104 SAFETY FUNDAMENTALS - Amdo



104. SAFETY FUNDAMENTALS

References:

[a] OPNAVINST 3500.39A, Operational Risk Management

[b] OPNAVINST 5100.23F, Navy Occupational Safety and Health (NAVOSH) Program

Manual

[c] OPNAVINST 3750.6R, Naval Aviation Safety Program

[d] OPNAVINST 4790.2H, Naval Aviation Maintenance Program (NAMP), Vol. I

[e] OPNAVINST 5102.1C, Mishap Investigation and Reporting

[f] NAVEDTRA 14325, Basic Military Requirements

[g] NAVEDTRA 14014, Airman

[h] Local Directives and Standard Operating Procedures

[i]

[j] NAVAIR 00-80T-105, CV NATOPS Manual

[k]

[l] NAVAIR 00-80T-109, Aircraft Refueling NATOPS Manual

.1 Discuss the concept of ORM. [ref. a, ch. 1]

* Operational Risk Management is a systematic, decision-making process used to identify and manage hazards that endanger naval resources. ORM is a tool used to make informed decisions by providing the best baseline of knowledge and experience available. Its purpose is to increase operational readiness by anticipating hazards and increase the potential for success to gain the competitive advantage in combat. ORM is not just related to naval aviation; it applies across the war-fighting spectrum

.2 Explain the following as they apply to ORM: [ref. a, ch. 1]

a. Identifying hazards

Begin with an outline or chart of the major steps in the operation or operational analysis. Next, conduct a preliminary hazard analysis by listing all of the hazards associated with each step in the operational analysis along with possible causes for those hazards.

b. Assessing hazards

For each hazard identified, determine the associated degree of risk in terms of probability and severity. Although not required, the use of a matrix may be helpful in assessing hazards.

c. Making risk decisions

Develop risk control options. Start with the most serious risk first and select controls that will reduce the risk to a minimum consistent with mission accomplishment. With selected controls in place, decide if the benefit of the operation outweighs the risk. If risk outweighs benefit or if assistance is required to implement controls, communicate with higher authority in the chain of command.

d. Implementing controls

The following measures can be used to eliminate hazards or reduce the degree of risk. These include engineering controls, administrative controls, and personnel protective equipment.

e. Supervising

Conduct follow-up evaluations of the controls to ensure they remain in place and have the desired effect. Monitor for changes, which may require further ORM. Take corrective action when necessary.

.3 Discuss the purpose of the NAVOSH Program. [ref. b, ch. 1]

* The primary objective is to preserve human and material resources. The program enhances operational readiness by preserving the resources used in accomplishing the naval aviation mission. The human resources include professional pride, high morale, physical well being, and life itself, all of which are susceptible to damage and destruction caused by mishaps. Material resources include property, which may be damaged by an aircraft mishap including naval aircraft, ships, facilities, and weapons.

.4 Discuss the purpose of the Naval Aviation Safety Program. [ref. c, ch. 2]

* PURPOSE OF THE PROGRAM

The Naval Aviation Safety Program enhances operational readiness when it preserves the lives and enhances the well-being of its members by protecting the equipment and material they need to accomplish their mission. The Naval Aviation Safety Program supports every aspect of naval aviation. Knowledge gained here may assist other safety efforts. The program may, therefore, yield benefits and preserve resources far beyond its intended scope.

* OBJECTIVE OF THE PROGRAM

1. The Naval Aviation Safety Program succeeds by preventing damage and injury. Potential causes of damage and injury under human control are termed hazards. The goal of the Naval Aviation Safety Program is to eliminate or control hazards.

2. The Director, Air Warfare Division (CNO (N78)) is responsible for naval aviation safety and the safety of assigned surface ships.

.5 State the purpose of the personnel injury/death/occupational illness report. [ref. e, ch. 1]

* Record keeping and reporting is vital to provide safety information to Department of the Navy (DON) and Department of Defense (DOD). These records and reports are required by federal law and provide information to identify unsafe acts and conditions, and apply corrective measures. With the inception of electronic reporting, mishaps or incidents that previously were only locally recordable, and not reportable outside the command, are all now in the reportable category, since all electronic entries are transmitted to the Commander, Naval Safety Center (COMNAVSAFECEN) mishap database. Besides material damage, fatalities and disability mishaps, data must also be collected on time away from work, light, limited, and restricted duty injuries and occupational illnesses for preventive efforts. Therefore all recordable mishaps are to be reported electronically to COMNAVSAFECEN.

