Hearing Loss Prevention
Improvements to DOD Hearing Conservation Programs Could Lead to Better Outcomes Gao ID: GAO-11-114 January 31, 2011In Process
Each of the armed services is taking steps to monitor hazardous noise, but inconsistencies in some hearing protection strategies and limited training weaken mitigation efforts. Services monitor noise periodically, depending on the level of risk servicemembers have in being exposed to hazardous noise (for example, annually for firing ranges and flight decks, and every 5 years for administrative offices). However, they lack a reliable system for detecting changes in noise levels that may occur outside the scheduled review cycle. Although DOD requires that noise be controlled by setting exposure limits and requiring the use of hearing protection, these strategies are not consistently used. For example, servicemembers told us that they do not always wear hearing protection, citing concerns with comfort and communication. Annual hearing-related training is required for at-risk servicemembers, but services are not able to fully determine who has completed annual training, and many servicemembers told GAO that training is not necessarily well timed. DOD's evaluation of services' hearing conservation programs has key weaknesses, but some services have taken steps to review and improve their own programs. First, DOD performance indicators are not sufficiently comprehensive. One key indicator--the rate of hearing loss among servicemembers in the hearing conservation programs--only measures program performance after hearing loss has occurred. Second, evaluation is limited by weaknesses in the processes used to capture, track, and use performance data. For example, the data may not accurately capture the number of servicemembers enrolled in the respective programs--a number required to calculate compliance rate. Third, audiologists, and other key stakeholders do not, on some bases GAO visited, routinely coordinate to share and evaluate hearing loss data to identify and mitigate noise hazards. Individual services have, at times, conducted reviews of their own programs and made some improvements. For example, once the Army decided that soldiers would not be deployed if the individual had not completed a required hearing test, the number of hearing tests rose significantly. DOD has developed, though not yet finalized, a plan for a Hearing Center of Excellence to improve hearing loss prevention and treatment as well as a plan for its registry to track and share information with VA on injured military personnel and veterans. Neither Congress nor the DOD set a date for when planning should be formally approved to implement the center, but a key DOD official estimated that plans may receive final DOD approval in the near future. In the meantime, an interim director for the center has begun to lay the groundwork for implementation of both the center and the registry. While data sharing between DOD and VA has been very limited to date, military and VA officials said the registry should ultimately facilitate sharing and development of best practices. GAO recommends that to improve hearing conservation programs, DOD should address issues with the type, timing, and tracking of training and education; develop an appropriate set of performance indicators; improve processes to collect and use performance data; and examine services' reviews to identify opportunities for program improvement. In reviewing a draft of this report, DOD concurred with GAO's recommendations. DOD and VA provided technical comments, which GAO incorporated as appropriate.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Daniel Bertoni Team: Government Accountability Office: Education, Workforce, and Income Security Phone: (202) 512-5988GAO-11-114, Hearing Loss Prevention: Improvements to DOD Hearing Conservation Programs Could Lead to Better Outcomes
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
January 2011:
Hearing Loss Prevention:
Improvements to DOD Hearing Conservation Programs Could Lead to Better
Outcomes:
GAO-11-114:
GAO Highlights:
Highlights of GAO-11-114, a report to congressional committees.
Why GAO Did This Study:
Exposure to hazardous noise can have negative implications for both
servicemember health and readiness. Moreover, in fiscal year 2009,
some of the most common impairments for veterans receiving Veterans
Affairs (VA) disability benefits were hearing related, as annual
payments for such conditions exceeded $1.1 billion. To examine
Department of Defense (DOD) efforts to prevent hearing loss, GAO is
reporting on (1) how well the DOD and armed services identify and
mitigate hazardous noise; (2) how well the military evaluates hearing
conservation program performance; and (3) the status of DOD‘s Hearing
Center of Excellence and the extent that DOD and VA are sharing
information to inform this and other efforts. GAO reviewed DOD and
services‘ policies and guidance, reviewed DOD performance data,
interviewed officials and servicemembers, and conducted site visits to
nine military bases.
What GAO Found:
Each of the armed services is taking steps to monitor hazardous noise,
but inconsistencies in some hearing protection strategies and limited
training weaken mitigation efforts. Services monitor noise
periodically, depending on the level of risk servicemembers have in
being exposed to hazardous noise (for example, annually for firing
ranges and flight decks, and every 5 years for administrative
offices). However, they lack a reliable system for detecting changes
in noise levels that may occur outside the scheduled review cycle.
Although DOD requires that noise be controlled by setting exposure
limits and requiring the use of hearing protection, these strategies
are not consistently used. For example, servicemembers told us that
they do not always wear hearing protection, citing concerns with
comfort and communication. Annual hearing-related training is required
for at-risk servicemembers, but services are not able to fully
determine who has completed annual training, and many servicemembers
told GAO that training is not necessarily well timed.
DOD‘s evaluation of services‘ hearing conservation programs has key
weaknesses, but some services have taken steps to review and improve
their own programs. First, DOD performance indicators are not
sufficiently comprehensive. One key indicator--the rate of hearing
loss among servicemembers in the hearing conservation programs”-only
measures program performance after hearing loss has occurred. Second,
evaluation is limited by weaknesses in the processes used to capture,
track, and use performance data. For example, the data may not
accurately capture the number of servicemembers enrolled in the
respective programs”a number required to calculate compliance rate.
Third, audiologists, and other key stakeholders do not, on some bases
GAO visited, routinely coordinate to share and evaluate hearing loss
data to identify and mitigate noise hazards. Individual services have,
at times, conducted reviews of their own programs and made some
improvements. For example, once the Army decided that soldiers would
not be deployed if the individual had not completed a required hearing
test, the number of hearing tests rose significantly.
DOD has developed, though not yet finalized, a plan for a Hearing
Center of Excellence to improve hearing loss prevention and treatment
as well as a plan for its registry to track and share information with
VA on injured military personnel and veterans. Neither Congress nor
the DOD set a date for when planning should be formally approved to
implement the center, but a key DOD official estimated that plans may
receive final DOD approval in the near future. In the meantime, an
interim director for the center has begun to lay the groundwork for
implementation of both the center and the registry. While data sharing
between DOD and VA has been very limited to date, military and VA
officials said the registry should ultimately facilitate sharing and
development of best practices.
What GAO Recommends:
GAO recommends that to improve hearing conservation programs, DOD
should address issues with the type, timing, and tracking of training
and education; develop an appropriate set of performance indicators;
improve processes to collect and use performance data; and examine
services‘ reviews to identify opportunities for program improvement.
In reviewing a draft of this report, DOD concurred with GAO‘s
recommendations. DOD and VA provided technical comments, which GAO
incorporated as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-11-114] or key
components. For more information, contact Daniel Bertoni at (202) 512-
7215 or bertonid@gao.gov.
[End of section]
Contents:
Letter:
Background:
Services Are Employing Strategies to Identify and Mitigate Hazardous
Noise, but Inconsistent Practices and Limited Training Weaken Their
Efforts:
DOD's Approach to Evaluating Hearing Conservation Has Key Weaknesses,
While Some Services Have Taken Steps to Review and Improve Their Own
Programs:
Plans Are Almost Complete for Both the Hearing Center of Excellence
and a System to Facilitate DOD and VA Data Sharing:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Key Elements of DOD Hearing Conservation Programs:
Table 2: Military Bases Visited during GAO Review of Hearing
Conservation Programs:
Figures:
Figure 1: Growth in Numbers of New VA Disability Compensation Awards
to Veterans for Hearing Loss and Tinnitus for Fiscal Years 2005
through 2009:
Figure 2: Example of a Noise Dosimeter and Sound Level Meter:
Figure 3: Examples of Hearing Protection Devices:
Figure 4: Example of a Hazardous Noise Sign That Does Not Include the
Level of Hearing Protection Equipment Needed:
Figure 5: Example of the Proximity of Flight Line Personnel to
Military Aircraft:
Abbreviations:
AFCESA: Air Force Civil Engineering Support Agency:
DOD: Department of Defense:
DOEHRS: Defense Occupational and Environmental Health Readiness System:
HCP: hearing conservation program:
IOM: Institute of Medicine:
NAS: Naval Audit Service:
OSHA: Occupational Safety and Health Administration:
STS: significant threshold shift:
VA: U.S. Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
January 31, 2011:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Howard P. "Buck" McKeon: Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
Military service can expose soldiers to hazardous levels of noise,
ranging from gunfire to military aircraft, all of which can lead to a
loss or damage in hearing if protective equipment and measures to
reduce exposure are not employed in advance. Well before retirement,
such damage can reduce servicemembers' ability to communicate and
affect the quality of their professional and personal lives. Moreover,
it can create additional costs to the government and taxpayers by
decreasing troop readiness and increasing the need for medical
services and disability compensation. To protect servicemembers'
hearing, the Department of Defense (DOD) and the armed services have
established hearing conservation policies and programs. Nevertheless,
U.S. Department of Veterans Affairs (VA) has reported that tinnitus
(ringing in the ears) and hearing loss remain some of the most common
service-connected disabilities. Approximately $1.1 billion in
disability compensation was paid out for these two conditions in
fiscal year 2009.
