Transcript Document 7492951

Executive Safety Course
Course presented by
Col Robert Diduch, National Safety Officer
Mr. Frank Jirik, NHQ, Safety
Chris Hamm, CAP-USAF, Director of Safety
Alaskan Grown
Helicopter Pilot
2nd Chance
Overview
Scope
• SMS - Preview
• Good, Bad, Ugly in Notifications and Mishap Reviews
• What is a “Safe” Commander
• Mishaps and the Media
• Conclusion
•
Scope
Scope
–
Introduction: Safely directing complex organizations, like Civil Air
Patrol, requires an understanding of the program requirements
and a safety mindset that is acquired by prior planning, ORM,
and constant situational awareness. This is a key function of the
corporate official in the wing. Safety requires vigilance to ensure
the proper education and prevention oversight reaches all of our
members in appropriate and relevant methods. When our
organization fails to be compliant, the wing commander is a key
individual in supporting investigations. A wing commander’s
responsibility is to ensure subordinate commanders’
recommendations for remedial training are accomplished.
Scope
–
Introduction: Safely directing complex organizations, like Civil Air
Patrol, requires an understanding of the program requirements
and a safety mindset that is acquired by prior planning, ORM,
and constant situational awareness. This is a key function of the
corporate official in the wing. Safety requires vigilance to ensure
the proper education and prevention oversight reaches all of our
members in appropriate and relevant methods. When our
organization fails to be compliant, the wing commander is a key
individual in supporting investigations. A wing commander’s
responsibility is to ensure subordinate commanders’
recommendations for remedial training are accomplished.
Scope
–
Introduction: Safely directing complex organizations, like Civil Air
Patrol, requires an understanding of the program requirements
and a safety mindset that is acquired by prior planning, ORM,
and constant situational awareness. This is a key function of the
corporate official in the wing. Safety requires vigilance to ensure
the proper education and prevention oversight reaches all
of our members in appropriate and relevant methods. When our
organization fails to be compliant, the wing commander is a key
individual in supporting investigations. A wing commander’s
responsibility is to ensure subordinate commanders’
recommendations for remedial training are accomplished.
SMS Preview
SMS Preview
This really happened.
The Notification
File the Mishap Notification – Form 78
Account: While flying an approach into XYZ airport that
was VFR day, with winds from the east, CAP flight 4173,
a C182 retractable gear flown by expert pilot Phillip
Flysalot, CAP ID 123456, flying a stabilized approach,
with all normal engine systems, landed smoothly, but
upon stopping realized that the landing gear was not
locked down.
The Notification
X
The Notification
File the Mishap Notification – Form 78
Account: Gear up landing (C182RG) occurred at XYZ
airport. No injuries.
The Notification
Col Rosendahl Ice’s ‘em!
The Mishap Review
•
The Mishap Review Officer is Appointed
–
Select someone that isn’t:
Unskilled
• Slow to get stuff done
• Biased or history of being opiniated, or dishonest
• Close friends with the member(s) involved
•
The Mishap Review
•
The Mishap Review Officer is Appointed
–
Consider selecting:
Someone from a different wing or region
• A trained mishap review officer
• Perceived of high character and professionalism
• Readily available
•
Mishap Review Mistakes
BUT NOT TOO FAST
Mishap Review Mistakes
TOP 10
10. Uncooperative People or System
9. Conflicting Objectives
8. Surface Causes Only
7. Politics
6. Unskilled Mishap Review Officers
5. Interview Biases / Untruthfulness
4. Untimely Mishap Review
3. Mishap Reviewer Biases
2. Ineffective Corrective Action
1. Not Reviewing Close Calls (Near Misses, Safety Deviations)
Your Turn
We’ll be back in the air in ‘no time!’
The Mishap Review
The Mishap Review (Form 79)
Factual Narrative: The pilots flying the C182RG aircraft did
have a smooth landing as noted by the straight marks in
the fuselage of the aircraft. No one was injured. The
pilot and crew were long time CAP veterans and are very
skilled. The gear was not lowered. This was a Form 5
check ride. The check ride was not completed.
The Mishap Review
XX
The Mishap Review
The Mishap Review (Form 79)
Factual Narrative: The flight crew of this C182RG aircraft
did not utilize the proper checklist or execute the before
landing checks required. Sterile cockpit procedures were
not observed. The gear up audible was checked and
functioning. Checklists in the aircraft were available.
Safety education currency was up to date on two of
three crewmembers.
What would you expect to see?
The Mishap Review
The Investigation – Form 79
Recommended Corrective Action: Assess the Pilot the $500
deductible. Caution the crew on listening for the landing
gear audible. Replace the checklists with a laminated
copy for better use.
Recommend crew be returned to full flight status.
The Mishap Review
XXX
The Corrective Action
The Mishap Review (Form 79)
Corrective Action:
•
•
•
•
•
Flight crew received remedial ground instruction on checklist use and crew
communications responsibilities.
The Pilot, the two CAP Check Pilots, received unique recertification in their
positions of responsibility and demonstration of crew communication be
required.
The aircraft be checked by maintenance to ensure required warning
notifications are operational.
