1-212 th Aviation Regiment SAFETY Accident Trends Accident
Prevention PL Procedures SOP Close Call Program Topics of
Discussion
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1-212 th Aviation Regiment SAFETY FY05 Class A 2 Class B 0
Class C 3 (2 material failure) Class D 6 (1 material failure) FY06
Class A 0 Class B 1 Class C 1 Class D 3 (1 material failure)
Battalion Accidents
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1-212 th Aviation Regiment SAFETY FY07 Class A 1 Class B 0
Class C 3 (2 ground, off-duty) Class D 3 (1 bus/pick up on flight
line) Class E 1 (reach pendant broke) FY 08 Class D 1 (Bird Strike)
Battalion Accidents
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1-212 th Aviation Regiment SAFETY FY 09 Class B 1 ( Blade
Strike @ Monroeville) Class D 2 (Search light, Bird Strike) Class E
7 (Search + landing lights, Birds, ENG Failure ) FY 10 Class D 1
(LTE, Overtorque) Class E 2 (#1 ENG Fire Light, ENG Failure)
Battalion Accidents
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(H) Stabilator damage found on post flight 26-JUL-05Crusader 90
86-24475 (E) Bird strike. Right chin bubble and foot plate
13-OCT-04 LSI $1,233.01 69-16226 OH-58 LSI Air Class E w/ damage
UH-60 E Air (H) Stabilator contact w/ gnd. Evasive
maneuver04-APR-05Crusader 89$8,392.0086-24514UH-60EAir (M)
Windshield cracked, anti-ice23-MAR-05Crusader
43$3,760.3285-24440UH-60EGDN (M) Broken tail wheel
assembly08-FEB-05Crusader 44$19,491.6186-24565UH-60EAir (H)
Stabilator contact with gnd. Terrain flt
decel18-JAN-05Wise$7,941.7587-24613UH-60EAir (H) Tail wheel damage
during ground taxi29-OCT-04Eagle 47$12,638.0084-24024UH-60FAirClass
D (M) Engine failure
in-flight28-JUN-05Gustafson$117,44671-20513OH-58LSIAir (H)
Fractured foot during PT test28-APR-05FergusonLost daysN/A EGND (H)
Cracked ribs, bruised lung during motorcross12-FEB-05KoberLost days
69-16307 EGND (H) Rolled ankle while washing
car12-DEC-04BumgardnerLost daysHHCGND (H) T/R tree strike, NVG, FS
XXI02-DEC-04Crusader 83$75,171.2486-24565UH-60EAirClass C Class B
(H) Uncommanded left yaw, D, BCS, FSXXI 29-MAR 05 Crusader 63
$6,600,00 81-23551 UH-60 E Air (H) Tower & wire strike (IPC)
12-FEB-05 Eagle 54 > $2M 86-24574 UH-60 F AirClass A
RemarksDateCall SignECODTail # A/C TypeUNITAir/Ground FY 05
Accidents Air E E UH-60 86-24575 $4,324.14 $133.00 Crusader 57
Crusader 66 16-APR-05 (H) Landing light / WOW switch. Roll-on. BCS,
Day AirLSI OH-58 PendingSamari 1404-APR-05(M) Hot start. Replaced
engine N/A 85-24404 $1763.64 (H) Stabilator contact with gnd.
