we are not. We are not.
When I meant training, I am talking holistic training,
exactly back to your part. Part of our suspicion with the T-6
is that the time change technical order for the On-Board Oxygen
Generating System does not exist. We are formulating it right
now. So we never trained our technicians on how to maintain
that piece of equipment.
What we found in the F-22s is the equipment that we had--
the aircrew flight equipment, the life support equipment, we
didn't have our crews trained properly to wear the equipment
properly, and we noticed the valve on the chest was part of the
solution.
Back to the altitude chambers, we have 10 altitude
chambers, but the altitude chamber that we did training 10
years ago or 20 years ago is different than what we do today.
So it is a holistic view of all of it.
So I think right now our suspicion is that the maintenance
of our On-Board Oxygen Generating System for our T-6s, after
having flown them for 2.1 million hours, needs to be repaired.
So we believe there is a repair that--but we don't know that
for sure.
The human physiological episode, we absolutely believe--as
I said with the NASA--that that--we have got to collect data.
We have ear cups data that we use in the F-35 that allows us to
take the blood. One of the things that we found is when we have
a physiological episode, we do not have the time quite right,
because the blood alkalinity changes. So we are putting testing
equipment that will meet the aircrew right at the airplane to
try to get the best data that we can get from the pilots in the
meantime.
So to answer your question, sir, we are working multiple
solutions. We think it is maintenance on the T-6 right now.
Mr. Kelly. One other quick question. And this is to both of
you. Grounding of the T-6 or the T-45 or whatever equipment, we
already have a pilot shortage across the board. What impact
does this have on the training pipeline? And what are we doing
to make sure that we don't have a prolonged impact which gets,
you know, the accordion effect as we go in time?
General Nowland. Sir, General Doherty, the 19th Air Force
commander, is working two solution sets. One is trying to get
the On-Board Oxygen Generating System to work properly. The
second one is an interim solution where we would modify the
CRU-60, which is what we connect our oxygen mask to, take it
off of the onboard generating system, use the ambient pressure,
and then modify the flight profile so that we stay between
6,000 and 7,000 feet on cabin pressure, and then we would stop
all solos. We would always fly our crews dual as we working the
simultaneous. We lose 700 sorties a day right now with the T-6
grounding. That will have an effect on our pilot training.
Admiral Joyner. For the T-45, we have turned the curve. Our
rate is maybe one-fifth of what it was at the point where we
were approaching the grounding, and that is a significant
change. We assess that we have identified the flow problem in
the T-45 as being the primary issue. We have taken steps to
mitigate it. We have long-term steps to solve it.
For right now, though, we have a training impact that is--
we are trying to absorb in all different phases of flight
through our follow-on training. We are bringing the Reserves to
bear against the training problem. We are extending the
resources of the contract support that we have on the T-45. And
we are trying to buffer that impact across the system, longer
term relying on some of our aviators to operate longer on a
volunteer basis at sea in order to try to blend this across the
system.
But there are impacts. And you can't deny those. We are
just trying to mitigate them at this point.
Mr. Kelly. Thank you, Chairman. My time is expired.
Mr. Turner. Thank you. Before I get to Mr. Langevin,
General, thank you for clarifying that. This is our fifth
hearing and briefing on this. We just sort of expect a
progression of shared values on issues, and I appreciate your
clarifying your language, because when we began this, as Mr.
Cragg has said, it is not just the human value, the pilot value
is not being honored. I appreciate you making that
clarification statement. Because there is at times when you
have something like this the question of, is it real? And this
committee certainly believes that what is occurring is real.
Mr. Langevin.
Mr. Langevin. Thank you, Mr. Chairman. I want to thank our
witnesses for being here today. It is a very important issue
that we need to get to the bottom of.
I haven't heard a whole lot that makes clear sense of all
this yet, except for some of the information I have before me
right now, so I will put this out there and then ask Mr. Cragg
to respond first. But the NASA review report states on page 15
that, quote, ``A problem with the breathing gas system as a
whole is that the onboard oxygen generation system gets fed
last. The enormous amounts of cooling air required for the
avionics and radars (especially on the E/A-18G Growlers) means
that the ECS [environmental control system] controls
preferentially direct flow to them'' instead of the OBOGS.
Then finding 10-7 of the report states that, and I quote,
``Avionics flow has priority over cabin flow in some
operational cases . . . data from the PE flights has directly
demonstrated cases in which high avionics flow results in lower
than required cabin airflow.''
Finally, observation 10-2 in the report states that, and I
quote, ``The Navy appears to have little insight into elements
of the ECS control programming logic. Discussions with
engineering teams at the Patuxent River and fleet support
activity North Island suggest that the logic programming
control sets were not part of the contract deliverable for the
F-18 and, therefore, may no longer be documented in any form.''
So if I had to summarize these three statements, it would
be that the crew's airflow comes last. But the Navy doesn't
seem to know exactly why that is the case. So given the
aircraft can't operate without its crew, one would think that
the opposite would be true.
So, Mr. Cragg, to you, would you agree with the overall
assessment? And what else would you like to add to what is in
the report on this subject?
Mr. Cragg. Thank you. Yes, I would agree with that
statement. The Navy does not fully understand the pressure
control logic, because as you mentioned, it wasn't part of the
F-18 design that was supplied to the Navy by Boeing.
But this somewhat gets to the theme--one of the themes of
our report that we think the Navy needs to do some human system
integration where they look at all aspects of what is going on
with the human, what is going on with the environment, and how
the system of the airplane itself operates. And if they don't
have an idea of how the logic control portion of a key
component, the environmental control system, that is a
deficiency.
And they need to do that. They need to figure out how that
operates so--you know, one, they can troubleshoot the system
properly, but at the other side, they need to do this human
system integration where they put everything together and
understanding exactly how your systems operate is key to that.
Mr. Langevin. Admiral Joyner, I also have several questions
for the Navy following the statements in the report. First of
all, what can be done to fix this? Does the Navy have all the
technical data on the F/A-18 to address this issue? And if
airflow to the crew was given first priority on the aircraft,
how would that affect mission systems? And then finally, does
the Navy have an effort in place with Boeing to address this
design issue in the current and new
F/A-18s?
Admiral Joyner. I would say I vary in my opinion and my
status on the ECS system. The OBOGS is the primary system that
is fed. And cooling air is not removed from the OBOGS system in
order to feed it elsewhere. There are instances where if the
avionics are overheating that it won't pull it from the OBOGS,
it will pull it from the cooling for the pilot in order to make
sure the avionics function. None of us want our avionics to
shut down, because it will result in an ejection, and that is
not something we want to see.
So overall, I would say that when I look at the ECS system
on the F/A-18, we need to regulate it better. That is where our
emphasis has been. Due to the timing of the legacy system in
the
F/A-18, a lot of what is available on the ECS system is analog.
It is in vaults and it is stored elsewhere. We have access to
those, but it is not as simple as looking it up on a system.
You have to go find that. And we are working directly with
Boeing to make sure we have access to all the support material
we need.
The engineers at NAVAIR reassure me and have walked me
through the system to explain to me why they know that the
pressure system and how they have tested it, but we realize we
want to test it further on the OBOGS system, and we are taking
advantage of the 711th lab that they have that they are able to
do dynamic testing that recreates the flow that is given to
that system in the OBOGS. So we are going to take advantage of
that testing, as well, to do dynamic testing, not just point
testing.
Mr. Langevin. Did I understand you, though, that you
completely disagree with NASA's findings that the OBOGS system
is fed last?
Admiral Joyner. My understanding of the system is that
OBOGS is prioritized first, ECS is second. The third system
that goes is the avionics cooling, except if it starts to
compromise those avionics systems. And then we are going to
pull heat but not pressure out of the system. The F/A-18 has a
lot of pressure, and it is--from what I see to date, it is more
about regulating that pressure, because we are causing over-
pressurization at times within that system. And that is an
issue that we have to--we are putting in eight corrections to
the ECS system in order to try to regulate that pressure better
and try to smooth the flow.