Many have raised concerns about the need to protect servicemembers'
hearing, including DOD, VA, Congress, and national organizations
dedicated to protecting hearing. Such concern on hearing-related
disabilities prompted Congress in October 2008 to require that DOD
establish a center dedicated to the prevention and rehabilitation of
servicemembers and veterans with auditory disabilities. Congress has
mandated GAO to review DOD's hearing protection efforts and report on
the status of the hearing center.[Footnote 1] Specifically, to respond
to this mandate and gain insight into DOD's efforts to prevent hearing
loss, we determined (1) how well the DOD and armed services identify
and mitigate hazardous noise; (2) how well the military evaluates
hearing conservation program performance; and (3) the status of DOD's
Hearing Center of Excellence and the extent to which DOD and VA are
sharing information to inform this undertaking and generally protect
servicemembers. To address objectives one and two, we reviewed DOD and
armed services hearing conservation policies and guidance, reviewed
other federal agencies that set standards and policy for hearing
conservation, and interviewed cognizant military officers from DOD,
Army, Navy, Air Force, and Marines, as well as stakeholders. We
reviewed past evaluations of DOD hearing conservation programs,
including a study conducted by the Institute of Medicine (IOM). We
conducted site visits to nine military installations. During these
site visits, we interviewed senior officials, audiologists, industrial
hygienists, servicemembers, safety officers, and other officials who
assess, measure, and mitigate occupational health hazards. We selected
these site visits based on a number of factors, including the military
branch, size of the installation, presence of different types of
hazardous noise, and geographic location. To determine how DOD and the
armed services monitor program performance, we also interviewed
cognizant officials, reviewed hearing conservation performance
measures and program data and reviewed documentation for DOD's Defense
Occupational and Environmental Health Readiness System (DOEHRS), and
analyzed key system reports for each of the armed services. To address
objective three, we interviewed the DOD Hearing Center of Excellence
program manager, the interim director of the Hearing Center of
Excellence, as well as representatives from the VA involved with the
center's development.
We conducted our overall performance audit from November 2009 to
January 2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient and appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives. For
additional information on our scope and methodology, see appendix I.
Background:
Noise is one of the most common occupational health hazards faced by
military servicemembers. Servicemembers may be exposed to high-
intensity noise of various types during their training and when
performing general job duties or combat operations. Without proper
protection, this exposure can cause or contribute to tinnitus and
hearing loss. The effects of tinnitus, a ringing in the ears
significantly associated with unprotected exposure to hazardous noise
and noise-induced hearing loss, can range from minor to debilitating
and can be permanent. Noise-induced hearing loss, and occasionally
tinnitus, can be rehabilitated with a hearing aid, but they are
permanent disabilities.
After leaving the military, servicemembers who sustain tinnitus or
hearing loss during service may qualify for compensation from the VA.
VA's disability compensation program compensates veterans for the
average loss in civilian earning capacity that results from injuries
or diseases incurred or aggravated during military service, regardless
of current employment status or income. In fiscal year 2009, VA
compensated 1.2 million claims for veterans with either tinnitus or
hearing loss injuries,[Footnote 2] representing an annual federal
expenditure exceeding $1.1 billion for disability compensation
payments.[Footnote 3] In 2005, auditory impairments, which include
hearing loss and tinnitus, became the most common service-connected
disabilities compensated by VA. Since 2005, VA has reported that the
numbers of veterans who have begun receiving compensation each year
for these disabilities have continued to grow, contributing to VA's
increasing annual expenditure on disability claims (see figure 1).
Figure 1: Growth in Numbers of New VA Disability Compensation Awards
to Veterans for Hearing Loss and Tinnitus for Fiscal Years 2005
through 2009:
[Refer to PDF for image: multiple line graph]
Number of awards for service-connected disabilities:
Tinnitus:
Year: 2005: 46,739;
Year: 2006: 51,360;
Year: 2007: 62,488;
Year: 2008: 67,689;
Year: 2009: 77,486.
Hearing loss:
Year: 2005: 38,657;
Year: 2006: 38,330;
Year: 2007: 46,591;
Year: 2008: 47,733;
Year: 2009: 54,450.
Source: Veterans Benefit Administration annual benefits reports,
fiscal years 2005 through 2009.
[End of figure]
Beyond the cash benefits VA provides to veterans with hearing-related
disabilities, there are other expenditures by both VA and DOD to
rehabilitate, treat, or correct auditory injuries. For example, VA
purchased almost 382,000 hearing assistive devices in fiscal year
2008, for an expenditure of approximately $154 million.[Footnote 4]
Both noise-induced hearing loss and noise-induced tinnitus may be
avoided through auditory injury prevention, referred to as hearing
conservation. Due to the introduction of the jet engine to military
environments and the number of World War II veterans who sustained
hearing loss during combat, hearing conservation became a concern of
the armed services in the late 1940s. According to a recent IOM study,
in 1948, the armed services began developing hearing conservation
programs and, in 1978, DOD issued the first departmentwide hearing
conservation directive that provided guidelines to unify the
implementation and goals of hearing conservation programs (HCP)
throughout the armed services.[Footnote 5]
According to DOD policy, the goal of hearing conservation is to
protect all servicemembers and other personnel from hearing loss
resulting from occupational noise exposure. The policy states that
each armed service is to implement a hearing conservation program,
including the Air Force, the Army, the Marine Corps, and the Navy, and
that these programs are to be implemented when personnel are exposed
to a certain level of noise.[Footnote 6] All the services have
policies that include the enrollment of personnel working in areas
with noise at or above levels that can be hazardous when performing
their general job duties. Though military operations are not subject
to federal civilian health and safety regulations, DOD's hearing
conservation instructions direct that the armed services' HCPs comply
with federal standards whenever practicable.[Footnote 7]
DOD policy incorporates the following key elements into its hearing
conservation programs: noise hazard identification, safety signs and
labels, noise mitigation, education and training, audiometric
surveillance, and program evaluation (see table 1).[Footnote 8] Each
armed service branch must submit a written plan to DOD that outlines
its program, including the strategies for implementing these elements.
Table 1: Key Elements of DOD Hearing Conservation Programs:
Element: Noise hazard identification;
Purpose: Measure noise levels in all potentially hazardous noise work
areas, evaluate and prioritize the risk in those areas, and keep an
inventory of hazardous noise areas.
Element: Safety signs and labels;
Purpose: Use signs to identify entrances to and boundaries of
hazardous noise areas and labels to designate equipment that can
produce hazardous noise.
Element: Noise mitigation;
Purpose: Eliminate exposure to hazardous noise by implementing
engineering and administrative controls and by providing and requiring
the use of hearing protection devices.
Element: Education and training;
Purpose: Inform personnel of the effects of noise on hearing, the
ability of hearing protectors to reduce exposure to noise, the purpose
of hearing protection, the purpose of audiometric testing, the proper
use of hearing protection and the actions to be taken for failure to
wear the hearing protection.
Element: Audiometric surveillance;
Purpose: Evaluate hearing levels of personnel through audiometric
testing and maintain records of all audiometric testing in a hearing
conservation database and in the individual's health record, along
with noise exposure information.
Element: Program evaluation;
Purpose: Use the information stored in the hearing conservation
database to annually evaluate the hearing conservation program's
effectiveness based on the percent of enrolled personnel who received
annual audiograms and on the prevalence of significant threshold
shifts (STS)[A].
Source: DOD and service-level guidance.
[A] An STS is a change in hearing, in comparison to a baseline
audiogram, of an average of 10 decibels or more in either ear at 2,000
Hz, 3,000 Hz, and 4,000 Hz.
[End of table]
DOD instructions require services to reduce noise to safer levels,
where possible, using three strategies: engineering controls, hearing
protection, and administrative controls. DOD policy requires that
engineering controls be the primary means of eliminating exposure of
personnel to potentially hazardous noise. To implement engineering
controls, services should design their work environment to reduce
noise below hazardous levels and purchase equipment with the lower
sound emissions. The use of hearing protection is considered an
interim measure, but if services determine that engineering controls
are not possible, DOD policy allows them to use personal hearing
protection as a permanent measure to mitigate noise. Furthermore, if
additional protection is needed, administrative controls, such as
modifying work schedules or procedures should be used to limit
exposure to hazardous noise.
In recent years, studies have addressed hearing loss and tinnitus in
the military. For example, in 2002, Congress directed that VA contract
with the National Academy of Sciences to conduct a study on noise
exposure with respect to hearing loss and tinnitus in the military.
[Footnote 9] The National Academies' IOM study examined the sources of
hazardous noise exposure in the military, levels of noise exposure
necessary to cause hearing loss or tinnitus, the course of hearing
loss following noise exposure, risk factors, and compliance by the
military services with requirements for audiometric testing and the
adequacy of their hearing conservation programs.[Footnote 10] The
study found that military hearing conservation programs were not
adequate to protect servicemembers' hearing. This conclusion was
supported by findings that the annual audiometric testing of
servicemembers enrolled in hearing conservation programs showed that
10 percent to 18 percent had a significant shift in their threshold,
which was estimated to be two to five times higher than rates
considered appropriate in industrial hearing conservation programs.
The study also found that the military programs may not perform the
required annual audiometric testing on all servicemembers exposed to
hazardous noise and that overall testing was not sufficient to
evaluate changes in hearing associated with military service for the
majority of servicemembers. Furthermore, while information was
limited, the study noted that a high proportion of servicemembers
(sometimes up to 50 percent in certain situations) may not be wearing
hearing protection when needed.
