Safety Without the Mishap

TITLE GOES HEREDiscussion

Why do mishaps occur?

TITLE GOES HEREProactive Aviation Safety

In 1952: 1,214 fatalities and 789 destroyed aircraft

In 2012: 9 fatalities, 10 destroyed aircraft

ASAP: Great at explaining WHY stuff happens

LOSA: Good at explaining the culture

MFOQA: Laser precision looking at WHAT happened

What proactive detectors does your wing use to prevent flight mishaps?

TITLE GOES HEREProactive Aviation Safety

“The 65% decrease in the fatal accident rate from 1997 to

2007 was fueled by proactive safety”

Honorable Christopher Hart (9 May 2011)

“By the way, aviation was already considered very safe in

1997.”

Honorable

Christopher A. Hart

NTSB Vice Chairman

TITLE GOES HEREASAP: Aviation Safety Action Program

“The self-reporting tool, Air Force Aviation Safety Action Program (ASAP)

allows aircrew to discuss ‘there I was stories’ in a non-punitive venue without

filing a High Accident Potential (HAP) report.

The more we can learn from our "near-misses,” the more likely we will prevent

future mishaps from occurring. This is proactive safety in action!”

- Chief, Investigations Branch, Human Factors Division, Headquarters AF

Safety Center

TITLE GOES HEREASAP: Overview

● Voluntary, identity-protected self-reporting

● Highlight errors and hazards

● Provides commanders insight (Risk vs Mission)

● Mitigation ideas flow both ways

● Reporting with no mishap occurring

● Provides identity protection to reporting personnel

● Promotes healthy safety culture

TITLE GOES HEREASAP: Reporting

What types of events should you report?

• Events not normally reported or captured by other methods

• Personal errors that could have led to a mishap/incident

• Unintentional errors

• Errors committed by other individuals or organizations

• Any unsafe action, event or condition encountered

• Observed hazards

TITLE GOES HEREASAP: Reporting

How can you submit a report?

• Online through http://www.safety-masap.com/

• Common Access Card holding members can access ASAP “Scoreboard”

• If you have any questions about when/how to submit a report, please use the ASAP user/training guide: http://www.safety-masap.com/asaptraining.html

TITLE GOES HEREExample of ASAP Submission

As submitted:

“We departed from KMOM with clearance to climb to 5,000 direct point FISH and contact ATC upon reaching. Col L.J. Silver was in the left seat as AC(IP) and I was in the right as a student FP. Capt Hook had jump seat duties. After takeoff, departure contacted us about a revised routing and we all went heads down to update the flight computer. We did not hear a radio call advising us of traffic and therefore were caught off guard when a RA alert sounded. We maneuvered as necessary and continued on course. I once again checked the revised flight plan and noticed that our first point was CUTBAIT, no longer FISH. I figured Col Silver had already checked the route and simply followed our climb. When we began our turn to CUTBAIT, ATC called and asked where we were going. We were momentarily confused until after asking both myself and Capt Hook, Col Silver discovered that no one had confirmed the read back with departure. After correcting to FISH while we confirmed the route in the box, we blew through FISH without contacting ATC and began to cross another jet way. We were heads-down, missed traffic, and never thought to ask the question of FISH or CUTBAIT?”

Grade code: O-3 Total Hours in Crew Position: <500 Wing Assigned to: 49 AMW Aircraft type: KC-135R

TITLE GOES HEREExample of ASAP Submission

As submitted – Identifying information highlighted

“We departed from KMOM with clearance to climb to 5,000 direct point FISH and contact ATC upon reaching. Col L.J. Silver was in the left seat as AC(IP) and I was in the right as a student FP. Capt Hook had jump seat duties. After takeoff, departure contacted us about a revised routing and we all went heads down to update the flight computer. We did not hear a radio call advising us of traffic and therefore were caught off guard when a RA alert sounded. We maneuvered as necessary and continued on course. I once again checked the revised flight plan and noticed that our first point was CUTBAIT, no longer FISH. I figured Col Silver had already checked the route and simply followed our climb. When we began our turn to CUTBAIT, ATC called and asked where we were going. We were momentarily confused until after asking both myself and Capt Hook, Col Silver discovered that no one had confirmed the read back with departure. After correcting to FISH while we confirmed the route in the box, we blew through FISH without contacting ATC and began to cross another jet way. We were heads-down, missed traffic, and never thought to ask the question of FISH or CUTBAIT?”

Grade code: O-3 Total Hours in Crew Position: <500 Wing Assigned to: 49 AMW Aircraft type: KC-135R

TITLE GOES HEREExample of ASAP Submission

Sanitized – Identifying information removed

“We departed from KMOM with clearance to climb to 5,000 direct point FISH and contact ATC upon reaching. [Pilot] was in the left seat as AC(IP) and I was in the right as a student FP. [Jump seat] had jump seat duties. After takeoff, departure contacted us about a revised routing and we all went heads down to update the flight computer. We did not hear a radio call advising us of traffic and therefore were caught off guard when a RA alert sounded. We maneuvered as necessary and continued on course. I once again checked the revised flight plan and noticed that our first point was CUTBAIT, no longer FISH. I figured [the pilot] had already checked the route and simply followed our climb. When we began our turn to CUTBAIT, ATC called and asked where we were going. We were momentarily confused until after asking both myself and [the jump seat], [The pilot] discovered that no one had confirmed the read back with departure. After correcting to FISH while we confirmed the route in the box, we blew through FISH without contacting

ATC and began to cross another jet way. We were heads-down, missed traffic, and never thought to ask the question of FISH or CUTBAIT?”