So we realize that our concentrator, our OBOGS system,
could have a better system and we are pursuing that, but we
don't necessarily agree that the--how it is prioritized is done
incorrectly.
Mr. Turner. We are going to have to take a recess. We do
have votes we have to run to. And I know Mr. Gaetz has
questions, and we will be returning for those.
[Recess.]
Mr. Turner. Okay, we will call the hearing back to order.
Please have a seat. Mr. Gallego, your questions, please.
Mr. Gallego. Thank you. My question is about the GGU-12 On-
Board Oxygen Generation System on our F/A-18s.
At three separate points in the report, NASA advises us of
testing and practices for the critical system that seem
abnormal. First, the report states that the Navy and Boeing
have not followed well-known industry best practices in a
system that is critical to the life support of our F/A-18
aircrews. Further, it appears that current test equipment does
not simulate real flight conditions actually encountered by the
F/A-18s.
So if that is true, it could generate false positive
results, as we are hearing from now, that may conceal
underlying problems with the system as it operates under real
conditions. And third, it appears that some of the underlying
design specifications for the
F/A-18's oxygen generation system are decades, decades out of
date and do not reflect the latest scientific knowledge on
aircrew breathing demands.
One of the report's key recommendations to bring these
specifications up to date to conform to standards developed in
2015. So, Mr. Cragg, taken together, these examples from the
report indicate that the breathing system of the F/A-18 has
serious problems. Do you agree?
Mr. Cragg. Yes, sir.
Mr. Gallego. And how would you summarize what these
problems are?
Mr. Cragg. Well, I would say unfortunately the original
OBOGS specifications were not put through the human systems
integration process that would have highlighted the fact that
it cannot deliver for all conditions, like high-stress portions
of the flight. That is why a key recommendation of our report
is to re-examine the OBOGS in light of the human system
integration effort. And additionally, as you pointed out, some
of the testing that is done on the OBOGS doesn't utilize in-
flight conditions. But I understand they are getting better and
closer to the real thing.
Mr. Gallego. They are getting better and closer to the real
thing. Is there a time period we understand that this is going
to be happening?
Mr. Cragg. I think you have got to ask the Navy that, sir.
Mr. Gallego. Lieutenant General Nowland, while you are not
Navy, do you have anything to add to Mr. Cragg's answer?
General Nowland. On the F/A-18, no, sir, I do not.
Mr. Gallego. Okay. I think many of us are a little anxious
to see some form of conclusion or time period, especially
involving the lives of our service members. I yield back.
Mr. Chairman, I yield back.
Mr. Turner. Mr. Carbajal.
Mr. Carbajal. Thank you, Mr. Chairman. Thank you all for
your service and for addressing us today.
The report makes two statements regarding leadership and
communications within the naval aviation community that I want
to touch on.
First, in finding 10-29, it states that, quote, ``There has
been a breakdown of trust in leadership within the pilot
community'' and that ``one notable area leading to a lack of
trust in leadership is the completion of Parts A/B/C of the
Physiologic Episode report. Once these questionnaires are
completed, they disappear through the `system,' only to be
examined months later. None of the pilots interviewed ever
received official word as to the cause of the incident or the
mitigation the U.S. Navy would be taking to reduce the
likelihood of a repeated event.''
Second, with regard to feedback from aviators, the report
observation 10-20 points out that, quote, ``The Navy has not
conducted a fleet wide survey of their F/A-18 air crew to
understand the PE problem from the human perspective, where
these events actually occur.''
Taken together, it appears that the communication issue
noted in the Navy's own comprehensive review conducted earlier
this year remains a problem.
Rear Admiral Joyner, what is the Navy doing to get feedback
on PE event investigations back to the crew members that
experience them?
Admiral Joyner. Yes, sir. What we do right now is we have a
quick look that we are doing. We start in T-45s, where we try
to come back at the 48-hour point, and we brief out our quick
look response of what we are receiving from the Parts A, B and
C, and information that we receive from the aircraft itself.
And we present that to the aircrew. Approximately 30 days
later, we come back with a full report, which outlines what we
found on the aircraft as far as any system failures, any
additional information we were able to derive from the data
sets.
So in F/A-18, we are using Slam Stick data, which tests the
pressure inside the cockpit. We are getting the OBOGS
information for any type of malfunctions we are able to find.
We also have a quick response force that falls in on the
aircraft. And rather than breaking the system, as we have
historically, we holistically analyze a system with a team on
station that includes a medical professionals. It includes
engineers. A Boeing rep [representative] is also onboard. And
the pilots are also involved with the pilot maintenance and the
aviation physiology, the aeromedical safety officer, all fall
in on the aircraft to do this analysis and try to figure out
root cause for each of the events.
That is all communicated back to the pilots. Part of that
communication plan is also what we call the PE road show, which
is--I just returned from Japan doing one out there, both Atsugi
and Iwakuni, and we addressed the pilots directly on what we
are finding with their aircraft, different trends. We are
getting a health monitoring system up online that basically
shows the prognostic health of their airframes by BUNO [bureau
number], and we are showing them on their aircraft what we are
seeing with the data. So the feedback loop has been
strengthened, and we are making sure that we are getting that
back down to the deckplates, to the aviators, site by site.
The second part is the survey. We just completed the survey
last Friday. We did get over 500 responses out of our aviation
community, but we also did maintainers, as well. It was a large
response. We got about 22 percent of aviators and maintainers
responded to the survey. And that survey is designed to go
ahead and solicit that feedback and get information about
different things that have impacted the pilots and how they are
operating.
So we did take both of those onboard, and we did move
forward on them quite regularly. And then we also have the
weekly newsletters and engagements that we do with the fleet. I
go site to site.
Mr. Carbajal. And was this done, this survey of the F/A-18
community, as well?
Admiral Joyner. Yes, sir, that was F/A-18 and T-45.
Mr. Carbajal. Great. May I ask how long this feedback loop
has been in place?
Admiral Joyner. The T-45 feedback loop has been in place
for roughly I think 3 months. When we stood it up and went back
to flying, back in September timeframe, we realized that we
needed to push that information down. And so in September, the
T-45 led the way, and now we have brought that onboard with F/
A-18 and we started that roughly November, December timeframe.
Mr. Carbajal. Great. Thank you very much, Mr. Chair. I
yield back.
Mr. Turner. Mr. Panetta.
Ms. Tsongas.
Ms. Tsongas. Thank you all for being here. I am sorry for
the break, but appreciate your patience. Admiral Joyner, I just
have a couple of quick questions, really only take a yes or no
answer, or a maybe if it is not clear that it is one or the
other.
The report states in finding 10-20 that there has been no
definable effort to use the OBOGS laboratory at the 711th Wing
at Wright-Patterson Air Force Base to assess effects on OBOGS
output gas. Is there currently a plan in place to conduct this
testing?
Mr. Turner. I was going to ask that, but I felt like I had
a conflict, so thank you for asking that. I did not ask her to
ask that, but that is important. That is in the report, and
that is a question.
Admiral Joyner. Yes, ma'am. We are intending to use the
711th Dynamic Testing Lab that they have on site.
Ms. Tsongas. It is an important resource, and it is a shame
it took this study to lead to that. Does the Navy intend to
issue a request for proposal in the near future for a new On-
Board Oxygen Generation System for the F/A-18?
Admiral Joyner. Yes, ma'am.
Ms. Tsongas. Does the Navy intend to develop and install a
new cabin air pressure monitoring and alerting system for the
F/A-18?
Admiral Joyner. Yes, ma'am.
