Safety Programs & Impact on Airfield Ops
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Safety Programs & Impact on Airfield Ops. HQ AFFSA: Ms. Diana Malone. Global Access for America. INTRO. Our Business was Built on the Mishaps of Others. Overview. Aircraft Mishap Review Process HATRs and CMA Violations MACA/BASH Program. Aircraft Mishap Review Process.

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Hq affsa ms diana malone

Safety Programs & Impact on Airfield Ops

HQ AFFSA: Ms. Diana Malone

Global Access for America


Intro

INTRO

Our Business was Built on the Mishaps of Others


Overview

Overview

  • Aircraft Mishap Review Process

  • HATRs and CMA Violations

  • MACA/BASH Program


Aircraft mishap review process

Aircraft Mishap Review Process

  • Safety Investigation Board (SIB)

  • Accident Investigation Board (AIB)

  • Memorandum of Final Evaluation (MOFE)

  • NTSB

It’s not the “Who”/It’s the “What, Why, and How” that’s Important


Aircraft mishap review process safety investigation board

Aircraft Mishap Review ProcessSafety Investigation Board

  • Governing Directives

    • AFI 91-204, Safety Investigations and Reports

    • AFMAN 91-223, Aviation Safety Investigations and Reports

    • AFI 13-204, Functional Management of Airfield Operations, Chapter 4


Aircraft mishap review process safety investigation board1

Aircraft Mishap Review ProcessSafety Investigation Board

  • The Primary Purpose of a Safety Investigation is to find the cause of an accident in order to take preventative actions.


Aircraft mishap review process safety investigation board2

Aircraft Mishap Review ProcessSafety Investigation Board

  • Interim Board Convened, Mishap Scene Secured and Relevant Data Collected

  • Convening Authority Appoints SIB Members

  • Investigation Completed Within 30 Days

  • SIB Produces 2-Part Final Report

    • Part I -- Non-Privileged, Factual Info

    • Part II-- Witness/Contractor Statements & Docs

      -- SIB Deliberations/Findings/Recs

  • Part II is Privileged Information

  • Primary Members May Publish Minority Opinion


Aircraft mishap review process safety investigation board3

Aircraft Mishap Review ProcessSafety Investigation Board

  • Airfield Ops Expert Serves as Primary “Conditional” Member

  • “Conditional” = If ATC/AM Involved

  • 13MX, 1C1X1 or 1C7X1 May be Requested at SIB President’s Discretion

  • If Resource not Available w/in Command, AFFSA/XA Assists in Selection

  • Completion of AMIC not Required

  • May Convert to Secondary Member Status if ATC/AM Determined not a Factor


Aircraft mishap review process accident investigation board

Aircraft Mishap Review ProcessAccident Investigation Board

  • Governing Directives

    • AFI 51-503, Aerospace Accident Investigations

    • AFI 13-204, Functional Management of Airfield Operations, Chapter 4

  • Commander who Convenes the SIB

    • Determines if AIB is Required

    • Convenes Corresponding AIB


Aircraft mishap review process accident investigation board1

Aircraft Mishap Review ProcessAccident Investigation Board

The Purpose of an Accident Investigation:

  • To Provide a Publicly Releasable Report of Facts and Circumstances Surrounding the Accident

    • Includes a Statement of Opinion on the Cause (s) of the Accident       

  • To Gather and Preserve Evidence for:

    • Claims

    • Litigation

    • Disciplinary/Adverse Administrative Actions

    • For All Other Purposes


Aircraft mishap review process accident investigation board2

Aircraft Mishap Review ProcessAccident Investigation Board

  • Investigation Separate/Independent of SIB

  • AIB not Authorized Access to Privileged Safety Documents (Part II of SIB Report)

  • AIB Produces Single Non-Privileged Report Based on Board President’s Assessment

  • Minority Option is not a Factor on the AIB


Aircraft mishap review process memorandum of final eval

Aircraft Mishap Review ProcessMemorandum of Final Eval

  • Final SIB Report is Not so Final…

  • AFSC Calls for Command Indorsement/ Comments for All Class A & B SIB Reports

    • Normally 30 Days to Provide Comments

    • Memorandum of Final Evaluation (MOFE) Produced by AFSC After Comments are Received

    • Historically, 6-12 months to Publish MOFE

  • MOFE Process for Class C & E Mishaps Determined by the MAJCOM


Aircraft mishap review process summary

Aircraft Mishap Review ProcessSummary

  • SIB Takes Priority Over the AIB

  • AOF Personnel may Serve as:

    • Primary/Secondary SIB Member

    • AIB Technical Expert

  • Goal of SIB is to Identify What Caused the Mishap and Take Preventive Action

  • MOFE - Real Final SIB Report

  • Punitive Action May Result from AIB

    • Could Result from SIB, if Witness Gives False Testimony


Ntsb investigations

NTSB Investigations

  • May Occur Concurrent with or Instead of SIB/AIB

  • May Take 12-18 Months to Produce Final Report

  • USAF May be Party to the NTSB

  • 50% of NTSB Investigations Occur Outside U.S.

