The Naval Safety Center’s Aviation MagazineJuly-August 2004 Volume 49 No. 4RADM Dick BrooksCol. Dave Kerrick, USMCJohn MahoneyNaval Safety CenterCommander, Naval Safety CenterDeputy CommanderHead, Marketing and Communications(757) 444-3520 (DSN 564) Dial the followingextensions any time during the greetingPublications Fax (757) 444-6791Approach StaffJack Stewartjack.stewart@navy.milAllan Amenallan.amen@navy.milGinger Rivesvirginia.rives@navy.milCol. Dave Kerrick, USMCdavid.kerrick@navy.milCdr. Chris Spainchristopher.spain@navy.milCdr. Chuck HuffCharles.E.Huff@navy.milCapt. Nicholas Websternicholas.webster@navy.milEditorExt. 7257Graphics, Design & LayoutExt. 7248Distribution (Magazines and Posters)Ext. 7256Aviation Safety ProgramsExt. 7225Aircraft Operations DivisionExt. 7203Aircraft Mishap Investigation DivisionExt. 7236Aeromedical DivisionExt. 7228AnalystsCdr. Mike Scavonemichael.scavone@navy.milCdr. “Skel” Barrickmandarryl.barrickman@navy.milMaj. “Spool” McCann, USMCdavid.b.mccann@navy.milLCdr. “Molly” Bateslyndsi.bates@navy.milLCdr. “Pooh” Williamsrobert.r.williams1@navy.milCdr. Jack ThomaJohn.Thoma@navy.milCdr. “Buc” Owensdonald.owens@navy.milCdr. Bob Lucasrobert.lucas@navy.milCapt. “Fancy” Shea, USMCedward.shea@navy.milLt. Scott Harveyscott.harvey@navy.milLCdr. Frederick B. Hoofrederick.hoo@navy.milACCS (AW/SW) Leslee McPhersonleslee.mcpherson@navy.milABEC (AW) Mark Bertolinomark.bertolino@navy.milCarrier Branch Head, EA-6B, A-4, F-5, T-2. T-38Ext. 7272E-2, C-2, UAVExt. 7212AV-8BExt. 7216FA-18, F-16Ext. 7217F-14Ext. 7274Shore-Based Branch HeadT-34, T-39, T-6, Flying ClubsC-130, E-6, C-9, C-40, C-20, C-35, C-26Ext. 7277P-3, EP-3, C-35, T-44, C-12Ext. 7210Helo Branch Head, H-3, H-60Ext. 7207AH-1 UH-1, H-57, NVGExt. 7266H-46, H-53, V-22Ext. 7208Air Facilities Branch HeadExt. 7281Air Traffic Control AnalystExt. 7282ALRE/Airfield AnalystExt. 7279Mission StatementMishaps waste our time and resources. They take our Sailors, Marines and civilianemployees away from their units and workplaces and put them in hospitals, wheelchairsand coffins. Mishaps ruin equipment and weapons. They diminish our readiness.This magazine’s goal is to help make sure that personnel can devote their time andenergy to the mission, and that any losses are due to enemy action, not to our own errors,shortcuts or failure to manage risk.We believe there is only one way to do any task: the way that follows the rules and takesprecautions against hazards. Combat is hazardous enough; the time to learn to do a jobright is before combat starts.Approach (ISSN 1094-0405) is published bimonthly by Commander, Naval Safety Center, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official viewsof, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artworkare representative and do not necessarily show the people or equipment discussed. We reserve the right toedit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine andauthor. Approach