Ms. Tsongas. Does the Navy intend to design and replace the
F/A-18's cabin pressure regulator valves?
Admiral Joyner. Yes, ma'am.
Ms. Tsongas. Is the Navy doing----
Admiral Joyner. We are looking into a suitable replacement
for that. We have gone through to repair them and to make sure
that the maintenance, when they come back out to the fleet, is
accurate. We are looking at a couple of different options for
that valve, but right now we have concerns about some of the
solutions we have been offered. So I wanted to clarify that.
Ms. Tsongas. Okay. Is the Navy doing upgrades to the ECS
software on F/A-18s and EA-18Gs to deal with icing in the ECS-
related water lines?
Admiral Joyner. Yes, ma'am.
Ms. Tsongas. And is the Navy planning to install an
automatic backup oxygen system in the T-45?
Admiral Joyner. Yes, ma'am.
Ms. Tsongas. Is it planning to do so for F/A-18s?
Admiral Joyner. It is not at this time.
Ms. Tsongas. Thank you.
Mr. Turner. Admiral, help us. We have had a total of five
now hearings and briefings. Ms. Tsongas and I both traveled to
you and have received briefings on this. We asked for this
report, and, Mr. Cragg, thank you so much for the detailed
information that is in this, and this is very, very helpful,
of, unfortunately, things that aren't happening after things
that aren't happening after things that aren't happening.
This has got to be fixed. This has got to stop. And I don't
have confidence that we are getting nearer to that. I believe
that there are a number of things that are being done and a
number of things that are not being done that are now being
done because the report said to do them.
But this would seem to me to be something that needs to be
done quickly and expeditiously and that this should not be a
research project. This should be a fix-it project. Help me get
some sense that we have in place things that are going to do
that, knowing that this started with our having an
understanding that pilots had to revolt and say, ``I won't
fly'' because the chain of command wasn't even recognizing
their complaints and their incidences, you know, all the way to
there is still a sense of morale of lives are at risk.
Help us get a sense that the work that we are doing and the
work that you are doing is going to result in something.
Admiral Joyner. Right now, T-45s are fully operational.
They operate every day. We have over 27,000 flight hours. We
have had six events in those aircraft, all mild in nature, one
of which was a system failure that was identified by the
system.
So we have turned the corner on T-45. We have long-term
corrections in place, design changes to the aircraft to fully
address it, so we are not declaring victory. We have an RCCA,
root cause corrective analysis, team that goes line by line,
starting with the human, ending with the human, trying to find
root cause for both the T-45 and the F/A-18.
Industry is involved. Aeromedical is involved. NASA helps
consult and keep us on track so that we don't lose sight of
things that may be falling out. We have a long-term goal of
adding a robust human systems integration effort on par with
our aircraft design requirements and engineering force. So we
are looking to fully integrate them within our efforts.
On F/A-18, we are turning the corner. We see now that we
are able to influence the pressure response on the aircraft. We
have been able to make noticeable and observable, measurable
changes to the F/A-18, which are resulting in a better, more
stable ECS system. There are long-term design changes in place
to ensure that we further stabilize that system and we have an
OBOGS concentrator that we are looking for a request for
proposal.
We are open to added things that are found along the way in
order to make sure that we are not missing anything. That root
cause effort is a longer-term effort that will lead us--the
medical force outcomes will take more time. Those are fully
funded through the FYDP [Future Year Defense Program] type of
efforts to fully define pressure and oxygen requirements for
pilots. We are working with the Air Force actively, and we are
pursuing all those answers long term.
I don't--every day I ask myself, what else could we be
doing that we are not doing? I turn to NASA and I ask those
questions. I work with the Air Force. And we make sure in
academia, as well. And we want to make sure that we are not
missing a single thing, and we have gotten your assistance, as
well, which is helping us do those efforts.
So all I can tell you is, my effort doesn't stop. I will
have somebody who will relieve me in this effort, and we won't
stop until we resolve it.
Ms. Tsongas. I want to thank Mr. Cragg for this very
important study that I think has helped create a path forward.
And I appreciate, Admiral Joyner, the seriousness of purpose
you have brought to this effort. Again, as I said in my opening
remarks, I am very concerned that you are being rotated out in
less than a year into this effort and remain very hopeful that
somebody will be put in your place who can stick with it a
little longer, because we know change does lead to setbacks.
And we can't afford to lose any more time.
And just wanted to say, as we are here, as we sit here
today, new F/A-18s are rolling off the production line at a
cost of about $69 million per aircraft. At some point, paying
$69 million for an aircraft we know has serious problems with
its life support system has to be questioned. So I am not
calling for stopping production, but it seems clear that the
Navy and Boeing need to work together and come up with
improvements to the F/A-18 that make them safer for our brave
men and women in the military to operate, because we know it
puts their lives at risk, and to make sure every single new F/
A-18 has those improvements built in from day one and we are
not back here a good number of years hence revisiting these
same problems yet again.
Thank you, and I yield back.
Mr. Turner. Thank you. Mr. Cragg, many times this committee
authorizes a request for a report to be done. You and NASA have
outdone yourselves. This was a phenomenal and excellent report.
It is great to see that work product translated from our
request. And thank you for the dedication of which you
approached this.
Appreciate all of your efforts for this. I hope as we get
to our--what will have to be a sixth hearing and/or briefing on
this, that we have a greater sense--although, Admiral, I
appreciated your closing comments of things that you are
accomplishing--a greater sense that this is being advanced in a
way that hopefully the committee can feel as if it is being
done in a way that our oversight is no longer necessary and
these can be just incidences that go into reports instead of
incidences that in the aggregate require congressional action.
Thanks. With that, we will adjourn.
[Whereupon, at 5:40 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
February 6, 2018
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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
February 6, 2018
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QUESTIONS SUBMITTED BY MR. TURNER
Mr. Turner. a) By centering your investigation on the human
element, what new information was revealed?
b) What were the shortages of evidence related to human health in
an F/A-18 environment that you encountered?
Mr. Cragg. 4a: 1. NASA flight surgeons, reviewing pertinent
Physiological Episode (PE) Medical information as a whole instead of
just individual cases, determined that > 80 percent of the PEs were
Hypoxia related. 2. The human system, specifically the requirements for
meeting human needs, was not represented in the integrated end-to-end
description of the F/A-18. This omission made it difficult for system
hardware engineers to find end-of-the line problems when isolated
individual systems appeared to be working well.
4b: There was and is hardly any data or measurements being taken in
the F/A-18 that addresses the human response to the flight environment.
Data needed includes:
i. breathing patterns (rate, depth, volume) in flight
ii. cabin pressure
iii. Oxygen levels, flow and pressure in the breathing gas system
iv. Exhaled CO2 levels in the mask
Data such as the above serve two purposes: 1) as a monitor of human
health in the dynamic flight environment, and 2) as specific diagnostic
checks on components of the integrated life support system.
Data that was collected included inflight sorbent tube samples from
EA-18 Growlers of pilot breathing gas. This data, when investigated by
NASA, demonstrated an unambiguous relationship between increased
contamination and the occurrences of PEs. The Navy did not and has yet
to conduct proper analysis on these samples. It is important to note
that the relationship is one of correlation; NASA did not conclude that
contamination was the cause of PEs.
Mr. Turner. a) Is the U.S. Navy capable of solving the PE problem?
b) Has the Navy been forthcoming with all of their data?
Mr. Cragg. 6a: Yes. When the NASA investigation started, the NASA
team saw dedicated individuals across the U.S. Navy doing their best to
find and fix the PE problem. However, they weren't working together in
an organized way, and their central focus was on the plane--not on the
pilot and importantly, not on the dynamic plane/pilot/environment
interaction.
6b: Yes. The Navy quickly provided us with everything we asked for.