Additionally, in fiscal year 2008, the Marine Corps identified hearing
loss among personnel as a risk in its annual Risk and Opportunities
Assessment and, in following up, requested that the Naval Audit
Service (NAS) conduct a review of its hearing conservation program.
The objective of the NAS audit was to determine whether the management
and implementation of the Marine Corps HCP is effective in protecting
servicemembers' hearing.[Footnote 11]
In response to serious auditory injuries incurred by servicemembers
associated with Operation Iraqi Freedom and Operation Enduring
Freedom, Congress mandated in October 2008 that DOD create a center of
excellence in the prevention, diagnosis, mitigation, treatment, and
rehabilitation of hearing loss and auditory system injury.[Footnote
12] A key responsibility of the Hearing Center of Excellence is to
create an electronic registry that tracks the diagnosis, treatment,
and follow-up for each case of hearing loss and auditory system injury
incurred by servicemembers on active duty. The center is required to
inform VA when any of these servicemembers transition from the armed
services to VA to help ensure the coordination and provision of
auditory system rehabilitative services.
Services Are Employing Strategies to Identify and Mitigate Hazardous
Noise, but Inconsistent Practices and Limited Training Weaken Their
Efforts:
Services Use a Risk-Based Approach to Monitor Sites for Hazardous
Noise Levels, but Lack Reliable Notification for Interim Changes:
According to services' policies, the services monitor noise levels at
various sites on a periodic basis according to the level of risk these
sites pose to servicemembers, but they do not provide guidance for a
reliable notification system for changes to site conditions that may
occur in the interim. DOD policy specifically requires the services to
measure noise levels, and we found that hearing conservation personnel
at each of the sites we visited use noise surveys to assess the level
at which specific work and training areas are likely to expose
servicemembers to hazardous noise. At the sites we visited, such site
noise is subsequently monitored through periodic surveys, scheduled
according to their respective level of risk. For example, at sites we
visited, high-risk areas, such as firing ranges and flight decks,
thought to pose the greatest chance of exposure to hazardous noise are
surveyed annually. Medium risk areas, such as flight hangars and light
industrial areas can be surveyed every 2 years; low-risk areas, such
as administrative offices, can be surveyed up to every 5 years,
depending on the service's policy. For example, Navy officials told us
they conduct noise surveys every 4 years for their administrative
offices, whereas Army officials conduct them every 5 years.
According to the policies from most services, responsibility for
measuring and reporting noise levels is delegated to experts in noise
abatement, such as industrial hygienists, who employ a number of
measuring devices, such as sound level meters and noise dosimeters, to
determine how loud the noise is and how long servicemembers are
exposed (see figure 2 for examples of measuring devices).[Footnote 13]
At the sites we visited, the results of the measurements were recorded
on noise survey forms that were used as the basis for reports that
were sent to safety offices, individual military units, work sites and
base leadership, depending on local base procedures.
Figure 2: Example of a Noise Dosimeter and Sound Level Meter:
[Refer to PDF for image: 2 photographs]
Source: GAO.
[End of figure]
At the sites we visited, while the frequency at which the services
monitor site noise depended on an initial determination of the site's
risk level, it did not appear that changes to a site that alter its
noise levels are always promptly and systematically reported. DOD
policy requires that noise be measured within 30 days of any change in
operations affecting noise levels; however, several noise abatement
experts at the sites we visited told us they are not always informed
of changes in noise. Instead, they more often encounter the changes in
noise levels during a scheduled noise survey. Some of these experts
suggested that servicemembers could be exposed to more hazardous noise
levels for a prolonged period of time if no one informs them of
changes to noise levels between scheduled surveys; some of which are
conducted only once every several years.
Services Employ Strategies to Mitigate Noise, but Some Practices Are
Inconsistent:
In accordance with DOD policy for those in the hearing conservation
program, the services employ a number of strategies to control the
amount of exposure to hazardous noise. These strategies include
engineering noise to safer levels, setting time limits on noise
exposure, and requiring the use of protective equipment; however they
are not consistently practiced.
Engineering Controls:
Mitigating noise thorough engineering controls can be carried out by
improving noise reduction technology, building barriers to deflect
noise, and through procurement of quieter equipment and technology.
Under DOD policy, the services are required to use engineering
controls as the primary means of eliminating personnel exposure to
potentially hazardous noise. During our site visits, we observed
examples of how the services have implemented such controls. For
example, at an Air Force base maintenance shop we visited, we observed
a "muff" being used to reduce the noise for a newly acquired water
drill. At a Navy base we visited, a separate building was constructed
apart from the maintenance shop to house a loud piece of equipment to
reduce servicemembers' noise exposure. Services are also required to
review equipment being considered for procurement to determine if they
produce hazardous noise and consider methods for limiting the noise
when technologically and economically feasible.[Footnote 14] In the
Air Force, when designing weapons and facilities such as firing
ranges, procurement decisions are not made at the base level, but are
decided centrally by the Air Force Civil Engineering Support Agency
(AFCESA). AFCESA attempts to strike a balance between operational
effectiveness and worker protection when making procurement decisions.
During this decision-making process, bioenvironmental engineers and
other staff are involved in examining safety, fire, and occupational
health issues--including hazardous noise. For example, AFCESA's
involvement in the procurement of the new F-22 fighter jet led to
considerations in how bases could redesign hangars to reduce the
impact of noise from this plane. Officials from the Army Office of the
Surgeon General said noise abatement experts are usually included in
the procurement process for weapons systems, though not necessarily
for non-weapon system procurements. Also several Navy officers from
the Office of the Surgeon General told us the Navy has recently
started to include industrial hygienists in the procurement of weapon
systems though, to date, this has involved only one such procurement.
Navy officials also added they are attempting to update their own
procurement guidance to include noise abatement experts. However, at a
number of sites we visited, several noise abatement experts told us
they are not involved in the procurement process.
Setting Time Limits:
In accordance with DOD policy, all the services have established
guidance detailing how long servicemembers can be exposed to certain
hazardous noise levels without the use of hearing protection--also
known as administrative controls. For example, the DOD allows
servicemembers to be exposed to 85 decibels of noise, a more stringent
threshold than the Occupational Safety and Health Administration
(OSHA) considers hazardous, for up to 8 hours without the use of
hearing protection equipment.[Footnote 15] However, according to a
number of hearing conservation personnel, controlling the amount of
time that servicemembers are exposed to noise is often more practical
for military personnel who work in civilian or industrial style, non-
military operations. By comparison, for servicemembers engaging in
military operations, abiding by specific time limits is more difficult
because their duties may require them to stay at their station beyond
recommended limits. For example, hearing conservation personnel aboard
an aircraft carrier we visited told us that personnel who work on the
flight deck have flight operations lasting as long as 16 hours.
Reflecting a similar point, an audiologist told us that controlling
the amount of time Marines are exposed to hazardous noise in battle is
unrealistic, as Marines cannot stop fighting because they have
exceeded their allotted exposure time to noise.
Personal Protective Equipment:
DOD policy requires servicemembers to wear personal protective
equipment, such as earplugs, when engineering controls are not
sufficient to reduce noise levels.[Footnote 16] Based on our
interviews with servicemembers and audiologists, we found that the
services largely make such equipment available. More specifically,
some servicemembers at the sites we visited told us they were able to
obtain hearing protection primarily from their units or from hearing
testing centers and from work or training areas (see figure 3 for
examples of hearing protection devices). However, according to several
hearing conservation personnel we spoke with, some of the services do
not have an up-to-date list of approved equipment that units can
choose from when purchasing hearing protection. They also said
purchasers have little to no experience with hearing protection and we
were told of a unit that, as a result, had purchased personal
protective equipment without determining whether it would be
effective. Hearing conservation personnel at one of the Army bases we
visited recounted a story where one unit deployed using untested
hearing protection that was later rejected. In addition, senior DOD
officials also told us that some servicemembers bought their own
hearing protection equipment that was below the required standards.
Finally, we observed that servicemembers themselves are not
necessarily using equipment provided to them or are not using the
hearing protection equipment properly.
Figure 3: Examples of Hearing Protection Devices:
[Refer to PDF for image: 3 photographs]
Source: GAO.
[End of figure]
To assure that the correct personal protective equipment is used,
DOD's policy requires that all hazardous noise areas and industrial
and military equipment have signs or labels that identify them as
producing hazardous noise. The signs and labels are also expected to
communicate the level of protective devices (i.e., single or double
hearing protection) that should be worn to prevent hearing loss while
working in or around the hazardous noise. However, at many of the
sites we visited, we observed signs and labels indicating hazardous
noise equipment or areas, although not all of the signs included the
protective measures required. (See figure 4 for an example of a
hazardous noise sign that does not include the level of hearing
protection needed.) In some limited instances, a sign was not posted
in an area that the safety officer guiding our walk-through noted
should have had proper signage.
Figure 4: Example of a Hazardous Noise Sign That Does Not Include the
Level of Hearing Protection Equipment Needed:
[Refer to PDF for image: photograph]
Hazardous Noise:
May Cause Hearing Loss.
Hearing Protection Required:
* During Normal Operations;
* During Other Operation (Specify);
* Plugs or Muffs;
* Plugs and Muffs.
Source: GAO.
[End of figure]
Also, some of the servicemembers at the sites we visited maintained
that enforcement of the wearing of protective equipment is limited.
