MER Safety Blitz – Nov ‘06

1. MER Safety Blitz – Nov ‘06 NOTE: The contents of this briefing are based entirely on a subset of the briefing prepared and delivered by Gary Woodsmall, National Chief of Safety, and entitledPreparing for the CAP National Safety Day It was tailored by MER/SE for the benefit of MER Units to use during their Safety Down Day as part of the Nov ’06 MER Safety Blitz

2. Why a Safety Down Day? • Pause for introspection • Look at unit culture – how the unit trains, talks, acts and listens • Look at your self – your attitude toward risk • Focus on problem areas (trends) • Both from a National and a local perspective • Learn how to manage risks • Formally and informally • This is a pre-emptive strike on future mishaps • To help keep us safe on and off-duty

3. Safety Down Day Topics • MER’s safety record for FY05 • Discuss record from an ORM perspective • Identify what controls could have been put in place to avoid or minimize the impact of each mishap. • Ideas and action plans for improvement during FY06 should be defined as appropriate. • Wing’s safety record for FY05-06 • Same topics and approach as above • Specific topics covered by unit to include: • Ground & Vehicle Operations • Aircraft Operations • Personal Safety (e.g., at home, traveling to/from CAP meeting, • Meetings and activities, including facilities used

4. Where Have We Been?(CAP Aircraft Accident Rate 1972 – 2004)

5. Where Are We Now?(As of 18 July 2005)

6. How Does CAP Compare? Comparison of Aircraft Accident Rates (Rate = Accidents per 100,000 Flight Hours)

7. How’s Your Organizational Culture Does your unit: • Demand integrity, self-discipline and accountability? • Promote teamwork? • Respect people and their ideas? • Encourage multi-directional, honest communication? • Support decision-making at the appropriate level? • Identify and correct unsatisfactory performance? If you answered NO to any of the above, your unit needs work!

8. MER and Unit Safety Record • MER Mishaps during FY05 • MER Mishaps during FY06 (YTD) • Wing/SQ Mishaps during FY05 • Wing/SQ Mishaps during FY06 (YTD)

9. Impact of Deficient Culture • Affects the ability to recruit and retain the right people • Adversely affects key decisions – like risk management • Lowers the standard of acceptable limits of personal and professional behavior • Undermines trust and respect • Reduces quantity and quality of unit output

10. Our Goal: Transform Safety from Compliance-Based to Culture-Based “An effective safety program must exist on a foundation of trust, integrity, and leadership created and sustained by effective communication.” Col Alan Groben, ANG So, how does a commander do this? • Straight talk - freedom to speak your mind • Hire the right people - Who they are, not who they know • Straight talk feedback - All directions - No person is exempt • Mentor leaders - Performance is the primary factor • Install responsibility and accountability - At all levels • Take action to correct what’s wrong • Make “best” decisions - For the Country, Unit or Organization - Not what’s best for me

11. Effective Safety Culture May Have Prevented This Accident • Mountain Flight Clinic • IP was an ATP, CFII. Mission IP & Check Pilot • 12,500 hours • 2- year history of undisciplined behavior • Routinely broke rules “meant for less skilled pilots” • Multiple aircraft incidents • Does this sound like a Check Pilot? • Leadership was aware but, failed to intervene • AM Ground School covered safety precautions • IP and 2 students flew into a draw with steep terrain 5 times at tree-top level • During the course reversal, the tail snagged a tree • The crash killed all three • A key position filled by the wrong person • Standards were not enforced

12. FY05 Trends • Aircraft • Taxiing into obstructions (6) • Ground handling (5) • Landings (4) • Vehicle • Failure to yield (4) • Deer strikes (3) • Obstructions (2) • Bodily Injuries (86% are cadets) • Slips and Falls (6) • Cuts (3)

13. Monroe, LA Aircraft Accident10 Jan 05 • First accident of FY05 • C-182R, 2 Commercial/Instrument pilots • Planned night proficiency - 2 sorties • No evidence of a flight release • No evidence that weather was checked • Initially VFR - deteriorated to 900’ BKN • Proficiency seemed to diminish with the weather • Signs of disorientation when not flying headings • Crew did not report any malfunctions • Instruments and vacuum pump were healthy

14. Louisiana Aircraft Accident10 Jan 05

15. Shelton, WA Aircraft Accident13 Mar 05 • CAPF 5 check ride • Winds for Runway 05 were 030/12G21 • Airspeed on final abruptly dropped 20kias • High sink rate • Landed on main gear first but, nose gear also struck hard. • Aircraft bounced into the air • Check pilot initiated a go-around • Damage estimated at $20,000. • No injuries

16. Shelton, WA Aircraft Accident13 Mar 05

17. Operational Risk Management

18. CAP ORM Vision “Create a Civil Air Patrol in which all personnel manage risk such that all operations are successfully completed at the least possible cost.”