Mr. Turner. The report notes in several observations and findings
that your team found specific design problems with the F/A-18's
environmental control system, onboard oxygen generation system, and
CRU-103 regulator. Can you explain those in detail?
Mr. Cragg. The F/A-18's Environmental Control System (ECS) is fed
high pressure air from a direct connection to the engine that varies in
its pressure whenever the pilot changes the throttle. The ECS feeds
other systems that must account for these pressure changes. One of
these systems, the cabin pressure control system, is prone to
instability which leads to pressure excursions in the cockpit. Others,
like the onboard oxygen generation system (OBOGS) and CRU-103
regulator, appear to be delivering oxygen to the pilot in a manner
inconsistent with nominal pilot performance for some flight regimes.
Put simply, all evidence supports that the pilot is not getting the
stable cabin pressure and breathing oxygen supply that he/she needs in
some cases, due to complex system interactions and deficiencies in the
design of the jet as an integrated system.
However, more generally and more importantly, these problems are
rooted in the lack of a (human system) ``requirements driven'' approach
to the design and engineering of the integrated environmental control
system, onboard oxygen generation system, and CRU-103. While these
systems may indeed meet individual documented requirements; it remains
evident that documented requirements are insufficient to
comprehensively support pilot physiological needs. There remains a
dearth of data surrounding the pressure and breathing performance needs
of a human being operating the F/A-18; and by extension a dearth of
data to support or refute when these performance needs are being met or
not met operationally by the aircraft.
Put simply again; the ECS, OBOGS, and CRU-103 were specified based
on an evolution of operational history and aircraft design legacy,
rather than validated performance data used to evaluate pilot demands
in the tactical jet flight environment. While this approach for
hardware design is sufficient to support pilot performance in most
cases; it supports no understanding of where the actual performance
envelope lies, and therefore no ability to anticipate or evaluate when
the performance envelope may be exceeded and result in a Physiological
Episode. Additionally, the GGU-12 OBOGS unit and oxygen delivery
schedule falls significantly short of meeting the newest requirements
of MIL-STD-3050. This new standard collects the best information on
meeting pilot breathing requirements for aircraft using OBOGS. The NASA
team also pointed out that the CRU-103 pilot breathing regulator, while
capable of providing additional pressure during periods of high-g
force, as is done for example in the F-22, is not used in this manner
in the F/A-18. This minor change in usage has been found to help pilots
breath more easily during high-stress combat maneuvers. NASA has not
monitored the continuing execution of the program. However, the agency
has been informed that the Department of Defense has fully accepted
NASA's finding that Physiological Episodes happen to people, not
aircraft. According to the DOD, these findings have driven their Navy
Physiological Episode Action Team (PEAT) to shape a holistic strategy
that examines Physiological Episodes as an interactive condition
between the human and the aircraft. Although physiological monitoring
is not a near-term capability, the DOD has indicated the PEAT is
aggressively pursuing acceleration opportunities and accelerating
mitigations to the fleet, where DOD is looking at mechanical fixes to
the machine but also directly assessing human health and performance in
the cockpit.
Mr. Turner. The report notes numerous concerns with the Navy's
``Human System Integration'' process. One finding stated that the
process is ``deficient''. Can you elaborate on those concerns?
Mr. Cragg. The Navy's Human System Integration process is indeed
``deficient.'' The Finding in question states: F10-30: Currently the
Human-Systems Integration (HSI) process within the U.S. Navy is
deficient; it appears to be associated with a decrease in the available
subject matter expertise in the fields of Aerospace Medicine,
Physiology, Human Factors Engineering, Cognitive Psychology, and Human
Systems Integration, as well as organizational barriers to meaningful
interaction amongst these disciplines across the U.S. Navy. NOTE: This
finding is similar to one made in the USAF F-22 Life Support System
review several years ago. In 2012, NASA was asked by the USAF to
provide a review of the F-22 Life Support System. One of the major
findings was a significant increase in the work-of-breathing for pilots
during flight. This issue was primarily the result of a lack of
thorough human-machine interface testing in the flight environment. The
work-of-breathing theory was evaluated by simply instrumenting a pilot
wearing standard aircrew flight equipment and placing them in a
centrifuge configured to replicate the life support system an
operational F-22 aircraft. These data led to improvements in the F-22
design and in the human performance associated with piloting an F-22.
In 2012, USAF General Gregory S. Martin testified before Congress
that (from the NASA report):
``Over the past 20 years, the capabilities and expertise of the
USAF to perform the critical function of Human Systems Integration have
become insufficient, leading to:
--The atrophy of policies/standards and research and development
expertise with respect to the integrity of the life support system,
altitude physiology and aviation occupational health and safety.
--Inadequate research, knowledge, and experience for the unique
operating environment of the F-22, including routine operations above
50,000 feet.
--Diminution of Air Force Materiel Command (AFMC) and Air Force
Research Laboratory (AFRL) core competencies due to de-emphasis and
reduced workforce to near zero in some domains.''
Many of these same underlying Human-Systems Integration
deficiencies are evident in F/A-18.
Human-Systems Integration (HSI) is defined as the
``interdisciplinary technical and management processes for integrating
human considerations within and across all system elements; an
essential enabler to systems engineering practice'' (Haskins, 2007).
The goal of HSI is to integrate the human into the system as a critical
element; the human is as critical to system design considerations as
the hardware or software.
With regard to fighter aircraft, the interaction of the human with
the aircraft (i.e., human factors) is one particular domain that
demands a great deal of attention because of the complexities involved,
and because of significant consequence associated with failure. This
domain is the comprehensive integration of human capabilities and
limitations (physical, sensory, cognitive, and team dynamics) into
systems designed to optimize human interfaces and facilitate human
performance in training, operation, maintenance, support, and
sustainment of a system. The Department of Defense has formalized the
role of HSI. There are nine domains of HSI: manpower, personnel,
training, human factors engineering, occupational health, environment,
safety, habitability, and human survivability. A commonly accepted HSI
success story was the development of the F119 engine for the F-22 by
Pratt & Whitney. Because both the USAF and Pratt & Whitney were
dedicated to HSI the development constantly included the human element.
The resulting design increased ease of assembly, maintenance, and
repair thereby reducing overall labor costs, servicing frequency, and
number of tools required. The USAF elevated the visibility of this
process and the contractor also shared in this vision by creating
testing facilities designed to better evaluate the engine to ensure
reliability. Ultimately, the key to successful HSI is the fervent
commitment from top-level leadership in maintaining the integral nature
of HSI. This has not been the case in the F/A-18.
To maintain the combat edge, weapon systems must change over their
life cycle. This is a fact. However, these changes must be
appropriately evaluated using an HSI analysis to explore the potential
impact to the human. The F/A-18 life cycle has been extended for years
beyond what was originally planned and has undergone a number of
modifications ranging from structural to digital. There is a vast
difference between the original F/A-18A ``Hornet'' and the EA-18G
``Growlers''. The oxygen system changed from liquid oxygen (LOX) to the
OBOGS. The EA-18G received advanced radar, various electronics counter-
measures components, and a second aircrew member who acts as the
Weapons Systems Operator (WSO). These changes impacted the demand for
engine bleed air but no rigorous assessment was conducted to determine
if the engine bleed air can meet these demands while maintaining
appropriate OBOGS oxygen concentration and flow throughout all phases
of flight. Just as the aircraft changes over time, new understandings
of human physiology also occur that must be considered in terms of the
overall system. Indeed, even during initial design phases, assumptions
about the human are made and sometimes these assumptions are not valid.
