RADM A'J' Blackjack Johnson

1
Brunswick Safety Brief
RADM A.J. Blackjack Johnson Commander Naval
Safety Center
2
Agenda

• Goals
• Aviation Mishaps Overview
• PMV / Off-Duty Mishaps
• Fatigue
• Risk Management
• Tools for Success
• Q A

3
Fatal motorcycle accident
April 2007, 100 am In excess of 100 mph
4
SECDEF Challenge
Our goal is zero preventable accidents and I
remain fully committed to achieving the 75
accident reduction target in 2008. The
current focus of our Safety Council is on
increasing the accountability of individuals and
leaders, as well as pursuing safety technologies.
We have no greater responsibility than to
take care of those who volunteer to serve.
5

• Naval Safety Center provides safety assistance
  and advice to the CNO, CMC, and the Deputy
  Assistant SECNAV for Safety in order to
• enhance the warfighting capability of the Navy
  and Marine Corps,
• preserve resources and
• improve combat readiness by preventing mishaps
  and saving lives

6
Aviation Safety Historical Perspective
776 aircraft destroyed in 1954
16 aircraft destroyed in 2007
Angled decks Aviation Safety Center
Naval Aviation Maintenance Program (NAMP),
1959 RAG concept initiated NATOPS Program,
1961 Squadron Safety program System
Safety Designated Aircraft
ACT ORM
Mishap rates per 100,000 flight hours
NSC Data 24 Jun 08
7
Naval Safety Center/CNO N09F
Code 00 Commander RADM (USN) BSC 00110
Code 00W Flag Writer E7 (USN)
Code 001 Aide LT (USN) BSC 00120
Code 003 Command Master Chief E-9 (USN)
Code 01 Deputy Commander Col (USMC)
Code 112 USMC Liaison LTCOL (USMC) (Dual hatted)
Code 021 Prgm Analyst (USN)
Code 02 Executive Director (USN)
NAVOSHENVTRACEN
OPNAV Liaison Staff OPNAV N09FB
Business Mgt Dept Code 04
Information Systems Dept Code 50
Aviation Safety Program Dir Code 10
Afloat Safety Program Dir Code 30
Administrative Dept Code 05
Data Mgt Analysis Dept Code 60
Shore Safety Program Dir Code 40
Comm Marketing Dept Code 70
Legal Division Code 055
Command Information Dept Code 07
Direct line to CNSC for Legal matters
Direct line to CNSC for some OPNAV N09F matters
8
Aviation Directorate
Code 10 Director, Aviation Safety Programs CAPT
(USN) BSC 04040
Code 10A EA, Aviation Safety Programs (USN)
Code 11 Aircraft Operations Division
Code 14 Aeromedical Division
Code 12 Aircraft Maintenance Material Division
Code 15 Safety Culture Division
Code 13 Investigations Division
Code 16 ORM Division
9
Magnitude of Accidents
In FY07, Navy and Marine Corps Operational
Mishaps Resulted In
NAVY
MARINE CORPS

• 1 Navy death every 77 hours (3.2 days)
• 1 POV death every 112 hours (4.7days)
• 1 Aviation death every 36 days
• 1 aircraft destroyed every 45 days
• 940K a day in aviation losses

• 1 Marine death every 69 hours (2.9 days)
• 1 POV death every 132 hours (5.5 days)
• 1 Aviation death every 33 days
• 1 Aircraft destroyed every 45 days
• 463K a day in aviation losses

10
Naval Aviation Class A FMLast 12 Months
NAVY
MARINE CORPS
Last 12 Months
Last 12 Months
COMBINED
Rolling Average!
Thru 24 Jun 08
Last 12 Months
11
CLASS A FLIGHT MISHAPSLast 10 FY - USN
The last VP Class A FM, March 1995
Number
Rate/100K Flt Hrs

24 Jun 08 24 Jun 07 CLASS A
MISHAPS/MISHAP RATE FY COMPARISON 14 /
2.06 3 / 0.45
FY07 MISHAPS/MISHAP RATE
9 / 0.95 10-YEAR AVERAGE (FY98-07)
MISHAPS/MISHAP RATE 16.5 / 1.54
12
Navy VP Comparison

• Last Class A Flight Mishap was 25 March 1995.
• Last PMV Fatality 22 June 2008.
• Last Off-duty/Rec fatality 15 June 2001.
• Last Class A Shore Operational mishap 6 June 2006.