is available for sale by the Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA15250-7954. Telephone credit card orders can be made 8 a.m. to 4 p.m. Eastern time at (202) 512-1800.Periodicals postage paid at Norfolk, Va., and additional mailing offices.Postmaster: Send address changes to Approach, Code 73A,Naval Safety Center, 375 A StreetNorfolk, VA 23511-4399Send articles and letters to the address above, or via e-mail to the editor,jack.stewart@navy.mil.Features5Saberhawk 74, Are You OK?By Cdr. Markus HannanAny way you slice it, the skipper takes the blame.8Motor-Vehicle Safety:Never Stop LearningBy Lt. J. B. EichelbaumMotorcycles and the school of hard knocks.10Nugget Test Pilot12Strike Out!20Stop Already26Gut Instincts28My First Day As SDO32The M WordBy Lt. Matt StevensonSkills taught in the training command areessential for survival.By Capt. Mark Bosley, USMCA flash of light is followed by the loss of a T-45engine—the typical instrument flight is no longertypical.By Lt. Bryan SchwartzDo you think this article has anything to do withbrakes?By LCdr. Rick ButlerWhat are you going to do when “something justdoesn’t feel right”?By Ltjg. Tim JohnstonYou’ve all been there: the duty. This JO gets thefull dose when he enters the pre-mishap-planworld.By 1stLt. Evan Hill, USMCA new HAC took CRM for granted—not now.Visit the Approach Vault. There arehundreds of unpublished articleswaiting for /Cruising for the summer? Visit thiswebsite for safety tips you can use atwork or at ys.htm
Photo by PH2 James H. Watson. Modified.18Nothing Holding Us Back—ReallyBy Ltjg. Matt WilkeningDon’t expect a day of carrier quals to go as scheduled.Departments22 CRM:2 Toward the Goal31BC Ready Room GougeCommitted to Protecting Our PeopleA message from the Commander Naval Safety Center.How Are We Doing?An update on our aviation-mishap rate. Visit our web pagefor the current status.3 Work ZoneThe Human Factors Analysis and ClassificationSystem (HFACS)By Lt. Laura Mussulman and LCdr. Deborah WhiteHFACS is the first step in the risk-management process.15 Your One-Stop Safety ShopOur Safety Center website has information you can use toimprove your safety program.Mishap-Free Milestones16 ORM Corner:All This for Some ShrimpBy Lt. Joe StrassbergerLet’s put a sanity check on risk taking.Rescue in the Gulf of OmanBy Lt. Harrison SchrammA good aircraft, a competent crew, and two braveswimmers combine for a successful rescue.Improved WESS is HereJuly-August ThanksThanks for helping with this issue Capt. Patrick Neill, USMC, HMH-363Lt Mark Vagedes, VQ-4Lt. Roger Jacobs, VAW-113Ltjg. Clint Miller, VS-31Capt. Grant Killmer, USMC, VMU-2LCdr. Kirk Volland, HSL-47LCdr. David Samara, VAQ-141LCdr. Scott Mulvehill, VFA-105Lt. Rob Sinram, HC-11Ltjg. Kevin Marsh, VAW-117On the cover: A CH-53E from HMM-266 offloads Marinesfrom MSSG 22 on USS Shreveport (LPD 12) during trainingexercise off Florida coast. Photo by LCdr. Steve Miller.
