Transcript Slide 1

Aug 09 Safety Meeting
Larry Brockshus
Overview
• Aug Sentinel
– SA
– Lightning
– CAP June Aircraft
Mishaps
• 2009 Aircraft
incidents
• 101 Critical Days of
Summer
• MN Wing Grounding
Loss of Situational Awareness Due to
Ineffective Scan
• Several CAP mishaps due to a loss of Situational
Awareness (SA).
– Landing our aircraft fast resulting in damaged
firewalls
– Slow resulting in hard landings.
– Vehicles are backing into objects/other vehicles.
– Members stepping into holes, tripping over curbs,
– Not keeping ourselves hydrated, cutting ourselves
with knives etc.
LSA/Scan
• Inappropriate/ineffective scan greatly
increases loss of situation awareness
(hereafter, LSA)
• Breakdown in scan is one of the leading
contributors to mishaps/LSA
• ‘Good’ scan requires training and practice.
What is Situation Awareness (SA)?
• SA: An attention-based phenomenon
reflecting the state of a pilot's awareness
based on:
– The perception & cognition of information related
to the spatial world in and about the aircraft and
the hazards in that environment.
– The systems (especially those that are
automated) onboard the aircraft itself.
– The nature of the tasks at hand.
Principles of scan and situational awareness
• Tactical visual scan: a sequential monitoring task where a pilot
combines the data gained from each separate outside and cockpit
instrument fixation into full situation awareness.
• Pilots quickly create scan and fixation patterns for each different
required maneuver (i.e., transition through heading and altitude,
takeoff, landing, etc.)
• Scan characteristics (pattern, frequency and duration of fixations):
– determined by the intrinsic nature,
– complexity,
• Importance of the information provided Scan patterns and fixations
may reflect a strategy based on what a pilot needs to know, or
thinks he/she needs to know, at a given time
What Causes scan to ‘Breakdown’?
– Distractions,
– Workload,
– Automation, display design - “Glass Cockpit”,
– Complacency,
– Inadequate/inaccurate mental model
– Lack of/poor scan training
Applies to all CAP members
• There is basically no difference in the scan vs.
situational awareness whether driving a CAP
vehicle or cadets and seniors performing
activities such as encampments, PT or ES.
• Scan for the hazards (ORM) and use this
information to keep yourself and others safe
Lightning Safety
• The National Weather Service lightning safety website
(http://www.lightningsafety.noaa.gov/overview.htm)
Lightning Safety
• The National Weather Service (NWS) reports a
30-year average of 58 deaths per year in the
United States
• At a wing encampment this year, lightning
struck a communications antenna mounted on
a trailer
– Damaged several pieces of equipment.
– Cadet was using a laptop experienced an electrical
shock.
– Neither the antenna nor the trailer was grounded
Tips to avoid injury during
thunderstorms:
• Thunderstorms
happen year round.
• Lightning can strike as far 10 miles from
the area of rain
• Remember: If you can hear thunder,
you are close enough to be struck by
lightning
There is little you can do to substantially reduce
your risk if you are outside in a thunderstorm
• Move to a safe shelter: fully enclosed, plumbing and/or
wiring.
– Unsafe buildings: Car ports, open garages, covered patios, picnic
shelters, beach pavilions, golf shelters, tents of any kinds, baseball
dugouts, sheds and greenhouses.
• Stay away from showers, sinks, hot tubs, and electronic
equipment such as TVs, radios, corded telephones and
computers.
• If you are unable to take shelter in a safe building, seek a
safe vehicle. One that is fully enclosed, metal topped
such as a hard topped car, minivan, bus, truck, etc.
– Unsafe vehicles include convertibles, golf carts, riding mowers, open
cab construction equipment and boats without cabins.
– Do NOT leave the vehicle during a thunderstorm.
If away from building/vehicle
• Avoid open fields, the top of a hill or a ridge top.
• Keep away from tall, isolated trees or other tall objects.
• Set up camp in a valley, ravine or other low area (consider
possible flash flooding).
• Stay away from water, wet items such as ropes, and metal
objects
• The vast majority of lightning injuries and deaths on boats
occur on small boats with no cabin.
– If you are caught in a thunderstorm on a small boat, drop anchor and
get as low as possible.
Summary of Form 78 Aircraft Accidents
and Incidents for June 2009
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Aircraft wingtip struck hangar while taxiing
Tow hook damaged during glider tow operation
Dent found on leading edge of right wing*
Aircraft wing tip grazed a light pole while taxiing
Tail tie down ring sheared off during soft field takeoff
Nose wheel tire flat on landing rollout
Found small dent and paint missing on wing tip*
Aircraft hit runway light while taxiing in grass to tie down
area
2009 MN Aircraft Incidents
MN Wing Aircraft Incidents
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19 Feb, #1218, Damage on horizontal stab
21 Mar, #1262, Hit tie down ring, Soft Field T.O.
17 Apr, #1303, Hit tie down ring, Student Solo
23 May, #1376, Bent Aileron
30 May, #1390, Scraped rear tail box
18 Jun, #1437, Wing leading edge dent
23 Jun, #1492, Scraped wing tip
23 Jul, #1604, Cadet solo aborted T.O., slid off runway
23 Jul, #1608, Wingtip hit porta-potty
Concerns
• 3 incidents of aircraft tail hitting to ground
– Training
– Technique
• 5 incidents had an unknown cause
– Poor pre/post-flights
– Integrity?