Recovery of roll-on Air E UH-60 85-24443 Pending Crusader 63
19-SEP-05(H) SEF hover, broken tail wheel, day, FSXXI
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1-212 th Aviation Regiment SAFETY November 4, 2006, Class-C
Accident Tip of thumb cut off using home table saw. human error
November 6, 2006, Class-C Accident Broken wrist from falling off a
horse, off duty. February 12, 2007, Class-D Accident. Damage to
tail yoke assembly by over controlling pedals with a broken tail
lock pin. Pilot didnt recognize it was broken as the switch still
indicated locked. Human error March 10, 2007, Class-A Accident
UH-60A, While performing a roll on landing the aircraft touched
down with nose left of center. Right strut snapped under sideward
pressure. May 3, 2007, Class-D Accident. Lowe shuttle bus collided
with ACLC pickup while bus driver was executing a left turn. The
driver failed to see the oncoming traffic. Human error July 11,
2007, Class-D Accident. Bird strike with TH-67, damage below
windscreen. FY 2007Accident Rate
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1-212 th Aviation Regiment SAFETY FY05 Trend Analysis 10 Class
A E w/ damage Human Error Aviation Accidents UH-6010 of 10 Tactics
6 of 10 Aircraft Tail 8 of 10 Recent MOI Grad 8 of 10 FSXXI 8 of 10
IP on Controls 5 of 10 Guest IP 4 of 10 NVG 3 of 10
UH-60 Roll On E 1-212 AVN For Accident Prevention Purposes
Only
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Summary of Event Date: 31 March 2004 Time: 1525 Hrs
Location:Stinson Stagefield Synopsis: While performing a roll on
landing during Flight School XXI, the main rotor blades contacted
the tail rotor drive shaft. Remarks: Class B ($467,000 ECOD)
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UH-60 Tail Rotor Strike E 1-212 AVN For Accident Prevention
Purposes Only
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Details of Event Date: 02 December 2004 Time: 2055 Hrs (NVG)
Location: RT 186 (EV879557) Synopsis: While turning during a 15ft
AGL hover, the crew of a UH-60 felt a vibration coming from the
tail of the aircraft. The crew flew the aircraft approximately 60
meters away then turned to see they had struck a tree. Inspection
revealed damage to all tail rotor blades and the stabilator. Class
C Accident, $75,171.00 damage
Distance Estimation Site (North Hover Area) LOWE AHP
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45 30 S W E N 45 degrees, 3 disk (not to scale) 30 degrees, 3
disk (not to scale) Lowe AHP Distance Estimation Site Site enables
IPs to train and demonstrate safe distance estimation cues for the
UH-60 to aid in clearing the tail. Also aids on recognizing proper
formation distance of 3 disk for multiship purposes Distance
measured from cockpit to tail +
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UH-60 Stabilator Damage E 1-212 AVN For Accident Prevention
Purposes Only
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Summary of Event Date: 04 April 2005 Time: 2047 hrs Location:
RT 367 (16R EV 985373) Classification: Class D ($8,392.00) Remarks:
Health Usage Monitoring System (HUMS) installed
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Summary of Event Synopsis: While conducting a terrain flight
deceleration in conjunction with an evasive maneuver, during
Initial Entry Rotory Wing (IERW) NVG training, the stabilator of
the UH-60 contacted the ground. The flight crew was unaware of the
ground contact and continued the mission. During post flight
inspection the crew did not inspect the stabilator. Inspection by
maintenance personnel the following morning revealed damage to the
trailing edge of the stabilator.
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TM 1-1520-237-10 para 9.12.b With pitch attitude beyond 25
there is the possibility of ground contact with the stabilator
trailing edge.
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BACKGROUND UNIT: E Company, 1-212 th Aviation Regiment
EQUIPMENT: UH-60A DATE/TIME: 29 MAR 05 / 0817(L) LOCATION: TAC X
RESULTS: Aircraft Destroyed COST: $6,600,000 MISSION: Individual
Aircrew Training, UH-60 Basic Combat Skills Training
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Board Synopsis Human ErrorTraining Failure. That is, the
Instructor Pilot (IP) through lack of experience and training,
perceived an emergency situation (left yaw as loss of tail rotor
thrust) and responded with an inappropriate procedure for the
perceived emergency. This caused the aircraft to impact the ground,
destroying the aircraft and injuring the occupants.
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330
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TAC X
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UH-60 Tower Strike F 1-212 AVN For Accident Prevention Purposes
Only
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Summary of Event Date: 28 February 2005 Time: 2257 hrs
Location: 16R FV 13584971 Synopsis: While in low level flight at
100 kts, on an IPC NVG mission, the UH-60 struck an unlit radio
tower. The crew felt a sharp jolt followed by severe vertical
vibrations. During the emergency (forced) landing the aircraft
struck wires and came to rest on its left side. Remarks: Class A
(>$2M).
