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10 Jan 10 "Dirty Dozen" - 12 Challenges for Aviation Safety

Years ago an industry panel developed the "Dirty Dozen" list that identified hazards in aviation, focused on mishaps that were occurring in air carrier operations. Take a look at the list and see which ones we've made some progress towards eliminating through introduction of new technology, training and operational procedures. Then consider which ones are still basically uncontrolled. The areas where we still need a lot of work are highlighted in red.

1. Midair collision-TCAS
2. Inadequate terrain separation-Enhanced GPWS, use of minimum safe/vectoring altitudes
3. Unstabilized approach-? See # 5. SOPs, approach gates for configuration, airspeed, altitude. Visual and electronic glide paths. Wind and surface info.
4. Weather related damage or injury-? SOPs and personal mins for turbulence, icing, convective activity
5. Runway excursions-? See # 3.
6. Abort before 100 knots-SOP
7. Significant operational deviation-SOPs and personal minimums, CRM.
8. Runway Incursion-ASDE-X at a few airports, but what about widely used cockpit technologies?
9. Landing on wrong runway/airport-Precision nav (FMS). Approach brief. Backup with instrument approach procedure. Landing clearances.
10. Altitude deviation-Readback hearback. CRM. Use of autopilot as additional crew.
11. Navigation deviation-Use of precision nav sources, GPS, FMS.
12. Ground injury or damage-? Slow down and be familiar with airport surface ops.

Runway Incursion - GA vs Air Carrier

We need to get a lot smarter and technologically advanced with regards to surface operations, because hazards will exponentialy compound as the number of operations increases. In some ways we are more exposed to hazards on the ground, because flight planning and ops support may not focus as much on these phases of "flight". We need to be very familiar with the winds, surface conditions, runway lengths, geometry and facility layouts, airport lighting and approach systems. We also need to be aware that the priority guidance to "Aviate, Navigate and Communicate" is essentially reversed when we are on the ground. The focus on the ground is to "Communicate", to listen and build a mental model of where other aircraft and vehicles are. Keep in mind that vision is our primary sensory input, and now we are asking the brain to shift priority to listening. The next priority is to "Navigate", we must know at a minimum where we are, in order to get to where we want to be. Charts and electronic moving maps assist in this area, but the key is to "Look outside". Lastly, it is harder to "Aviate" on the ground, we are not "aircraft" in this regime but rather ground vehicles with limited visibility, reduced maneuverability and many of our warning systems have little or no functionality on the ground. Couple this with the fact that the areas we are maneuvering in are confined and many times unfamiliar, and the fact that the runways are areas where there is great potential for a high energy collision, then we certainly have challenges to manage.

What can be done to improve the system? The first step is to study the operational environment, and the next step is to identify hazards, so that we can avoid them and implement programs to eliminate them. One good way to do this is to put in a report via NASA ASRS, because folks who manage airspace systems need this information to improve the system. Another good investment is to participate in the Wings program, and dedicate ourselves to lifelong learning in our chosen craft. The best way we will learn is from each other.

Fly Smart,
Kent

09 Jan 10

2 semesters down for the MLS, 2 to go. Had some great classes last semester in Library Technology, Research Methods and Library Management. This semester we'll go over Collection Development, Academic Libraries and Online Information Retrieval. My favorite text from last semester was Administrative Behavior by Noble Prize winner Dr Herbert Simon.

I set up a Human Factors and Safety Management Systems (SMS) seminar in Dallas for March 31 April 1. The registration fee is only $75 and we have a great line up of speakers. Check out the details on my Signal Charlie wiki. On of our speakers will be Dr Terry von Thaden, who has her PhD in Library and Information Science, and teaches human factors at Univ of Illinois Urbana-Champaign. We'll also get an update on safety culture surveys from Dr Ciavarelli of Human Factors Associates and an applied research brief from Dr Frank Durso of Georgia Tech. 16 speakers total, so be sure to check out the lineup and get signed up for Wings credit

Most interesting event this week, met Dr Sidney Dekker and we spent the afternoon with some ALPA Air Safety and Delta Air Lines Flight Safety folks in Atlanta. We had a good time and Delta was a great host to Sidney, he even got some time in the sim. The best part was when the intern failed the engine on takeoff, and Sidney managed to keep us shiny side up.

