MISHAP INVESTIGATIONS SIR Part 2

SIR PROCESS OVERVIEW Get the Facts Review Lines of Evidence Determine Causal Factors (CF) Place CF’s in Domino Chain Order Analysis: Using your “Lines of Evidence” tell how the AMB determined “proved” this WAS or WAS NOT Causal to the Mishap CF’s in Domino Chain Order Privilege Mishap Narrative Insert the CF’s determined in Domino Chain Order “telling the story”, but no ANALYSIS Recommendations Tie-In recommendations to the appropriate CF’s SIR Clean-Up (Format): Attachments Definitions and Acronyms Lines of evidence not used

DEFINITION: CAUSE Definition: Causal Factors are the hazards that where not identified or were identified but not corrected; identified but given such a low priority that adequate corrective action was not taken prior to the mishap. Elements: True statement – it happened Contributed to the mishap (if removed the mishap would not have occurred)

ANALYSIS The timeline “Murphy” Plane Crashes Fact Fact Fact Fact Fact Latent Conditions Active Errors

Without one of them, there would be no mishap (pg 6-28 (2)(a)) CATEGORIES OF CAUSE PG 6-20 Human Factor “ACT” - Individual or Aircrew, ATC, Maintainer, etc. “Preconditions” – Existed, active or latent “Supervision” - DH, CO/XO, ISIC “Organizational Influence” - Squadron, ISIC, CNO, Naval Aviation Enterprise PG 6-27 Material Factor Component – Equipment, Piece or Part Without one of them, there would be no mishap (pg 6-28 (2)(a))

HFACS (CHG 4; APPX O) TAKE A DEEP BREATH Reason’s Model (1990) Nano codes (thread analysis) and statistics from all DoD services for gathering and distributing valuable information to mitigate Latent failures - conditions, events, series of errors that exist within the squadron or in the CoC that effect the tragic sequence of events Active failures – actions or inactions by individuals believed to cause a mishap

HUMAN FACTOR Simply stated: Specific act of Commission or Omission Who did What and Why Specific act of Commission or Omission Human Factor: “WHO did WHAT” MP hit the landing gear handle with his knee. or CO failed to ensure MP was current in aircraft. Why: ANALYSIS using evidence and deliberation.

HFACS INDIVIDUAL (who) did (what) ACT, DUE TO/BECAUSE OF (why) Appendix L (Chg 4 L-3 or NSC website) Act, Preconditions, Supervision, Organizational Influence Present analysis and insert Nano codes from the “4 Tiers” List Major Tiers, Sub Category, Nano Code, Brief Description

4 TIERS Acts: of operators, maintainers, facilities personnel, leadership, etc. Errors: Operator Mental or Physical Failure Violations: Willful Disregard of Rules Preconditions: fatigue, complacency, illness, loss of SA Environmental: Physical / Technological Individual Condition Personnel: CRM / Stress Supervision: Supervisory Chain of Command Inadequate Inappropriate Failure to Correct known problems Violations Organizational Influences: Fallible decisions by upper level management Resource Management, Organizational Climate, Operational Process Communications, Actions, Omissions, Policies

LET’S PUT IT ALTOGETHER (PG 51 IN SUPP FOR GUIDANCE) HUMAN FACTOR - THE CO FAILED TO PROVIDE PROPER SIMULATOR TRAINING. ACCEPTED. CO STATED HE DID NOT SEE ANY REASON TO EMPHASIZE SIMULATOR TRAINING (AE-201). HE ALSO STATED THAT SIMULATOR TRAINING VALUE WAS VERY LIMITED AND THAT IN HIS OPINION IT DID LITTLE TO IMPROVE OR MAINTAIN THE PROFICIENCY OF HIS CREWS (PC-205, PC-208, OC-003). OPNAV 3710 RECOMMENDS SIMULATOR TRAINING BE USED IN CONJUNCTION WITH ACTUAL FLIGHT TIME TOWARDS DEVELOPING AIRCREW PROFICIENCY. BASED ON THE ABOVE ANALYSIS THE AMB CONCLUDES THAT THE CO FAILED TO PROVIDE PROPER SIMULATOR TRAINING DUE TO POOR JUDGEMENT AND LACK OF MOTIVATION. When ACCEPTED Close with: “BOTAA-TACT/DUE TO”

