ASSASS

Mr. Bob Hahn

Associate Director, School of Aviation Safety

Naval Aviation Schools Command

NAS Pensacola

MISHAP PREVENTION EDUCATION

IN

NAVAL AVIATION

ASSASS SIGNAL CHARLIESIGNAL CHARLIE

Dallas TX 29-30 Mar 2011Dallas TX 29-30 Mar 2011

ASSASS 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 …

ASSASS It’s a big outfit

• … that’s the mission of the USN/USMC School of Aviation Safety and the Naval Safety Center

Navy/Marine Corps Navy/Marine Corps ChallengeChallenge

““I challenge I challenge all of you to all of you to reduce reduce mishaps . . . mishaps . . . at least 75% at least 75% by FY 12.”by FY 12.”

--Secretary of Defense--Secretary of Defense

ASSASS Purpose of the ASO CoursePurpose of the ASO Course

• Prepare officers in the policy, philosophy, and techniques of Prepare officers in the policy, philosophy, and techniques of managing and effective command aviation safety programmanaging and effective command aviation safety program

• Teach mishap investigation and preparation of investigation Teach mishap investigation and preparation of investigation reportsreports

• Educate officers in aeronautical topics to add to the Educate officers in aeronautical topics to add to the professional knowledge base in fleet squadrons in order to professional knowledge base in fleet squadrons in order to cultivate critical thinking skills which in turn contribute to cultivate critical thinking skills which in turn contribute to safety in the dynamic environment of naval aviation.safety in the dynamic environment of naval aviation.

ASSASS

• Enhance Combat Readiness!

• Operational Risk Management

• Training and Education

• Accountability

• Leverage New Technologies

• Proactive vs Reactive

• Mishaps vs Accidents

NAVAL SAFETY STRATEGY

Naval Aviation Safety Programs (SMS)

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

SAFETY EDUCATIONSAFETY EDUCATION

Its more than just education, its about Its more than just education, its about leveraging the Navy-Marine Corps culture leveraging the Navy-Marine Corps culture and inspiring our students to create a and inspiring our students to create a climate within the command that influences climate within the command that influences good decision making at all levels.good decision making at all levels.

Navy-Marine Corps leadership translates Navy-Marine Corps leadership translates into practices and behaviors that result in into practices and behaviors that result in safe operations which in turn enhance safe operations which in turn enhance mission effectivenessmission effectiveness

ASSASS 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

ASSASS 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

ASSASS

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

UnsafeSupervision

Loss of Situational Awareness

Poor Crew Resource Management

Preconditionsfor

Unsafe Acts

Failed to Scan Instruments

Penetrated IMC when VMC only

UnsafeActs

Mishap & Injury

Crashed into side of mountain

Failures in theFailures in theSystemSystem

ASSASS

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

ASSASS HAZARD REPORTINGHAZARD REPORTING

• Every mishap represents many more near Every mishap represents many more near misses and incidents that may go unreportedmisses and incidents that may go unreported

• ““Obligation” to report HazardsObligation” to report Hazards• Identify Human or Material Causal FactorsIdentify Human or Material Causal Factors• Recommend Recommend corrective actioncorrective action to Eliminate to Eliminate

the Hazard (Minimize/Mitigate Risk)the Hazard (Minimize/Mitigate Risk)• Document a continuing hazard to establish Document a continuing hazard to establish

severity/probability and FUNDING to severity/probability and FUNDING to eliminate Hazardeliminate Hazard

• Proactive vs ReactiveProactive vs Reactive

ASSASS SUMMARY

Active Safety Climate Set by Leadership and Required by All

Hands

Mishap Prevention Leads to Combat Effectiveness