The Safety Win

BY LTCOL JESSE JANAY

From left to right: Recovery teamlead Cpl Sean Gutzmer (HMLA-167), aircraft commander Capt Gil McMilliann (HMLA-467), and airframes collateral duty inspector LCpl Brian Jennings (HMLA-167 stand next to the UH-1Y that made a precautionary emergency landing near Prescott, Arizona on Sept. 18, 2015. (Photo by Co-pilot ,Capt Ferrell/USMC).

On Sept. 17, 2015, Capt Gil “Pebble” McMillian and his UH-1Y Huey crew had a transmission chip light and they made a precautionary emergency landing (PEL). Not a big news story in itself, but there is a bigger win here: a possible mishap did not occur because the safety management system worked.

It was day four of four on a cross-country from North Car­olina to Arizona to deliver the aircraft for the next weapons and tactics instructor (WTI) course in Yuma. This particular leg was through the canyons of Sedona on the way to the last fuel stop at Lake Havasu. When the transmission chip caution light illuminated, there were no suitable landing zones; noth­ing but canyons on the left, and a mountain range blocking the nearest divert to Prescott.

The gauges showed no secondary indications and the crew’s initial instinct was to press over the mountains to the divert, but right at that specific moment, right during the make risk decisions part of the risk-management process, the crew remembered a ready room brief from their squadron aviation safety officer two weeks prior of a safety investigation report (SIR). It was the HMLA-169 Class A mishap on Jan. 23, 2015 at Twentynine Palms that killed both pilots. The un-privileged summary from The Marine Corps Times article is that “About 34 minutes into the 49-minute flight, the pilots noticed that their oil pressure gauge fluctuated and then plummeted to zero.

While the warning lights typically indicate an emergency, the pilots likely assumed the problem was due to a faulty gauge, not actual fluid loss, because of recent maintenance issues. With Twentynine Palms Calif., more than 15 minutes away, the pilots decided to continue flying. They passed two airports where they could have landed safely before the trans­mission froze, the investigators found.” The actual SIR goes into great detail and I’d highly recommend all aircrew read it. Back to Pebbles PEL and his transmission chip.

Within minutes, the crew spotted a power line slash and found a small field next to it to execute a PEL. Safe-on-deck. No crash. Phone calls were made, a maintenance recovery team was launched, and the local sheriff was on scene shortly thereafter. A confirmed transmission chip and two nights later in that same field, the aircraft and crew made it to Yuma safely. Throughout this process, squadron, group, and wing leadership supported and applauded the aircrew’s risk man­agement application and decision-making ability.

Normally, this kind of story would never have seen the light of day because it was just a PEL. It only did because several weeks later, as the wing director of safety and stan­dardization (DSS), I just happened to go flying with the same pilot and he told me that the SIR saved him and his crew’s lives.

Because of a safety program that worked, we are able to hear about this and not read another mishap report. This pilot was briefed on a previous mishap with similar circumstances, learned from the causal factors, and it entered his decision loop at a critical moment. We rarely, if ever, hear about these safety wins. We only hear about the bad ones.

It is hard to know when your safety management system works, but it is definitely easy to see when it does not; hence our almost religious tracking of our mishap statistics. Both civilian and military aviation professionals track them, but the problem is that they are a lagging metric. In safety, we need better leading metrics. One proposal: The safety win.

We seldom know when our safety program has prevented a mishap. How can one capture a non-eventful; safety wins? We always focus on the bad and how this pilot did this or that wrong. There is great merit in this approach… learning from others mistakes, but we can do better.

Our reporting systems are geared to report mishaps and we rarely hear about the near-mishaps. There needs to be a culture shift that the safety department is not here just to talk about what pilots did wrong, but also to talk about what pilots did right— for making the right call, executing the correct proce­dures, and not pushing it—the safety win.

Here’s an idea put into action: Higher headquarters buy-in and support are essential to the success of the safety win. The 2nd Marine Aircraft Wing DSS team has done this by briefing a weekly safety win to the commanding general (CG) and his staff, posting them on the digital billboards across the base weekly, and staffing a quarterly CG’s safety award (borrowed that idea from a Navy counterpart from the aviation safety manager’s course) that really incentivizes the safety win by giving time off to the winning squadron. The safety culture shift in the wing is certainly noticeable because everyone likes a win.