.6 Discuss how the following causal factors contribute to aviation mishaps: [ref. c, ch. 6]

a. Human: Human error causes an alarmingly high number of mishaps. Human error is part of nearly every mishap. It includes those personnel who may have maintained or repaired equipment or even the worker at the factory where a part was manufactured. Human error involves both physical and mental factors including ergonomics (design of the workplace), physical strength of the individual, physical stress, and mental factors including the person's attitude, behavioral factors, etc.

b. Material: Consider all material failures and malfunctions thoroughly, whether the failures or malfunctions occurred because of faulty design, defective manufacture, or repair. Most mishaps blamed on material failure may really involve maintenance factors or human error.

.7 Define the following aircraft mishap severity classes: [ref. c, ch. 4]

a. Class A: The resulting total cost of reportable material property damage is $1,000,000 or more; or an injury or occupational illness results in a fatality or permanent total disability.

b. Class B: The resulting total cost of reportable material or property damage is $200,000 or more, but less than $1,000,000; or an injury or occupational illness results in permanent partial disability; or three or more personnel are inpatient hospitalized.

c. Class C: The resulting total cost of reportable material or property damage is $10,000 or more, but less than $200,000; a non-fatal injury that causes any loss of time beyond the day or shift on which it occurred; or a non-fatal illness or disease that causes loss of time from work or disability at any time (lost time case). For reporting purposes, reportable lost workday Class C mishaps are those which result in 5 or more lost workdays beyond the date of injury or onset of illness (exceptions apply).

d. Class D: The resulting total cost of reportable material or property damage is less than $10,000 or a non-fatal injury (no lost time or first aid case) that does not meet the criteria of a Class C mishap.

.8 Define the following aircraft mishap categories: [ref. c, ch. 4]

a. Flight mishap (FM). This category encompass those mishaps which result in $20,000 or more damage to a DOD aircraft or UAV or, the loss of a DOD aircraft or UAV - when intent for flight for DOD aircraft or UAV existed at the time of the mishap. Other property damage, injury or death is irrelevant to this classification.

b. Flight related mishap (FRM). Those mishaps which result in less than $20,000 damage to a DOD aircraft or UAV -when intent for flight existed at the time of the mishap and, additionally, $20,000 or more total DOD and non-DOD damage or a reportable injury or death occurred.

c. Aircraft ground mishap (AGM). Those mishaps in which the intent for flight did not exist but a DOD aircraft or UAV was lost, or more than $20,000 damage was sustained by a DOD aircraft or UAV, or DOD or non-DOD property was damaged in the amount of $20,000 or more, or a reportable injury occurred.

.9 Discuss the composition and purpose of the Aircraft Mishap Board. [ref. c, ch. 2]

1. An Aviation Mishap Board must investigate every naval FM, FRM, and AGM, then report on them as this instruction directs. Each aircraft reporting custodian shall maintain at least one standing Aviation Mishap Board (AMB).

2. Composition.

a. Appointment of AMBs. The aircraft controlling custodian or the designated appointing authority shall appoint AMB members by name and in writing. On all Class A Mishap Investigations, appoint the senior member from commands not involved in the mishap - preferably from outside the expected endorsing chain. The senior member will be a Naval Aviator or Naval Flight Officer (A commander or lieutenant colonel or above), a graduate of the ASO or Aviation Command Course, or have other suitable training or qualifications acceptable to the aircraft controlling custodian. On other mishaps the senior member may be from the reporting custodian and of any rank senior to the Pilot in Command and Mission Commander.

b. Basic AMB Composition. The following applies to AMBs under all conditions, except direct enemy action:

(1) Members of Aviation Mishap Boards shall be drawn from the ranks of commissioned officers on active duty in the U.S. Navy or U.S. Marine Corps. Officers on Exchange Duty from other services (U.S.A. or foreign) may serve on AMBs, but may not be the senior member. Chapter 6 describes the requirements for inter-service participation on AMBs. Enlisted personnel with the rank of E-6 and above may serve on AMBs for UAVs.

(2) Minimum AMB membership shall consist of four officers drawn from the command's standing board: an ASO (NAVPGSCOL ASO course graduate), a flight surgeon, an officer well-qualified in aircraft maintenance, and an officer well qualified in aircraft operations.

(3) The senior member of each AMB shall be a Naval Aviator or Naval Flight Officer. The senior member of a Class A mishap board has message releasing authority for Mishap Data Reports and SIRs. All other senior member functions will remain the same as outlined in this instruction.

(4) Sometimes an appointing authority may not have enough qualified personnel in the command, may be operating in a remote location, or for other reasons be unable to field a complete AMB. In such cases, one may appoint AMB members from outside the command. For instance, with no flight surgeon assigned, it is altogether proper to borrow one from another command.