These servicemembers said their superiors did not consistently check
for equipment usage, and there is little to no discipline for members
who are not using them. Some services also placed the responsibility
for reminding their members about the importance of hearing protection
with servicemembers who are often of lower rank and thus lack the
authority to enforce adherence to the requirements. Army Hearing
Program personnel described to us a program that assigned specific
soldiers to disseminate information on hearing conservation issues and
remind individuals to wear hearing protection. However, according to
some Army Hearing Program staff these assigned soldiers were of low-
rank with limited authority to ensure their peers and superior
officers were educated on hearing conservation or wore appropriate
hearing protective equipment.
During our interviews with DOD officials and servicemembers, we heard
that in some cases, servicemembers do not wear required hearing
protection. During our site visits, many servicemembers expressed a
number of reasons why they chose not to wear the required hearing
protection. Some servicemembers said the protective equipment was
uncomfortable. At the sites we visited we spoke with a number of
servicemembers working on a flight line in close proximity to fighter
jets who are required to wear double hearing protection. While they
were generally aware that they were required to wear double
protection, each was wearing single protection and many cited comfort
as a reason for their non-compliance. (See figure 5 for an example of
the proximity of flight line personnel to jet airplanes.) At other
locations we visited, servicemembers cited the impact of hearing
protection on communication. They said that the protection can
interfere with the need to communicate with their colleagues and to
hear orders from superiors. Still others said they perceived that
wearing hearing protection in combat can put them in harm's way
because they cannot hear an enemy approach or determine where enemy
gunfire is coming from. Finally, many servicemembers expressed the
view that hearing loss is part of the military experience and many
accepted this as a fact of a military career. For those that used
hearing protection equipment, we heard of a number of instances where
hearing protection equipment was not worn properly. Across many of the
military sites we visited, servicemembers told us of hearing
protection either falling out of their ears or getting dirty to the
point of being unsanitary to wear.
Figure 5: Example of the Proximity of Flight Line Personnel to
Military Aircraft:
[Refer to PDF for image: photograph]
Source: GAO.
[End of figure]
Educating Servicemembers on Hearing Conservation Is Not Necessarily
Tracked or Well Timed:
In accordance with DOD policy for the armed services' hearing
conservation programs, participating servicemembers should be educated
and trained annually with regard to hearing conservation requirements.
Per DOD policy, servicemembers should be educated on topics such as
the effects of noise on hearing and the purpose of hearing protection.
The policy allows services to design their own specific training.
Among the sites we visited, servicemembers told us they received
education on hearing conservation through a variety of training
methods, including Safety Stand Downs, videos, posters, and supervisor
initiatives.[Footnote 17]
Although services have a number of training options for educating
servicemembers on hearing conservation, officials from some of the
services reported they were unable to verify whether servicemembers
have taken any training. For example, Army Hearing Program personnel
noted that the Army has no method for tracking whether soldiers have
received such training. Also, Navy hearing conservation personnel told
us the Navy operates systems for tracking individual training
activities, but servicemembers are not required to record their
training in the system. However, Air Force officials require that
workplace supervisors document a servicemember's annual training on
hazardous noise exposures and equipment on an Air Force Record of
Training form.
We also found that educating servicemembers on hearing conservation is
not necessarily conducted prior to servicemembers' first exposure to
hazardous noise or during hearing tests, when they are interfacing
with audiologists or audiometric technicians with hearing conservation
expertise. At many of the sites we visited, we were told that
servicemembers, as new recruits, were given very little education on
hearing conservation prior to the first time they fire weapons during
basic training in these locations.[Footnote 18] The education
generally consisted of instructors telling new recruits to simply use
hearing protection in their ears, but not explaining its importance or
the proper technique to insert such equipment. A few servicemembers
stated they were told not to wear hearing protection during training,
with the justification that training should be conducted under the
same conditions as combat, which does not include hearing protection.
Also, at the sites we visited, a number of servicemembers added that
educating new recruits on hearing conservation may be difficult during
basic training because there is little time for any additional
education. Despite these observations, a number of hearing
conservation personnel told us that even a single exposure to
hazardous noise can trigger some level of hearing loss and believe
that educating new recruits on hearing conservation during basic
training would help underscore the importance of hearing protection.
[Footnote 19]
Lastly, several audiologists and audiometric technicians--hearing
testing personnel--at sites we visited told us there is no formal
training in conjunction with the hearing examination process for those
servicemembers in a hearing conservation program. Similarly, a number
of servicemembers we spoke with noted that the training they receive
from hearing testing personnel primarily consists of reminding them to
wear hearing protection. That stated, several hearing conservation
personnel at the sites we visited told us they provided more in-depth
informal training to servicemembers who fail their hearing
examinations, consisting of an explanation of test results, a
demonstration on the proper fitting of hearing protection, and a
reminder to wear hearing protection.
DOD's Approach to Evaluating Hearing Conservation Has Key Weaknesses,
While Some Services Have Taken Steps to Review and Improve Their Own
Programs:
DOD Lacks Adequate Performance Indicators:
DOD delegates most program evaluation to the services, but lacks
adequate performance indicators to proactively assess how well
services are reducing hearing loss among servicemembers. At the time
of our review, DOD policy required that services evaluate their
hearing conservation programs on an annual basis based on two annual
performance indicators both targeted for servicemembers enrolled in a
hearing conservation program--(1) the percentage of servicemembers
that take a required annual hearing test and (2) the rate of
significant hearing loss.[Footnote 20] Several senior service-level
hearing program managers expressed concern about the adequacy of the
indicators. More specifically, they told us that the current
performance indicators are not sufficiently comprehensive and that the
rate of significant hearing loss only provides a measure of
performance after damage has occurred. In general, key officials in
the services we spoke with expressed a desire for more leading
indicators that could signal to program managers that targeted
interventions are needed before hearing loss has occurred. Moreover,
some Army officials told us that they would like to see indicators
that are more closely aligned with their readiness--which is a basic
measure to assess each servicemember's ability to deploy. A senior-
level DOD official told us they convened two working group sessions--
which involved representatives from across the services--since spring
2010 to discuss amending existing performance indicators. According to
another senior-level DOD official, additional indicators were put in
place in December 2010 when DOD released its updated hearing program
guidance. This guidance includes indicators designed to be more
proactive in hazard evaluation and intervention prior to measurable
hearing loss, such as the percentage of noise hazardous workplace
characterizations completed and an index of unacceptable noise
exposures. The guidance also encourages services to develop additional
measures of program effectiveness.
Limitations in Information System Processes Hinder Program Evaluation
Efforts:
Program evaluation is also hindered by limitations in the processes
used to capture, track, and use hearing-related performance data. DOD
has multiple information systems related to its hearing conservation
program, including one that tracks servicemember hearing test results
and another that tracks servicemembers' exposure to occupational noise
hazards. But officials we spoke with identified limitations in the
processes designed to support these systems that, collectively,
compromise the reliability or usefulness of performance data that they
generate.[Footnote 21]
We found limitations in the process to identify whether hearing loss
for an individual may have occurred. Typically, immediately prior to
administering a hearing test, an audiometric technician will query the
hearing test system to retrieve a servicemember's prior test results,
which are used as a baseline with which to establish whether a loss
has occurred. However, on some occasions, prior hearing test data
cannot be located in the system and must be entered manually by
audiometric technicians before they administer the hearing test. For
example, at one base we visited, if a servicemember did not bring
their original paper examination to the test, technicians told us they
would sometimes have to categorize the test as a "non-hearing
conservation" hearing test or have to re-establish the baseline
hearing test, making it difficult to assess whether a significant
hearing loss has occurred because there would not be two comparison
points. Audiometric technicians must also manually enter into the
hearing test system whether a servicemember is receiving an initial or
follow-up hearing test. However, Navy researchers conducting system
reliability tests told us they have found anomalies in how initial and
subsequent hearing tests were categorized, making it difficult to tell
whether tests were given in the proper sequence. They attributed many
of these problems to technicians' manual data entry errors and the
lack of a consistent review process to ensure these entries are
accurate, which undermine the accuracy of the test data.
We also found limitations in the process to establish that hearing
loss for an individual has actually occurred. If a hearing loss is
detected during an annual examination, it is generally considered
temporary until the hearing loss is confirmed in at least two
additional follow-up examinations.[Footnote 22] According to DOD
officials, servicemembers must appear for the follow-up examinations
within 90 days of an annual test. However, we found that when
servicemembers who fail their annual tests do not appear for follow-up
examinations within the required period, the system will automatically
count their temporary hearing loss as permanent. To the extent this
occurs, the rate of permanent hearing loss could be inflated. Without
a reliable rate for hearing loss, services are unable to properly
assess the effectiveness of their program or properly target
prevention efforts.
Finally, in reference to hearing tests, we found limitations in the
process used to identify the number of servicemembers enrolled in the
services' respective hearing conservation programs--which is essential
to calculating the hearing test compliance rate. Because the system
designed to track hearing tests does not automatically capture the
number of enrollees, each service must estimate its number from other
data sources. For example, Air Force hearing program enrollment
information is maintained in a separate database that does not link to
the hearing test system. Consequently, Air Force officials resort to
using an often time-consuming manual process to tally the number of
servicemembers enrolled in the hearing conservation program.