Grade code: [redacted] Total Hours in Crew Position: [redacted] Wing Assigned to: [redacted] Aircraft type: KC-135R

TITLE GOES HEREASAP Results

• 219 ASAP reports received in 2013

• Majority are tracked for trends, action taken on some

2010-01

2010-03

2010-05

2010-07

2010-09

2010-11

2011-01

2011-03

2011-05

2011-07

2011-09

2011-11

2012-01

2012-03

2012-05

2012-07

2012-09

2012-11

2013-01

2013-03

2013-05

2013-07

2013-09

2013-11

2014-01

0

5

10

15

20

25

30

35

40

Number of ASAP Reports (2010-PRESENT)

TITLE GOES HEREASAP: Benefits

• Uncovers latest hazards at deployed locations

• Brief-up threats and errors

• Navigation and weather traps

• Specific MDS related issues

• Different from Class E (HAP) reporting

• Takes advantage of the small events

TITLE GOES HEREASAP: FAQ

Q: Will my leadership be told an ASAP was filed?

A: No. ASAPs are not reported to individuals or organizations. We circulate a sanitized version of the report to our SMEs to identify any hazards/trends and then publish our recommendations to the scoreboard. No unit notification is accomplished.

Q: Does ASAP protect me from punitive actions?

A: ASAP is a non-punitive program, meaning ASAP reports cannot be used to punish crews, but it does not protect from punitive actions from other sources. While MAJCOM/CC guidance includes the expectation to promote Just Culture and not punish for honest mistakes, commanders have final authority on what actions are taken after crew errors. For example, if a commander receives notification through formal FAA channels of a pilot deviation, the commander may take action against the crew involved regardless of whether an ASAP is submitted or not. Because ASAP is identity protected, the commander likely will not even be aware that an ASAP has been submitted.

TITLE GOES HERELOSA: Line Operation Safety Audit

“Aviators have undergone many hours of Crew Resource Management (CRM)and LOSA can measure the effectiveness and utility of this program.”

“A LOSA observer can provide a crew with feedback on how well theyutilized CRM.”

- Chief, Investigations Branch, Human Factors Division, Headquarters AFSafety Center

TITLE GOES HERELOSA: Overview

What does LOSA do?

• Identifies systematic and flight crew performance issues without relying on an incident or accident

What powers the LOSA tool?

• Jumpseat observations during regular flight operations

• Threat and error management

TITLE GOES HERELOSA: Overview

Losa Process managed by AMC flight safety

• Non jeopardy observation ride, voluntary participation, sample operational missions

Results?

• Unique data about “threats and errors”

• Provide continual data feed to OpsRAMS

• Develop actionable findings and recommendations

TITLE GOES HERELOSA: Reporting

What do observers report?

• Threats

• Errors

• Undesired Aircraft States

Results:

• Unique data

• Continual data feed to OpsRAMS

• Develop actionable Findings and Recommendations

TITLE GOES HERELOSA: Benefits

• Threat and error management training safer operators

• Exposure to worldwide operations

• Individual and unit contributions to improve ops

• Errors (Largest: Callout Errors)

• Higher workload = more missed calls

TITLE GOES HEREMFOQA: Military Flight Operations Quality Assurance

According to a DON study to improve operational readiness of Naval

Aviation:

“The increased objectivity that the MFOQA post-flight analysis and reporting

capabilities provided to aircrew and maintenance debriefs, and actionable

information to other relevant end users, was assessed to have a positive

impact on operational readiness.”

TITLE GOES HEREMFOQA: Overview

MFOQA allows us to know:

• Changes to flight technique

• Most likely profile points

• Thrust management techniques

• Landing AOA, sink rates, and flare points

• Weapons employment parameters

• Unreported prohibited maneuvers

Why is it important to identify this type of information?

TITLE GOES HEREMFOQA: FAQ

● Where does the MFOQA data go?

● How does MFOQA determine trends?

● Can MFOQA data be used to initiate punitive or adverse action?

TITLE GOES HEREMFOQA: Benefits

• Validating effectiveness of tactics

• Comparing actual versus calculated aircraft performance data

• Unstable approaches and go-arounds

• Detecting exact parts of profiles

• Measuring variations in mission accomplishment

• Customized analyses that lend specific insights

How do you think specific insights would help improve operations at your wing?

TITLE GOES HEREAdditional Discussion

Proactive Aviation Safety allows previously unknown hazards to be:

• Detected

• Measured

• Trended

Does your wing use any of these three ProSef programs?

What are the pros/cons of using each of these programs?