National Safety Team FY11 Mishap Review and Recommendations 1 Oct 2011 – 30 June 2011

1. National Safety TeamFY11 Mishap Reviewand Recommendations1 Oct 2011 – 30 June 2011

2. Mishap Review Overview • Mishap Classification Trends • Expanded Classification Details • Bodily Injury – Suggested Focus Areas • Bodily Injury Prevention Recommendations • Expanded Classification Details • Vehicle – Suggested Focus Areas • Vehicle Mishap Prevention Recommendations • Expanded Classification Details • Aircraft – Suggested Focus Areas • Aircraft Mishap Prevention Recommendations • National Safety Team Comments • Closing Emphasis

3. Mishap Classification Trends • The following graphs depict the current mishap classification trends based on the recent National Board approved classification changes to CAPR 62-2.

4. Mishap Classification Trends • Bodily Injury mishaps continue to lead aircraft and vehicle mishaps and recommendations to abate bodily injury mishaps should be considered for prevention of future occurrences. • Vehicle mishaps have increased this year. CAP has had two major vehicle accidents resulting in the total loss of CAP assets. Both mishaps were on exit ramps. One lost control due to road conditions, the other attributed to lack of familiarity and fatigue.

5. Mishap Classification Trends • Pre-existing conditions lead the trend rate of mishaps that only the individual member can control. These are a result of unknown or undeclared medical conditions. If CAP leaders know of a pre-existing condition, restrictions must be observed and members should consider non-participation, as one option, to prevent exposure or added risk or responsibility to other participants and CAP leaders. • Bodily injury mishaps have the highest occurrence among ALL reported mishaps. Emphasis on program changes should be immediate and recommendations should be strongly considered to reduce future occurrences.

6. Mishap Classification Trends • Vehicle mishap reporting is showing a positive balance of accidents, incidents, and minor mishaps. Emphasis on safety deviation reporting is highly recommended. • Mishap reporting for vehicle mishaps have demonstrated a large number of weather related mishaps, not previously noted. This classification of mishap may require review of vehicle parking protocols to include covered parking options. • The increase in the classification of OTHER is primarily related to wildlife strikes, primarily deer (5).

7. Mishap Classification Trends • Aircraft mishap reporting has balanced from previous fiscal years. This is an indicator that CAP members have begun to trust the safety program, previously deemed very negative. This positive improvement is also noted by Near-Miss and Safety Deviation reporting, areas that could benefit CAP by increased emphasis. • All mishaps are closely reviewed in this area to ensure accuracy of reporting and alignment with NTSB reporting rates

8. Expanded Classification Trends • Pre-existing Conditions are defined as any mishap where a member’s undisclosed, underlying medical condition results in a mishap, or significantly aggravates the ultimate outcome. This could also be attributed to a member’s failure to follow limitations set for a disclosed medical condition. This includes chronic (e.g., diabetes, asthma) and acute (e.g., knee sprain, concussion). • The shuttle run for cadets was an emphasis item in FY10 and improper posture in formations resulting in fainting injuries remains high. One cadet required an airlift for treatment after a fainting injury while representing CAP.

9. Bodily Injury Prevention Recommendations • It is recommended that Wing Commanders follow-up with all members that are party to mishaps that result due to pre-existing conditions. A stern progressive handling of this with direct contact to the member or parents of cadets, starting with an education letter of CAP’s requirements and limitations from the Wing Commander. NHQ Safety, in coordination with GC, will provide a template draft for approved use. • For all physical fitness training an understanding of appropriate warm-ups must be implemented. More importantly, leadership oversight must ensure members, particularly cadets are held accountable to perform proper warm-ups and stretching as required. Non-compliance to this requirement should result in non-participation. Additionally, risk management evaluations must be completed to ensure training surfaces are appropriate and without hazards, such as holes, sand, or other hidden objects in grass areas where PT may be performed. Consideration should always be given to the physical ability of the member participating. Unnecessary pressure from cadet or senior member leaders should be avoided.