*********PG 7-14 BOOK ERROR********* HFACS ANALYSIS: 4 Tiers *********PG 7-14 BOOK ERROR********* HUMAN FACTOR: THE CO FAILED TO PROVIDE PROPER SIMULATOR TRAINING. (“TERSE” STATEMENT BY AMB OF WHO DID WHAT) ACT: JUDGEMENT AND DECISION-MAKING ERRORS, AE-201 - INADEQUATE REAL-TIME RISK ASSESSMENT PRECONDITIONS: PSYCHO-BEHAVIORAL FACTORS, PC 205 – PERSONALITY STYLE PRECONDITIONS: PSYCHO-BEHAVIORAL FACTORS, PC 208 – COMPLACENCY (ABSENCE OF WORRY) SUPERVISION: INADEQUATE SUPERVISION, SI 001 – COMMAND OVERSIGHT INADEQUATE SUPERVISION: INADEQUATE SUPERVISION, SI 003 – FAILED TO PROVIDE PROPER TRAINING SUPERVISION: INADEQUATE SUPERVISION, SI 004 – FAILED TO PROVIDE APPROPRIATE POLICY/GUIDANCE ORGANIZATIONAL INFLUENCE: ORGANIZATIONAL CLIMATE, OC 003 – ORGANIZATIONAL OVER-CONFIDENCE ORGANIZATIONAL INFLUENCE: ORGANIZATIONAL PROCESSES, OP 005 – FLAWED PHILOSOPHY LEADS TO UNNECESSARY RISKS

MATERIAL FACTOR Component had a failure Mode due to an Agent COMP: Smallest, most specific component, assembly or system MODE: How it failed (fracture, stripped threads, jammed, leaked) AGENT: Acts or events which led to failure (fatigue, fire, over loaded) EX: “MATERIAL FACTOR - THE CROSSFEED VALVE VAPOR LOCKED DURING SINGLE ENGINE OPERATION. ACCEPTED. COMPONENT: FUEL CROSSFEED VALVE MODE: VAPOR LOCKED AGENT: AIR INGESTION 3750.6R Page 6-27

HFACS MATERIAL ANALYSIS Comp had a failure Mode due to an Agent Agent may include HFACS Improper maintenance, poor design, improper aircrew technique, ETC. “MATERIAL FACTOR - THE CROSSFEED VALVE VAPOR LOCKED DURING SINGLE ENGINE OPERATION. ACCEPTED. COMPONENT: FUEL CROSSFEED VALVE MODE: VAPOR LOCKED AGENT: AIR INGESTION AGENT: DESIGN FAILURE

HFACS MATERIAL ANALYSIS Accepted Material factor may require an associated Human Factor AGENT: DESIGN FAILURE HUMAN FACTOR: NAVAIRSYSCOM FAILED TO UPDATE DESIGN. ACT: NONE PRECONDITIONS: NONE SUPERVISION: NONE ORGANIZATIONAL INFLUENCE: RESOURCE/ACQUISITION MANAGEMENT, OR 004 – PURCHASING OR PROVIDING POORLY DESIGNED OR UNSUITABLE EQUIPMENT ORGANIZATIONAL INFLUENCE: RESOURCE/ACQUISITION MANAGEMENT, OR 005 – FAILURE TO REMOVE INADEQUATE/WORN-OUT EQUIPMENT IN A TIMELY MANNER

REJECTED CAUSAL FACTOR Rejected because.... Did happen, but not in the chain of events Didn’t pass the Litmus Test Didn’t happen Why to include in the SIR Board looked into it as a possibility Endorser may question it Outside, LOOKING IN.” What would a Prosecutor ask?

REJECTED CAUSAL FACTOR HUMAN FACTOR - MP MISUSED ENGINE CONTROLS. REJECTED. THE MCP STATED HE MADE NO ATTEMPTS TO MANIPULATE THE ENGINE CONTROLS, EI REVEALED ALL COMPONENTS FUCTIONING, AMB DETERMINED IMPACT COMPRESSOR BLADE WITNESS MARKS SHOW THE ENGINES WERE AT APPROXIMATELY 93% RPM AND WITNESS INTERVIEWS SUGGESTED THEY HEARD A WHINING NOISE CONSISTENT WITH AN OPERATING ENGINE… (4 separate sources said it didn’t happen) THEREFORE, THE BOARD CONCLUDES THAT THE MP’S ACTIONS DID NOT CAUSE THE ENGINE FAILURE.