(5) In unusual or complex mishaps, the AMB may benefit from having officers with specific expertise as members. In such cases the senior member should request the appointing authority assign these additional members (a flight deck officer, perhaps, or an aerospace physiologist) to the AMB.

c. Required Changes to Composition of AMBs. The following may require adjustments in the membership of the AMB by the appointing authority, depending on the circumstances of a mishap under investigation:

(1) The senior member of each AMB shall be senior to the pilot in command and mission commander involved. The appointing authority, with the concurrence of controlling custodian, may waive this requirement in isolated cases where compliance would require unreasonable measures.

(2) For manned aircraft mishaps, at least one member of the AMB shall be a pilot who is NATOPS-qualified in the model aircraft involved.

(3) Personnel directly involved in a mishap shall not serve on an AMB conducting an investigation of that mishap.

(4) Members whose personal interest in a mishap might conflict with the objective and impartial performance of their duties shall not serve on the AMB investigating that mishap.

(5) Do not allow someone who may be called upon to endorse the SIR to sit on the AMB investigating the mishap.

d. Insufficient AMB Membership

(1) Sometimes AMB members are involved in mishaps. Address plans for such eventualities (particularly important for detachment operations) in pre-mishap planning.

(2) When, despite their best efforts, appointing authorities find themselves with too few members to constitute a board, they may: request relief or waiver from investigating and reporting the mishap, or request help with the investigation from the controlling custodian.

.10 Discuss the safety precautions to be observed when:

* Self explanatory

a. Working in confined spaces [ref. b, ch. 27]

b. Working near or utilizing electrical equipment [ref. b, ch. 24]

c. Working in spaces with high noise levels [ref. b, ch. 18]

d. Working with flammable (paints, solvents, etc.) [ref. b, ch. 20]

e. Working near compressed gases [ref. h]

f. Working with composite materials/beryllium [ref. b, ch. 17]

g. Lifting heavy objects [ref. k]

h. Working in RADHAZ areas [ref. b, ch. 22]

i. Working with/near asbestos [ref. b, ch. 17]

.11 Discuss the safety precautions to be observed during a fire. (e.g., space security, evacuation routes, mustering, etc). [ref. g]

* Self explanatory

.12 Discuss the safety precautions which must be implemented aboard your ship/station to prepare for severe weather or when severe weather is being experienced. [ref. g]

1. NORMAL WEATHER CONDITIONS

In general, the following procedures apply when securing aircraft under normal conditions:

1. Plane captains of landing aircraft stand by with tie-downs on the flight deck in a designated area. They join their aircraft as they are being parked. If an aircraft is moved to the hangar bay below, its plane captain should board the elevator with it if he can do so safely.

2. Aircraft-handling crews stand by in a designated area during recoveries and act as chock men while aircraft are being taxied and parked. They put on the initial tie-downs and are assisted by the plane captain when possible.

3. When the aircraft reaches the final spot, the director will signal the pilot of the aircraft to lower its tail hook. This automatically straightens the nose wheel to center. Some aircraft must have the nose wheel aligned to center manually.

4. The plane captain connects the ground wire and installs wing fold jury struts, parking harness and batten boards, engine and cockpit covers, and tie-downs needed other than the initial tie-downs put on by the aircraft-handling crews. Detailed procedures for securing a specific aircraft are found in the maintenance instruction manual (MIM) for that aircraft.

2. HEAVY WEATHER PROCEDURES

The procedure for securing aircraft during heavy weather differs very little from that used in normal weather. The main difference is that more tie-downs are used. All flight control surfaces are secured with battens, and controls inside the aircraft are secured. When extremely heavy weather is anticipated, as many aircraft as possible are spotted on the hangar deck. The remainder are spotted in the fly 2 (center) and fly 3 (aft) areas of the flight deck. Avoid securing aircraft athwart ship and in the heavy weather spot. Aircraft remaining on the flight deck should be spotted inboard along either side of the center line of the deck. Leave a clear area around the perimeter of the flight deck. If possible, spread the wings on the aircraft that are spotted on the flight deck. For special instructions on securing an individual aircraft, refer to the aircraft's specific maintenance manual. When the ship is not at flight quarters or during heavy weather conditions, the Air Department is required to maintain a security/integrity watch on the flight deck and hangar deck to ensure that each aircraft remains properly secured. The watch must be especially alert for loose or broken jury struts, tie-downs, battens, chocks, engine intake/ exhaust and canopy covers, any leakage, or hazardous conditions. Extreme caution is necessary when you handle aircraft in heavy weather.