Similarly, Navy and Marines officials told us that at some locations,
officials must construct enrollment information from multiple sources,
including paper files. Compiling enrollment numbers from multiple
sources can lead to errors in calculating the compliance rate. For
example, we found that the Army reported a compliance rate that
exceeded 100 percent in 2007.
In reference to the system that tracks hazard exposure information--
including the time, place, and amount of servicemembers' exposure to
hazardous noise--we identified some limitations with the current
usefulness of the system. This system is designed to track
servicemembers' occupational exposure to noise and other hazards over
the course of a military career. However, based on the information we
received, the system is not yet fully implemented at some
installations. Moreover, Army industrial hygiene officials at one
installation told us that they had been trained on the system, but did
not have the staff resources to upload exposure information into the
system from individual files. In discussing this issue, Army officials
told us that 300 new industrial hygiene personnel they expect to hire
over the next 3 years will aid systems implementation. A senior-level
Air Force official told us that the Air Force has fully implemented
the hazard tracking system across all installations. However, Air
Force industrial hygiene officials expressed concern to us about the
system's capacity to generate reports in a format that provides useful
performance information. More specifically, they noted that to get
critical information about the hazards that exist in each Air Force
work site, the new system generates a 14-page report. To overcome the
system's limitations, the Air Force developed a reporting process that
could produce the same information in 2 pages. A senior-level Air
Force official told us it is necessary for them to upload hazard
information twice daily from the new system into an existing Air Force
form to get the performance information needed to effectively mitigate
noise hazards on base and meet DOD requirements, respectively.
Moreover, the hazard exposure tracking system is not currently
integrated with the hearing test system. DOD initially designed these
systems with the intent to integrate data from both systems to
identify the impact of each servicemember's individual exposure to
noise and other occupational hazards. Although the DOD hearing test
system has been active since 1999 and the hazard exposure system was
initiated in 2006, to date, these systems have not been linked. As a
result, hearing conservation managers told us it is difficult to
systematically analyze the causes of hearing loss and effectiveness of
mitigation measures. According to DOD officials, DOD has not
determined when they plan to integrate the two systems.
Program Stakeholders Do Not Appear to Routinely Coordinate to Evaluate
Program Performance:
Evaluating an installation's implementation of the hearing
conservation program requires information that often resides across
various departments on base. This information includes noise hazard
data; steps actually taken to mitigate hazards; and hearing tests
results. As indicated by DOD guidance and supported in principle by
many of the stakeholders we spoke with, it is necessary for various
stakeholders, including workplace supervisors, industrial hygienists,
audiologists, and safety officials, to communicate and share
information about potential noise hazards and hearing loss trends in
order to effectively manage and evaluate the hearing conservation
program. However, based on interviews with senior-level officials and
our site visits, coordination does not appear to routinely occur at
some bases. For example, at a Navy and Marine base we visited,
industrial hygienists were responsible for identifying hazardous noise
at work sites and making recommendations on how to mitigate these
hazards, but they had no authority to oversee the implementation of
their recommendations. Across all the services, officials, who reside
in a separate department from industrial hygienists, are responsible
for monitoring hearing loss and following up and enforcing industrial
hygiene recommendations, but we were told on some bases these two
departments rarely coordinate. At one base we visited, industrial
hygiene and audiology officials had never met one another prior to our
visit. However, we did document one instance of effective coordination
at one Army installation, whereby an audiologist responsible for
hearing testing identified an increase in hearing loss among
servicemembers at a particular work site. In order to prevent further
hearing loss, the audiologist shared this information with the
industrial hygiene officials on base and they were able to conduct an
assessment of potential noise hazards and make recommendations to
mitigate these hazards.
Services Have Made Efforts to Review and Improve Their Own Hearing
Programs:
Each service has taken some steps to review their own hearing
conservation programs and identify opportunities for improvement.
These include scheduled reviews of hearing loss data and hearing test
audits, among other efforts.
Air Force Occupational and Environmental Health Working Group:
The Air Force developed a mechanism to aid coordination across
multiple departments by requiring each base to establish an
Occupational and Environmental Health Working Group to review data on
a wide range of health hazards and indicators. At one site we visited,
the working group had members from multiple departments, including
Flight Medicine, Safety, Bioenvironmental Engineering, Aerospace
Physiology, Public Health, and Audiology. Members of the working group
told us they review hearing loss data each month for each unit on base
to determine if there are incidences of significant hearing loss. If
significant loss is identified, the working group will conduct a site
visit to determine its cause and make recommendations for noise
mitigation.
Audit of Marine Corps Hearing Tests:
After the Headquarters Marine Corps Safety Division designated hearing
loss as a high risk issue for the Marines in fiscal year 2008, the
Marines requested that the Naval Audit Service conduct an audit of its
program. The audit focused on audiometric testing and reviewed a
representative sample of Marines discharged in 2007 to determine how
many had received hearing tests both at the beginning and end of their
military service.[Footnote 23] Additionally, the review included an
assessment of the reliability and consistency of hearing test data and
a survey of senior leadership on who is responsible for the hearing
conservation program, how often the program has been evaluated, and
the effectiveness of these evaluations, action plans, performance
measures, and standard operating procedures. The audit found that the
Marine Corps had not effectively protected the hearing of Marine Corps
personnel and noted that 6,300 Marines from 2001 to 2008 had hearing
loss or hearing-related injuries. NAS also found that 84 percent of
the medical records of Marines who left the service in fiscal year
2007 did not have an entrance or exit audiogram within 60 days of
their entry or exit from the service. The report makes several
recommendations to improve the effectiveness of the Marine Corps
hearing conservation program, including performing a one-time review
to identify all current Marines who are due for an audiogram and
establishing controls to ensure that Marines receive timely access to
care for required audiograms.
Navy Survey of Hearing Protection Equipment aboard Aircraft Carriers:
In 2005, the Naval Air Systems Command published a survey of sailors
aboard six aircraft carriers assessing the extent to which hearing
protection equipment was being appropriately fitted, used, and
maintained.[Footnote 24] The study included interviews with flight
deck personnel on their duties, noise exposure, and their perceptions
about the adequacy and comfort of their equipment. The reviewers
reported that almost 50 percent of the sailors surveyed reported never
wearing earplugs and only 7 percent had inserted the earplugs deeply
enough to achieve the recommended protection. Moreover, they found
that, for flight deck personnel studied, 79 percent received noise
reduction of only 0 to 6 decibels from their equipment--this despite
working in conditions that required double hearing protection.
Although helmets were found to be properly fitted for 90 percent of
those surveyed, some were found to be in poor condition, or to have
been shared among sailors or worn over hats or scarves. The report
recommended the following actions: (1) improve the effectiveness of
hearing protection equipment, including helmets, earplugs, and muffs;
(2) instruct servicemembers on how to select the proper size and
correctly wear and maintain hearing protective equipment; (3) make
hearing protection part of the uniform; and (4) set penalties for
noncompliance with the appropriate use of hearing protection.[Footnote
25]
Army Program Review:
Concerned about the high rate of hearing-related injuries incurred
during the early stages of Operation Iraqi Freedom, the Army released
in 2005 a broad-based review of its hearing conservation program with
regard to training, base, and combat environments.[Footnote 26] The
reviewers concluded that the Army's hearing conservation program was
more suitable for industrial rather than military conditions. For
example, military audiologists were serving in Iraq but their role was
largely limited to evaluating--not preventing--hearing loss. In
addition, the review found that the Army's readiness requirements were
not specific enough to reflect the critical importance of hearing to
soldiers in combat. The reviewers recommended a number of policy
changes to make hearing protection policies more effective for active
duty soldiers, such as requiring that, in order to meet combat
readiness standards, soldiers must be up to date on their periodic
hearing tests and be fitted with combat arms earplugs. Subsequently,
the Army instituted a policy that soldiers who did not meet the
hearing readiness standard could not be deployed. Army officials we
spoke with told us that implementing this enhanced readiness standard
has improved compliance with hearing tests, and have given individual
soldiers and unit commanders clear accountability for taking steps to
protect soldier hearing. The Army reported that audiograms increased
from 168,000 in 2003 to almost 440,000 in 2006; officials attributed
this increase to the new hearing readiness standard. Several Navy and
Marine officials with whom we discussed the Army's hearing readiness
standard expressed interest in considering a similar approach for
their respective services.
The same report also recommended that military audiologists be
assigned broader responsibility for hearing conservation, given their
combination of medical skills, military training, and knowledge of
protective and communication equipment designed for combat. In
response, the Army reports that it plans to increase the number of
Army military audiologists from 25 to 45. In addition, to determine
whether the Army's staffing policy would effectively support military
audiologists' expanded role in hearing conservation, the Army
conducted a pilot study in 2008 at Fort Carson, Colorado. The Army
found that an increase from one to two military audiologists at the
base allowed them to spend time performing preventative services, such
as training medics and noise-exposed soldiers on proper earplug use,
giving briefings on hearing conservation, and inspecting noise-
hazardous areas, in addition to their clinical work.[Footnote 27] At
Fort Carson we observed a military audiologist and medic meeting with
soldiers on the firing range, assessing earplug fit and answering
questions, as well as providing individually-fitted combat arms
earplugs and distributing boxes of foam earplugs in different sizes.