OTHER DAMAGE/INJURY Causal Factors Examples: True – it did happen If removed, the mishap still happens, but Avoidable damage or injury does not Examples: Non-crashworthy fuel system Inadequate survival training Faulty life support equipment Egress: Ejection / Helo Seat improper design

COMMON SIR MISTAKES (PG 102 SUPP) Causal Factor Paragraphs Individual did what ACT and Preconditions, Supervision, and/or Organizational Influences that lead to why it happened. Specific act of Commission or Omission Who and HFACs: Appendix L Comp had a failure Mode due to an Agent Smallest, most specific component, assembly or system How it failed (fracture, stripped threads, jammed, leaked) Acts or events which led to failure (fatigue, fire, over loaded) Only One Individual/ACT or Comp/Mode Many Human Factors or Agents

TAKE THESE LOE’S According to the fuel chit, the acft took with 2000 lb. fuel at 1425(L). (fuel chit) Cargo manifest listed 3 pallets of milk at 1000 lb. per pallet for a total weight of 3000 lb. (manifest) According to MHAC’s kneeboard card, acft weighed 20,300lb. with cargo and fuel. Kneeboard calculation also indicated 71% torque required for HOGE. (kneeboard card) (P) AMB determined that each carton of milk weighed 1 kilogram. There were 1000 cartons per pallet for total cargo weight of 6600 lb. (AMB worksheet) (P) AMB calculated acft weight with cargo to be 23,900lb.and Torque Required for HOGE is 85%. (AMB worksheet) CH-46 NATOPS indicates max gross weight is 23,000 lb. and max torque avail in mil is 81%. (NATOPS pg 3, para 2)

AND THESE According to the fuel chit, the acft took with 2000 lb. fuel at 1425(L). (fuel chit) Cargo manifest listed 3 pallets of milk at 1000 lb. per pallet for a total weight of 3000 lb. (manifest) (P) AMB determined that each carton of milk actually weighed 1 kilogram. There were 1000 cartons per pallet for total cargo weight of 6600 lbs vice 3,000 lbs. (AMB worksheet) According to MHAC’s kneeboard card aircraft weighed 20,300lb. with cargo and fuel. Kneeboard calculation also indicated 71% torque required for HOGE. (kneeboard card) (P) AMB calculated The AMB calculated MA weight was 900 pounds over max gross. (AMB worksheet) (P) AMB determined an engine direct from the manufacturer could not produce 85% torque at 23,900 lbs. (AMB worksheet) CH-46 NATOPS indicates max gross weight is 23,000 lbs and max torque avail in mil is 81%. (NATOPS pg 3, para 2) (P) No interviews with MAC indicate aircraft had engine problems. (MAC witness statements)

AND… Use lines of evidence: NATOPs, AMB calculations, witness statements, etc. Use the evidence to prove statement false and thus should be REJECTED. If true, use evidence to prove it didn’t lead to the mishap or other damage and injury

VOILA! Material Factor - Engines failed to produce sufficient power. Rejected. The cargo manifest incorrectly stated the milk was in pounds instead of kilograms. The AMB calculated MA weight was 900 pounds over max gross. CH-46 max torque available for NATOPs limited gross weight is 81%. AMB calculated max torque needed to fly, being 900 pounds overweight, was 85%. Even a perfectly functioning, brand new, out-of-the box engine could not produce 85% torque at that gross weight and would not have given them the power required to maintain flight. MAC never voiced concerns about an engine failure. Therefore, the board concludes that the engines were functioning normally at the time of the mishap. When REJECTED: Close with: Therefore, the board concludes that

VOILA! PART DEUX Human Factor - MHAC exceeded gross weight limits for CH-46. Accepted. Lines of evidence that support your analysis and tell the story “beyond a reasonable doubt” - Close with: Based on the above analysis the AMB concludes that the MHAC exceeded gross weight limits for the CH-46 due to critical information not communicated. Human Factor: MHAC exceeded gross weight limits for CH-46. Act: Skill Based Error, AE 103 - Procedure not followed correctly Precondition: Communication Factors, PP 106 - Critical Information Not Communicated Precondition: Perceptual factors, PC 506 - Inaccurate Expectation Supervisory: None Organizational Influence: Organizational Processes, OP 001 - Pace of Ops-tempo Creates Unsafe Situation