The unit maintenance officer ensure the proper checklists are available
within the aircraft.
FRO re-education on flight release responsibilities to ensure non-compliant
members in safety education are not allowed to participate in CAP activities.
What would you expect to see?
If you can’t think, someone already HAS!
A quick fix to a CAP Van?
If you can’t think, someone already HAS!
No frost issues here
If you can’t think, someone already HAS!
Where is the nosewheel?
If you can’t think, someone already HAS!
Hey cadet, pass me your flashlight.
If you can’t think, someone already HAS!
Don’t scratch my door when you get in.
If you can’t think, someone already HAS!
Cadets always have chips!
The Corrective Action
The Mishap Review (Form 79)
Wings Corrective Action:
•
•
•
•
•
•
THESE PILOTS WILL NOT ACT AS PIC OF CAP AIRCRAFT OR AS MEMBERS OF CAP AIR CREW EXCEPT
TO COMPLETE THE
FOLLOWING REMEDIAL TRAINING, GIVEN BY A XXWG OR XXR CHECK PILOT EXAMINER:
A MINIMUM OF 1 HOUR OF INSTRUCTION IN EACH OF THE FOLLOWING AREAS:
1. STABILIZED APPROACHES
2. NIGHT LANDINGS
3. EMERGENCY PROCEDURES.
CHECK PILOT INVOLVED IN THIS MISHAP MUST SUCCESSFULLY ACCOMPLISH ALL MANEUVERS
FROM FRONT RIGHT SEAT.
PILOTS MUST SUCCESSFULLY COMPLETE AN ADM COURSE THAT MEETS FAA WINGS STANDARDS IN
ORDER TO RETURN TO FLYING STATUS.
UPON COMPLETION OF REMEDIAL TRAINING AS ENDORSED BY THE CHECK PILOT EXAMINER,
PILOTS MUST PASS A SPECIAL FLIGHT CHECK GIVEN BY A CHECK PILOT DESIGNATED BY XXR/CC.
•
AFTER SUCCESSFUL SPECIAL FLIGHT CHECK, RECOMMEND RETURN TO CAP FLYING STATUS.
•
ALL XXWG CHECK PILOTS WILL RECEIVE GUIDANCE FROM XXWG/CC TO CONFINE MANEUVERS
DURING CHECK RIDES TO PUBLISHED CAP FORM 5.
What is a Commander?
A Commander IS:
•
He/She is THE Safety Officer
–
•
He/She is THE Safety Program Manager
–
•
Not just the authority, but the person that is responsible for everyone’s safety
A strong program is led.
He/She is THE Risk Manager
–
They do not walk by risk without correcting it. Not saying anything really says, I condone
this.
Pyramid Theory
Accidents
1
Data FY08 – FY10
Incidents
20-50
Minor Mishaps
600
Accidents
Bodily Injury
Nat'l Total
Incidents
Minor Mishaps
19
10
3
29
36
51
12
87
231
308
39
539
Vehicular
Nat'l Total
0
1
0
1
21
21
9
42
38
51
8
89
Aircraft
Nat'l Total
3
4
1
7
84
92
20
176
32
60
6
92
*Data Current as of 2/10/2010
Pyramid Theory
Accidents
1
Data FY11 – present
Incidents
20-50
Minor Mishaps
600
Accidents
Incidents
Mishaps
Bodily Injury
Nat'l Total
19
10
7
1
36
51
76
20
231
308
270
184
Vehicular
Nat'l Total
0
1
0
1
21
21
21
10
38
51
21
12
Aircraft
Nat'l Total
3
4
2
1
84
92
46
15
32
60
27
36
*Data Current as of 2/10/2010
Mishaps and the Media
•
In all mishaps that involve the FAA or NTSB, NHQ Safety
signs in as “Party to the Investigation.”
•
By federal law, the FAA or the NTSB Investigator in
charge (IIC) becomes the voice of all information related
to the mishap.
•
Civil Air Patrol is bound by this same federal law to not
disclose information and to direct all media inquiries to
the IIC.
•
It should be assumed the FAA or NTSB is involved in all
mishaps until otherwise confirmed by NHQ Safety.
Summary
Scope
• Practical Exercise
• Good, Bad, Ugly in Notifications and Mishap Reviews
• Mishaps and the Media
• What is a “Safe” Commander
•
Closing Comments
Safety should be:
•
•
•
•
•
A positive environment without any obstacles for disclosure and discussion
Foster a willingness to share and learn
Safety should be proactive not reactive
Should be supported at all levels of leadership and integrated in all CAP programs
Safety should be easy to navigate
If you think it, it can be done.
Remember
Who can change the Safety Culture of CAP?
The Leader You See In The Mirror Each Morning.
The answer is before you.
Questions?
Where is the next mishap going to occur?
Please feel free to send your questions and comments directly to the National Safety Team and
NHQ Safety
@
[email protected]
QUESTIONS?
Contact Information
Col Bob Diduch
Frank Jirik
National Safety Officer
[email protected]
609-731-5600
Safety, CAP NHQ
[email protected]
800-227-9142 ext. 232
907-350-7559 cell
[email protected]