Fly Smart,
Clark

I am starting on my Masters in Library Science. It will be fun to learn about different types of libraries and management of information systems. That will be helpful in my aviation human factors work.

26 FEB 91
Secretary of the Navy Washington
The President of the United States takes pleasure in presenting the NAVY CROSS to Lieutenant Colonel Michael M. Kurth United States Marine Corps for services set forth in the following citation: For extraordinary heroism as Commanding Officer of Marine Light Attack Helicopter Squadron 369 during Operation Desert Storm on 26 February 1991. As the 1st Marine Division attacked north to prevent Iraqui forces from escaping, Lieutenant Colonel Kurth's repeated acts of bravery in providing Close In Fire Support to embattled Marines helped collapse the Iraqui defenses. With visibility nearly impossible due to hundreds of burning oil field fires, and with total disregard for his own safety, he flew under and perilously close to high voltage power lines. Placing himself at grave personal risk to intermittent Iraqui ground and anti-aircraft fire, Lieutenant Colonel Kurth flew continuously for ten hours during the most intense periods of combat, twice having to control crash his aircraft. Employing a commercially borrowed Forward Looking Infrared Radar and LASER designator, he flew through the Al Burquan oil field fires, between the AH-1W holding pattern and task Force Ripper's forward lines, leading flight after flight of rearmed gunships to requesting units and then remaining dangerously exposed forward of friendly lines as he designated Iraqui armored vehicles for engagement. Lieutenant Colonel Kurth's courage and fearless dedication rallied fellow Marines and resulted in the destruction of as many as 70 Iraqui armored vehicles destroyed that day. By his outstanding display of decisive leadership, unlimited courage in the face of heavy enemy fire, and utmost devotion to duty, Lieutenant Colonel Kurth reflected great credit upon himself and upheld the highest traditions of the Marine Corps and the United States Naval Service. For the President Secretary of the Navy

What also needs to be placed here is a Distinguished Flying Cross citation for Captain Carl "Mooch" Reynoso. Mooch was actually the Aircraft Commander on this mission. Spot jumped in last minute in the left seat where Nasty was due to fly. Spot and Mooch took their FLIR operator, Crew Chief and Gunner through the hellish conditions and prevented the 1st Marine Division CP from being overrun, among other cited acts. On the ground a LAV commander deployed a screening force during a heated tank battle and was also awarded the Navy Cross. Mooch's recommendation died on SecNavs desk in late 1991, when SecNav refused to approve any awards for Naval Aviators due to the 1991 Tailhook scandal. This made no sense at all, seeing as Mooch is one of the finest marines ever to serve, a Mustang who previously served with distinction in Force Recon. He traded boots for wings and is a natural stick, most at home in the Huey. A helo guy who never went to Tailhook. Maybe someday the award recommendation will resurface and be awarded late, due to "administrative oversight".

15 JAN 91

Flew around with PeeWee, Space and Super Dave doing some simple tactics training. No mail for me today, boo hoo. I know it's out there somewhere, Iraquis probably have it or some Air Force REMF.
No action from US/UN or Iraq today. Tomorrow morning, we'll see. I hope to see bombers going overhead.

Today was a fun day. The khaki flight suits arrived. Normal training day, standard classes on tactics and NBC. It's been raining hard all day, which was fun to watch from indoors.
Found out the flight suits hit supply this morning. Went to supply and signed for all of them about $15,000 for 83 of them.Got them back to the terminal and issued them out. Guys at the Wing did a good job getting them here as quick as they did, and the Flight Suits Limited folks did some quality work on a large order.
Today in the AOM the S-4 said "don't mail home green cammies, and if you have, send to have them returned". After a chorus of "screw you...dream on...no way" and lots of laughter Spot said "don't have them sent back". I guess we'll have to stay here if we don't have woodland cammies to wear home.