Plans Are Almost Complete for Both the Hearing Center of Excellence
and a System to Facilitate DOD and VA Data Sharing:
A Plan for the Center Has Been Submitted for Final Department Approval:
DOD has developed, but not yet finalized, its planning for the DOD
Hearing Center of Excellence that Congress mandated in October 2008 to
be established. While DOD maintains final authority on decisions for
the center, it is coordinating the planning effort with the VA and has
assigned the Air Force responsibility to draft plans for the center.
The Air Force, in turn, designated an interim director for the center
in November 2009. Subsequently, the center's interim director
completed basic logistical planning, such as identifying space and
budgeting for the center, along with developing proposals to hire
staff and purchase equipment. He also led the internal workgroup that
included representatives from all the armed services and VA that
jointly developed early drafts of the concept of operation for the
center to delineate its mission, goals and structure. As of September
2010, each of the armed services had reviewed the current draft. The
draft was awaiting approval by the DOD Assistant Secretary of Defense
of Health Affairs before it could be sent to the VA for approval.
Neither Congress nor DOD set a date for when planning should be
formally approved to implement the center, but a key DOD official
estimated that the concept of operations may get final DOD approval in
the near future.
As described by the center's interim director and Air Force Surgeon
General, the current plan envisions a "hub-and-spoke concept"----the
center's headquarters as the hub and selected DOD and VA regional
medical centers and research sites as spokes--to integrate,
facilitate, and coordinate clinical care and research for
servicemembers and veterans with the latest treatment and research on
hearing loss, tinnitus, and auditory system injury.[Footnote 28] The
Lackland Air Force Base in San Antonio, Texas, will serve as
headquarters, while the regional sites have yet to be named. The
director told us that the plan also describes the center as
facilitating the sharing of information between DOD and VA on clinical
advances related to the management and rehabilitation of hearing loss
and injury. This arrangement is intended to optimize clinical care and
research and avoid unnecessary duplication. DOD also has planned for
possible consolidation of common support functions, such as
administrative support and contract support, for all the DOD centers
of excellence to help ensure operational economy and efficiency.
[Footnote 29]
Furthermore, the interim director told us that the focus of the center
will be to:
* research and support field testing of the best available protection
and communication devices currently available, as well as developing
improved hearing protection, along with better education and training
on its use;
* create best practice guidelines for improving hearing outcomes after
injury and explore new lines of therapy to protect or restore hearing
loss or injury;
* determine how many hazardous noise exposures are too many for a
servicemember and the level of hearing needed for selected jobs to
facilitate appropriate job assignments;
* develop and implement better restorative and rehabilitative devices;
* promote standards for implementing hearing awareness and treatment
into medical air evacuations for injured troops; and:
* collaborate with academic centers and industry in all these pursuits
to mitigate or restore hearing loss.
Data Sharing between DOD and VA Is Expected to Increase with
Implementation of a New Electronic System:
While attempts have been made by DOD and VA to share data, officials
from both departments told us that a new data sharing system is needed
so that sufficient information is available to address hearing
injuries and loss, such as assessing the effectiveness of the DOD and
armed service hearing conservation programs, providing and assessing
treatment, and making disability compensation decisions.[Footnote 30]
A recent data sharing experience between the two departments
demonstrates some of the current weaknesses that may be resolved by
the pending implementation of a new data system. In January 2010, VA
responded to the hearing center's interim director's request for data
to help evaluate the scope and rate of hearing loss specific to each
service. VA was able to provide much of the information requested,
such as the number of new VA approved claims for hearing loss and
tinnitus grouped by each military branch of service and the disability
rating,[Footnote 31] for each year from 2004 through 2009. However,
VA's system, developed to process claims and make disability payments,
was not able to provide the other data requested in a format to meet
DOD's needs for information on all claimants with hearing loss, such
as date of separation from the military, period of military service,
and military job. Without this additional information, the center's
interim director reported to us that he could not sufficiently
evaluate the military's hearing conservation programs, in part,
because he could not determine the rate or trends of unique claims
that could be attributable to the current conflict, specific at-risk
locations or duties, or prevention efforts.
Although not yet finished, the plan for a comprehensive "registry"--
for tracking and exchanging data between DOD and the VA on hearing
loss, injury, treatment, and outcomes--is close to completion. While
the concept of operations for the registry was initially expected to
be developed for final review by the Assistant Secretary of Defense by
July 2010, it was still under preliminary review by the armed services
and the VA as of late 2010. According to the center's interim director
and a working group member, the development of the registry's plan
will be facilitated by borrowing from the design of the Vision Center
of Excellence's registry, such as using some of the same data fields
and data sources for both registries. The interim director also told
us that the hearing center's registry would use data from the existing
DOD and VA systems. Pending DOD approval of the registry plan, the
interim director anticipates launching a pilot registry in the summer
of 2012.
A key DOD official, armed services officials, and VA officials told us
they expect the registry to provide a wealth of information to assess
techniques for hearing protection and to develop best practices for
treatment of those with hearing loss and injury. They expect the
registry data to contain information on hearing loss and injury
incurred during active duty, by virtue of tracking servicemembers'
injuries, interventions, and outcomes. According to the center's
interim director, this information will enable the armed services to
better assess their hearing conservation programs, hearing protective
efforts, therapies and procedures for auditory injury, and
rehabilitation. The center's efforts could, he noted, reduce hearing
impairments and with it, the cost of VA compensation for hearing loss.
The Center's Interim Director Has Been Laying the Groundwork to
Facilitate the Implementation of the Center and Data System:
In preparation for implementation, the center's interim director has
taken a number of steps to build alliances with academic institutions
to address prevention, clinical care, rehabilitation, and research
gaps. For example, to establish visibility for the center and build
relationships with academic institutions, the director has contacted
the Deafness Research Foundation, which has an alliance of 10
laboratories that conduct stem cell, metabolic, and other types of
restoration research for hearing injuries and loss. According to the
center's interim director, this alliance is needed because DOD and VA
lack resources and expertise in this area. In February 2010, the
interim director facilitated a symposium of academics and officials
from DOD and VA on addressing war fighter injuries. The group
identified 23 relevant research projects and several areas of focus
for the center's research.
Additional steps taken to prioritize and facilitate research on
prevention and treatment include (1) spearheading the formulation of a
white paper to identify gaps and propose solutions to coordinate and
link research efforts across DOD and VA hearing research labs and
clinical sites and (2) initiating discussions to create within DOD a
centralized and independent Institutional Review Board to be linked
with VA's centralized Institutional Review Board. The center's interim
director envisions that such a board would not only meet the standard
research requirement for an independent body to protect patients and
patient data, but would also shorten the time it takes for any of
DOD's Centers of Excellence to get board approval for research and
access to data.
With regard to the data sharing network that includes the registry,
the center's interim director has taken a number of steps to develop
its capacity. To move forward with data sharing, he has requested a
military-wide health system certification of auditory software that is
needed to allow DOD and VA to collect and share hearing test results.
The hearing center registry has also been developed so that it can
linked with other registries and centers, to help integrate
servicemember data on hearing with other sensory deficits, as well as
traumatic brain injury. He has also assisted with the development of a
module to include auditory data collection in DOD's front-line medical
treatment information registry.[Footnote 32]
Conclusions:
Good hearing is critical to a servicemember's performance and well-
being, whether in combat or in carrying out peaceful operations. The
U.S. military system has, in recent years, undertaken measures to
preserve the hearing of military personnel and alter the assumption
that military duty must inevitably lead to a loss in hearing capacity.
Nevertheless, hearing loss and tinnitus remain conditions that most
often require disability compensation for veterans. Yet both are
largely preventable.
The inconsistencies that we found in the various military strategies
for hearing protection and the lack of good monitoring and oversight
suggests that these programs are not realizing their full potential.
The fact that new servicemembers do not necessarily receive
instruction on using protective equipment before they are exposed to
hazardous noise in basic training, for example, undermines the first
stage of any defense, which is prevention. Moreover, servicemembers
enrolled in a hearing protection program that do not necessarily
receive more education and training when they appear for their
periodic exams represent another lost opportunity for hearing loss
prevention. Aside from the lack of more thorough and carefully timed
training programs, the services and DOD have no uniform system for
tracking who has received training on hearing loss prevention. The
services and DOD must ensure that service personnel are cognizant of
the immediate and long term risks to hearing posed by exposure to
hazardous noise.
In terms of strategy, DOD itself is not in a position to assess the
adequacy of the programs and practices it now requires of the services
for hearing preservation without a full set of performance indicators.
Additionally, without more reliable data and reporting capability, and
an integrated system of records that relate hearing injuries to work
sites, DOD will further lack the ability to approach the problem of
hearing loss more strategically--by capitalizing on areas of success
and targeting areas of weakness.
While each of the services has made some effort to review and improve
its hearing loss prevention practices, weaknesses remain in DOD
efforts to identify and mitigate hazardous noise. Some of these
individual initiatives, if expanded across each of the services,
likely hold promise for addressing these issues. Without efforts to
expand these initiatives, new insights and improvements could be lost--
to the detriment of the services and servicemembers.
Recommendations for Executive Action:
To position DOD and the services to better protect servicemembers from
hearing loss, we recommend that the Under Secretary for Personnel and
Readiness work with the Assistant Secretary for Health Affairs and
take the following four actions to ensure that:
* DOD and the services improve upon the type, timing, and tracking of
training and education provided to servicemembers on hearing
protection, by providing information that is more comprehensive and
training that is more frequent and possibly earlier in servicemembers'
careers.