Thus, the requirements based on incorrect assumptions or an incomplete
understanding of human physiology can be costly to correct. In 1993, a
study identified that pilots could over-breath the on-board oxygen
generation system (OBOGS). A recommendation was made to change MIL-D-
85520 to require the oxygen systems of tactical aircraft to produce
peak inspiratory flow rates of at least 260 LPM (NAVAIR TM-93-59 SY).
This recommendation was not implemented. It is noteworthy that MIL-STD-
3050 (2015) now contains a similar minimum flow requirement. During the
early stages of the spike in reports of F/A-18 PEs, the Navy assumed
that the PEs resulted from a defect in the aircraft. The aircraft was
taken out of service and inspected. No consideration was given to the
integration of the human and machine during flight operations. While an
inspection could determine if a component was operating within spec in
a controlled environment, it remained unknown if the component
performed as expected on the aircraft during dynamic flight.
Furthermore, it remained unknown if these established specifications
met the demands of the human system during flight, and if they
continued to meet those demands following various system changes. The
human was not considered as a critical element; the HSI was deficient.
As new information about the machine and the human is learned, we now
recognize that the physiologic requirements determined for the original
system design were already partially inadequate. Due to the increased
cooling needs in latest models of the F/A-18, this inadequacy has
increased. The greatest concern is the lack of data to answer the
question: how inadequate?
It's impractical to instrument an entire system of any significant
complexity, however, key pieces of information are required to
correctly diagnose problems. For example, the F/A-18's pressure
fluctuations are difficult to assess because there is no inlet or
output sensor that directly records these data for analysis. This is a
knowledge gap in terms of characterizing and assessing the machine
performance. Similarly, there are critical knowledge gaps in
characterizing the human system. In fact, the most important data
required to identify and solve PEs is entirely absent; there is no data
collected to objectively define the human physiological experience in
the cockpit during operational flight. There is no routinely recorded
data about oxygen pressure, flow, or percentage. Additionally, there is
little data on pilot breathing rates, breathing volume, cabin pressure,
etc. Without data, the human subjective report of a PE cannot be
compared with in-flight exposure and potential causal factors cannot be
confirmed or dismissed. Furthermore, without measurements to
characterize the current conditions, it will be challenging to know if
the results of the Navy's changes positively or negatively impacted the
human. To be clear, the PE rate is a deeply insufficient metric as
human participation can be influenced by various factors far easier
than data. This is a hindrance to exploring and assessing the validity
of any solution.
Like the USAF in 2012, the Navy's critical core competency of HSI
expertise has atrophied due to a lack of investment and support.
Currently, the emphasized expertise is aircraft engineering solutions.
The best way to affect change for a human-machine system is by
integrating the human into the system and assessing that integration
with each subsequent design modification. Without appropriate HSI
expertise at the table, the most integral, intelligent, and valuable
part of the system--the human--isn't represented.
Mr. Turner. In the FY17 NDAA, this Congress directed the Secretary
of the Navy to conduct an independent review of the plans, programs,
and research of the Department of the Navy with respect to
physiological episodes affecting aircrew of the F/A-18 Hornet and F/A-
18 Super Hornet aircraft, as well as the efforts of the Navy to prevent
and mitigate the effects of such physiological events. This
subcommittee is interested in hearing what the Navy found valuable from
NASA's report and how are you using NASA's findings today to inform
future efforts with the F/A-18 series aircraft?
Admiral Joyner. The Navy found NASA's report useful in identifying
organizational constructs that were not working well to respond to the
urgent issue of physiological episodes (PEs), including communication
shortfalls, stove-piping of information, and lack of a single clear
leader for PE efforts. NASA's recommendations provided a catalyst for
reorganization and the adoption of a broader view of the Naval Air
Systems Command's (NAVAIR's) systems engineering boundaries when
addressing the PE problem, specifically inclusion of the human factors
and physiological needs in system design and function of the aircraft.
Additionally, NASA bolstered support for a comprehensive Root Cause
Corrective Action (RCCA) investigation that the Navy has fully embraced
as the path to solving the PE issue. Below are NASA's 8 key
recommendations and the Navy's actions: 1. Measure parameters that
directly assess human health and performance. Make measurements in the
cabin environment whenever possible. The Navy is exploring every option
to measure and record meaningful data in the cockpit. Several
development efforts are ongoing in coordination with PMA-202, the
Aircrew Systems Program Office and the Navy Bureau of Medicine and
Surgery (BUMED) to field sensors that can directly measure human
performance and physiological response while not being intrusive or
interfere with cockpit duties. While human-mounted sensor technology
matures, integration of multiple sensors in the aircraft cockpit and
aircrew flight gear continues. One example of a newly fielded sensor is
the SlamStick, a small pressure sensing and recording device carried in
aircrew pockets. SlamSticks are carried on every F/A-18 and E/A-18
sortie. Data is downloaded after flight and uploaded to a central
database for analysis. This data has been used extensively to
characterize and understand the cockpit environment.
Mr. Turner. Navy leadership has consistently said physiological
episodes are the number one safety priority within Naval Aviation as it
is directly related to aircrew health. This Congress has consistently
asked what it can do to help in this effort. As a result, the Budget
Request for Fiscal Year 2018 was shaped to provide the financial
resources required to address the issue. Can you briefly describe to
the subcommittee what solutions are being accomplished with these
funds?
Admiral Joyner. To address issues in the T-45, the Navy received
resources in FY18 in the form of additional O&M funds which are funding
the ongoing T-45 Root Cause and Corrective Action (RCCA)
investigations. The funds will also be utilized to fund a contract with
the OEM (Boeing) to support the RCCA and provide Field Service
Representatives (FSRs) at all Chief of Naval Air Training (CNATRA) T-45
training sites. Some examples for T-45 include: Enhanced Emergency
Oxygen System (EEOS). Maximizes the oxygen storage capacity of the
emergency oxygen system for retrofit of the SKU-10/A (F-18) and SKU-11/
A (T-45) Seat Survival Kit Assembly. T-45 Oxygen Concentrator.
Obsolescence issues with the T-45 OBOGS concentrator (GGU-7A), coupled
with a need for additional reliability and safety enhancements drive a
need for a replacement OBOGS concentrator. The GGU-25 was designed in
2008 by Cobham and was partially tested for use with the T-45. In FY18,
the Navy funded F/A-18 PE efforts targeting three primary areas. The
first was to fully fund all the RCCA requirements. The RCCA is
investigating 427 branches on the fault tree. Closure of these branches
will require a massive data collection effort and engineering analysis.
Below are some of the examples of RCCA efforts underway being funded by
FY18 budget: Flight test--Multiple flight test effort are ongoing to
collect data in support of the RCCA. The major effort is the extensive
instrumentation of an F/A-18C to execute a flight test plan that will
fully characterize the dynamics of the ECS and breathing gas delivery
systems. Manned and Unmanned aircrew and life support systems testing
(KBRWyle Brooks, San Antonio)--will test aircrew and life support
systems using pressure chambers and centrifuge to create realistic
operational conditions to characterize and measure performance in a
controlled environment.
Mr. Turner. The subcommittee understands the Navy stood up the
Physiological Episodes Action Team (PEAT) to unify mitigation efforts
across Naval Aviation, and address shortfalls in communication and data
sharing between PEAT core members and external fleet stakeholders.
While the subcommittee believes establishing the PEAT for these
purposes makes sense for the Navy, we are interested in hearing what
the PEAT is doing to find synergies within the Department of Defense,
and how are these efforts being executed to find a solution?