10. Expanded Classification Trends • Weather has again taken it’s toll on CAP’s vehicles. Hail damage and debris has had an impact on CAP’s vehicles, pun intended. CAP vehicles should be strategically parked and garaged when available. • When driving at night, be aware of wild-life. Deer are nocturnal and if we didn’t hit the deer this year, they charged our vehicle. Be alert, particular on roads that aren’t frequently traveled. • RV style communications trailers and FEMA trailers are not maintained in regular maintenance schedules and are solely the responsibility of the wings. It is very important that all trailer tires are checked and replaced before traveling. Trailer tires tend to deteriorate at a higher rate because they are impacted by solar degradation and not exercising them, doesn’t give the tire the opportunity to breath, usually resulting in catastrophic failure. It has been several years since these trailers were purchased, therefore near the end of the tire lives in a storage environment. Please check load ratings on these types of trailers to ensure they are proper rated and installed.

11. Vehicle Mishap Prevention Recommendations • Road conditions and awareness have contributed to two accidents this year. A couple of close-calls have also shown that weather can have an impact on driving. Reduction of speed, choosing alternate routes or times of day, or cancelling a trip are all viable solutions to prevent road condition mishaps. • On a couple of occasions, lack of rest has contributed to judgment and situational awareness. It is recommended that drivers plan for long trips by starting with adequate sleep. ORM analysis should demonstrate adequate rest requirements and using aircraft rest requirements outlined in CAPR 60-1 for aircrews is highly recommended for all vehicle operators.

12. Expanded Classification Trends • Flat Tires – Controllable – This is related to crew proficiency on aircraft brakes. Typically too much pressure, foot attire that cannot sense pressure, or inexperience. It is recommended that a good flight instructor demonstration be given to crews on short field landing capabilities without brakes. If the landing is too fast, practice a go-around. • Wing Strikes while operating aircraft was a high emphasis resulting in a Safety Alert; however recently, ground handling mishaps have increased. The biggest concern is getting aircraft into and out of hangars. It is recommended that aircraft be moved by full crews as much as possible, but hard stationary objects in hangars should be padded or protected in case an aircraft inadvertently comes in contact. Trailing edge and corner foam guards with “Remove Before Flight” streamers could be installed on ALL CAP aircraft that are in the hangar as an alternative.

13. Aircraft Mishap Prevention Recommendations • CAP has lost four aircraft this year due to weather related mishaps. Additionally two hangars were destroyed by storm winds. This highlighted the need to understand what approved ropes should be used to tie down aircraft and to ensure that ropes are tied tight to prevent the aircraft from “flying” off the ground during storms. Additionally, if storms are forecast, it is better to store aircraft inside or to relocate aircraft to an area where severe storms will not have an impact. For gliders, use trailers if available. Lastly, ALL personnel need to know where appropriate storm shelters are. Thin aluminum hangars have proved NOT to meet that need, resulting in injuries of CAP members. • Ground movement and ground handling of aircraft has surfaced again this year as a top cause for aircraft damage. It is recommended that all potential impact surfaces of the aircraft be protected with foam padding before moving aircraft. Also, wing clearance streamers, like a tennis ball that marks the parking stop point of personal auto garages, could be used to show wing clearances in hangars. Permanently fastened chocks to the floor would also assist in tail protection when pushing aircraft into the hangar. Use of all crew and ground members is necessary to ensure safety movement of aircraft.

14. General Awareness Recommendations • Communication of safety awareness items to the lowest level is key. To accomplish a positive habitual safety culture, safety has to be supported from the top, but owned and implemented from the bottom up. It has been recommended that wings use published safety alerts is highly recommended; however in discussion with squadron level membership, it is found that information does not effectively flow to members at the squadron level. This doesn’t fit all wings; however seems to be very common. Supporting members from the top would be getting the information and tools the members need to be successful and ensuring that it is communicated to them. • Positive re-enforcement is a KEY component to success. All members should look at all situations positively. As an example, a pilot has a bad landing, hits a runway light on landing. It is assumed the pilot was in error, but could it have been the pilots superior skill that prevented a mishap from being worse. Even in the worst case scenarios, members should be praised for making an effort. 4:1 positive to negative is the fertilizer of success for CAP’s future in a non-punitive safety environment. Suspending members for not completing courses, means non-participation, ultimately leading to reduced proficiency.

15. If you have any questions or comments, please contact safety@capnhq.gov. Thanks for your attention and support of safety.