13 JAN 91
Rainy and cool, thunderstorms in the area. Went to squadron for a few hours to check on the flight suits. They're in country somewhere. Found out that they aren't "here" yet. Maybe tomorrow. It was fun watching the rain pour down at the terminal vs watching it from the tent. Went back to the tent and found that my corner was flooded. Most things I had in plastic or sitting up off the floor, but some stuff still got wet. Most ents are treated with water repellent, doesn't seem that ours was, or it was done 20 years ago. Picked up my stuff and drilled some drain holes in the wooden floor. After I dried it. The did some sandbag surgery and moved liner away from wood frame, and that seems to be working. If that doesn't work, I suppose I'll float away tonight on the air mattress.
Getting to and from chow was an adventure, didn't get too muddy.

12 JAN 91
Ops normal, nothing out of the ordinary. Flew a photo mission today to film the Cobras shooting. I was having fun until it dawned on me that I had "stolen" the aircraft. Actually got to sign for the bird today as aircraft commander vs copilot. Hadn't signed for one in a while, so I forgot. I remembered as we were transitioning down the runway. Not a big deal, but get to catch flak from the maintenance folks. That qualifies as entertainment for them. Entertained Spot and Irish too, free of charge. Spot nodded and smiled when I got back and Irish said "Consider yourself thrashed." Public humiliation held to a minimum.
It was fun filming the Cobras and flying some form, then we landed and watched from the ground for a while. I flew with Space, his finger has healed.
Spent more time in the afternoon looking for flight equipment b.s. New flight suits are on the way. Reps at the Wing have been extremely helpful, some other folks at Group are perfecting the shoulder shrug. They did get an open purchase request in for the Mike Lites, $12,000.

11 JAN 91
Ops Normal. We've gone back to 8 hour crews after a week or so of 12 hour crews. The idea was to concentrate heavily on maintenance and inspect as many aircraft as possible, within their 100 hour phase cycle. Now we can fly another 100 hours without a major inspection. It was good to have something to do while I was med down. Our guys worked real hard. Even Spot and Irish agree.
Flew a basic section tactics hop today to start bringing the FNG up to speed. Saw some more guys from flight school, Jeff, Todd and Curt. Anyway, flew with PeeWee, Bean flew with the FNG. Did some low level and practiced hiding behind dust devils and small bushes. Flew by several Marine positions, that was fun. They wave and we get a chance to wave back. I think it helps them to know we're out here with them. I know I like it when I see the jets going overhead, heading north for patrol.
Chames went out and trained for aerial gunner. He has a good attitude and is up to speed on the history of the region. He's always cheerful and it is fun to work with him. Plus he has a good sense of humor.
Time for M&Ms.

10 JAN 91
Goofed around all day with Trimble GPS receivers, mount kits and antennas. There's finally an interest in this and I'm the only guy in the squadron smart on it, plus the XO. So I spent the day telling guys what it will and won't do. Plus deciding where it should be installed in the Huey. Plus getting more install kits. The units are hand held, but can be hard mounted, and wired with external power and external antennas. That provides better coverage from the constellation and doesn't burn through batteries. Fun stuff.
Leif is here, F.E. OIC for 775. We traded some notes and I tried to steal their binos, no luck. Perry's wife is here on a reporting trip and they'll get to spend a day or two together. He says they weren't going to let them check into the hotel because they didn't have a copy of their marriage license. What a backwards, screwed up country. What if we told them they couldn't observe their prsctices and religions while they were in our country? Sorry, no veils, no mosques. What a bunch of hypocrites. I wish we'd hurry up and figure out how to drill sideways.
Gonna fly some basic tactics tomorrow with PeeWee, Bean and the FNG. Should be fun. Weather is cooling down again. Maintenance push went well, birds are in good shape, especially Hueys. Tent is doing good too.

Another day, another chance to flai away with the rhetoric. Listened to the Baker_Aziz conference for a bit, what a bunch of b.s. I'm glad they met and stated their opinions, but why can't it be the U.N. meeting with Hussein. Maybe he's afraid to come out an play. My favorite line was that Iraq was going to attack Israel, hmmm, guess they really are crazy. If they do, they will probably get nuked. Or Israel may have to line up behind Russia or China.
Worked on inventory today. We should get the new flight suits this week. Our MAG has priority. They're also going to buy 600 ML-2s, good for everyone. Now I have to work on long johns and flight jackets, plus binos, more helmets, etc... Hindsight being 20/20, I might have been beter off flying less and getting more stuff while the checkbook is open? Naaaaaah.
Should be read to fly tomorrow!

