Aug 09 Safety Meeting

1
Aug 09 Safety Meeting

• Larry Brockshus

2
Overview

• Aug Sentinel
• SA
• Lightning
• CAP June Aircraft Mishaps
• 2009 Aircraft incidents
• 101 Critical Days of Summer
• MN Wing Grounding

3
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.

4
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.

5
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.

6
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

7
What Causes scan to Breakdown?

• Distractions,
• Workload,
• Automation, display design - Glass Cockpit,
• Complacency,
• Inadequate/inaccurate mental model
• Lack of/poor scan training

8
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

9
Lightning Safety

• The National Weather Service lightning safety
  website (http//www.lightningsafety.noaa.gov/overv
  iew.htm)

10
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

11
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

12
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.

13
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.

14
Summary of Form 78 Aircraft Accidents and
Incidents for June 2009

• 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

15
2009 MN Aircraft Incidents
16
MN Wing Aircraft Incidents

• 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

17
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

18
101 Critical Days of Summer
19
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

20
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
• Dont drive impaired
• Plan your trip
• Inspect your vehicle
• Dont speed (or go too slow)
• Dont tailgate

21
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
• Use a designated Captain
• Dont overload the boat
• PFDs on weak swimmers
• Explore water/feet first
• Keep throwable PFD nearby
• Use the engine kill switch

22
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

• Stay inside when storms are approaching
• Listen for information on Watches and Warnings

23
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!

24
MN Wing Grounding

• MN Wing must develop program to decrease
  incidents
• Col Theis requested inputs from commanders and
  staff
• Input from teleconference
• 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

25
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
•  

26
A Management problem

• Deming 90 of problems are caused by management
• John Laubner NTSB- Corporate culture has a very
  real influence on attitudes and
  performancemanagement 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.
•  

27
The solution (One proposal)

• 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.

28
The solution (One proposal)

• 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.

29
Be Safe