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Radio Tower Power Line A/C N
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Broken Poles
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BACKGROUND UNIT: UH-60 -- F Co, 1-212 th Aviation Regiment
OH-58 LSSI, Tactics Division, Shell Field EQUIPMENT: UH-60A, OH-58C
DATE/TIME: 11 May 06 / 2253(L) LOCATION: 16R FV76387079 (Elba AL.)
RESULTS: Two Aircraft Moderately Damaged COST: $376,903.13 +
$65,352.00 = $442,255.58 MISSION: Individual Aircrew Training,
UH-60 Instructor Pilot Course and OH-58 Basic Combat Skills
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RT 216 400m
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1-212 th Aviation Regiment SAFETY
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1-212 th Aviation Regiment SAFETY
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FACTOR ANALYSIS ENVIRONMENTAL: Not Contributing MATERIEL: Not
Contributing HUMAN: Present & Contributing
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PRESENT AND CONTRIBUTING: (Human Error Individual Failure) Both
aircrews failed to detect another aircraft that was closing on
their position while in the terminal area of the landing site Both
Aircrews failed to ensure that adequate scanning techniques were
used in vicinity of the landing site That is, they failed to
Maintain Airspace Surveillance while performing terrain flight
FINDING - 1
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PRESENT AND CONTRIBUTING: (Suspect Human Error Individual
failure) During NVG terrain flight to RT 216, the UH-60A and OH-58C
aircrews did not hear the other aircraft transmitting on the
assigned RT frequency. FINDING - 2
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PRESENT AND SUSPECT CONTRIBUTING: (Human Error Individual
failure) Both Aircrews failed to ensure proper radio procedures
were followed. Mandatory "1K call" required by the 1-212th SOP was
not accomplished at the correct location in order to advise other
traffic in the vicinity of the RT. Accomplishment of this call may
have alerted the other aircraft vicinity of the RT of his presence
FINDING - 3
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UH-60 Roll On E 1-212 AVN For Accident Prevention Purposes
Only
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While conducting a roll-on landing at Skelly Stagefield in a
UH-60A during Initial Entry Rotary Wing training, the instructor
pilot (IP) failed to take appropriate action to correct an unsafe
condition. That is, when the pilot trainee (PT) improperly
manipulated the flight controls, the IP allowed the flight
condition to deteriorate beyond acceptable limits contrary to
guidance in TC 1-237. As a result, in the ensuing crash, the
aircraft was destroyed, the instructor pilot (IP) received fatal
injuries, and three PTs received minor injuries. Roll On, Class A,
10 MAR 07
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SE NW SW NE SS W W E E NN
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1. 2. 3.4. Aircraft touches down nose high, heading left of
centerline Right main landing gear touches down hard with minimal
collective and aft right cyclic inputs. Main rotor blade contacts
and severs tail rotor drive shaft Right main landing gear drags
right until strut snaps off Rotors contact ground and aircraft yaws
to the right 540 degrees, breaking off the tail section in the 2 nd
180 degrees
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W W E E N N S S NW NE SW SE
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Tailboom Tail Rotor Gearbox SE NW SW NE SS WW EE NN AFT Troop
Seat
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FY 09 Accident Pictures
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1-212 th Aviation Regiment SAFETY Down and Safe An aircraft
with an emergency that has landed without any damage to the
aircraft, civilian property, or any injuries. Must be released by
competent maintenance personnel to the PC depending on
circumstances prior to recovery. The following are examples of down
and safe. engine chip light master caution light with no other
indications low fuel indications weather boost off conditions ECU
will not go out of LOCKOUT Hydraulics off Tail wheel pin broken**
Engine failure (when no visible damage occurs) Completion of an
AAAR or AAAR worksheet is required to be filed at the appropriate
Basefield Operations. The release authority for the crew is the
PIC. SOP
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1-212 th Aviation Regiment SAFETY Down with Suspected
Damage/Injury When an aircraft has landed with the possibility of
damage or personnel injury: (a) The following incidents are
examples of down with suspected damage and can be released by the
Battalion Commander. spike knock (once confirmed by maintenance)
bird strikes hot start overspeed over temp over torque (b) The
following incidents are categorized as down with suspected injury
and can only be released or transported by FLATIRON. sick flight
personnel smoke and or fumes in the aircraft Any injury that occurs
during flight duties after takeoff Completion of an AAAR or AAAR
worksheet is required to be filed at the appropriate Basefield
Operations. SOP
1-212 th Aviation Regiment SAFETY Secured area An area, which
provides sufficient protection to preclude vandalism or
unauthorized tampering with the aircraft. The following are
considered secure areas: (a) Military airfields, which are
operational or have a monitor/guard during non-operational hours.