13
Navy Marine Corps Comparison

• Leading Causal Factors
• Human Error (90)
• Aircrew (breakdown in Crew Resource Management,
  poor decision making, failure to properly perform
  emergency procedures)
• Supervisory (failure to provide adequate
  guidance and training)
• Material/Systems Malfunction (10)
• Material/component catastrophic failure (no human
  error involved)

13
NSC Data 3 April 08
NHA Symposium. April 14-17 2008
14
Causal Factor Human Error
USN/USMC, FY03-07
Human Error
No. of Class A Mishaps
USN Aviation
81 of 86
HE 94
USMC Aviation
52 of 57
HE 91
NSC Data 22 Feb 08
14
NHA Symposium. April 14-17 2008
15
Causal Factor Human Error
TRENDS
TAKEAWAYS

• Mishap Investigations
• Human error (aircrew) Leading causal factors
• - Skill-based errors
• - Decision errors
• Leading preconditions for errors
• - CRM failures
• - Adverse mental states
• Inexperience
• Training issues

• Adherence to basic rules, regulations and NATOPS
  procedures
• Proper pre- flight planning
• Training
• Proficiency
• Institutionalize ORM CRM
• Enforce standards
• Increase checks and balances

SOURCE FY07-08 SIRs
16
Human Errors for Class A FM Swiss Cheese Model

• ORGANIZATIONAL PROCESS
• Failed to provide adequate guidance
• RESOURCE MANAGEMENT/ACQUISITION
• Inadequate design

• INADEQUATE SUPERVISION
• Failed to provide adequate guidance
• Failed to provide adequate training

Unsafe Supervision

• ADVERSE MENTAL STATES
• Channelized attention/Fixation
• Loss of situational awareness
• CREW RESOURCE MANAGEMENT
• Failed to communicate/Coordinate
• Failed to backup

Preconditions for Unsafe Acts
Unsafe Acts

• SKILL-BASED ERRORS
• Breakdown in visual scan
• Failed to recognize extremis
• DECISION ERRORS
• Wrong response to emergency
• Poor decision

Failed or Absent Defenses
Accident Injury
Adapted from Reason (1990)
17
Human Error The Blue Threat

• Are we learning from our costly mistakes?
• Aircraft Movement
• 2000 Tow tractor hit parked acft. Fatal injury.
  
• 2003 During acft towing, person fatally crushed
  between store dolly
• 2004 Sqdn acft under tow direction of yellow
  shirt ran over ship's blue shirt. Permanent
  disability
• 2005 Wing walker's leg run over by acft during
  move - permanent disability
• 2006 Acft ran over airman's right leg during
  taxi on flight deck - permanent disability
• 2007 While towing acft airman caught and dragged
  under right wheel and suffered skin and muscle
  damage
• 2007 Wing walker injured while acft being towed.
• Lack of supervision guidance enforcement
• Perceived Low Risk evolution
• Time Critical ORM applied?