3. COLD WEATHER PROCEDURES

Handling aircraft during cold weather operations is extremely difficult. Keep as many aircraft on the hangar deck as is possible during extremely cold weather. Keep the flight deck clear of ice and snow. The following methods, gear, and equipment for snow and ice removal are often used:

1. Mobile equipment removal—some aircraft tow tractors may be fitted with snowplow blades or with rattan or wire rotary brushes.

2. Manual removal—conventional methods include brooms, crowbars, shovels, wooden mallets, and scrapers. Use compressed air to blow snow from pockets. Use firemain water at 100 psi and steam lances for undercutting ice. Use deck scrapers and auxiliary hot-air heaters to clear flight-deck equipment, such as wires, sheaves, arresting gear, and elevators, of ice. Use normal deck procedures in cold weather, but considerably more time is required because of the excessive hazards involved. Use battens on control surfaces. Jury struts and cockpit covers are recommended. Tie-down the controls inside the aircraft to eliminate the chance of movement of outer control surfaces. Aircraft on ice or snow should always be moved slowly. Avoid using the brakes as much as possible when turning aircraft.

.13 Describe the purpose of the Navy's Tag-Out Program. [ref. b, ch. 24]

* ENERGY CONTROL PROGRAM (LOCKOUT/TAGOUT)

a. Purpose: This chapter establishes Navy policy and minimum procedures for locking out or tagging the sources of energy to equipment or systems under the requirements of reference 24-1 and the minimum performance standards of reference 24-2.

b. Scope and Application: The requirements of this chapter apply to the control of energy during servicing and maintenance of machinery and equipment ashore. These requirements apply only when the unexpected energizing or movement of machinery/equipment or the release of energy during the maintaining or servicing of such equipment/machinery could cause injury to personnel and/or property damage.

Reference 24-1. Title 29 Code of Federal Regulations (CFR) 1910.147 of 13 Feb 96, The Control of Hazardous Energy (lockout/tagout), latest revision, and Title 29 CFR 1910.332 of 6 Aug 90, Electrical-Safety-Related Work Practices

.

Reference 24-2. American National Standards Institute (ANSI) Standard Z244.1-2003, American National Standard for Personal Protection Lockout / Tagout of Energy Sources-Minimum Safety Requirements (NOTAL), .

.14 Discuss the following first aid procedures: [ref. f]

a. Removing a victim from an energized circuit [ch. 14]

* Rescuing a person who has received an electric shock is likely to be difficult and dangerous. Use extreme caution or the rescuer may also be electrocuted. Don’t touch the victim’s body, the wire, or any other object that may be conducting electricity. Some procedures you might use to rescue a person who’s received an electric shock are as follows:

* Look for the switch first of all, and if you find it, turn off the current immediately. Don’t waste too much time hunting for the switch; however, every second is important.

* If you cannot find the switch, you should try to remove the wire from the victim with a dry broom handle, branch, pole, oar, board, or similar non-conducting object.

* It may be possible to use dry rope or dry clothing to pull the wire away from the victim.

* You can also break the contact by cutting the wire with a wooden-handled axe, but that is extremely dangerous because the cut ends of the wire are likely to curl and lash back at you before you have time to get out of the way. When you are trying to break an electrical contact, always stand on some non-conducting material, such as a dry board, newspaper, or clothing.

Administer artificial ventilation immediately after freeing the person from the wire if the electric shock caused breathing to stop. Check the victim’s pulse, since electric shock may also cause the heart to stop. If you do not feel a pulse, immediately administer CPR. Get the victim to a medical facility as soon as possible.

b. Treatment for shock [ch. 14]

* Keep an injured person warm enough for comfort, but do not let the victim become overheated. The best position to use to prevent or to treat shock is one that encourages the flow of blood to the brain. If possible, place the injured person on his or her back on a bed, a cot, or a stretcher. Raise the lower end of the support about 12 inches so that the feet are higher than the head. If you can’t do that and it’s possible, raise the feet and legs enough to help the blood flow to the brain. Sometimes it’s possible to take advantage of a natural slope of ground and place the victim so that the head is lower than the feet.

* If you have any doubts about the correct position to use, have the victim lie flat on his/her back. The basic position for treating shock is one in which the head is lower than the feet. Do the best you can under the particular circumstances to get the injured person into this position. In any case, never let a seriously injured person sit, stand, or walk around.

c. Treatment for burns [ch. 14]

* The most effective immediate treatment of burns and of pain is as follows:

1. If the burn area covers less than 20% of the body, immerse the burned area in cold water, or apply cold compresses if immersion is impracticable. Cold water not only minimizes pain but also reduces the burning effect in the deeper layers of the skin. Gently pat dry the area with lint-free cloth or gauze.