    • Led by State (country) where Accident Occurs

    • Accredited Representatives from State of Registry, Operator, Design and Manufacture

    • Investigation Under Control of Investigator-in-Charge (IC) with Core Team of Investigators and Party Participation

    • Family Members/News Media not part of the Investigation, but May be Present at the Site – not in Team Deliberations


Ntsb reference publications

NTSB Reference Publications

  • ICAO, ANNEX 13 to the Convention on International Civil Aviation

  • TITLE 49 – Aircraft Accident Reporting

  • 49 CFR, PART 831 – Investigation Procedures

  • Manual of Aircraft Accident and Incident Investigation

  • TITLE 49 – Accident Hearings and Reports

  • ICAO Human Factors Training Manual


Manual of aircraft accident and incident investigation

Manual of Aircraft Accident and Incident Investigation

  • The Sole Objective of an NTSB Aircraft Accident or Incident Investigation (Defined in Annex 13) is the Prevention of Future Accidents and Incidents

  • It is Not the Purpose of an Investigation to Apportion Blame or Liability

  • Any Judicial or Administrative Proceedings to Apportion Blame or Liability Should be Separate from Any Investigation Conducted Under the Provisions of Annex 13

  • The Emphasis of an Aircraft Accident or Incident Investigation is on Remedial Actions


49 cfr part 831 accident injury investigation procedures

49 CFR PART 831 – Accident/Injury Investigation Procedures

  • 831.7 Right to Representation.

    Any person interviewed by an authorized representative of the Board during the investigation, regardless of the form of the interview (sworn, unsworn, transcribed, not transcribed, etc.) has the right to be accompanied, represented, or advised by an attorney or non-attorney representative.


Ntsb summary

NTSB Summary

  • Purpose of an NTSB investigation is the same as for a SIB – prevention of future accidents or incidents

  • Protection of the NTSB report is equivalent to AIB

    • public hearings; news releases; press interviews

    • posted on NTSB web site http://www.ntsb.gov/default.htm

  • Any person interviewed has the Right to Representation

    • One person of your choosing may accompany – Choose wisely


Hatr cmav program

HATR/CMAV PROGRAM

  • Sole Purpose of the Program is Mishap Prevention

  • Reports are Not Privileged Information and May Be Released Outside USAF Channels

  • Anyone Aware of a Reportable Incident May File a HATR or CMAV

  • Guidance in AFMAN 91-223


Class e events

Class E Events

  • HATRs and CMA Violations - Both Class E Events

  • If the Violation Resulted in the Endangerment of an Aircraft, Report as a Class E HATR Event

  • Both Now Reportable to Flight Safety

    • Report All HATR Events Using the AF Form 651

    • Report CMA Violations Using the AF Form 457

  • AOF/CC Comments Are Required on All HATRs Involving ATC/AM Services

    • Minimum: Concur or Non-Concur

    • If Non-Concur, State Why


Maca bash programs

MACA/BASH Programs

  • MACA/BASH Programs Established in

    AFI 91-202, USAF Mishap Prevention Program

  • Wing Flight Safety Owns Program Management

  • AOF Supports MACA via Pilot/Controller Liaison Program per AFI 13-204

  • BASH – AFPAM 91-212, Bash Management Techniques

    • BHWG

    • Wing BASH Plan

BASH Management is a Team Event


Airfield operations safety web page

Airfield Operations Safety Web Page

  • Published off of AFFSA/XA Web Site

    • Comments Regarding MOFE Status/Corrections

    • Crossfeed for HATRs and Associated Training

    • History of OIF HATRs with Links to Text

    • History of CMA Violations

AFFSA XA XA AIRFIELD CONTACT

HOME DIVISIONS MAIN MENU OPERATIONS SAFETY

Aviation MishapsHATRsContingency HATRsCMA ViolationsAMIC Grads

https://private.andrews.amc.af.mil/AFFSA/xa/affsaxa_dir.htm


In the blink of an eye

1 second

to near miss

In the blink of an eye...

What’s your role in preventing mishaps?


Final thoughts

Final Thoughts…

“I don’t care Who made this mess…How do we keep it from happening again?”


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