CAPT Jim Fraser Naval Safety Center Surgeon Naval

CAPT Jim Fraser Naval Safety Center Surgeon Naval Safety Center 5001

Naval Aviation Mishap Rate (FY 50 -99) 776 aircraft destroyed in 1954 22 aircraft destroyed in 1999 Angled decks Aviation Safety Center Naval Aviation Maintenance Program established in 1959 (NAMP) RAG concept initiated NATOPS Program initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT Fiscal Year

Year 1991 1989 1987 2 1985 1983 1981 1979 1977 Class A, B, & C Mishaps/100, 000 Flight Hours All NAVY/MARINE Class A, B, & C Mishaps 16 14 12 Human 10 8 6 4 Mechanical 0

“Knowledge is Good…” Credo, Faber College Data Information Knowledge Wisdom …but wisdom is what we need!

The “Swiss Cheese” Model of Accident Causation (Reason, 1990) Organizational Factors w. Excessive cost cutting w. Reduction in flight hours Unsafe Supervision w. Deficient training program w. Improper crew pairing Preconditions for Unsafe Acts w Loss of Situational Awareness w Poor CRM Unsafe Acts w. Failed to Scan Instruments w. Penetrated IMC when VMC only Failures in the System Accident & Injury w Crashed into side of mountain

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Inadequate Supervision Failed to Correct Problem Supervisory Violations PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Crew Resource Mismanagement Personal Readiness UNSAFE ACTS Errors Decision Errors Skill-Based Errors Violations Perceptual Errors Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors VIOLATIONS äViolation of Orders/Regulations/SOP - Failed to Inspect ACFT after In-Flight Caution Light - Violated Squadron SOP Restricting Flight Below 500’ - Failed to Comply with NATOPS During Streaming - Conducted Night Training and Ops Mission with PAX - Elected to File VFR in Marginal Weather Conditions - Failed to Use Radar Advisories from ATC - Inadequate Brief and Limits on Mission - HAC Knowingly Accepted Non-Current Crew äFailed to Adhere to Brief äNot Current/Qualified for Mission äImproper Procedure

IR TA N US CA TA CA IR lo He US M C N US US M C He lo Percentage of Mishaps U. S. Navy/Marine Corps Class A Mishaps Violations (FY 90 -96)

Percentage of Human Error Mishaps Associated with Violations (FY 91 -99) USN/USMC TACAIR & HELO CLASS A MISHAPS Fiscal Year

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional SKILL-BASED ERRORS Unsafe Acts ä Breakdown in Visual Scan (53) ä Failed to See and Avoid (12) ä Poor Technique (12) ä Omitted checklist item (10) ä Inadvertent Operation of Control (10) ä Improper Use of Flight Controls (10)

Percentage of Human Error Mishaps Associated with Skill-based Errors (FY 91 -99) USN/USMC TACAIR & HELO CLASS A MISHAPS

Back to the Basics Focus on: Reemphasize the need for an efficient visual scan Prioritizing attention Recognizing extremis situations Refine basic flight skills (Stick-and-Rudder) Practice procedures

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Inadequate Supervision Failed to Correct Problem Supervisory Violations PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States (83%) Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Crew Resource Mismanagement (60%) Personal Readiness UNSAFE ACTS Errors Decision Errors Skill-Based Errors Violations Perceptual Errors Routine Exceptional

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Crew Resource Mismanagement Personal Readiness Preconditions for Unsafe Acts ADVERSE MENTAL STATE Ø Channelized Attention/ Task Saturation (48) Ø Fatigue (11) Ø Distracted (10) Ø Complacency (9) Ø Loss of SA (7)

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Crew Resource Mismanagement Preconditions for Unsafe Acts CREW RESOURCE MISMANAGEMENT Ø Failed to Communicate/Coordinate (26) Ø Failed to Backup (17) Ø Failed to Conduct Adequate Brief (11) Personal Readiness

Why are We Seeing an Increase in Skill-based Errors? n n n n Lack of flight time? Quality of flight time? Decreasing experience Ops. Tempo? Perstempo? Shortcoming in our training program? Shortcoming in our operational practices? Would increased simulator-flight time be an effective intervention?

Focus for Intervention Strategies Skill-based Error Distribution by ACFT Model n Skill-based Error by Mission Profile n u Administrative Phase of Flight u Mission-related Phase of Flight n Skill-based error by Mishap Characteristics u Out-of-Control Flight (OOCF) u Controlled-Flight into Terrain (CFIT) u MIDAIR n Skill-based error by Pilot Experience u AV-8 Snapshot

Tacair In-Model Flight Hour Distribution vs. Tacair Skill-Based Errors Pilot Flight Hour Distribution % Skill-Based Error Mishaps FY 90 - FY 98 65 Mishaps

Helo In-Model Flight Hour Distribution vs. Helo Skill-Based Errors Pilot Flight Hour Distribution Skill-Based Errors FY 90 - FY 98 21 Mishaps

