SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents

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

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

SouthwestCirrus.com Definitions LAZY 8 SC Owner 7 Mechanics

SouthwestCirrus.com Definitions DIVE Local pilot hangout

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

SouthwestCirrus.com Definitions SUITABLE LANDING FIELD The good-looking one

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

SouthwestCirrus.com 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

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

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

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

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

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

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

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

SouthwestCirrus.com Prioritization Life –Limb Environment –Economy Your priorities may not match other stakeholders Burden may shift, but not OPR

SouthwestCirrus.com Distribution All stakeholders need access to info OPR must take the lead ASRS?

SouthwestCirrus.com Causal Analysis Direct and root causes Why? OK, then why that? DIRECT CAUSE PROXIMATE CAUSE PROXIMATE CAUSE ROOT CAUSE PROXIMATE CAUSE ROOT CAUSE

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

SouthwestCirrus.com Dissemination Allocation of resources Action offices Limit to interested parties

SouthwestCirrus.com Resolution Tracking Employment/Resolution Continuous process improvement Solution Identification Implementation ResultsDissemination Process Improvement

SouthwestCirrus.com Case Study Subject: Electrical System From: Date: 9/19/2005 7:12 pm To: …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?)… Subject: Electrical System From: Date: 9/19/2005 7:12 pm To: …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?)…

SouthwestCirrus.com 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

SouthwestCirrus.com Case Study Subject: Electrical System From: Date: 9/19/2005 7:12 pm To: …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 Subject: Electrical System From: Date: 9/19/2005 7:12 pm To: …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......

SouthwestCirrus.com Case Study Analysis Incomplete causal analysis  Incomplete solution identification  Repeat failure Distribution and Dissemination?

SouthwestCirrus.com 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.