Admiral Joyner. Finding synergies between organizations is part of
the PEAT charter, which did not limit the team from looking outside of
the Department of the Navy or Department of Defense. There are several
aspects to investigating PEs: from analysis of the aircraft,
determining what system effects are on the human, and developing
strategies for current and future aircraft. The PEAT has engaged a
broad swath of internal and external partners, including subject matter
experts from United States Air Force (USAF), National Aeronautics and
Space Administration, Federal Aviation Administration, industry,
academia, medical, and dive communities. In addition, we've established
regular fleet communication to share all data and progress related to
PEs. While investigating the aircraft, we have leveraged work that was
done by the USAF while conducting a review of the F-22 aircraft in
2012. Specifically, the methodology of using a Root Cause Corrective
Action team and performing a rigorous analysis of root cause has
enabled us to employ high-velocity learning and not repeat mistakes of
past efforts. While determining human and physiological understanding,
the PEAT has employed the efforts of the Naval Medical Research Unit-
Dayton (NAMRU-D) to actively research multiple topics where medical
understanding is immature. NAMRU-D enjoys a strong partnership with the
USAF 711th Human Performance Wing (HPW) providing complementary
capabilities for aeromedical research while supporting cross service
collaboration in both research and experimentation. As we continue to
research strategies for future aircraft, it should be noted that we are
currently developing joint solutions for two shared aircraft-the T-6
and the F-35, and we are embedded with the Joint Program Office as well
as the USAF's PE team, being led by Brig Gen Doorenbos. We are sharing
information and resources, which will yield a higher quality product
for the warfighter.
Mr. Turner. The Chairman and Ranking Member of this subcommittee
visited Naval Air Station Patuxent River, Maryland, on 15 September
2017 in an effort to see firsthand what the Navy is doing to address
physiological episodes. It was a very informative visit and impressive
to see the number of both active duty service members and DOD civilians
dedicated to solve the current issues affecting F/A-18 and T-45
aircraft. As it was thoroughly described during the visit, could you
please briefly explain to the subcommittee the processes set in place
when a physiological event happens, how the investigative process is
performed and what the feedback mechanism is to return findings and
information back to the aviators?
Admiral Joyner. Physiological Episode (PE) reporting protocol
commences when aircrew reports physiological symptoms during or after
flight. Safe recovery and aircrew treatment are prioritized above any
and all data collection or reporting requirement. Aircrew are met
plane-side by an ambulance for initial evaluation and treatment, if
required. The data collection and reporting effort are guided by three
Naval Safety Center forms, Parts A/B/C. Part A is used to capture the
aircrew's narrative of the flight and PE event, mission type and
profile, environmental conditions and self-reported aircrew symptoms.
Part B directs the aircraft be placed in a ``down'' status and
prescribes numerous diagnostics tests and inspections of the aircraft
and aircrew flight gear as well as a thorough review of the aircraft
maintenance history. Part C documents the medically relevant data
collected during post-flight evaluation by a flight surgeon, including
previous medical history, 24-hour physiological and human factors
history, all post PE findings and treatment. The reporting squadron is
assisted by the PE Rapid Response Team (PERRT). Upon report of a PE,
the squadron's Safety Officer (or duty officer in his absence) will
notify the cognizant Aeromedical Safety Officer (AMSO--aerospace
physiologist), flight surgeon, and Naval Aviation Technical
Representative or Field Service Representative. The PERRT is
collectively responsible for ensuring all data collection and reporting
requirements are complete. Additionally, they will assist the squadron
in the decision to return both the aircraft and aircrew to flight. The
data collected by the PERRT, including SlamStick cockpit pressure data,
recorded aircraft flight data, and post-flight findings are immediately
shared with all stakeholders for review and analysis. Ideally, there is
enough data within the first 24 hours to provide immediate feedback to
aircrew and the squadron on causality of the PE. In some cases, where
more extensive testing or engineering investigation is needed, feedback
may be delayed up to 30 days. Ultimately, PE information that is
collected and investigated is submitted into the Naval Safety Center's
WESS Aviation Mishap and Hazard Reporting System (WAMHRS) as a hazard
or mishap investigation report. The hazard or mishap investigation
report is released using WAMHRS providing a link to the report. This
link is transmitted to safety personnel using a collection of email
addresses called a community of interest. This provides feedback on
evidence, analysis, causal factors and recommendations to prevent
recurrence as well as subsequent endorsements and responses to
recommendations in the report.
Mr. Turner. The NASA report states that ``The Navy has not
conducted a fleet wide survey of their F/A-18 air crew to understand
the PE problem from the human perspective, where these physiological
events actually occur''. Why has such a survey not been conducted?
Admiral Joyner. The Physiological Episode Action Team, in concert
with Naval Postgraduate School (NPS) developed and administered a
comprehensive aircrew survey. The survey was broadly distributed
amongst F/A-18, EA-18, and T-45 aircrew and maintainers. The survey
concluded 02 Feb 2018. Over 1,400 responses were received, reflecting
participation from 21.6 percent of the Fleet, which is considered
statistically significant to provide a representative sample of Fleet
opinion. NPS, in conjunction with the Center for Naval Analysis, are
currently compiling and analyzing the data and results which will be
used to inform the Root Cause Corrective Action investigation.
Mr. Turner. The NASA report notes that the F/A-18's oxygen
monitor--the CRU-99--does not log data, but that the plan to replace it
with the more advanced CRU-123 was cancelled. Is that the case and if
so why was this upgrade canceled?
Admiral Joyner. The CRU-123 program was launched to incorporate a
low pressure warning and data logging capability for the aircraft's
oxygen system. Funding constraints at the time resulted in these
requirements being allocated to a new oxygen monitor: the CRU-123. PMA-
265 spent years developing the CRU-123 for the F/A-18. Numerous
setbacks eroded confidence in the manufacturer's ability to produce a
product that would meet the reliability requirements for the F/A-18.
The Navy cancelled the CRU-123 program for the F/A-18 after a lengthy
development effort in which the CRU-123 repeatedly failed qualification
standards and was unable to survive the harsher operating conditions
encountered by the F/A-18 as opposed to the T-45 which has successfully
flown with CRU-123. PEAT acknowledged the need for data logging, and
current planning includes the installation of a limited number of CRU-
123s to assist in data collection while waiting for Cabin Pressure and
OBOGS Monitoring System (CPOMS) development and fielding. In addition
to needing a robust and reliable system for this critical function, the
Navy shifted course to the CPOMS to take advantage of additional
capabilities that could provide aircrew increased real-time in-cockpit
situational awareness of critical life support systems' health. CPOMS
will incorporate a digital display that will replace the current analog
cabin pressure altimeter and provide an easy to read display of cabin
pressure and warnings for schedule deviations of cockpit pressure,
oxygen concentration and flow. CPOMS also has critical growth potential
for desired features such as integrated cautions and warnings on
current aircraft displays, and the ability to automatically perform
actions, such as selection of emergency oxygen under certain degraded
conditions or system malfunctions. The requirement to log critical
OBOGS performance data is now allocated to the CPOMS and the new
concentrator for the F/A-18, which is in development by the Aircrew
Systems and F/A-18 and EA-18G program (PMAs-202 and 265) concentrator.
This new approach will provide data recording on the aircraft's data
bus, which is a significant improvement over the earlier approach to
record it remotely on the CRU-123.
Mr. Turner. How is the Air Force addressing physiological events,
and onboard oxygen generation system issues with sister services?
General Nowland. The Headquarters Air Force Unexplained Physiologic
Event (UPE) Integration Team and the Navy's Physiological Episodes
Action Team (PEAT), both led by General Officers, continue to work
closely together to investigate in a complimentary manner. Together,
they have engaged abroad range of internal and external partners,
including subject matter experts from the Air Force and Navy, National
Aeronautics and Space Administration (NASA), Federal Aviation
Administration (FAA), Industry, academia, along with medical and dive
communities to resolve these issues.