2. If the burn area covers more than 20% of the body, apply sterile, dry bandages. Aspirin is also effective for the relief of pain. Continue treatment until no pain is felt when the burned area is exposed to the air. Burn victims require large amounts of water, which should be slightly salted. Because of the nature of the injury, most burns are sterile. Therefore, the best treatment for uninfected burns is merely to protect the area by covering it with the cleanest (preferably sterile) dressing available. Some actions that should not be taken when dealing with burns are as follows:

* Never apply ointments to a burn or use petrolatum gauze.

* Don’t attempt to break blisters or to remove shreds of tissue or adhered particles of charred clothing.

* Never apply a greasy substance (butter, lard, or Vaseline™), antiseptic preparations, or ointments. These may cause further complications and interfere with later treatment by medical personnel.

d. Treatment for bleeding [ch. 4]

* Blood is circulated throughout the body by three different kinds of blood vessels. 1. Arteries, which are large vessels that carry the blood away from the heart 2. Veins, which are large vessels that carry the blood back to the heart 3. Capillaries, which form a connecting network of smaller vessels between the arteries and the veins

* Hemorrhage (escape of blood) occurs whenever there is a break in the wall of one or more blood vessels. In most small cuts, only capillaries are injured. Deeper wounds result in injury to veins or arteries. Bleeding severe enough to endanger life seldom occurs except when arteries or veins are cut.

* The only way to stop serious bleeding is by the application of pressure. In practically all cases, bleeding can be stopped if pressure is applied directly to the wound. If direct pressure doesn’t stop the bleeding, pressure should be applied at the appropriate pressure point. In those very rare cases where bleeding is so severe that it cannot be controlled by either of these methods, pressure can be applied by a tight constricting band. The actual procedures you should use to stop bleeding are shown in chart on pages 14-10 and 14-11. Read Reference.

e. Treatment for heat exhaustion [ch. 14]

* To treat heat exhaustion victims, you should treat them as if they were in shock.

* Loosen the clothing; apply cool, wet cloths.

* Move the victim to either a cool or an air-conditioned area, and fan the victim.

* Do not allow the person to become chilled.

* If the victim is conscious, administer a solution of 1 teaspoon of salt dissolved in a quart of cool water.

* If the victim vomits, don’t give any more fluids.

* Transport the victim to a medical facility as soon as possible.

f. Treatment for frostbite [ch. 15]

* Frostbite and immersion foot are serious injuries that can happen even when you’re wearing enough clothing to stay fairly comfortable. Frostbite usually affects the hands, face, or feet, and it most often occurs on windy, very cold days. Affected parts of the body turn stiff, pale, and numb. To prevent frostbite, keep exposed parts of the body as warm as possible and maintain circulation. If frostbite occurs, treat the affected part immediately by placing it in contact with a warm part of your body. Cover it with your hand or put frozen fingers inside your clothing. Don’t rub the affected parts; that could result in damage to frozen tissue.

* Immersion foot is the swelling of the foot accompanied by numbness and pallor (lack of color) or discoloration. Immersion foot is caused by poor circulation in the legs, particularly when the foot remains wet for several days. To prevent immersion foot, exercise the ankles and toes for a few minutes several times each day. Keep your feet warm, dry, and elevated as much as possible. Unlace your shoes or take them off. If you have no dry socks or wrappings for your feet, put them under the arms or in the lap of a shipmate. Never treat immersion foot by rubbing. As with frostbite, tissue damage may result. Rewarming is the only proper treatment.

104.15 Discuss the following:

a. Sight conservation [ref. b, ch. 19]

b. Battery safety [ref. g, ch. 7]

c. Foot protection [ref. b, ch. 20]

d. Head protection [ref. b, ch. 20]

e. Toxic material protection [ref. b, ch. 20]

f. Hazardous material label [ref. b, ch. 7]

g. Electromagnetic radiation hazards [ref. b, ch. 22]

h. Hearing conservation [ref. b, ch. 18]

* Self explanatory

.16 Discuss the following services provided by the Naval Safety Center: [ref. i]

* Access the web site:

a. Periodicals

b. Messages

c. Surveys

d. Web site

.17 Define the following terms as used in aviation maintenance publications: [ref. d, ch. 1]

a. Warning: refers to a procedure or practice that, if not correctly followed, could result in injury, long term health hazards, or death.

b. Caution: refers to a procedure or practice that, if not correctly observed, could result in damage to or destruction of equipment.

c. Note: refers to a procedure or condition that requires emphasis.

d. FYI, The concept of word usage and intended meaning that has been adhered to in preparing this instruction is as follows:

(1) "Shall" means procedure is mandatory.