Toward the Goal Reducing mishaps by 50 %Committed to Protecting Our PeopleWhat does it take to stop the loss of life, the missed opportunities, the wasted potential, and the broken familiesresulting from preventable mishaps?Finding ways to reduce these mishaps was the thrust ofrecent discussions during the Navy and Marine Corps SafetyCouncil’s first meeting. I and my then-counterpart, Col. BuckDewey from USMC headquarters Safety Division, co-chairedthe Washington, D.C ., gathering. The meeting’s importancewas emphasized by the presence of the Secretary of the Navy,the Honorable Gordon England; the Deputy Assistant Secretary of the Navy for Safety, Ms. Connie DeWitte; and 30 flagand general officers. Many others from throughout the Navyparticipated via video teleconference.Secretary England emphasized, “Safety is very, very high onmy personal agenda.” Not only is attention to safety “a great visible sign of your commitment to our men and women, but safetyprograms produce a very large, direct benefit to the total force.”Ms. DeWitte opened the meeting by noting her agendaincluded using the opportunity to move safety forward. “I believewe can make the [Secretary of Defense’s] 50-percent goal and alsocreate some deep roots for future programs,” she said. The unprecedented attendance of so many senior officers discussing safetyprovided the momentum to integrate safety into all operations.Four committees, representing the aviation, afloat, ashore,and ground-tactical communities, are forging ahead with theagenda set by the council’s discussions, which focused on shortand long-term initiatives and resource issues. Significant topicsincluded operational risk management, safety culture, and traffic mishaps. The 50-percent mishap-reduction campaign alsowas a major topic, but, as Secretary England pointed out, “Thegoal isn’t really fifty percent. We’ll settle for fifty percent, butwe don’t want anyone injured or killed.”Approach magazine is dedicated to reducing aviation mishaps. With a very high percent of all aviation mishaps tied tosome form of human error, we need to rededicate our efforts,change the way we do business, and target our weakest link:preventable human errors. You can see in the aviation-mishapstatus update below that we have quite a ways to go to reachour goal.An overall, across-the-board reduction of mishaps requiresintrusive leadership and everyone’s dedicated efforts. It alsorequires changes in how way we do things, what we expect ofeach other, and what we accept as being operationally “normal.”Finally, it requires every Sailor, Marine and DoN civilian totake a turn on looking out for each other—the same way youlook out for your family members.RADM Dick BrooksCommander Naval Safety CenterHow are we doing?Here’s information on our safety status as we work toward the goal.Aviation (Rates Mishaps Per 100,000 Flight Hours)Class-A Flight Mishaps (FY04 thru 8 June)Service Total/RateUSN:USMC:FY03thru 8 June9/1.2717/2.1510/4.44 8/2.99* Goals based on FY02 baseline.FY04/05 rate above goal.FY04 Goal*14/1.2410/2.75FY05 Goal*10/0.887/1.94FY01-03 o1/.705/4.95For current information on aviation statistics n/default.htm
THE HUMAN FACTORS A NALYSIS ANDCLASSIFICATION SYSTEM (HFACS)By Lt. Laura Mussulman and LCdr. Deborah WhiteTo err is human; to prevent human error makes fora strong safety program. Humans make mistakes,and the military system has developed checksand-balances to catch human errors before they lead tomajor mishaps. Unfortunately, when the control measuresdon’t catch the human error, accidents happen. Untilrecently, no tool was available to enable a CO or mishapboard to identify the “holes” in the controls.The Human Factors Analysis and ClassificationSystem (HFACS) was developed in response to atrend that showed some form of human error, at various levels, as a primary causal factor in 80 percent ofall flight accidents in the Navy and Marine Corps.HFACS identifies the human causes of an accident andprovides a tool to not only assist in the investigationprocess, but to target training and prevention efforts.HFACS looks at four levels of human failure (seefigure of “Swiss cheese” model). These levels includeunsafe acts (operator error), preconditions for unsafe acts(such as fatigue and inadequate communication), unsafesupervision (such as pairing inexperienced aviators for adifficult mission), and organizational influences (such aslack of flight time because of budget constraints).Using HFACS to analyze hundreds of aviationmishap reports, the Naval Safety Center has identifiedthe following human errors as leading contributors toClass A mishaps:Unsafe Acts of OperatorsOrganizational Latent FailuresInfluences Inadequate proceduresUnsafeSupervisionLatent Failures High OPS Tempo Poor trainingPreconditions forUnsafe ActsLatent and/or Active Failures Weak brief Fixated on caution lightUnsafe ActsActive Failures Poor instrument scan Inappropriate responseAccident Pilot flies into the groundFailed or Absent DefensesThe “Swiss Cheese” Model of Accident Causation Skill-based errors are“stick-and-rudder” and other basicflight skills that are not performedcorrectly. These skills require littleif no thought on the part of theaircrew and often are susceptible toattention failures.