One area where the USN and USAF are working together is in aircrew
air quality assessment. The 711th Human Performance Wing has developed
systems to test aircrew air quality in flight such as the real time air
quality sensor (RTAQS) which is in-line air supply monitor that detects
contaminants and elucidates OBOGS function. It is being used to
baseline T-6 (USN/USAF), T-45 (USN), and F-18 (USN) aircraft and is
also prepared for use in the F-16 (USAF). Additionally, we have
established an OBOGS lab that allows us to replace flight conditions
and test the performance of OBOGS to detect abnormal performance. This
lab has been used to support both USAF and USN UPE investigations.
Another area of collaboration is in aircrew physiological sensing.
The 711th HPW in collaboration with industry, academia and government
partners have developed several aircrew physiological state sensing
systems. Some, such as VigilOx and Mask Sensing System (MASES), monitor
inhaled and exhaled air but others assess tissue oxygen saturation,
core temperature, heart rate, etc. VigilOx is slightly ahead of some of
these other technologies and is undergoing verification and validation
testing. Due to the urgency of the UPE issue, it has been flight tested
in the T-38 (USAF) and F-18 (USN). Four devices have been delivered,
two for testing and one each to the USAF and USN for preemptive
operational assessments. Our end goal with this sensor development is
to feed into an autonomous life support system that will adjust to keep
the pilot in a physiologically safe condition.
Finally, the 711th Human Performance Wing has a robust
collaborative relationship with Naval Aeronautical Research Unit-Dayton
(NAMRU-D). The 711th HPW with NMRU-D have collaborated with several
academic, governmental, and industry partners in exploring how the
human body responds to the unique stressors of the flight environment.
We continue to explore such topics as hypocapnia, hyperoxia, hypobaria,
work of breathing, contamination, pulmonary function, and environmental
priming--all issues that may precipitate ``hypoxia-like'' symptoms. The
711th HPW's unique location with NAMRU-D is particularly fortunate as
this affords the two organizations to leverage each other's expertise
and move forward as one entity on many of the research efforts.
Mr. Turner. Why is root cause attribution to physiological events
so difficult to ascertain?
General Nowland. The root cause for Unexplained Physiologic Events
(UPEs) has been difficult to ascertain, primarily due to the lack of
in-flight cockpit sensors to verify both the content of the breathing
gas mixtures from the oxygen system (oxygen concentration, flow,
pressure), and the physiologic status of the aircrew (expired oxygen/
carbon dioxide levels, heart rate, respiratory rate, blood oxygen
saturation). Such sensors are currently in development and will be able
to objectively determine the root cause of physiologic events by
measuring these variables and characterizing the integration between
the human, the cockpit environment, and aircrew flight equipment. Until
such sensors are in place, investigations to assess the cause of UPEs
must resort to modeling human physiological response based on
extrapolated assumptions of aircraft system performance as gas
delivery, rather than the actual data itself. In addition to the lack
of sensors, the extremely low rate of UPEs makes it difficult to
identify trends which could be used to indirectly identify possible
root cause of these events.
The two principal means to mitigate the hazards associated with
high altitude flight are to provide increased concentrations of oxygen
in aircrew breathing gas mixtures (to prevent hypoxia), and to
pressurize cockpits to prevent adverse effects associated with a
hypobaric environment. In modern aircraft, cockpit pressurization is
provided by engine bleed air supplied to the Environmental Control
System (ECS). Oxygen for the breathing gas mixture comes from either a
Liquid Oxygen Supply or an ``On-Board Oxygen Generating System (OBOGS),
which also uses engine bleed air to supply breathing gas to aircrew.
The non-specific nature of UPE symptoms (e.g., lightheadedness,
headache, confusion) and the complexity of the interaction between the
oxygen system, aircrew flight equipment, and the aircrew, makes it
challenging to identify the root cause of many Pes.
Current aircrew monitoring systems undergoing testing and
evaluation at the 711th Human Performance Wing include, Canary,
VigilOx, physiologic health status of isolated personnel (PHYSIO), and
mask sensing system (MASES).
______
QUESTIONS SUBMITTED BY MS. TSONGAS
Ms. Tsongas. The committee has been examining the issue of elevated
PE rates in F-18 aircraft for more than two years. Throughout that
time, we have been told that improvements to the GGU-12 onboard oxygen
generation system were an important part of reducing the risks of such
events. As a result, I was troubled by several things the NASA report
had to say about this specific piece of critical equipment on F-18s.
First, in paragraph 10.2.2 the report states that ``The first and most
significant thing to note about the GGU-12 is the disconnect between
best practices of pressure swing absorption systems and operating
conditions of the GGU-12 . . . Best engineering practices for effective
gas separation using PSA is constant conditions. [However], the GGU-12
is fully dynamic--nothing about the GGU-12 is constant.'' The report
further states that ``The GGU-12 is tested in the lab and in the field
with clean, dry air with a fixed flow rate and fixed inlet pressure.
This does not match any actual operating conditions. The GGU-12 testing
program does not adhere to the best practice summarized by `fly what
you test and test what you fly'.''
Finally, the report's finding 10-1 has this to say about the
underlying design standards for the GGU-12: ``The NESC team found
evidence that traced the oxygen peak flow rate requirement to outdated
information from the 1960s, which apparently neglected to address newer
information on pilot breathing demands document in Navy TM-93-59-SY.
The GGU-12 OBOGS maximum performance requirement does not meet human
system demand requirements for flow and oxygen concentration during all
phases of flight.'' Does the Navy have a plan to upgrade the OBOGS
system in the F-18? What is the schedule? Is there a cost estimate?
When would fielding commence and be complete? When will Navy OBOGS
systems in F-18s meet the updated military specifications published in
2015?
Admiral Joyner. NASA is correct that best practices for a Pressure
Swing Adsorption (PSA) technology is to maintain constant operating
conditions. While this practice is well suited for a stationary
industrial air separation plant, it certainly presents a challenge for
an advanced high altitude all weather fighter aircraft operating in
extreme conditions. The F/A-18 OBOGS actually represents a significant
step forward in the maturation of supply air integrity and stability.
The F/A-18 was the first fighter attack aircraft to move the bleed air
supply from a direct engine bleed port where the temperature and
pressures vary widely, to a diversion off of the aircraft's
Environmental Control System (ECS) where the temperature, pressure, and
water content of the air supply is significantly more stable. The F/A-
18 was also first to introduce a redundant bleed air route that
continues to provide source air to the OBOGS in the event of an ECS
failure. Finally, the GGU-12 was fully qualified across environmental
conditions which include bleed air temperatures ranging from -15 to
+250F and in ambient temperatures from -65 to +160F. In actuality, the
GGU-12 as installed in the F/A-18 receives conditioned air from the ECS
that are well within these design parameters. Regarding testing, NASA
is confusing routine performance checks with qualification testing. The
GGU-12 was fully qualified against robust temperature and pressure
extremes that exceed the actual environment in which it operates.
Decades of reliable performance would attest to this assertion as well
as more recent checks conducted to support the Root Cause Corrective
Action (RCCA) investigation. It is true that many of the performance
checks conducted by the fleet are performed at ground level using
hangar air with flow conditions that are not reflective of aggressive
flight. However, it is incorrect to assume that these conditions are
inadequate to identify a failing system. It is noteworthy that the U.S.
Navy is the only service that performs routine testing of the OBOGS for
prognostic health monitoring. This test, which is performed on the
aircraft every 84 days is designed to catch a failing OBOGS before it
results in an aborted flight or physiological event. This comprehensive
system test checks the system's ability to produce oxygen, the health
of the sieve beds, the timing circuits, the accuracy of the low oxygen
warning sensor, the oxygen plumbing integrity, and the ability of the
system to enunciate failure conditions. In addition, the GGU-12 is
removed from the aircraft every 400 flight hours for a more stringent
off-aircraft test. This approach is in compliance with MIL-STD-3050. It
is fair to say, however, that there is a dearth of information across
the services and our international partners regarding the life and
longevity of an OBOGS. The validity of the pass/fail criteria used by
the Navy is being validated under a surveillance program to better
understand the natural degradation in OBOGS. To date, none of the 28 F/
A-18 or 28 T-45 aircraft that have undergone this very demanding test
have shown significant degradation in their molecular sieve or carbon
monoxide catalyst. NASA is also incorrect in applying the
recommendation of Navy TM-93-59-SY to the GGU-12 oxygen concentrator.
