1. Mr. Bob Hahn Associate Director, School of Aviation Safety Naval Aviation Schools Command NAS Pensacola MISHAP PREVENTION EDUCATION IN NAVAL AVIATION

2. SIGNAL CHARLIE Dallas TX 29-30 Mar 2011

6. It’s a big outfit We have a lot (over 300) Squadrons We have a lot of people – staff, maintainers, pilots, aircrew We have a broad span of operations How to daily make the right decisions at all levels, and operate the airline company safely …

7. It’s a big outfit … that’s the mission of the USN/USMC School of Aviation Safety and the Naval Safety Center

8. Navy/Marine Corps Challenge “I challenge all of you to reduce mishaps... at least 75% by FY 12.” --Secretary of Defense

9. Purpose of the ASO Course Prepare officers in the policy, philosophy, and techniques of managing and effective command aviation safety program Teach mishap investigation and preparation of investigation reports Teach mishap investigation and preparation of investigation reports Educate officers in aeronautical topics to add to the professional knowledge base in fleet squadrons in order to cultivate critical thinking skills which in turn contribute to safety in the dynamic environment of naval aviation. Educate officers in aeronautical topics to add to the professional knowledge base in fleet squadrons in order to cultivate critical thinking skills which in turn contribute to safety in the dynamic environment of naval aviation.

11. ... 80% of our mishaps are attributable to human error …

12. ... The science of human factors has studied the root causes of why we make mistakes …

13. ... But how to make this academic and theoretical framework a practical solution? …

14. ... That’s where Programs come in. Programs are the rules we comply with, and the things we do in the squadron, in the aircraft, and in our daily actions…

15. ... Good programs take the human factors academic underpinnings and make them “the way we do business.” …

16. ... You will see the link between the programs you are required to administer and their human factors underpinnings. …

17. ... In this way, you will see programs as a proactive mechanism to manage human factors and behaviors to effect positive outcomes in all your squadron’s endeavors. …

18. ... An effective safety program takes daily effort, hard work, and above all, leadership on your part. As an ASO …

19. Enhance Combat Readiness! Operational Risk Management Training and Education Accountability Leverage New Technologies Proactive vs Reactive Mishaps vs Accidents NAVAL SAFETY STRATEGY

20. Naval Aviation Safety Programs (SMS)

21. SAFETY EDUCATION Aviation Safety Command Course  6 Days  Commanding Officers Aviation Safety Officer Course  Aviation Safety Officers  4+ Weeks Intensive Instruction Crew Resource Management Course  5 Days  Train the Trainer

22. SAFETY EDUCATION Its more than just education, its about leveraging the Navy-Marine Corps culture and inspiring our students to create a climate within the command that influences good decision making at all levels. Navy-Marine Corps leadership translates into practices and behaviors that result in safe operations which in turn enhance mission effectiveness

23. COMMANDING OFFICERS Entrusted with every aspect of Squadron Operations “Naval Aviation Safety program is an inherent responsibility of command.” Set Standards and Ensure Accountability Enable a Just Culture to establish a Command Climate that will promote safe and professional operations to achieve mission accomplishment

24. AVIATION SAFETY OFFICER Act as principal advisor to Commanding Officer on all aviation safety matters Advise and assist Commanding Officer in complying with instructions Maintain safety records & mishap statistics “ASO” shall be primary billet assignment Coordinate safety matters among squadron staff Graduate of ASO course (recommended within 4 yrs.) Principal Investigator for mishaps and near misses

25. The “Swiss Cheese” Model of Accident Causation (Reason, 1990)  Excessive cost cutting  Reduction in flight hours resulting from inability to control cost of spare parts Organizational Factors  Deficient training program  Improper crew pairing Unsafe Supervision  Loss of Situational Awareness  Poor Crew Resource Management Preconditions for Unsafe Acts  Failed to Scan Instruments  Penetrated IMC when VMC only Unsafe Acts Mishap & Injury  Crashed into side of mountain Failures in the System

26. SAFETY INVESTIGATION REPORTS (SIR) The final product written by the Aircraft Mishap Board after a mishap Used to Report Hazards Uncovered by the Investigation Offers Opportunity to Make Recommendations Assigns Risk Assessment to Each Hazard Command Influence Strictly Prohibited Requires “Special Handling” Due to Privileged Info

27. HAZARD REPORTING Every mishap represents many more near misses and incidents that may go unreportedEvery mishap represents many more near misses and incidents that may go unreported “Obligation” to report Hazards“Obligation” to report Hazards Identify Human or Material Causal FactorsIdentify Human or Material Causal Factors Recommend corrective action to Eliminate the Hazard (Minimize/Mitigate Risk)Recommend corrective action to Eliminate the Hazard (Minimize/Mitigate Risk) Document a continuing hazard to establish severity/probability and FUNDING to eliminate HazardDocument a continuing hazard to establish severity/probability and FUNDING to eliminate Hazard Proactive vs ReactiveProactive vs Reactive

28. SUMMARY Active Safety Climate Set by Leadership and Required by All Hands Mishap Prevention Leads to Combat Effectiveness