– Breakdown in visual scan– Failure to recognize extremis– Improper use of flight controls Decision errors are “honestmistakes” that resulted in actionsor inactions based on the pilot’slack of knowledge or poor choices.– Wrong response to emergency– Poor decision– improper procedure executedContinuedJuly-August 2004 approach3
Preconditions for Unsafe Acts Adverse mental states are those mental conditions and attitudes that affect performance.– Channelized attention or fixation– Loss of situational awareness– Inattention or distraction Crew resource management errors involvepoor communication skills or coordination among allpersonnel involved with the flight or mission, not justthe flight crew.– Failed to communicate or coordinate– Failed to backup– Failed to conduct an adequate briefUnsafe Supervision Inadequate supervision errors occur whensupervision was inappropriate or absent.– Failed to provide adequate guidance or oversight– Failed to provide adequate training– Failed to track quals or performanceOrganizational Influences Organizational process errors result frominadequate or misinterpreted corporate decisions orrules that govern everyday squadron activities (such asSOP, NATOPS).– Failure to provide adequate guidance– Inadequate documentation– Failure to provide adequate or professionalprocedures.How does HFACS help decrease the mishap rate?HFACS is the first step in the risk-managementprocess: Identify the human-factor problems. The nextstep is to implement interventions at squadron andorganizational levels to reduce the number of mishaps,based on the data gathered by HFACS.For more information on HFACS visit ourwebsite: n.Lt. Mussulman is a reserve aerospace physiologist, and LCdr. White isthe human-factors analyst with the Naval Safety Center.4approach July-August 2004
Are You OK?RADM. R. E. BrooksCommander, Naval Safety CenterBy Cdr. Markus HannanWe strapped on our SH-60B andlaunched out of NAS NorthIsland for a day, warm-up flightto OLF Imperial Beach (IB). With 3,750pounds of fuel, a crew of four, the Core BHellfire missile-modification incorporated,and the left-hand extended pylon andFLIR installed, our helicopter was nearmax gross weight.We took off more than an hour latebecause of a maintenance delay. Since Iwas scheduled for a “double,” I wantedto knock out the first hop in 75 minutes,instead of the scheduled 2.0, and thenshave a half-hour off the second 2.5-hourflight. This plan would allow me to landon time and keep the remainder of theschedule on track. IB was ops normal fora late midweek summer afternoon: busy,high density altitude (DA), hazy, windout of the west, and sun in our face. Mycopilot was a new pilot-qualified-in-model(PQM), fresh out of the FRS, and withlittle flight time. Me? I’m the CO.We arrived at IB about 15 minutesafter takeoff. I had my copilot “bust rust”July-August 2004 approach5
for 30 minutes on the pads. We transitioned tothe runway for autos, but, before shooting thefirst one while on downwind, I briefed the crewwe were over the recommended 18,500 poundsgross weight (GW). The fuel totalizer read 2,980pounds, putting the aircraft at 19,620 poundsGW.At 1815, and because the outside-air temperature and DA had come down, I felt we safelycould complete the autos. I shot the first auto;it was picture perfect. I was proud of myselfbecause I had had all of 10 minutes of stick timeduring the flight. I silently patted myself on theback, as I passed the controls to my PQM.My copilot entered the auto and did adecent job controlling heading, airspeed, rotorrpm (Nr), and ball. He began his flare at 200feet; however, the nose of the aircraft got alittle too high. As a result, our groundspeedrapidly bled off, and then the rate of descentincreased—events happened faster than usual.As we descended through 60 feet AGL , I called“power” and came on the controls. Nr wasdrooping below 90 percent as we leveled thehelicopter. I felt the strong jarring that accompanies a hard landing.IB tower immediately called, “Saberhawk74, are you OK? ”Fortunately, no one was hurt. The onlyaircraft damage was a scraped radar dome. Whatfollows is an excerpt from my endorsement tothe hazrep—what the legendary radio figurePaul Harvey calls, “the rest of the story.” I hopemy comments put this story in context.The Rest of the StoryThe truth be told, as CO, I could haveelected to sweep this whole affair under therug. However, the message I want to send tomy wardroom does not include: Do as I say, notI felt the strong jarring thataccompanies a hard landing.6approach July-August 2004Photo by Matthew J. Thomas