AV-8 In-Model Flight Hour Distribution vs. AV-8 Skill-Based Errors AV-8 Pilot Flight Hour Distribution % By Number Mishaps AV-8 Skill-Based Errors FY 90 - FY 98 10 Mishaps

Conclusions n Tacair u. Experience Counts (500+ In-Model Hours) u. Most Prevalent Skill-Based Errors F Breakdown in Visual/Instrument Scan/Cross Checking/See & Avoid u. Most Prevalent SBE Preconditions F Adverse Mental State • Channelized Attention/Task Saturation F CRM

Conclusions cont. n Helo u. Experience Counts (500/1000+ In. Model Hours) u. Most Prevalent Skill-Based Errors F Breakdown in Visual/Instrument Scan/Cross Checking/See & Avoid u. Most Prevalent SBE Preconditions F Adverse Mental State • Channelized Attention/Task Saturation F CRM

Intervention Strategies n Increase the in-model experience pool toward 500/1000+ hours F use simulator time to augment flight time and achieve earlier proficiency n Emphasize development of psychomotor skills F use simulator time to augment flight time and the development of a proper scan and stick and rudder skills n Emphasize avoidance of preconditions F use simulator time to augment flight time and development of automated basic flight skills that enable an aviator to avoid channelized attention/task saturation and improve CRM skills

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Ø Not Working as a Team Ø Poor Aircrew Coordination Ø Improper Briefing Before a Mission Ø Inadequate Coordination of Flight Personal Readiness

Percentage of Human Error Mishaps Associated with Crew Resource Management Failures (FY 90 -98) Fiscal Year

Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90 -98) Percentage TACAIR Helo Preflight Routine Operations Flight Condition Emergency

Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90 -98) TACAIR Percentage Helo Preflight Routine Operations Flight Condition Emergency

Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90 -98) TACAIR Percentage Helo Preflight Routine Operations Flight Condition Emergency

CRM SUMMARY Even after the systematic, fleet-wide implementation of ACT, over 50% of TACAIR and Rotary Wing human factor mishaps involved at least one instance of CRM failure. USMC Rotary Wing, 1997 The need to tailor ACT to the specific needs of the fleet is clear, yet data required for developing such curriculum has bee lacking.

CAPAS: Computer-Aided Performance Analysis System n Simulation-based technology designed to: u Maintain/improve aircrew proficiency u Maintain/improve CRM skills u Identify unsafe trends u Augment standardization of training efforts

HOW DO WE MATCH UP? TACAIR Comparison USN/ USMC (139) Unsafe Acts Errors Skill-based Error Decision Error Perceptual Error Violations Preconditions for Unsafe Acts Substandard Condition Adverse Mental State Adverse Physiological State Physical/Mental Limitation Substandard Practice Crew Resource Management Personal Readiness Unsafe Supervision Inadequate Supervision Planned Inappropriate Ops Failed to Correct Problem Supervisory Violation Rotary Wing Comparison USAF (72) 61% 55% 24% 28% 60% 43% 31% 7% 73% 23% 6% 53% 31% 11% 53% 4% 35% 23% 12% 6% 9% 17% 4% 8% 3% 3% 3% 0% USN/USMC: FY 90 -FY 98; USAF: FY 91 -FY 97 Unsafe Acts Errors Skill-based Error Decision Error Perceptual Error Violations Preconditions for Unsafe Acts Substandard Condition Adverse Mental State Adverse Physiological State Physical/Mental Limitation Substandard Practice Crew Resource Management Personal Readiness Unsafe Supervision Inadequate Supervision Planned Inappropriate Ops Failed to Correct Problem Supervisory Violation USN/ USMC (60) USA 37% 58% 33% 48% 37% 45% 27% 75% 28% 12% 74% 3% 6% 80% 3% 50% 32% 13% 12% 39% 0% 32% 23% 8% 5% 3% USN/USMC: FY 90 -FY 98; USA: FY 92 -FY 97 (62)

Command Culture “A shared characteristic or characteristics of a particular social group, organization, or society…”

Squadron Safety Surveys • Cultural Assessment Questionnaires • Informal Interviews Aircrew/Maintenance • Confidential and anonymous • No written report, verbal feedback to Skipper and officers of his choice

Culture Workshop (CWS) • Senior Naval Reserve Officers serve as facilitators • Naval Safety Center to serve as model manager • CWS by command request • 2 day observation • Small group meetings divided by rank • Confidential and anonymous • No written report, verbal feedback to the Skipper and other officers of his/her choice

“Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one thing in mind. He. . . made a judgment. He believed in it so strongly that he knowingly bet his life on it. That his judgment was faulty is a tragedy, … Every instructor, supervisor, and contemporary who ever spoke to him had the opportunity to influence his judgement, so a little bit of all of us goes with every pilot we lose. ” --Anonymous USN Rotary Wing, 1997

Questions 5045