19. The CAP ORM Concept • Risk is inherent in all operations • Risk can be controlled • All members are responsible for controlling risk with ORM

20. The Compliance Culture • My job is to comply with the standard • I am told what the standard is • If I am not told, I don’t usually act • When I am given a standard, the standard is my objective • When I meet a standard, that’s it Sound familiar?

21. The Performance Culture • My job is to optimize risk; to perform • I’m given a standard, but that is only a baseline. I use ORM to exceed it • Standards are only a start point • Meeting a standard means little; I continuously improve.

22. ORM Principles • Accept no unnecessary risks. • Make risk decisions at the appropriate level. • Accept risks when benefits outweigh costs. • Integrate ORM into doctrine and planning at all levels.

23. The ORM 6 - Step Process 1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Risk Control Implementation 3. Analyze Risk Control Measures 4. Make Control Decisions

24. Step 1: Identify the Hazards Any real or potentialcondition or behavior that can cause: • Personnel • Injury • Illness • Death • Property • Loss • Damage • Mission • Failure • Degradation

25. Step 2: Assess the Risk Determine the probability that a hazard will cause a mishap • Use estimated or actual numbers • From research, analysis and evaluation of historical data • Should refer to the probability of a mishap with consequence • Document supporting rationale for future reference Determine the severity if the mishap did occur • In terms of potential impact on what’s at risk • Base assessment upon worst possible outcome that can reasonably be expected

26. Risk Assessment Matrix Probability Frequent Likely Occasional Seldom Unlikely A B C D E S Extremely I Catastrophic E V II High Critical High High E R III Moderate Medium I T Low IV Negligible Y Risk Levels

27. Step 3: Analyze Risk Control • Identify control options (brainstorm) • Start with the highest priority risk • Explore ways to reduce probability, severity or both • Engineer (design a better widget) • Guard or control (yellow line, guarded switch) • Limit exposure (distance, contract out) • Selection of personnel (most qualified) • Procedures (rules, restrictions, limitations) • Training/Education (always can use more) • Warn (signs, horns, whistles, lights) • Reduce effects (use of PPE)

28. Step 4: Make Control Decisions • Analyze the level of risk with the proposed controls in place • Determine if the benefits now exceed the level of risk (potential cost) Costs Benefits

29. Step 5: Implement Risk Controls • Select one or more from among the possible control measures evaluated • Allocate available resources • Time • Money • Manpower

30. Step 6: Supervise and Review • Measure • Is the control having the desired effect? • Was the anticipated cost valid? • What’s the effect on performance? • Reevaluate • Changes in the mission? • Different environment? • Did the control mitigate the risk?

31. RM Variants • Time-critical RM • “On the run” mental or oral review • For time-compressed situations • Most easily applied level of RM • Great in off-duty situations • Can be as simple as asking – “What’s the worst thing that can happen”? • Deliberate RM • Used to plan an operation or activity • Most effective when done in a group • Controls can be built into the “Ops Plan”

32. Complicated? No 1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Risk Control Implementation 3. Analyze Risk Control Measures 4. Make Control Decisions

33. Other Suggested Topics Need some more topics? Here are some that “subject-matter experts” in your unit can choose from to discuss. Other topics can be found in the Sentinel archive at: http://level2.cap.gov/visitors/programs/safety/newsletters/ • Aviation • Taxiing safely • Winter flying • Carburetor icing • Local bird hazards • Emergency procedures • Ground handling techniques • Distractions in the cockpit • Weight and balance • Landing characteristics of the C-182, C-206, MT-7-235 or GA-8 • The challenges for aging pilots • Instrument refresher course • Crew Resource Management • Carbon monoxide – insidious killer

34. Other Suggested Topics Cont. • Driving • Turning characteristics and roll hazards of 15 passenger vans • Coping with deer on our highways • Hazards of winter driving • Cell phones and driving • Fatigue • Highway emergencies • Defensive driving • The dangers of driving impaired • Railroad crossings • Aggressive driving and road rage • Tire maintenance • How aging affects driving safety • The effectiveness of seatbelts

35. Other Suggested Topics Cont. • Personal Safety • Preventing falls • Knife safety • Confidence course safety • Eye protection • The dangers of mixing cleaning solutions • Power line safety • Cadet sports injuries • Avoiding lightning strikes • Protecting yourself in a tornado • Food safety • Cadet supervision • Fire extinguisher training • Lawnmower safety • Protecting your hearing

36. Summary • The Commander should be leading this charge • Make it fun and interesting • Keep it short • It’s not just one day – consider safety everyday • Risk management can be as simple as asking: “What’s the worst thing that could happen?” • Watch out for each other • Remember, the fun stops when someone gets hurt Safety First, it is not a box we check, it is the way we Operate!