IDENTIFY CAUSAL FACTORS Two or more causal factors “Chain of events” Litmus test Remove the factor - Does the mishap occur? Rejected Causal Factors What does everyone else think caused the mishap??? Other Identified Non-Causal Hazards If it couldn’t CAUSE the mishap or other damage or injury THEN it doesn’t belong in the SIR Environment doesn’t CAUSE mishaps Environment doesn’t Cause the Mishap, it may be responsible after you have ruled out all the Human Factors as being Causal to the Mishap and you don’t have any left, then you can say the Environment is Responsible.

ANALYSIS SUMMARY Rejected Material or Human Factor Accepted Material or human Factor CF: Who did What or Comp/Mode statement. ACCEPTED Prove the statement is True Show how it led to the mishap or other damage/injury Discuss Why: HFACS/Agent Conclude with: Based on the above Analysis The AMB concludes that… restate EXACTLY your opening Who did What or Comp/Mode statement due to an L code or Agent. YES: HFACS and Nano coding YES: COMP, MODE, AGENT Rejected Material or Human Factor CF: Who did What or Comp/Mode. REJECTED Prove the statement is False, or Even if it is TRUE that it DID NOT lead to the mishap (or other damage and injury) Conclude with: Therefore, the Board concludes that... - No HFACS nor Comp, Mode, Agent

OTHER DAMAGE/INJURY Separate Causal Factors Avoidable damage Same “litmus test” as Mishap Causal Factors Examples: Non-crashworthy fuel system Inadequate survival training Faulty life support equipment Non-compatible equipment Violation of Policy (SOP, 3710, NATOPS)

HUMAN FACTOR MP FAILED TO LOWER THE LANDING GEAR AN E.I. REVEALED LANDING GEAR SYSTEM WAS FULLY OPERATIONAL AT THE TIME OF THE MISHAP AND POST-MISHAPINVESTIGATION AND PHOTOGRAPHS INDICATE THE LANDING GEAR HANDLE IN THE UP POSITION. MP HAD ONLY FOUR HOURS SLEEP (PC-307) PRIOR TO THE FLIGHT. THE COMMAND DID NOT HAVE AN ADEQUATE DUTY OFFICER INSTRUCTION AND THE DUTY OFFICER CALLED THE MP TO ANSWER SCHEDULING QUESTIONS THEREBY, NOT ALLOWING HIM THE REST REQUIRED BY OPNAVINST 3710.7 (SV-001). BASED ON THE ABOVE ANALYSIS THE AMB CONCLUDES MP FAILED TO LOWER THE LANDING GEAR BECAUSE HE LACKED ADEQUATE REST AND WAS DISTRACTED BY A RADIO CALL. RAC-1 ACCEPTED.

OTHERS To avoid command influence, Appointing Authorities or any endorsers of an SIR SHALL NOT review a class A SIR prior to its release via message. Appointing authorities of Class B and C AMBs may review SIRs for completeness (as opposed to review for concurrence or non-concurrence) prior to the release of the SIR message and mailing of the enclosures. Should the appointing authority consider the investigation or report incomplete, he/she should send the report back to the AMB along with sufficient direction to ensure an acceptable. (pg 7-29) OPNAV 3750.6R page 7-29

AMB CONDUCT DETERMINE CAUSAL FACTORS (CFs): WHO did WHAT WHY HFACS: Human Factor, Acts, Preconditions, Supervision, Organizational Influence Component, Mode, Agent (HFACS if involved) DETERMINE DOMINO CHAIN OF EVENTS for CFs: Usually Chronologically WHO did WHAT and WHEN Policy, Planes/Parts, People Have it make sense for your SIR Time Management – 4 Hours dedicated for Deliberation: SAS Instructors for Guidance Senior Member for Steerage Everyone has a vote Don’t be Narrow minded, Something unusual rears its head

AMB CONDUCT OTHERS: REJECTED CFs are almost as important as ACCEPTED What will someone from the outside looking-in think caused this mishap Now, PROVE him wrong RECOMMENDATIONS: Natural Progression after CFs How to fix it today, tomorrow, and the future Squadron, Community, Navy