Presented By

1. Presented By Colonel Bob Diduch National Safety Officer – CAP, Major Chris Hamm Director of Safety CAP-USAF, Frank Jirik Chief of Safety Civil Air Patrol NHQ Created 18-Mar-2008 Design Modifications and Updates By Lt Colonel Fred Blundell TX-129 Fort Worth Senior Squadron Revision 6.0 03-Jan-2014 For Local Training Only

2. This Training Slide Show is a project undertaken by Lt Colonel Fred Blundell of the TX-129 Fort Worth Senior Squadron, Fort Worth, TX for local use to assist those CAP Members interested in advancing their skills. The information contained herein is for CAP Member’s personal use and is not intended to replace or be a substitute for any of the CAP National Training Programs. Users should review the presentation’s Revision Number at the end of each file name to ensure that they have the most current publication.

3. Overview Scope Mishap Definition Update Practical Exercise Good, Bad, Ugly in Notifications and Investigations What is a “Safe” Commander Conclusion

4. Scope

5. Scope(Continued) Introduction Safely directing complex organizations, like Civil Air Patrol, requires an understanding of the program requirements and a safety mindset that is acquired by prior planning, ORM, and constant situational awareness. This is a key function of the corporate official in the wing. Safety requires vigilance to ensure the proper education and prevention oversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensure subordinate commanders’ recommendations for remedial training are accomplished.

6. Scope(Continued) Safely directingcomplex organizations, like Civil Air Patrol, requiresanunderstandingof the program requirementsanda safety mindset that is acquired by prior planning, ORM, and constant situational awareness. Thisis a key function of the corporate official in the wing.Safety requires vigilance to ensure theproper education and preventionoversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensuresubordinate commanders’ recommendations forremedial trainingare accomplished.

7. Scope(Continued) Safely directing complex organizations, like Civil Air Patrol, requires an understanding of the program requirements and a safety mindset that is acquired by prior planning, ORM, and constant situational awareness. This is a key function of the corporate official in the wing. Safety requires vigilance to ensure the proper educationand prevention oversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensure subordinate commanders’ recommendations for remedial training are accomplished.

8. Definition Update Mishap (New definition) Any unplanned or unsought event, or series of events, that result, in or has the potential to cause death, injury, or damage to equipment or property.

9. Practical Exercise

10. Practical Exercise

11. The Notification File the Mishap Notification – eServices Safety Management System Account: While flying an approach into XYZ airport that was VFR day, with winds from the east, CAP flight 4173, a C182 retractable gear flown by expert pilot Phillip Flysalot, CAP ID 123456, flying a stabilized approach, with all normal engine systems, landed smoothly, but upon stopping realized that the landing gear was not locked down.

12. The Notification WRONG! X

13. The Notification File the Mishap Notification – eServices Safety Management System Account: Gear up landing, A/C N1234CP, a C182RG, occurred at XYZ airport. No injuries.

14. The Notification CORRECT!

15. The Investigation • The Investigator is Appointed • Select someone that isn’t: • Unskilled • Slow to get stuff done • Biased or history of being opiniated, or dishonest • Close friends with the member(s) involved

16. The Investigation(Continued) • The Investigator is Appointed • Consider selecting: • Someone from a different wing or region • A trained investigator • Perceived of high character and professionalism • Readily available

17. InvestigationMistakes

18. InvestigationMistakes TOP 10 10. Uncooperative People or System 9. Conflicting Objectives 8. Surface Causes Only 7. Politics 6. Unskilled Investigators 5. Interview Biases / Untruthfulness 4. Untimely Investigation 3. Investigator Biases 2. Ineffective Corrective Action 1. Not Investigating Near Misses

19. Teamwork

20. We’ll be back in theair in ‘no time!’ Really?

21. The Investigation The Investigation – eServices Safety Management System Factual Narrative: The pilots flying the C182RG aircraft did have a smooth landing as noted by the straight marks in the fuselage of the aircraft. No one was injured. The pilot and crew were long time CAP veterans and are very skilled. The gear was not lowered. This was a Form 5 check ride. The check ride was not completed.

22. The Investigation WRONG! XX

23. The Investigation The Investigation – eServices Safety Management System Factual Narrative: The flight crew of this C182RG aircraft did not utilize the proper checklist or execute the before landing checks required. Sterile cockpit procedures were not observed. The gear up audible was checked and functioning. Checklists in the aircraft were available. What would you expect to see?

24. The Investigation CORRECT!

25. The Investigation The Investigation – eServices Safety Management System Recommended Corrective Action: Assess the Pilot the $500 deductible. Caution the crew on listening for the landing gear audible. Replace the checklists with a laminated copy for better use. Recommend crew be returned to full flight status.

26. The Investigation WRONG! XXX

27. The Corrective Action The Investigation – eServices Safety Management System Recommended Corrective Action: • Flight crew received remedial ground instruction on checklist use and crew communications responsibilities. • The Pilot, the two CAP Check Pilots, received unique recertification in their positions of responsibility and demonstration of crew communication be required. • The aircraft be checked by maintenance to ensure required warning notifications are operational. • The unit maintenance officer ensure the proper checklists are available within the aircraft.

28. The Corrective Action CORRECT!

29. Quick FixesNOT! A quick fix to a CAP Van?

30. Quick FixesNOT! No frost issues here!

31. Quick FixesNOT! Where is the nose wheel?

32. Quick FixesNOT! Hey cadet, pass me your flashlight.

33. Quick FixesNOT! Don’t scratch my door when you get in.

34. Quick FixesNOT! Cadets always have chips!

35. The Corrective Action The Investigation – eServices Safety Management System Wings Corrective Action: • These pilots will not act as pic of cap aircraft or as members of CAP air crew except to complete the • Following remedial training, given by a XXWG or XXR check pilot examiner:

36. The Corrective Action(Continued) A minimum of 1 hour of instruction in each of the following areas: 1. Stabilized approaches 2. Night landings 3. Emergency procedures. Check pilot involved in this mishap must successfully accomplish all maneuvers from front right seat.

37. The Corrective Action(Continued) Pilots must successfully complete an ADM course that meets FAA wings standards in order to return to flying status. Upon completion of remedial training as endorsed by the check pilot examiner, pilots must pass a special flight check given by a check pilot designated by XXR/CC. After successful special flight check, recommend return to cap flying status. All XXWG check pilots will receive guidance from XXWG/CC to confine maneuvers during check rides to published CAP Form 5.

38. What is aCommander? A Commander IS • He/She is THE Safety Officer • Not just the authority, but the person that is responsible for everyone’s safety • He/She is THE Safety Program Manager • A strong program is led. • He/She is THE Risk Manager • They do not walk by risk without correcting it. Not saying anything really says, I condone this.

39. The Facts Accidents 1 Data FY 08 - Present Incidents 20-50 600 Mishaps Accidents Incidents Mishaps Vehicular Aircraft Bodily Injury *Data Current as of 2/10/2010

40. Closing Comments Safety Should Be • A positive environment without any obstacles for disclosure and discussion • Foster a willingness to share and learn • Safety should be proactive not reactive • Should be supported at all levels of leadership and integrated in all CAP programs • Safety should be easy to navigate If you think it, it can be done.

41. Remember Who can change the Safety Culture of CAP? The Leader You See In The Mirror Each Morning. The answer is before you.

42. Where is the next mishap, incident, accident going to occur? QUESTIONS? Please feel free to send your questions and comments directly to the National Safety Team and NHQ Safety safety@capnhq.gov