(b) Any area, which has military personnel or civilian police on
duty as monitors/guards. (c) Stagefields will be considered secure
areas as long as a stagefield crew (ATC operator) is on duty or
during hours of operation as depicted on Fort Rucker Form 196,
Stagefield and Support Requirements. Secure Airfield An airfield
that has a tower that is staffed by military personnel and is
operational. Example If an aircraft is left at an airfield, other
than a basefield, that has a tower staffed by military personnel
and is operational, the responsibility of security is transferred
to the tower personnel, who are required to remain on site until a
guard arrives, thereby maintaining uninterrupted aircraft security.
SOP
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1-212 th Aviation Regiment SAFETY Logbook Entries following a
PL: Prior to recovery of aircrews, the aircraft must be marked with
chemsticks and a write-up entered on the DA Form 2408-13-1. The
entry will state, chemstick markers placed on tail rotor and
windshield, along with a write-up explaining the deficiency. The
aircraft key will be returned to the basefield operations upon
return. Crash Control: PLs for other than low fuel and weather
require notification of Cairns Crash Control. No one may interrupt
the crash system sequence once a PL has been declared. The aircrew,
cover ship, AMC, or ATC will not reject flatiron. PL aircraft will
not be moved unless released by maintenance personnel or the
Battalion Commander or designated representative as applicable.
PC/IP Responsibilities: The PC will remain with the PL aircraft at
unsecured locations until relieved by maintenance or a guard.
SOP
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1-212 th Aviation Regiment SAFETY AAAR/ACR Requirements: 1.
After making a PL, aircrews will report to their Basefield
Operations and complete the DA Form 2397-AB (AAAR) IAW the example
posted in operations. The AAAR will be completed by the IP/PC
anytime after the starter is energized and an unscheduled
termination occurs, regardless of whether or not a PL is declared.
It is incumbent of the PC that the AAAR or AAAR worksheet is
completed at appropriate Basefield Operations, as soon as
practicable after the incident. 2. An aircraft landed due to a
weather PL will complete the AAAR with aircraft recovered or
aircraft secured at, and give location. 3. A complete form to
include Page 2 is required anytime damage or injuries exist. 4.