08 JAN 91
Made a few phone calls, wrote some letters, read some mail. Almost done with the meds for the head cold.

07 JAN 91
Med down for a few days, seemed to have found a cold somewhere. Not much going on, provided moral support for shop and did some work on AWS material. Caught up on a few more projects. The Group CO likes the mike lite and forwarded my requisition letter, recommending that MALS open purchase about 4-500 of them. One small step. Teh desert flight suits are in at Wing, and we should get them this week. Next projects are cold weather gear and night vision gyro stabilized binos. Plus about 30 other things. Ahd they're finally interested in installing the GPS receivers, which, thank God, I have nothing to do with.

04 JAN 91
The Reserves continue to show up, an awful lot of old looking guys. The Hueys from New Orleans are here. Everyone assumes that our frag load will be lightened, but I figure they have their own folks to fly around.
I feel sorry for those recalled and having to leave their day job, but I guess that's part of the deal. We have the potential of being involuntarily extended, I read the other day that it is not a "volunteer" service anymore.. They'll let us go when they're ready

03 Jan 91

Today I flew with PeeWee, Injun and Stoney in Dash 2. We flew Gen Boomer around to check out some grunt ops. Very simple but time consuming flight. Weather was cloudy, windy and cool, with a few sprinkles here and there. Visibility was 3-4 miles. We had fun, no problems. Ate oreos and had some cherry beverage powder in the LZ while we were waiting. I had a real smooth landing coming in, because the wind blew away our burble as we touched down. The Marines in the LZ tossed out a smoke grenade to show us wind direction. I like landing where the smoke swirls through the rotor wash. Gee, the thrills I get.

Chow was good, yaki soba and shrimp fried rice. Back to tent to yak and play paper boy.

02 Jan 91

Tip of the Spear update: There's now a few thousand ground troops in front of us, the jets can be in and out of Baghdad airspace before we reach the border, there must be something...367 is parked further North than us, everyone got desert cammies before us, and cots before us. Maybe we're the noisiest? But we must remain focused on the mission, just don't know if it's completing MCIs or waging war. Micromanagemnet and the zero-defect mentality reign supreme today, plus boring training classes. Thank goodness someone had the briefing room reserved at 1630, or else we'd still be there.

We're starting a pool to see when Spot is going to keel over, we don't think he sleeps at all or leaves the squadron. He probably wonders how he got stuck here with us?

Highlight of the day was turning in sleeping bag and poncho liner to the laundry. After 4 months it was taking on a life of its own. So it's clean and ready for another 4 months now. Now if the other guys would get theirs cleaned.

Becky and Randy sent me a box, and on the side it said pork sausage. Someone had blacked out pork, which was funny because it was wrapped in Christmas paper. They sent some chips, salsa and an electronic game called Paper Boy. It's great. You get points for breaking non-subscriber's windows, hitting dogs and trash cans with the paper, etc...The paper boy gets creamed by skateboarders, cars and light poles. Just like the real thing.

01 Jan 91

New Year 91. Let's hope this one turns out better than last, at least from August on. Flew today, carrying some East Coast and Reserve guys. I was in Dash 2, with our FNG. Diamond was Lead, with the Group CO getting some flight time. We flew north to look at some prospective sites. Still lots of talking/planning and little action. They are getting some areas ready to move too, glad I don't have to do the embark plan. Don't know if we'll move or the new forces coming in will go there. We'll be going North eventually, even if it's "grab an MRE and get going". Going to live in the Kuwait City Hilton sounds good.

While we were waiting at one strip we met the Saudi crew and Scottish Flight Nurse of tan aeromedical service. The plane was a nice Gulfstream. There were some Saudi helos here too. The crew was real nice, they let us get up in the cockpit. They fly VIP when they're not doing medevac. And the nurse was real cute!

Got back to base around 1500 and went to chow. Good steaks tonight, with pork and beans minus the pork. Plus pasta salad and a Pepsi.