Predict And Prevent

STORY BY LCDR C.J. Warren / Peer Reviewed by CAPT Billy Murphy

Safety Center teams continually seek opportunities to predict and prevent potential mishaps

A pilot assigned to HSC-22 preflights one of the squadron's MH-60Ss for flight. (U.S. Navy photo by Visual Information Specialist John W. Williams)

A pilot assigned to HSC-22 preflights one of the squadron’s MH-60Ss for flight. (U.S. Navy photo by Visual Information Specialist John W. Williams)

Who doesn’t enjoy a good inspection? Last-second running around to update program binders that haven’t been referenced in years; vision statements, policies, and designation letters finally signed by the commanding officer just 10 short months after the change of command; the pleasant aroma of nervous sweat as division officers wait their turn to be told every mistake Airman Fumblefingers made while an angry-looking master chief looks over his shoulder.

Ahh, the sunny disposition of deck plate leaders who know that this is just the first in a series of redundant inspections. The best part? When the inspection is over, the squadron can finally go back to doing things the way they’ve always been done … until the next inspection.

Who doesn’t enjoy inspections? The Naval Safety Center, that’s who! In 2015, the Safety Center switched from conducting safety surveys (everyone knew “survey” was just a sneaky way of saying inspection), to safety assessments.
It may seem like a simple change in semantics, but there truly is a difference between an inspection and an assessment. An inspection digs into program binders and documentation to determine whether or not a squadron is adhering to rules and regulations. An assessment is more focused on observing how you implement those programs and whether or not your procedures facilitate or hinder mission accomplishment. Aviation safety assessors spend a lot of time simply observing how a squadron executes its daily operations. To quote the great Yogi Berra, “You can observe a lot by watching.”

So what have we observed during assessments? (Glad you asked.)  We’ve found that many barriers to safe mission accomplishment are outside of squadron control: manning, training, and equipment challenges have become so pervasive that junior Sailors and Marines often don’t ask for help since they know there’s no point in raising concerns when everybody knows there’s no money to address the issue. It makes leadership proud to see our Sailors and Marines finding resourceful ways a way to get the job done; however, it’s disappointing that they are often ill-equipped to get the job done properly and on time.

The observed work-around solutions are common: longer work hours, executing fewer flights, completing tasks without proper training, and/or unintended utilization of equipment. These solutions frequently create unrecognized hazards. Aviation assessment teams bring these hazards to the attention of commanding officers and their immediate superior in command (ISIC), enabling them to solicit and provide the proper manning, training, and equipment or consciously accept the associated risks. Aviation assessment teams share these fleetwide concerns with the Commander, Naval Safety Center, enabling him to give a powerful voice to these shortcomings at the flag and, at times, the congressional level.

Some barriers to safe mission accomplishment are within the squadron’s control, however. The most common problems are procedural non-compliance and improper supervision. At almost every squadron, assessment teams observe the following: Sailors and Marines completing maintenance without referencing Interactive Electronic Technical Manuals (IETMs), collateral duty inspectors (CDIs) performing the maintenance they are supposed to be inspecting, and khaki leadership at their computers bogged down with administrative duties. We’ve discovered a simple means to fix these universal issues – better supervisory presence. It turns out that our wrench-turners tend to actually use IETMs when khaki leadership is watching. CDIs resist the urge to do a job themselves when chiefs and officers are personally engaged. While there is no cure for every administrative task, there are far fewer required reports when Sailors aren’t getting injured and aircraft aren’t getting damaged. Besides, who joined the Navy to sit at a desk all day? Stretch your legs every once in a while and take a walk to the hangar bay or flight line!

Assessments also provide an opportunity to interact with the fleet. Best practices are captured and shared with other squadrons, on-the-spot training can be conducted, hazards are discovered which are shared with sister squadrons and even with other communities. After an assessment trip, the team members return to their roles as safety analysts and disseminate the lessons learned, benefiting squadrons that were not lucky enough to be included in the assessment.

In 2016, the Safety Center continued to refine the assessment process, providing a more comprehensive report for commanding officers and their ISICs. This improved the delivery of actionable recommendations to mitigate hazards and issues facing the fleet. Squadron personnel are often pleasantly surprised that we would rather hear about their barriers to mission accomplishment than critique their program binders. In contrast to an inspection, going back to doing things the way they’ve always been done after the assessment is less likely, because the actionable items provided to the squadron and ISIC are aimed at equipping squadrons with the tools and resources required to get the mission done right.

In FY 2016, our aviation assessment teams conducted 87 fleet squadron safety assessments throughout the Navy and Marine Corps and our facilities assessment team (who concentrates on airfield support operations) assessed 14 installations. These assessments, combined with mishap and hazard reporting, inform the Safety Center’s daily analysis activities.

The Naval Safety Center continually seeks opportunities to get left of the bang; to predict and prevent potential mishaps. Our country relies upon the Navy to always be ready to fight and win. That task is infinitely harder if we have broken personnel, broken aviators, or broken aircraft. By getting left of the bang, it allows our Sailors and Marines to preserve assets and save lives, so that they are ready to accomplish the mission when called upon.



LCDR Warren is an analyst specializing in H-60, MH-53, and TH-57 in the aircraft operations division of the Aviation Safety Programs Directorate at the Naval Safety Center. This article was reviewed by CAPT Murphy, head of the aircraft division.


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