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1. CAPT Jim Fraser Naval Safety Center Surgeon Naval Safety Center 5001

2. Naval Aviation Mishap Rate (FY 50-99) 776 aircraft destroyed in 1954 22 aircraft destroyed in 1999 Angled decks Aviation Safety Center Naval Aviation Maintenance Program established in 1959 (NAMP) RAG concept initiated NATOPS Program initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT Fiscal Year

3. All NAVY/MARINE Class A, B, & C Mishaps 16 14 12 Human 10 8 Class A, B,& C Mishaps/100,000 Flight Hours 6 4 Mechanical 2 0 1979 1981 1987 1985 1983 1989 1991 1977 Year

4. “Knowledge is Good…” Credo, Faber College Data Information Knowledge Wisdom …but wisdom is what we need!

5. Organizational Factors The “Swiss Cheese” Model of Accident Causation (Reason, 1990) • Excessive cost cutting • Reduction in flight hours • Deficient training program • Improper crew pairing Unsafe Supervision • Loss of Situational Awareness • Poor CRM Preconditions for Unsafe Acts Unsafe Acts • Failed to Scan Instruments • Penetrated IMC when VMC only Failures in the System • Accident & Injury • Crashed into side of • mountain

6. ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Physiological States Physical/ Mental Limitations Crew Resource Mismanagement Adverse Mental States Adverse Mental States Personal Readiness UNSAFE ACTS Errors Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional

7. UNSAFE ACTS UNSAFE ACTS Errors Violations Perceptual Errors Decision Errors Skill-Based Errors VIOLATIONS • Violation of Orders/Regulations/SOP • - Failed to Inspect ACFT after In-Flight Caution Light • - Violated Squadron SOP Restricting Flight Below 500’ • - Failed to Comply with NATOPS During Streaming • - Conducted Night Training and Ops Mission with PAX • - Elected to File VFR in Marginal Weather Conditions • - Failed to Use Radar Advisories from ATC • - Inadequate Brief and Limits on Mission • - HAC Knowingly Accepted Non-Current Crew • Failed to Adhere to Brief • Not Current/Qualified for Mission • Improper Procedure

8. U.S. Navy/Marine Corps Class A Mishaps Violations (FY90-96) Percentage of Mishaps USN Helo USMC Helo USN TACAIR USMC TACAIR

9. Percentage of Human Error Mishaps Associated with Violations (FY 91-99) Percentage USN/USMC TACAIR & HELO CLASS A MISHAPS Fiscal Year

10. UNSAFE ACTS UNSAFE ACTS Errors Errors Violations Perceptual Errors Decision Errors Skill-Based Errors Skill-Based Errors Routine Exceptional SKILL-BASED ERRORS • Breakdown in Visual Scan (53) • Failed to See and Avoid (12) • Poor Technique (12) • Omitted checklist item (10) • Inadvertent Operation of Control (10) • Improper Use of Flight Controls (10) Unsafe Acts

11. Percentage of Human Error Mishaps Associated with Skill-based Errors (FY 91-99) USN/USMC TACAIR & HELO CLASS A MISHAPS

12. Back to the Basics Focus on: Reemphasize the need for an efficient visual scan Prioritizing attention Recognizing extremis situations Refine basic flight skills (Stick-and-Rudder) Practice procedures

13. ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States (83%) Crew Resource Mismanagement (60%) Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Personal Readiness UNSAFE ACTS Errors Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional

14. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts ADVERSE MENTAL STATE Unsafe Acts • Channelized Attention/ Task Saturation (48) • Fatigue (11) • Distracted (10) • Complacency (9) • Loss of SA (7)

15. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts CREW RESOURCE MISMANAGEMENT Unsafe Acts • Failed to Communicate/Coordinate (26) • Failed to Backup (17) • Failed to Conduct Adequate Brief (11)

16. Why are We Seeing an Increase in Skill-based Errors? • Lack of flight time? • Quality of flight time? • Decreasing experience • OpsTempo? • Perstempo? • Shortcoming in our training program? • Shortcoming in our operational practices? • Would increased simulator-flight time be an effective intervention?

17. Focus for Intervention Strategies • Skill-based Error Distribution by ACFT Model • Skill-based Error by Mission Profile • Administrative Phase of Flight • Mission-related Phase of Flight • Skill-based error by Mishap Characteristics • Out-of-Control Flight (OOCF) • Controlled-Flight into Terrain (CFIT) • MIDAIR • Skill-based error by Pilot Experience • AV-8 Snapshot

18. Tacair In-Model Flight Hour Distributionvs. Tacair Skill-Based Errors Pilot Flight Hour Distribution % Skill-Based Error Mishaps FY90 - FY98 65 Mishaps

19. Helo In-Model Flight Hour Distributionvs. Helo Skill-Based Errors Pilot Flight Hour Distribution Skill-Based Errors FY90 - FY98 21 Mishaps