(2) "Should" means procedure is recommended.

(3) "May" and "need not" mean procedure is optional.

(4) "Will" indicates futurity and never indicates any degree of requirement for application of a procedure.

.18 Discuss the role of the ship/station Industrial Hygienist, in aviation maintenance operations. [ref. b, ch. 8; ref. i]

* Navy industrial hygiene personnel anticipate, recognize, evaluate, and make recommendations to control unacceptable workplace exposures. Exposure assessment of Navy workplaces requires a sound, logical strategy and shall be based on references 8-2 through 1.1.1.

Inform the Secretary of Defense on 8-5. The purpose of such a strategy is to accomplish at least four goals:

(1) To assess potential health risks faced by Navy personnel by understanding their exposures, to differentiate between acceptable and unacceptable exposures, and to control unacceptable exposures.

(2) To establish and document a historical record of exposure levels for Navy personnel and to communicate exposure monitoring results.

(3) To ensure and demonstrate compliance with safety and health exposure criteria.

(4) To provide a basis for medical surveillance examinations.

Reference 8-1. OPNAVINST 5100.19D, of Dec 05; Navy Occupational Safety and Health (OSH) Program Manual for Forces Afloat

.

8-2. DODI 6055.5 of Jan 89, Industrial Hygiene and Occupational Health

.

8-3. Industrial Hygiene Field Operations Manual of Dec 04, NEHC Technical Manual, NEHCTM6290.91-2, .

8-4. AIHA “A Strategy for Occupational Exposure Assessment”, latest revision (NOTAL)

.

8-5. “DOD IH Exposure Assessment Model of January 00,” DOD Industrial Hygiene Working Group Report 2000-1. smodelv8.html.

104.19 Discuss the flight deck/line safety precautions applicable to the following:

a. Flash photography [ref. h]

b. Flight deck clothing [ref. j, ch. 2]

c. Hazards of turning main rotor blades and rotor blade downwash [ref. j, ch. 4]

d. Hazards of turning tail rotor blades [ref. j, ch. 4]

e. Ship maneuvering [ref. h]

f. Cold/heavy weather operations [ref. h]

g. Aircraft movement hazards [ref. j, ch. 6]

h. REMOVE BEFORE FLIGHT warning flags/streamers [ref. h]

i. Trip hazards associated with flight deck/hangar deck [ref. h]

j. Divisional/hangar/elevator doors [ref. h]

k. Weapons elevator hatches [ref. h]

l. AESS hatches/stations [ref. h]

m. Aircraft fueling [ref. l]

n. Fuel, oil, and hydraulic leaks [ref. h]

o. Weapons/chaff [ref. j, ch. 6; app. C]

p. Emergency landing [ref. j, ch. 5]

q. Night operations [ref. h]

MORE AMB INFO

a. Responsibilities.

Mishap investigation and reporting responsibilities of AMB members take precedence over all other duties.

(1) Aircraft or UAV reporting custodians, paragraph 107k.

(2) Senior member, AMBs, paragraph 107m.

(3) Members, AMBs, paragraph 107n.

b. Organization for Investigation

(1) The Standing AMB. The program requires reporting custodians appoint in writing and maintain a standing AMB. Paragraph 206b requires a minimum of four members with experience and knowledge in the specialized fields of safety, aeromedical, operations, and maintenance. The AMB's senior members must be sure their boards are trained and ready to investigate mishaps.

(2) Changes in Board Membership. When changes in Board membership are necessary, it is the senior member's responsibility to recommend to the appointing authority appropriate changes of AMB membership to comply with this instruction. The senior member may also recommend additional members be seated if the investigative effort requires. For example, in a mishap involving Aviation Life Support Systems, the senior member may recommend the assignment of a local AMSO to the Board.

(3) Use of Board Members. The senior member may excuse any member from active participation in the investigation if that individual's particular skills are no longer needed. The individual retains board membership until removed by the appointing authority

c. Conduct of the Investigation. NAVAIR 00-80T-116, Vols. I-II, Technical Manual, Safety Investigation Techniques; and Aviation Safety Programs, Aircraft Mishap Investigation Notebook tells how to conduct a naval aviation mishap investigation.