* DOD work with the services to develop an appropriate set of
performance indicators that assess how well services are reducing
hearing loss among servicemembers.
* DOD and the services address limitations in the processes used to
capture, track, and use performance data. This effort should address
issues with data reliability, data entry, reporting capability, and
integration across relevant databases.
* DOD work with the services to examine the appropriateness and
feasibility of expanding those service-level initiatives that hold
promise of improving---on a DOD-wide basis---the military hearing
conservation programs. Particular attention should be focused on those
efforts that already appear to have either increased compliance with
program requirements or have demonstrated the potential to reduce
hearing loss among servicemembers, such as establishing hearing loss
as a readiness issue, improving the comfort and design of hearing
protection, and including noise experts more consistently in the
procurement process.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOD and VA for review and
comment. DOD provided written comments and agreed with our
recommendations. DOD's comments have been reproduced in appendix II.
VA did not provide formal written comments, but both DOD and VA
submitted technical changes to the draft of the report, which we
incorporated into the report as appropriate.
In its comments, DOD stated the agency's ongoing and planned actions
in response to our recommendations. Specifically, to improve upon the
type, timing and tracking of hearing conservation training provided to
servicemembers, DOD plans to monitor the progress of the services in
their efforts to implement improvements, encourage the sharing of
lessons learned, and standardize improvements across services as
appropriate. DOD agreed with our recommendation to more proactively
assess how well services are reducing servicemembers' hearing loss. As
noted in our report, in December 2010, DOD issued updated guidance
that included new performance indicators designed to be more proactive
in hazard evaluation and intervention prior to measurable hearing
loss. The services also plan to review these indicators and develop
additional indicators as needed. DOD also stated that it plans to
address limitations in the processes used to capture, track, and use
performance data. In addition, DOD agreed to work with the services to
examine the appropriateness and feasibility of expanding DOD-wide
those service-level initiatives that hold promise of improving the
military hearing conservation programs. To this end, DOD stated that
it will continue to use its annual Safety and Occupational Health In-
Progress Review and the DOD Hearing Conservation Work Group as
mechanisms of sharing service-level improvement initiatives. Our
review of the department's new guidance and its planned actions
indicate that DOD is taking steps in the right direction. If the
department follows through with its efforts, we believe that it will
be responsive to our recommendations.
We are sending copies of this report to the Secretaries of Defense and
Veterans Affairs, interested congressional committees, and other
interested parties. The report also is available at no charge on the
GAO Web site at [hyperlink, http://www.gao.gov].
Please contact me on (202) 512-7215 if you or your staff have any
questions about this report. Contact point for our offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. Key contributors to this report are listed in
appendix III.
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
To address the objectives of this study, we used a variety of methods
including:
* reviewed professional journal articles and studies on audiology,
military audiology, and hearing conservation;
* researched relevant federal laws, regulations, standards, and
Department of Defense (DOD) and armed services' guidance;
* interviewed 12 military and civilian audiologists, 5 audiology
technicians, 30 representatives of professions who assess, measure,
and mitigate occupational health hazards such as industrial hygienists
and safety officials, and 123 servicemembers across each of the armed
services; and:
* interviewed senior-level officials from DOD, Veterans' Affairs (VA),
and the armed services, including the Army, the Navy, the Air Force
and the Marines. We also conducted informational interviews with
officials at the National Institute of Occupational Safety and Health
(NIOSH), the Occupational Safety and Health Administration (OSHA), and
the Institute of Medicine.
To review how well the services identify and mitigate hazardous noise
and evaluate their hearing conservation programs, we visited nine
military installations across the country--with at least two locations
for each of the armed services, to review hearing conservation
activities and interviewed officials both responsible for and
participating in each base's hearing conservation program. (See table
2.) We selected sites to visit based on the size of the installation,
the presence of hazardous noise, and geographic location. During our
site visits, we met with senior officials from the installation and
public health commands and interviewed audiologists, audiometric
technicians, industrial hygienists, other occupational safety
personnel as well as servicemembers with experience in combat or other
missions with hazardous noise. We visited various installation work
sites, including maintenance shops, a firing range, and an aircraft
carrier to observe signs and labels designating hazardous noise areas
or equipment; the availability of hearing protection equipment in or
around such areas; and the use of personal hearing protection. We also
observed audiologists and technicians conduct hearing conservation
activities, including performing hearing tests, interviewing and
educating servicemembers about hearing protection, and assessing
appropriate fit and use of hearing protection equipment at noise
hazardous sites.
Table 2: Military Bases Visited during GAO Review of Hearing
Conservation Programs:
Service: Army;
Base: Fort Meade (MD);
Noise-hazardous areas observed: Vehicle security.
Service: Army;
Base: Fort Carson (CO);
Noise-hazardous areas observed: Firing range.
Service: Navy;
Base: Naval Station Norfolk (VA);
Noise-hazardous areas observed: Aircraft carrier.
Service: Navy;
Base: Naval Station San Diego (CA);
Noise-hazardous areas observed: Aircraft carrier.
Service: Air Force;
Base: Andrews Air Force Base (MD);
Noise-hazardous areas observed: Maintenance shop.
Service: Air Force;
Base: Eglin Air Force Base (FL);
Noise-hazardous areas observed: Maintenance shop.
Service: Marine Corps;
Base: Marine Corps Base Quantico (VA);
Noise-hazardous areas observed: Air facility.
Service: Marine Corps;
Base: Marine Corps Base Camp Lejeune (NC);
Noise-hazardous areas observed: Tank maintenance shop.
Service: Marine Corps;
Base: Marine Corps Base Cherry Point (NC);
Noise-hazardous areas observed: Military aircraft, ground operations,
and aircraft maintenance hangar.
Source: GAO.
[End of table]
To further review DOD and the services' program evaluation efforts, we
discussed performance goals, measures, and information systems at the
leadership and the installation levels. We interviewed officials from
NIOSH and OSHA--organizations responsible for creating hearing
conservation program review standards for civilian workers, as well as
DOD and armed services officials responsible for oversight of military
hearing conservation programs. More specifically, we interviewed DOD
officials and reviewed documentation related to the armed services'
program evaluation activities, such as setting targets and reviewing
performance trends. To determine the availability and usefulness of
information to support program evaluation, we interviewed officials
responsible for managing DOD's hearing conservation data system as
well as officials who are familiar with and use the system, including
installation hearing conservation program managers and technicians. We
reviewed data dictionaries and other technical documentation for the
Defense Occupational and Environmental Health System (DOEHRS), DOD's
database for tracking servicemembers' hearing test results and their
occupational exposure to noise and other hazards. After an internal
review of standard data reports provided by the services, we
determined that it would not be feasible to validate data consistent
with GAO's reliability standards within our planned time frames.
To determine the status of the DOD Hearing Center of Excellence and
its registry and efforts to share information to improve hearing
protection, we interviewed officials from DOD, including the center's
interim director and the representatives of the armed services and VA
involved in these efforts. We also reviewed planning documents for the
center and registry and data shared between DOD and VA.
[End of section]
Appendix II: Comments from the Department of Defense:
Office Of The Under Secretary Of Defense:
Acquisition, Technology And Logistics:
3010 Defense Pentagon:
Washington, DC 20301-3010:
January 19, 2011:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Mr. Bertoni:
This is the Department of Defense (DoD) response to the GAO Draft
Report, GAO-11-114, "Hearing Loss Prevention: Improvements to DOD
Hearing Conservation Program Could Lead to Better Outcomes," dated
December 7, 2010 (GAO Code 130967).
We provide in the enclosure the DoD responses to the GAO
recommendations. We concur with all recommendations.
Sincerely,
Signed by:
Dorothy Robyn:
Deputy Under Secretary of Defense (Installations and Environment):
Enclosures: As stated:
[End of letter]
GAO Draft Report Dated December 7, 2010:
GAO-11-114 (GAO Code 130967):
"Hearing Loss Prevention: Improvements To Dod Hearing Conservation
Program Could Lead To Better Outcomes"
Department Of Defense Comments To The GAO Recommendations:
Recommendation 1: DoD and the services improve upon the type, timing,
and tracking of training and education provided to servicemembers on
hearing protection, by providing information that is more
comprehensive and training that is more frequent and possibly earlier
in servicemembers careers.
DoD RESPONSE: Concur. The Military Services are in various stages of
developing and implementing improvements to the type, timing, and
tracking of training and education of service members. The Office of
the Secretary of Defense (OSD) will monitor progress of the Military
Services in implementing improvements, provide for cross-flow of the
lessons learned across the Military Services' improvements, and
standardize those improvements across all Military Services as
appropriate.
Recommendation 2: DoD work with the services to develop an appropriate
set of performance indicators that assess how well services are
reducing hearing loss among servicemembers.
DoD Response: Concur. Improved DoD performance indicators were issued
in the update to DoD Instruction 6055.12, "Hearing Conservation
Program (HCP)," dated December 3, 2010. The Military Services will
review these indicators and develop additional indicators as needed to
assist them in monitoring program execution and effectiveness.
Recommendation 3: DoD and the services address limitations in the
processes used to capture, track, and use performance data. This
effort should address issues with data reliability, data entry,
reporting capability, and integration across relevant databases.