20. AV-8 In-Model Flight Hour Distribution vs. AV-8 Skill-Based Errors % By Number Mishaps AV-8 Skill-Based Errors FY90 - FY98 10 Mishaps AV-8 Pilot Flight Hour Distribution

21. Conclusions • Tacair • Experience Counts (500+ In-Model Hours) • Most Prevalent Skill-Based Errors • Breakdown in Visual/Instrument Scan/Cross Checking/See & Avoid • Most Prevalent SBE Preconditions • Adverse Mental State • Channelized Attention/Task Saturation • CRM

22. Conclusions cont. • Helo • Experience Counts (500/1000+ In-Model Hours) • Most Prevalent Skill-Based Errors • Breakdown in Visual/Instrument Scan/Cross Checking/See & Avoid • Most Prevalent SBE Preconditions • Adverse Mental State • Channelized Attention/Task Saturation • CRM

23. Intervention Strategies • Increase the in-model experience pool toward 500/1000+ hours • use simulator time to augment flight time and achieve earlier proficiency • Emphasize development of psychomotor skills • use simulator time to augment flight time and the development of a proper scan and stick and rudder skills • Emphasize avoidance of preconditions • use simulator time to augment flight time and development of automated basic flight skills that enable an aviator to avoid channelized attention/task saturation and improve CRM skills

24. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT • Not Working as a Team • Poor Aircrew Coordination • Improper Briefing Before a Mission • Inadequate Coordination of Flight

25. Percentage of Human Error Mishaps Associated with Crew Resource Management Failures (FY 90-98) Percentage Fiscal Year

26. Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90-98) TACAIR Helo Percentage Preflight Emergency Routine Operations Flight Condition

27. Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90-98) TACAIR Helo Percentage Preflight Routine Operations Emergency Flight Condition

28. Percentage of CRM Failures by Flight Conditions and Aircraft Community (FY 90-98) TACAIR Helo Percentage Preflight Routine Operations Emergency Flight Condition

29. CRM SUMMARY Even after the systematic, fleet-wide implementation of ACT, over 50% of TACAIR and Rotary Wing human factor mishaps involved at least one instance of CRM failure. The need to tailor ACT to the specific needs of the fleet is clear, yet data required for developing such curriculum has bee lacking. USMC Rotary Wing, 1997

30. CAPAS: Computer-Aided Performance Analysis System • Simulation-based technology designed to: • Maintain/improve aircrew proficiency • Maintain/improve CRM skills • Identify unsafe trends • Augment standardization of training efforts

31. HOW DO WE MATCH UP? TACAIR Comparison Rotary Wing Comparison USN/ USAF USMC (139) (72) Unsafe Acts Errors Skill-based Error 61% 60% Decision Error 55% 43% Perceptual Error 24% 31% Violations 28% 7% Preconditions for Unsafe Acts Substandard Condition Adverse Mental State 73% 53% Adverse Physiological State 23% 31% Physical/Mental Limitation 6% 11% Substandard Practice Crew Resource Management 53% 17% Personal Readiness 4% 4% Unsafe Supervision35% 8% Inadequate Supervision 23% 3% Planned Inappropriate Ops 12% 3% Failed to Correct Problem 6% 3% Supervisory Violation 9% 0% USN/ USA USMC (60) (62) Unsafe Acts Errors Skill-based Error 37% 48% Decision Error 58% 37% Perceptual Error 33% 45% Violations 48% 27% Preconditions for Unsafe Acts Substandard Condition Adverse Mental State 75% 74% Adverse Physiological State 28% 3% Physical/Mental Limitation 12% 6% Substandard Practice Crew Resource Management 80% 39% Personal Readiness 3% 0% Unsafe Supervision50% 32% Inadequate Supervision 32% 23% Planned Inappropriate Ops 12% 8% Failed to Correct Problem 13% 5% Supervisory Violation 12% 3% USN/USMC: FY90-FY98; USAF: FY91-FY97 USN/USMC: FY90-FY98; USA: FY92-FY97

32. Command Culture “A shared characteristic or characteristics of a particular social group, organization, or society…”

33. Squadron Safety Surveys • Cultural Assessment Questionnaires • Informal Interviews Aircrew/Maintenance • Confidential and anonymous • No written report, verbal feedback to Skipper and officers of his choice

34. Culture Workshop (CWS) • Senior Naval Reserve Officers serve as facilitators • Naval Safety Center to serve as model manager • CWS by command request • 2 day observation • Small group meetings divided by rank • Confidential and anonymous • No written report, verbal feedback to the Skipper and other officers of his/her choice

35. “Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one thing in mind. He...made a judgment. He believed in it so strongly that he knowingly bet his life on it. That his judgment was faulty is a tragedy,… Every instructor, supervisor, and contemporary who ever spoke to him had the opportunity to influence his judgement, so a little bit of all of us goes with every pilot we lose.” --Anonymous USN Rotary Wing, 1997

36. Questions 5045