Completion of an Aircraft Condition Report (ACR) is required
anytime scheduled maintenance is not completed properly, aircraft
condition is not flyable, and the starter switch(s) have not been
pressed. SOP
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1-212 th Aviation Regiment SAFETY Downed Aircraft Site: The
crew of the first aircraft discovering an accident/incident will
orbit the area not lower than 500 AGL, squawk emergency, and
contact HUB/ATC, giving approximate location and request that radar
position be marked and reported to Crash Control. The aircraft will
continue to orbit as long as practical, or until FLATIRON, THE
BATTALION SAFETY OFFICER / DESIGNATED REPRESENTATIVE, or a
MAINTENANCE recovery aircraft arrives. Extreme care will be
exercised if landing is necessary to render emergency assistance to
the downed aircrew. Aircraft landing at the crash site will ensure
adequate safe landing area remains for FLATIRON. Pilots will
monitor frequencies 30.10 FM and 139.450 and 243.0 UHF. Solo
aircraft may be relieved by any aircraft with two rated aviators
onboard or any aircraft with an Instructor Pilot onboard. SOP
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1-212 th Aviation Regiment SAFETY USAAVNC Form 1891 Dated FEB
2009 BN OPS 255-4033 (Lowe) / 255-4157 (Shell) BN SAFETY 255-4372
BN SAFETY Cell (334) 470-7635 HUB Radio 255-8431/8435
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1-212 th Aviation Regiment SAFETY Crew Endurance: Maximum duty
hours per day 12 Maximum factored flight hours per duty day 8
Maximum factored flight hours per 7-day period 40 Maximum factored
flight hours per 30-day period110 NOTE 1: Factors applying to
aircraft time flown: Day/SFTS1.0 Contact/Combat Skills/Terrain
Flight1.5 Spanish/MTP1.5 Night /Instrument/Hood/NVG2.0 3:1
Flight2.0 NOTE 2: The Battalion Commander is the extension
authority and is the only person that can authorize deviations of
any crew endurance factors. SOP
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1-212 th Aviation Regiment SAFETY The individual aviator will
ensure he does not exceed crew endurance limits. The individual
aviator is the final authority when fatigue is a factor for flight.
The duty day begins when the aviator departs his place of residence
enroute to duty and ends when he is released from duty. Crewmembers
will receive at least 10 hours of off duty time between duty days.
Crewmembers will receive at least 10 hours off between shift
changes from AM/PM to Nights or from a Night schedule to an AM/PM
schedule. SOP
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1-212 th Aviation Regiment SAFETY Student Pilots: Students will
not factor their individual flight times. Flight time, including
OR/CP time, will not exceed 6.0 hours daily. IERW NVG PI time will
not exceed 2.5 hours per training day. IPC and AQC will not exceed
4.0 hours of NVG time per training day. SOP
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1-212 th Aviation Regiment SAFETY Any tools or maintenance
equipment found in or around the helicopter will be reported to
ACLC immediately. Do not move the FOD until ACLC has completed
their inspection. All personnel are required to police the aircraft
and the immediate area around the parking pads for objects that
could create a FOD hazard. Report significant FOD hazards to the
Battalion FOD Control Officer or Safety Officer as soon as possible
to help prevent recurrence of similar problems. Dont leave FOD
(cans, papers etc.) behind. FOD
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1-212 th Aviation Regiment SAFETY FOD EXAMPLES
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The program was developed to fill the gap between accident
reporting and the avoided accident to identify hazards prior to an
accident occurring Prior to the program, the first time a hazard
was recognized was when an accident occurred Close Call
Program
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Hazards are reported via a sheet located in all briefing and
debriefing rooms The unit ASO is responsible for collection and
database entry The applicable ASO reports to the commander any new
hazards or spikes of a particular hazard Close Call Written On
Close Call Sheet Annotated in database Database Searched Weekly
Risk is Determined Awareness Conducted Reporting &
Tracking
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What this gives the Commander
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Random Hazards The command is made aware of new hazards and the
risk management process can be implemented Driven Hazards The
command is made aware how their policies or procedures may be
causing unwarranted risk The command can make a risk decision based
upon the data and adjust policies or procedures accordingly What
this gives the Commander
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An MS Access based database Can data mine info based on the
completed fields: Location Time Task The Close Call Database
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Queries of specific hazards Provides objective data to leaders
Commanders Tools
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Falcon View Overlay: Allows data to be displayed visually Crew
briefings / Awareness TNG Commanders Tools
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Falconview 10
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Advantages Ease of use Performance metric Identifies previously
unknown risk Provides Historical Continuity Instills sharing not
shying Disadvantages Requires active participation by unit members
Additional work for ASO or designated assistant. Advantages vs.
Disadvantages