DoD Response: Concur. OSD and the Military Services will address a)
limitations in the processes used to capture, track, and use
performance data, and b) issues with data reliability, data entry,
reporting capability, and integration across relevant databases.
Recommendation 4: DoD work with the services to examine the
appropriateness and feasibility of expanding those service-level
initiatives that hold promise of improving ---on a DoD-wide basis---
the military hearing conservation programs. Particular attention
should be focused on those efforts that already appear to have either
increased compliance with program requirements or have demonstrated
the potential to reduce hearing loss among servicemembers,
such as establishing hearing loss as a readiness issue, improving the
comfort and design of hearing protection, and including noise experts
more consistently in the procurement process.
DoD Response: Concur. OSD will continue to use the annual Safety &
Occupational Health In-Progress Review and the DoD Hearing
Conservation Work Group as mechanisms for direct cross-flow and
application of individual Military Service improvement initiatives.
Examples of initiatives include: standardizing criteria for evaluating
hearing protection devices for entry into a qualified products list;
improving the processes for weapon system procurement and use of
engineering controls; implementing management system approaches that
achieve high audiometric exam compliance rates; consolidating
requirements for research and development of improved hearing
protection; and using the results from audits of Military Service
programs to improve compliance with safety requirements.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni (202) 512-7215 or bertonid@gao.gov:
Acknowledgments:
Brett Fallavollita (Assistant Director) and Michelle Bracy (Analyst-in-
Charge) managed all aspects of the assignment. Julie DeVault, David
Forgosh, Suzanne Rubins, and Melissa Baker made significant
contributions to all aspects of this report. In addition, Walter Vance
and Beverly Ross provided technical support in the design and
methodology; James Rebbe provided legal support; Susan Bernstein and
Mimi Nguyen assisted in the message and report development; and Sara
Edmondson, Jessica Gray, Jonathan McMurray, and Ronni Schwartz
assisted with quality assurance.
[End of section]
Footnotes:
[1] S. Rept. No. 111-35, at 146, accompanying the National Defense
Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84 (Oct. 28,
2009).
[2] VA, Veterans Benefits Administration Annual Benefits Report Fiscal
Year 2009 (Washington, D.C.) p. 5.
[3] VA, Rehabilitation Research and Development, National Center for
Rehabilitative Auditory Research, Annual Report for Calendar Year 2009
(Portland, Ore.) p. 88.
[4] Dr. Lucille B. Beck, Chief Consultant, Rehabilitation Services and
Director of Audiology, VA, "Update on Audiology," p. 15.
[5] The IOM study also stated that in 1948, the Air Force was the
first armed services to issue hearing conservation regulations, with
the Navy following suit in 1955 and the Army in 1956. See Larry E.
Humes, Lois M. Joellenbeck, and Jane S. Durch, editors, Committee on
Noise-Induced Hearing Loss and Tinnitus Associated with Military
Service from World War II to the Present, Noise and Military Service:
Implications for Hearing Loss and Tinnitus (Washington, D.C.: The
National Academies Press, 2005).
[6] DOD defines this threshold level of noise as (1) continuous or
intermittent noise that has an 8-hour time-weighted average noise
level of 85 decibels or above, (2) impulse noise with sound pressure
levels of 140 decibels or greater, and (3) "uppersonic and ultrasonic
acoustic radiation" determined to be hazardous (DODI 6055.12, 6.2).
[7] DODI 6055.1, E3.4.2.1.
[8] DOD's hearing conservation program instruction also includes
several other elements that we did not focus our review upon, such as
access to information, training material, and records and personnel
assignments.
[9] Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 104, 116
Stat. 2822 (2002).
[10] Humes, Joellenbeck, and Durch, "Noise and Military Service:
Implications for Hearing Loss and Tinnitus."
[11] U. S. Department of the Navy, Naval Audit Service, Management and
Implementation of the Marine Corps Hearing Conservation Program (Jan.
14, 2011).
[12] Duncan Hunter National Defense Authorization Act for Fiscal Year
2009, Pub. L. No. 110-417, Div. A. tit. VII, § 721, 122 Stat. 4506
(2008).
[13] A sound level meter is the basic instrument for investigating
noise levels and can be used to determine an employee's noise dose
whenever use of a noise dosimeter is unavailable or inappropriate.
Sound level meters identify and evaluate individual noise sources for
abatement purposes, aid in determining the feasibility of engineering
controls for individual noise sources, and evaluate hearing
protectors. A dosimeter is worn by individuals in order to determine
noise doses during a specified time period.
[14] Navy policy states that it is much less costly to eliminate
potential noise problems in the design or procurement stage for new
processes, equipment, and facilities than it is to make retrofits or
modifications after the fact.
[15] Pursuant to OSHA regulations at 29 C.F.R. § 1910.95(b)(2), the
minimum level at which noise protection measures must be taken is 90
decibels.
[16] Hearing protection devices are expected to reduce noise to safer
levels. Depending on the intensity of the noise, services will require
two forms, or double, hearing protection being worn at the same time,
to further reduce noise.
[17] Safety Stand Downs focus on correcting safety deficiencies and
conducting safety training that will result in changes in behavior to
prevent accidents and injuries and protect property.
[18] Although not part of DOD policy, hearing conservation personnel
told us servicemembers are enrolled into a hearing conservation
program based on their occupation or where they work, which occurs
after basic training.
[19] The Army has recently initiated a pilot program to incorporate
hearing protection into basic training.
[20] STS or significant hearing loss occurs when there is a change in
hearing threshold relative to an initial hearing test result of an
average of 10 decibels.
[21] The Defense Occupational and Environmental Health Readiness System
- Hearing Conservation (DOEHRS-HC) provides the ability to conduct and
track automated baseline, annual, pre-and post-deployment hearing test
results. The Defense Occupational and Environmental Health Readiness
System-Industrial Hygiene (DOEHRS-IH) is used to collect, maintain,
and analyze hazard and exposure data.
[22] In the Air Force, only one follow-up examination is required to
confirm that permanent hearing loss has occurred.
[23] U. S. Department of the Navy. Naval Audit Service, Management and
Implementation of the Marine Corps Hearing Conservation Program (Jan.
14, 2011).
[24] Bjorn, V.S.; Albery, C.B.; Shilling, R.; and McKinley, R.L.
(2005), "U.S. Navy Flight Deck Hearing Protection Use Trends: Survey
Results."
[25] Participants in this study were self-selected or were asked to
participate by their commanders. Information about whether
participants regularly wear hearing protection was self-reported and
there was no objective measure or corroborating information used to
assess this self-reported information. The information in this study
is not generalizable and only applies to the six aircraft carriers
that were tested. However, researchers did provide some information
comparing the studied population to the overall Navy population, but
did not directly assess similarities and differences on measured
variables.
[26] Gates, Kathy (Col.) and Fallon, Eric (Ltc.), "Army Hearing
Conservation Program Analysis" (June 2005).
[27] Cleveland, Leanne (Cpt.), "Fort Carson: An Army Hearing Program
Success Story," Army Department Medical Journal, April-June 2009. This
study describes the effect of the addition of a second audiologist at
the Army base in Fort Carson, Colo. While the study proves that the
addition of the second audiologist would increase the number of
servicemembers receiving testing and training, it does not provide
sufficient evidence to support that an additional audiologist led to
reduced hearing loss. For example, the study interprets shifts in the
hearing loss and readiness rates as being directly attributable to the
availability of a second audiologist, but the study does not consider
other factors that could also have had effects, such as overseas
deployments, changes in equipment, and changes in training.
[28] Department of Defense Medical Centers of Excellence: Hearing
before the House Comm. on Armed Services, 111TH Congress (2010)
(statement of Lt. Gen. Charles B. Green, Surgeon General, U.S. Air
Force).
[29] Senate Report No. 111-20, accompanying S. 1054 (providing
supplemental appropriations for fiscal year 2009) directed DOD to
develop a strategic plan for locating, staffing, and resourcing of
medical centers of excellence to ensure they can provide "the highest
quality of care, treatment and utilization of research funds for
servicemembers who are suffering wounds from war." As of late 2010,
DOD had drafted but not finalized its strategic plan to respond to the
Senate report. The medical centers of excellence currently include:
the Hearing Center of Excellence (HCE), the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury (DCoE),
the Vision Center of Excellence (VCE), and the Extremity Injury and
Amputation Center of Excellence (EACE).
[30] DOD and VA are required to develop and implement electronic
health record systems and to accelerate the exchange of health care
information between the departments. National Defense Authorization
Act for Fiscal Year 2008, Pub. L. No. 110-181, § 1635, 122 Stat. 460
(2008). According to a recent GAO report, the departments are now
exchanging pharmacy and drug allergy data on patients. For more
information on their progress, see GAO, Electronic Health Records:
DOD's and VA's Sharing of Information Could Benefit from Improved
Management, [hyperlink, http://www.gao.gov/products/GAO-09-268]
(Washington, D.C.: Jan. 28, 2009).
[31] After VA determines that a claimed disability is related to a
veteran's military service, VA assigns a percentage rating to the
disability that corresponds to the disability's severity. The ratings
range from 0 percent to 100 percent and are assigned in increments of
10 percent.
[32] DOD uses its Joint Theater Trauma System and Joint Theater Trauma
Registry to collect data and improve the outcomes of soldiers injured
on the battlefield.
[End of section]
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