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HUMAN FACTORS QMB INVESTIGATION OF CFIT MISHAPS AND POSSIBLE INTERVENTIONS

HUMAN FACTORS QMB INVESTIGATION OF CFIT MISHAPS AND POSSIBLE INTERVENTIONS. OVERVIEW. 47 OUT OF 347 CLASS A MISHAPS SINCE FY90 INVOLVED CFIT! CFIT WORKING GROUP FORMED TO INVESTIGATE POSSIBLE CFIT INTERVENTIONS SAFETY CENTER PROVIDED RELATED MISHAP DATA FLEET OPERATORS QUERIED FOR INPUT

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HUMAN FACTORS QMB INVESTIGATION OF CFIT MISHAPS AND POSSIBLE INTERVENTIONS

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  1. HUMAN FACTORS QMB INVESTIGATION OF CFIT MISHAPS AND POSSIBLE INTERVENTIONS

  2. OVERVIEW • 47 OUT OF 347 CLASS A MISHAPS SINCE FY90 INVOLVED CFIT! • CFIT WORKING GROUP FORMED TO INVESTIGATE POSSIBLE CFIT INTERVENTIONS • SAFETY CENTER PROVIDED RELATED MISHAP DATA • FLEET OPERATORS QUERIED FOR INPUT • QMB EXAMINED DATA AND FLEET RESPONSE, BRAINSTORMED IDEAS, SET INITIAL COURSE OF ACTION

  3. INPUT FROM THE SAFETY CENTER • 14% OF OF USN/USMC MISHAPS SINCE 1990 INVOLVED CFIT • 22% OF HUMAN FACTORS RELATED MISHAPS INVOLVED CFIT • LATENT CAUSAL FACTORS OF CFIT MISHAPS • LESS THAN ADEQUATE ENGINEERING • LESS THAN ADEQUATE SUPERVISION • LESS THAN ADEQUATE PERSONNEL CONDITIONS

  4. Engineering Control Administrative Control Personnel Control 90% of all Mishap Recommendations Fall into These Two Categories!!!!!!! X X Error Prevention “We Need to Start Thinking Out of the Box” INPUT FROM SAFETY CENTER Performance Enhancement

  5. HELO CFIT Distribution Strike CFIT Distribution DAY NIGHT DAY NIGHT 46% 16% 25% 25% EMBARKED ASHORE EMBARKED ASHORE 0% 38% 6% 44% (n=24) (n=16) STRIKE A/C AND HELO CFIT ENVIRONMENT & TIME COMPARISON

  6. INPUT FROM FLEET OPERATORS • RESPONSES ADDRESSED MULTIPLE ISSUES IN THREE GENERAL CATEGORIES • HARDWARE/SOFTWARE • SUPERVISION/REGULATION • TRAINING • THESE CORRESPOND TO THE LATENT CASUAL FACTOR GROUPS NOTED BY SAFETY CENTER EARLIER

  7. HARDWARE/SOFTWARE • SIGNIFICANT FLEET RESPONSE CONCERNING THE PRIORITY, FUNDING, DEVELOPMENT AND FIELDING OF TECHNOLOGIES THAT MIGHT COMBAT CFIT • LEADERSHIP MUST SUPPORT THE INCREASED PRIORITY OF COUNTER CFIT TECHNOLOGIES IN THE PROCUREMENT PROCESS

  8. SUPERVISION / REGULATION • REQUIRED OPERATIONAL CAPABILITIES • WHAT ARE THEY, WHAT IS THE ENVIRONMENT IN WHICH THEY ARE TO BE PERFORMED • LAT TRAINING RULES IN OPNAV-3710 • CURRENCY (HIGH TO LOW MIND SET) • MANDATORY BRIEFING ITEMS • TYPEWING CORE SOPs • CURRENCY, BRIEFING ITEMS, AIRCREW CHECKLISTS AND RESPONSIBILITIES, ALT LIMITATIONS • COMMUNITY SPECIFIC RADALT PROCEDURES

  9. TRAINING • INCORPORATION OF RADALT DISCIPLINE IN THE EARLIEST STAGES OF TRAINING COMMAND • STANDARDIZE POST FRS TRAINING FOR INDIVIDUAL COMMUNITIES • (SFTI PROGRAM) • AEROMEDICAL TRAINING • MORE FREQUENT • G-AWARENESS (CENTRIFUGE) • SPATIAL DISORIENTATION

  10. TRAINING • EXAMINE INSTRUMENT GROUND SCHOOL AND CHECK FLIGHT PROCESS • FLEET WIDE, TYPE A/C • SCOPE • EXTERNAL CHECK RIDES • INCORPORATION OF ACT

  11. TRAINING • MAXIMUM USE OF SIMULATORS • BASIC INSTRUMENT FLYING • RADALT AND GPWS DOCTRINE • HIGH TASK LOAD DURING TAKE-OFF AND APPROACH • AIRCREW COORDINATION TRAINING • CHECK LIST • CREW RESPONSIBILITIES AND CROSS SCAN • COCKPIT RESOURCE MANAGEMENT TRAINING • DEDICATED LAT TRAINING • MORE? / NONE? (IS IT A REQUIREMENT?)

  12. WHAT’S NEXT • OPERATIONAL RISK MANAGEMENT • OPERATIONAL REQUIREMENTS • ENVIRONMENT IN WHICH WE NEED TO PERFORM • TRAINING REQUIREMENTS TO BE CURRENT / PROFICIENT

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