The intent of TM-93-59-SY was to establish dynamic breathing
requirements for OBOGS plumbing and breathing regulators. The F/A-18
OBOGS plumbing is designed to absorb the pneumatic shocks and cyclic
flow demands of human breathing. It does this by using a 100 cubic inch
plenum for each cockpit. The size of the plenum and the diameter of the
oxygen plumbing are designed to maintain the oxygen pressure at the
pilot's breathing regulator so that it performs well. Thousands of data
files from F/A-18 and EA-18G operations using pilot monitoring
equipment have confirmed that there is more than adequate supply
pressure being provided at the pilot's breathing regulator to meet
human system demand requirements. The primary shortcomings of the GGU-
12 center on the lack of oxygen concentration control and the lack of
recorded data. Both of these requirements are new since the CY2015
release of MIL-STD-3050. PMA-265 and PMA-202 are developing a new
concentrator for the F/A-18 that will address these issues.
______
QUESTIONS SUBMITTED BY MR. GAETZ
Mr. Gaetz. I understand that many in the military and aerospace
communities feel that the reasons for the physiological events plaguing
military aviation are mechanical. However, in light of the continuing
problems with hypoxia in our front-line fighter and training aircraft,
has anyone within your respective Services collaborated with academic
institutions with known expertise in human performance and aerospace
physiology/medicine. Has that option been talked about or explored in
any way?
Mr. Cragg. We believe this question is better answered by both the
U.S. Navy and the U.S. Air Force.
Mr. Gaetz. I understand that many in the military and aerospace
communities feel that the reasons for the physiological events plaguing
military aviation are mechanical. However, in light of the continuing
problems with hypoxia in our front-line fighter and training aircraft,
has anyone within your respective Services collaborated with academic
institutions with known expertise in human performance and aerospace
physiology/medicine. Has that option been talked about or explored in
any way?
Admiral Joyner. Yes, Navy is actively engaging with academia. The
Johns Hopkins University Applied Physics Laboratory will assist in
contaminant evaluation of the collected Hydrocarbon Detectors and
Sorbent Tube Adapters. The Naval Air Systems Command (NAVAIR)
Educational Partnership Program will be hiring a PhD Chemist from St.
Mary's College to assist in PE efforts. Also, NAVAIR AIR-4.6 has hired
Aeromedical experts to consult on the review of PEs in the Aviation
Environment Scientific Advisory Board. Stanford University's ``Hacking
4 Defense'' will start working on this problem in April 2018. This is a
no-cost collaboration with graduate and undergraduate students who will
look at the OBOGS-Hypoxia linkage with a naive/fresh set of eyes.
Members of the team will be from disciplines that include pre-med,
computer science, engineering, etc. Stanford University has recently
done work with the U.S. Navy to include proposals to prevent/reduce PEs
with Special Warfare SEAL Delivery Vehicle drivers caused by multiple
ascents/descents during long missions.
Mr. Gaetz. I understand that many in the military and aerospace
communities feel that the reasons for the physiological events plaguing
military aviation are mechanical. However, in light of the continuing
problems with hypoxia in our front-line fighter and training aircraft,
has anyone within your respective Services collaborated with academic
institutions with known expertise in human performance and aerospace
physiology/medicine. Has that option been talked about or explored in
any way?
General Nowland. The Air Force remains committed to solving
unexplained physiologic events across the fighter and training
aircraft. Academic institutions play a vital role in helping understand
the role of human factors in physiologic episodes. The 711th Human
Performance Wing (HPW), the Air Force's aeronautical research facility,
with Naval Medical Research Unit--Dayton (NAMRU-D) have collaborated
with several academic institutions like Case Western Reserve
University, Norwegian University of Science and Technology, and the
University of Notre Dame in exploring how the human body responds to
the unique stressors of the flight environment. We continue to explore
such topics as hypocapnia, hyperoxia, hypobaria, work of breathing,
contamination, pulmonary function, and environmental priming--all
issues that may precipitate ``hypoxia-like'' symptoms.
The Air Force continually explores additional options to
collaborate with other academic institutions to leverage their
expertise in contribution to help better understand the problem space.
Institutions like Embry-Riddle Aeronautical University have specialized
expertise the Air Force can leverage to help identify human errors
associated with physiologic episodes; provide data-driven
recommendations for addressing human error; and recommend improvements
for current human factors data collection.
[all]
| MEMBERNAME | BIOGUIDEID | GPOID | CHAMBER | PARTY | ROLE | STATE | CONGRESS | AUTHORITYID |
|---|---|---|---|---|---|---|---|---|
| Graves, Sam | G000546 | 8014 | H | R | COMMMEMBER | MO | 115 | 1656 |
| Langevin, James R. | L000559 | 8140 | H | D | COMMMEMBER | RI | 115 | 1668 |
| Turner, Michael R. | T000463 | 8093 | H | R | COMMMEMBER | OH | 115 | 1741 |
| Bishop, Rob | B001250 | 8189 | H | R | COMMMEMBER | UT | 115 | 1753 |
| Tsongas, Niki | T000465 | 7970 | H | D | COMMMEMBER | MA | 115 | 1884 |
| Wittman, Robert J. | W000804 | 8192 | H | R | COMMMEMBER | VA | 115 | 1886 |
| Brooks, Mo | B001274 | 7790 | H | R | COMMMEMBER | AL | 115 | 1987 |
| Cook, Paul | C001094 | H | R | COMMMEMBER | CA | 115 | 2103 | |
| Veasey, Marc A. | V000131 | H | D | COMMMEMBER | TX | 115 | 2166 | |
| McSally, Martha | M001197 | H | R | COMMMEMBER | AZ | 115 | 2225 | |
| Gallego, Ruben | G000574 | H | D | COMMMEMBER | AZ | 115 | 2226 | |
| Knight, Stephen | K000387 | H | R | COMMMEMBER | CA | 115 | 2228 | |
| Kelly, Trent | K000388 | H | R | COMMMEMBER | MS | 115 | 2294 | |
| O'Halleran, Tom | O000171 | H | D | COMMMEMBER | AZ | 115 | 2306 | |
| Panetta, Jimmy | P000613 | H | D | COMMMEMBER | CA | 115 | 2309 | |
| Carbajal, Salud O. | C001112 | H | D | COMMMEMBER | CA | 115 | 2310 | |
| Gaetz, Matt | G000578 | H | R | COMMMEMBER | FL | 115 | 2314 | |
| Cooper, Jim | C000754 | 8152 | H | D | COMMMEMBER | TN | 115 | 231 |
| Banks, Jim | B001299 | H | R | COMMMEMBER | IN | 115 | 2326 | |
| Brown, Anthony G. | B001304 | H | D | COMMMEMBER | MD | 115 | 2331 | |
| Bacon, Don | B001298 | H | R | COMMMEMBER | NE | 115 | 2337 | |
| Rosen, Jacky | R000608 | H | D | COMMMEMBER | NV | 115 | 2339 | |
| Suozzi, Thomas R. | S001201 | H | D | COMMMEMBER | NY | 115 | 2341 | |
| Jones, Walter B., Jr. | J000255 | 8026 | H | R | COMMMEMBER | NC | 115 | 612 |
| LoBiondo, Frank A. | L000554 | 8044 | H | R | COMMMEMBER | NJ | 115 | 699 |
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