Near-Miss Analysis - PowerPoint PPT Presentation

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Near-Miss Analysis

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  1. Near-Miss Analysis Predicting and Preventing General Aviation Accidents

  2. Definitions STEEP TURN Excessive bank maneuver with massive loss of altitude

  3. Definitions STALL A tactic used to explain higher AVGAS costs to the mortgage company

  4. Definitions LAZY 8 SC Owner 7 Mechanics

  5. Definitions DIVE Local pilot hangout

  6. PILOT Definitions ANGLE OF ATTACK Pickup lines frequently used at the DIVE

  7. Definitions SUITABLE LANDING FIELD The good-looking one

  8. Definitions PRECISION APPROACH Performed at a suitable landing field with appropriate approach clearance

  9. Definitions NEAR-MISS A Near-Miss is an opportunity to improve safety, health, environmental impact and security of an operation based on a condition or an incident with potential for more serious consequences. - Wharton Risk Center

  10. Safety Pyramid Major Accidents Minor Accidents Incidents & Observations (Near-Misses) - Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”

  11. Safety Pyramid NTSB Accident Database Major Accidents ASRS Never Again I Learned… Minor Accidents Individual Pilot Experience Incidents & Observations (Near-Misses) - Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”

  12. Safety Pyramid NTSB Accident Database Major Accidents ASRS Never Again I Learned… Minor Accidents Individual Pilot Experience Incidents & Observations (Near-Misses) - Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”

  13. Incident/Accident Analysis Identification Reporting Prioritization Distribution Causal Analysis Solution Identification Dissemination Tracking

  14. Safety Pyramid NTSB Accident Database Major Accidents ASRS Never Again I Learned… Minor Accidents Individual Pilot Experience Incidents & Observations (Near-Misses) - Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”

  15. Identification • What, Where, When • Preceding circumstances • Flight conditions • Aircraft condition • Flight plan / flight log • Other remotely-related information

  16. Reporting • You as Office of Primary Responsibility (OPR) • ATC / FAA? • Airport? • NTSB? • Manufacturer(s)? • Trainers? • Repair Station? • Others?

  17. Prioritization • Life • Limb • Environment • Economy • Your priorities may not match other stakeholders • Burden may shift, but not OPR

  18. Distribution • All stakeholders need access to info • OPR must take the lead • ASRS?

  19. Causal Analysis • Direct and root causes • Why? • OK, then why that? • OK, then why that?

  20. Solution Identification • Solution(s) for EVERY defined cause • Less than ideal solutions OK • “No solution for time being” • Predetermine possible ancillary results

  21. Dissemination • Allocation of resources • Action offices • Limit to interested parties

  22. Resolution Tracking • Employment/Resolution • Continuous process improvement Solution Identification Process Improvement Results Dissemination Implementation

  23. Case Study Subject: Electrical System From: XXX@aol.com Date: 9/19/2005 7:12 pm To: blorber@southwestcirrus.com …As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)…

  24. Case Study Analysis • Reporting: pilot and repair station • Prioritization: High • Distribution: N/A? • Causal Analysis: • 1) “Voltage regulator for 1 had blown” • 2) “Coupling for 2 was shot” • Solution Identification: Replace Both • Dissemination: N/A? • Resolution Tracking

  25. Case Study Subject: Electrical System From: XXX@aol.com Date: 9/19/2005 7:12 pm To: blorber@southwestcirrus.com …As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?) Fixed both, made it to Smyrna TN and Alt 1 comes on again! Voltage regulator again....hmmm. Found a field wire chafed and shorted against the engine, front right corner, fixed both and no more problems......

  26. Case Study Analysis • Incomplete causal analysis • Incomplete solution identification • Repeat failure • Distribution and Dissemination?

  27. Near-Miss Analysis • Be alert for “off-the-script” conditions • Formalize analysis and solution tracking • Report your results • Critically analyze the results of others • Eat good food, don’t litter, don’t talk to strangers, get plenty of rest, fly safe.