Bottom line
Action / Inaction by own forces causing losses
far exceeding those caused by Red Threat
Degradation in mission readiness Impact to
mission accomplishment
18
Red vs. Blue Threat (FY 91- present)

• RED THREAT Aircraft Destroyed
• 18 Aircraft
• Marine Corps -13
• Navy - 5
• vs.
• BLUE THREAT

What about Class B And Class C Mishaps?
VP Recent History (since FY00) 42 Class B/C
Mishaps 5 Class B/C this FY! Of those 5, 3 are
human factors-related!
542 Aircraft
19
Human Causal Factors this FY

• FOD ingested during ground maintenance turn
• B2-stand towed into aircraft
• Aircraft struck vehicle during taxi

20
Blue Threat Mitigation Strategies
Human Factors Analysis
CSA/MCAS
ORM CRM Programs
Blue Threat Counter Tactics
Safety Surveys
Fundamental Flight Skills
Well address some of these in a minute but
first
Culture Workshops
Simulators
Technology MFOQA Smart Aircraft
21

• What is the top killer of our sailors?

22
How Did Our Sailors and Marines Die?
182 Died in FY07
217 Died in FY05
241 Died in FY06
PMV Off-Duty Recreation Aviation Shore / Ground /
MV Operational / PT Surface Ships/Sub/Diving
105 (48) 32 (15) 40 (18) 39 (18) 1
(1)
111 (61) 25 (14) 21 (12) 23 (13)
2 (1)
144 (60) 26 (11) 21 (9) 50
(21) 0 (0)
NSC Data 30 Sep 07
23
Armed Forces Traffic Death Rates (FY90-08)
Civilian rate adjusted for sex and age balance
(USMC 94/6 Navy 85/15 M/F and high of youth,
especially in the Marines)
25.21 (36) USMC
17.2 (86) Army
16.47 (44) Navy
7.23 (20) USAF
Percentage of Force Under 26 Years USMC
69 Army 48 Navy 45 USAF 39
Fiscal Year
Rates per 100,000 active duty military personnel
per year.
Through 23 Jun 08
24
Factors In Traffic Deaths(USN/USMC, FY02-06)
FY02-06 Deaths 627 (USN 350) / (USMC
277) FY02 140 (USN 75) / (USMC 65) FY03 119
(USN 66) / (USMC 53) FY04 119 (USN 73) /
(USMC 46) FY05 105 (USN 58) / (USMC
47) FY06 144 (USN 78) / (USMC 66)
Fatigue is considered a major factor
in traffic deaths, but is under-reported
throughout the fleet.
DECISION-BASED ERRORS
25
4-Wheel PMV FatalitiesUSN ONLY
Number
Rate/100K Persons per Year
24
Jun 08 24 Jun 07 CLASS A
FATALITIES/FATALITY RATE FY COMPARISON 24 /
8.98 23 / 8.36 FY07
FATALITIES/FATALITY RATE 33 / 8.80 10-YEAR
AVERAGE (FY98-07) FATALITIES/FATALITY RATE 42.7
/ 10.67
26
Motorcycle Types
Dirt Bike 50-650cc High ground clearance, not
road ready
Sport Touring 1100-1800cc 450-650lb, High
performance
Standard 650-1800cc, 700-1200lb, High power
Super Sport 650-1100cc 290-350lb, High
performance
Intro Bike 125-500cc, 200-500lb
Sport Unclad 650-1100cc 290-350lb, High
performance
Scooters 50-650cc
27
Motorcycle FatalitiesUSN ONLY
Last VP Motorcycle fatality, 22 Jun 2008
Number
Rate/100K Persons per Year
24
Jun 08 24 Jun 07 CLASS A
FATALITIES/FATALITY RATE FY COMPARISON 18 /
6.74 17 / 6.18
FY07
FATALITIES/FATALITY RATE 19 / 5.07 10-YEAR
AVERAGE (FY98-07) FATALITIES/FATALITY RATE
18.1 / 4.52
28
OPNAVINST 5100.12H
Change Summary Entry Level and Continuous
Traffic Safety Training Retains DoD required
entry level training (4 hours). Added
requirement for 2 hours of annual refresher
training for all members age 26 and under.
Government Motor Vehicle Operator Driver
Improvement Training Changed the requirement
that all operators of GOVs must complete driver
improvement training to Only those personnel
whose primary duty involves GOV operation, or who
operate a government motor vehicle more than 8
hours a week must complete the 8-hour course.
Recurring Motorcycle Safety Training
Requires motorcycle riders to complete refresher
training every three years. Specialty
Vehicle Added requirements for specialty
vehicles, i.e., low speed vehicles (LEV)..
29
OPNAVINST 5100.12H
Cell Phone/Driver Distractions Prohibits
operator use of cell phones during vehicle
operation on Naval Installations or in GOV on- or
off-base, unless a hands-free device is used or
the vehicle is safely parked. Daytime Running
Lights (DRL) Recommends use of DRLs or
headlights on motor vehicles at all times.
Requires use of headlights during periods of
reduced visibility. Motorcycle Protective
Clothing To eliminate confusion recommends outer
garments be constructed of brightly colored
material. Maximum driving time POV
Recommends continuous PMV travel not exceed 10
hours in a 24-hour period for single drivers and
16 hours in a 24-hour period for multiple
drivers. Recommends use of the Travel Risk
Planning System (TRiPS) to assess hazards
associated with liberty/leave travel plans.
30
OPNAVINST 5100.12H
Liberty Limits Requires commanders to
establish liberty limits based on the local
situation. Change (1) Release
ASAP Requires - Completion of Military Sport
Bike (MSBC) Course for all
Sport Bike Riders - Completion of ERC for all
non-Sport Bike Riders - Completion of MSBC or
ERC every three years - Availability of trainer
bikes to meet BRC requirements - Commanding
Officers to maintain information on all
command motorcycle riders, to ensure riders are
provided the opportunity to attend required
training, and to establish measures to
provide riders the means to be successful
motorcyclists.
31
MOTORCYCLE SAFETY
Issue Sport Bike fatalities increasing
rapidly FY07 37 Fatalities, 57 Sport
Bikes FY08 18 Fatalities, 100 Sport Bikes No
Sport Bike Training Initiative Develop and
provide Sport Bike Training Nov 07 NSC,
CMC(SD) and MSF coordination Dec 08 SECNAV
briefed Initial course Beta
tests Jan 08 Instructor course Beta
tests Feb 08 Curriculum finalized Mar 08
MSF production of course materials Apr 08
Course IOC - RiderCoach Trainer
Certifications May 08 RiderCoach Trainers
qualify Rider Coaches in MSBC Jun 08 Rider
Coaches begin training students in MSBC
32
Fleet Best Practices PMV