as I do; honesty in reporting only applies whenit does not make you look bad; or commandingofficers are bulletproof. The unique feature ofthis hazrep is that it is based on human errors—my errors. While you may find my remarks tobe somewhat untraditional, I hope you also willfind them refreshingly candid.The bottom line is I made a series of poorchoices and overestimated my ability to recognize, react, and recover from a poor autorotation flown by my copilot. I took a nugget whohad recently graduated from the FRS, andplaced him in a situation that required him toperform at the level of a seasoned fleet aviator.My safety box (comfort zone) as a helicopter-aircraft commander (HAC) and flightinstructor had become too large. Uponreflection, here are the salient details. (YouSwiss-cheese-model fans are going to eat thisup—pun intended.)Slice one. I have more than 18 years ofaviation experience, have 2,000 hours of totalflight time, have successfully completed threeLAMPS deployments on small decks withoutincident, was a HT flight instructor, and haveflown with hundreds of students. While somemight argue these facts are a recipe for complacency, I will tell you I am neither satisfiednor content. More appropriately, I had becomeoverconfident in my abilities.Slice two. My copilot had graduated fromthe FRS a mere five months before this incident. Since his arrival, he had flown 20 timesand accumulated 55.6 flight hours. Of that total,he had only 12.2 flight hours in the last 60 daysand 3.9 flight hours in the last 30 days.Slice three. Unbeknownst to me, my copilot had had difficulty with autorotations in theFRS.Slice four. After our launch was delayed,instead of flying our scheduled two-hour day“back in the saddle” warm-up hop, I pressed toaccomplish the “X” in about 75 minutes, justover the minimum one-hour limit.Slice five. I knowingly launched withapproximately 3,750 pounds of fuel on a flightin which autos are a required maneuver. Thus,aircraft gross weight was destined to be high atthe time autos were conducted.Slice six. It was late on a typical San Diegosummertime afternoon (Read: the sun was inour eyes, and the density altitude was high).Slice seven. The aircraft gross weight was19,620 pounds. My squadron defensive-posturing instruction, which provides aircraft commanders guidance on conducting high-riskmaneuvers, states, “High-density altitude and/orhigh gross-weight autorotations above 18,500pounds gross weight should be avoided.” I choseto disregard my instruction.Slice eight. As HAC, I had performed thefirst auto; it was picture perfect, and I was quiteproud of myself. Hey, the old man still has it! Iproved to the young lad an auto could be accomplished safely, despite everything mentionedabove. When I passed him the controls, myconfidence was overflowing.Slice nine. As my copilot commenced thenext auto, I was near the controls, instead ofriding the controls with him. When we reached60 feet, I got that sinking feeling in my stomach, indicative of a tail slide. I called for powerand reached for the controls—too slow and toolate. (Trust me, my pucker factor was pegged.)As Nr drooped, we leveled the aircraft and madea “power-on full autorotation.”This ignominious incident completely wasavoidable. If you take nothing else away fromthis story, do not be foolish enough to repeatmy mistakes. I am not as good as I thought Iwas—“pride precedeth the fall.” I did not consider the relative inexperience of my copilot—Ishould have. I was not familiar with my copilot’sstrengths and weaknesses—I did not review histraining record. I wanted to get the “X”—it wasnot critical. I launched with a heavy aircraft—itcould have been defueled. I disregar
The Naval Safety Center’s Aviation Magazine Features July-August 2004 Volume 49 No. 4 RADM Dick Brooks Commander, Naval Safety Center Col. Dave Kerrick, USMC Deputy Commander John Mahoney Head, Marketing and Communications Naval Safety Center (757) 444-3520 (DSN 564) D
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June 23 8:26-30 15 June 30 8:31-39 19 July 7 9:1-31 23 July 14 10:1-21 27 July 21 11:1-36 31 July 28 12:1-13 35 August 4 12:14-21 39 August 11 13:1-14 43 August 18 14:1-23 47 August 25 15:1-33 51 September 1 16:1-27 55 *Dates correspond to the Sunday the week begi