(1) The Investigative Effort. The amount of investigative energy expended in discovering the causes of mishaps has nothing to do with the amount of damage they cause. Your job is to identify the hazards associated with the mishap. A complex or mysterious mishap may require extensive investigative efforts; a simple, well-defined mishap might be investigated with minimal effort. The extent of the investigative effort depends on the senior member's desire.

(2) Collection of Evidence. It is impossible to accurately predict what kinds of evidence should be collected under what circumstances in every mishap investigation. For this reason, we rely on the AMB senior member's judgment.

(3) Medical Evidence. Because medical evidence is quickly lost, we must immediately notify the AMB flight surgeon when a mishap occurs. The flight surgeon is primarily concerned with medical, physiological, social, behavioral and psychological factors which may reveal mishap causal factors.

(a) Pre-Mishap Planning. The flight surgeon shall participate fully in AMB pre-mishap planning, including planning for the collection of medical evidence. (See appendix 2B, Pre-Mishap Plan Checklist.)

(b) Physical Examinations. Regardless of his/her military service affiliation, the first flight surgeon on a mishap scene, or the one to whom mishap victims are brought, shall immediately perform examinations and laboratory procedures required by the flight surgeon's service. However, the parent service of the victims must delineate unique requirements and assume responsibility for the aeromedical portion of this investigation as soon as possible.

(c) Radiographs. They shall perform Radiology studies as clinically indicated. Full spinal x-rays are required after all ejections, bailouts, and crashes with or without suspected back injuries.

(d) Biological Samples. In all Class A and Class B mishaps and when necessary following Class C mishaps and incidents with potential to meet defined naval mishap limits, biological sampling shall take place immediately after the mishap. The importance of this knowledge is unrelated to the severity of the mishap. Include biological sampling policies which conform to current Navy and DOD directives in every Pre- Mishap Plan. Take enough blood and urine specimens for blood alcohol, carbon monoxide, drug screen, hemocrit, hemoglobin, glucose and urinalysis testing. Freeze and store an aliquot of each specimen for at least 90 days following the mishap for verification or for other studies as may be necessary later.

(e) Pathological Studies. Conduct an autopsy, including full body x-rays, whenever a fatality occurs as a result of a naval aviation mishap.

(f) Drug-Assisted Interviews and Hypnotic Techniques. Drug-assisted interviews and hypnosis are prohibited without the specific, written authority of CNO (N78). These interviews and techniques will be authorized only when critical safety-related information cannot be obtained any other way and the subject agrees voluntarily. When authorized, the procedure shall be conducted by a member of the medical department qualified in the procedure, with the AMB flight surgeon in attendance. Other attendees are discouraged. (The value of these efforts is suspect and the probability of getting false, inaccurate, and misleading information from them must be considered.)

d. Deliberations. As the AMB collects evidence it must begin to attach significance to that evidence and decide what part it may have played in the mishap. The SIR format provides a guide for the deliberations of the Board. The SIR outline reflects a pattern of deductive reasoning:

- What the Board knows (paragraph 10, Evidence).

- Reasoning of the Board (paragraph 11, Analysis).

- Deductions of the Board (paragraph 12, Conclusions).

- The Board's recommendations to prevent recurrence of the mishap, or damage and injury occurring during the mishap (paragraph 13, Recommendations).

(1) Analysis and Causal Factors. The AMB must analyze the evidence available to them in order to determine the causes of the mishap. The resulting list constitutes the causal factors of the mishap. Causal factors have three elements which (1) describe the people or the equipment, and (2) define the actions or the events, and (3) tell why this causal factor contributed to the mishap.

Defining these elements is essential for determining the cause of the mishap. Thus, causal factors fall into two general classifications: human and material.

(a) Human Factors. Determining how people contribute to mishaps is of obvious importance. To describe fully and to understand human factors requires us to identify the elements: WHO, WHAT, and WHY in each occurrence. It is not enough to describe the human portion of mishaps as "personnel error," or "pilot technique". Such labels are not nearly detailed enough to encompass the entire cause of a human factor mishap; they fail to explain why the event happened. Normally, there are few questions about WHAT occurred; usually it is self evident: A gear-up landing is just that. Likewise, the WHO lends itself to quick identification: the pilot. Still, the most significant element, from the standpoint of prevention, is missing: the WHY. This is the element that lends itself to remedial action. Flight surgeons are trained and thus must always have a role in the identification and analysis of human factors.