• 1 ignored taxi obstacle clearance criteria
• 1 could have led to catastrophic injury/aircraft
damage
• All were preventable
101 Critical Days of
Summer
101 Critical Days of Summer
•
Memorial Day Weekend through Labor Day Weekend
– “Critical” because many lose their lives
– More activities mean more risk
– More risk means more injuries
– Safety = Planning with knowledge of the past and
making choices that prevent mishaps
– Some risk is necessary for a meaningful life
– Must weigh benefits and costs of each risk
Vehicle Safety
• As a result of 6,000,000 car accidents in the
US each year
– 3,000,000 will be injured
– 42,000 will be killed
– The leading cause of fatal mishaps
during this period
• Contributing factors include: Fatigue,
alcohol, drugs, speeding & not using
seatbelts
• Survival plan:
– Insist on seat belt use
– Don’t drive impaired
– Plan your trip
– Inspect your vehicle
– Don’t speed (or go too slow)
– Don’t tailgate
Water Safety
• Each year in the US,
– 3,500 drown
– 4,500 injured while boating
– 700 killed while boating
• PFDs could reduce fatalities 90%
• Contributing factors include: alcohol,
lack of PFDs, horseplay, and underwater
obstructions
• Survival plan:
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Use a “designated Captain”
Don’t overload the boat
PFDs on weak swimmers
Explore water/feet first
Keep throwable PFD nearby
Use the engine kill switch
Weather
• Weather Dangers
– All Thunderstorms are
dangerous
– Lightning kills more people each
year than tornadoes
– Hailstones can fall at speeds in
excess of 100 mph
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Stay inside when storms are approaching
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Listen for information on Watches and Warnings
Summary
• The goal is FUN this summer!
• When someone is injured - it stops being fun!
• Make your own luck by managing risks
• Have fun by being careful out there!
MN Wing Grounding
• MN Wing must develop program to decrease
incidents
• Col Theis requested inputs from commanders and
staff
• Input from teleconference:
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Take pictures of aircraft damage
Hold safety clinics/add to SAR exercises
Develop use robust pre/post checklists
Publish form 78/79s
Avoid non-value added paperwork
Additional input from a highly
experienced instructor and safety
officer (not me)
• Things That do Not Work
– Posters
– Slogans
– Pledges
– One way communication
– Blaming the victim
– Trying to change people, not processes
A Management problem
• Deming – 90% of problems are caused by management
• John Laubner NTSB- Corporate culture has a very real influence on
attitudes and performance…management decisions and actions cause
accidents.*
• J. Lederer- Every accident, no matter how minor is a failure of
organization.*
• Processes not people must change
• The best example of CAP process change was to switch from tailwheel to
tricycle aircraft. The accident rate dropped dramatically.
• The outstanding safety record of the airlines is due to the establishment of
effective processes that cover all aspects of their operation.
• Management, must demonstrate scrupulous adherence to the rules if a
rule based culture is to be established.
The solution (One proposal)
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Management at all levels must demonstrate strict adherence to the
rules. e.g. if the compass card is missing, the airplane is grounded on the
spot. Publicize this action.
A safety conscious culture is established by management demonstrating
the desired behavior; is reinforced by peer pressure.
Peer pressure is established through frequent personal contact among
those affected, e.g. unit pilots meet at least once a month and discuss
nothing except details of their flying operation. Everyone knows what
everyone else is doing. Every pilot feels that all the other pilots are
looking over his shoulder.
Publicize all incidents.
Review what processes were involved in each incident. Affect changes
that should improve these processes. e.g. installation of stops in the St.
Paul hangar ; insisting on a static rpm check on takeoff /establishing an
abort point.
The solution (One proposal)
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Appoints squadron maintenance officers. Among his duties should be to
determine the action required for each aircraft squawk. He should coordinate
repairs or deferral with Wing operations, keeps the unit informed.
Return units to flying status upon appointment of a maintenance officer,
establishment of a pilot
Meet with all squadron commanders, teach that a safe culture begins with
managers exhibiting the desired behavior and expecting the same from their
subordinates.
Teach that process change and that continuous process improvement is as
applicable to safety
Establish channels for safety improvement at all levels. Make it easy for any one
to offer a safety suggestion and insure that they are taken seriously. Follow up.
Processes are most often improved by a multitude of small changes initiated
from the bottom up. Major changes initiated from the top down are less often
effective.
Be Safe