Accidents & Incidents

1. Authored by Randy SwainModified by Lt Colonel Fred BlundellTX-129 Fort Worth Senior Squadron For Local Training Rev 6.0 09-Jan-2014

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. Accidents & Incidents The vast majority of aircraft accidents and incidents in the aviation industry have been cause by “The Human Element” … Is 9 out of 10 really true? You don’t have to “Screw Up” in order to cause an accident…

4. What is the “Error Chain”? • Accident is caused not by a single event, but a sequence of events that build upon each other to result in an accident or incident. • Breaking any link will prevent the accident. Note: Not every link must be a “BAD” decision to lead to misfortune!

5. Crew Resource Management Performance Markers • Situational Awareness • Communication • Decision Making • Leadership/ Followership • Reliance on Automation • Contingency Planning

6. What does it mean????? Before we go fly, let’s get out of the “Academic Realm” and look at some traits to set the stage for “…Breaking the Chain…”. The Challenge is that there is no “Right Way” to do it!

7. How do wereally do that?? • Let me take a few brief minutes today and pass on some of the truths I have seen and learned through my years in flying and leadership.

8. How do wereally do that??(Continued) • These truths are valid in: • Flight Crew • Squadron • Wing • Region • Any size aircraft… …Or Any Organization…

9. 1 - Confidence in real abilities • Have faith in and know your “REAL” abilities • The Objectof your confidence? • How about…Today? • Do you “Understand” or have “Rote” Knowledge • CL600 Pilot • F-4 Pilot - Travis • Holland’s Bomber

10. Confidence in Real Abilities(Continued) • A few minutes later… • The Colonel in the jumpseat was retiring this day…” • …his wife and family were watching “The Show”.

11. 2 - Know your limitations • Know your limitations: • Long term & short term • Individual & Team • I do not know what I do not know! • Jams 71 example • Bye Bye Birdee • F4 at Red Flag • Use the strengths of your team!

12. 3 - Continue to learn • Never stop learning • What is your motivation to learn… • To impress others? • “Intimidate others”? • NASA Astronaut • Focused on Improving • You have not arrived! • F-4 over Atlantic • F-4 into Alligator River • What knowledge have you missed?

13. 4 – Always have options • Always have 2 viable realistic options • Prior to the aircraft • Give yourself options • Lost on the Moon Exercise • Learjet 500 lbs • If your primary plan is all you have…events are now in control… • …NOT YOU!!!!!

14. 5 - Check your attitude! • Professional or…? • SAR - Atlantic WSO • Sioux City, Iowa – United crash. • How does your attitude affect the team… • Synergy or drain • Never Give Up! • Flat Spin example

15. 6 - PIC - It’s not about YOU !! 49 CFR Part 91.3… • “…Sole Authority as to the safe operation…” • No Conflict here!!! • PIC is on the hook to use all resources to safely accomplish the mission and/or flight. • Understand the entire situation…as it is!

16. PIC – Who is it about ??? • Stakeholders • The people who are flying with you • The people over whose house and life you fly • The victims you are assisting • Air or Ground Based Team-members • Fresno Learjet Crew • First Officer inputs

17. 7 – Leadership(…”aircraft managers are planting aircraft all over this planet”) • Leaders are successful by ensuring other’s success • Position your crew for success • Find out from them what they need to Excel for the crew and mission • Build a Real TEAM! • “Servant Leadership”

18. Advice given to General Tommy Franks by hisBattalion Commander • “Tom…the troops will work a lot better if you will work a little better with them.” • “Loyalty must run UP- and Down- the chain” • American Soldier – General Tommy Franks

19. PIC - Leadership • Use the appropriate amount of “action” • PIC’s real emergency authority • Deviate “…From the Rules of this Part, To The Extent Needed” in order to handle Emergency…” • Plan for contingencies • Aircraft goes where it is planned, not where it is wished…

20. 8 - Corporate Culture • EasyJetExample • What is the culture of your unit… • …Or Your Crew today! • What do you value as a leader?? • As the leader of your crew, what do you practice???

21. 9 - SLOJ Behavior SUDDEN LOSS OF JUDGEMENT Why do otherwise Professional, Competent, Safe and Sharp pilots…all of a sudden do the dumbest thing you ever heard & usually cause a death?

22. Food For Thought - #1 • …THE SUPERIOR PILOT IS ONE WHO USES HIS/HER SUPERIOR JUDGMENT…SO AS TO NEGATE THE NEED for the REQUIRED APPLICATION OF SUPERIOR SKILLS…

23. Food For Thought - #2 • …If the hair is standing up on the back of your neck…there is probably a reason and “it” knows something… • What about “Gut Feeling”? • Gut feel is a conduit for Tacit learning • LISTEN to the Voice!!!

24. Food For Thought - #3 • …When your flight starts to read like the first few paragraphs of an accident report, you have probably already forged the 1st links of the chain…so change something…anything! • “Do you hear the faint metal clanking sound”?

25. Food For Thought - #4 • …The 2nd best plan is the best plan if the team buys into it… • …The “Best Plan” IS NOT…if the team does not believe in it…

26. Food For Thought - #5 • …Considering all the aspects we have briefly examined… • …It is not about where you are…it is about where you are going!!!!! • Lesson from Martial Arts

27. Summary • Setting the Stage to Break the Error Chain • Be realistically confident in our abilities • Know & (using the team) minimize limitations • Never, Never, Never stop learning • Always have 2 realistic, viable options • Check your attitude (…and keep it in check) • Realize that “…It is not about me”! • Be a true leader (learn from mentors / mentor others) • Watch your culture and values, espoused & enacted! • Avoid the “SLOJ Monster”

28. Questions?Always think safety!