1. WHO. There are four kinds of people who can contribute to an aviation mishap. They are: aircrew, supervisors, facilities and maintenance personnel.

a. Aircrew. The people (including instructors) in the aircraft, in the formation, or controlling the UAV, are listed under the aircrew factor classification. We must identify their contributions to the mishap - whether or not they survived.

b. Supervisory. People in command and operations -related support – up and down the chain of command – fall into the supervisory factor classification. Consider the behavior of supervisors at every level, their publications, and their policies, all of which may contribute to a mishap.

c. Facilities Personnel. Classify errors committed by people involved in air traffic control (tower, prifly, CATCC, etc.), runway watches, aircraft or UAV ground handling, crash and rescue, and search and rescue under Facilities Factors.

d. Maintenance. Errors committed by people engaged in the production, servicing, or repairing of aircraft are listed under the maintenance factor classification.

2. WHAT. The actions of those who caused the mishap are the “WHAT” of a human causal factor. The WHAT is a hazard statement defining an act of omission or commission which led to the mishap. Appendix L is matrix of actions performed, or not performed, by the four classifications.

3. WHY. One assumes no naval aviation professional would purposefully commit an act that would result in a mishap. Circumstances like fatigue, lack of training, misinformation, and motivational dysfunction may combine to create a situation that leads to a mishap, but even negligence lacks the specific intent to cause damage or injury. They are subdivided into six groups:

- Communication/Coordination

- Psychosocial

- Environment

- Performance

- Human Engineering

- Medical/Psychological

(b) Material Factors. Even in material failures, there may be enough evidence for the AMB to identify human factors; someone misused something, or did not maintain or service it, or designed it improperly, or made or reworked it below standards. Even so, including material factors in the set of mishap causal factors is important because, while human factors are surely involved, the material factor is often the weak link in the chain. It may be possible, for example, to redesign and strengthen a part. On the other hand, there may be no evidence supporting human factor involvement and a material failure may be the only possibility. Thus, we include material factors in this set of mishap causal factors.

1. Component. The smallest, most specific part, assembly, or system identified as having failed is the component.

2. Mode. How the component failed. Specifically, "WHAT" occurred, is the Mode. Typical examples are: fracture (load bearing member broke), stripped threads, jammed, leaked, etc.

3. Agent. The acts or events which led to the failure mode are the agents. Typical examples are overload, fatigue, fire, or spalling. These are the "technical" agents; each component failure must have, at least, one "technical" agent. In addition, the AMB may discover further "human factor" agents. These might include improper maintenance procedures, poor design or improper aircrew procedures. We will address "human factor" agents as separate causal factors (Aircrew, Supervisory, Maintenance and Facilities), and will analyze the WHO/WHAT/WHY more fully.

(2) Conclusions. AMBs must base their conclusions as to which hazards caused the mishap, damage, or injury during the mishap, on all available information and their own deductions. They may test the conclusions under consideration with the question: "Absent this causal factor would there have been a mishap?” You may use the terms "Hazard,” "mishap cause and causal factor," and "causal factor of damage or injury,” interchangeably.

(a) Mishap Causal Factor Determination. The SIR is the report of the mishap causal factors determined by the AMB.

(b) Causal Factors of Other Damage and Injury Occurring during a Mishap.

(c) Environmental Conditions.

(d) Noncontributory Hazards Discovered During the Investigation.

(3) Recommendations. AMBs should use the guidelines in appendix C when formulating their recommendations, and test these recommendations with the question: "If this had been done before the mishap, would these additional hazards have been eliminated?" Don't include any recommendations that fail this test; rather, report them in a Hazard Report.

* PRE-MISHAP PLANS: A pre-mishap plan describes - in advance - the steps that must be taken when a mishap occurs. Anticipate all reasonable eventualities and devise measures to cope with them. Deficiencies may be identified through periodic drills designed to ensure the plan's smooth execution when a mishap occurs. While the content of a pre-mishap plan is largely at the option of the command, plans for Navy and Marine Corps airfields and aircraft operating facilities must address:

a. Coordination with local news media, area law enforcement officials, civil fire and rescue agencies, the Environmental Protection Agency (EPA), and the FAA.

b. Coordination with tenant commands to be sure required support for engineering services, supply, medical assistance, and hazardous material disposal will be available.

c. Coordination with nearby military aviation facilities to clearly describe the geographic boundaries of responsibilities for immediate responses to an aviation mishap

d. Provisions for an immediate telephone report to the reporting custodian of aircraft mishaps within the airfield's area of cognizance.

e. Plans to protect aircraft wreckage so that it remains undisturbed for at least 24 hours.

f. Provisions for explosive ordnance disposal (EOD) services which will render explosives in the aircraft wreckage safe and provide authorized storage facilities.

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