• Understand who your risk takers are and help them
  manage risk engaged mentorship
• Recognize that becoming a safe driver is part of
  a young persons maturing process and is not
  complete until age 25
• Use the Traffic Safety Toolbox on the Safety
  Center Website to help reduce mishaps
• Engage in partnerships with local community.
  (Click It or Ticket, You Drink, You Drive, You
  Lose, MADD)
• Solicit family members to help keep loved ones
  safe with letters home

33
Off-Duty/Rec FatalitiesUSN ONLY
Last VP Off-Duty/Rec fatality, June 2001
Number
Rate/100K Persons per Year
24
Jun 08 24 Jun 07 CLASS A
FATALITIES/FATALITY RATE FY COMPARISON 16 /
5.99 6 / 2.18
FY07 FATALITIES/FATALITY
RATE 10 / 2.67 10-YEAR AVERAGE (FY98-07)
FATALITIES/FATALITY RATE 19.2 / 4.80
34
Best Fleet Practices Off-Duty Rec

• Ensure all supervisors are engaged in Risk
  Management and Recreation, Athletics and Home
  Safety programs.
• RAHS Program Managers Ensure command personnel
  attend seasonal hazard awareness training.
• Employ the risk management process during all on
  and off-duty activities.
• Use Individual Off-Duty Risk Assessment Form to
  assess behavior factors and indicators related to
  off-duty recreation mishaps.
• Make use of qualification training and skills
  test provided by MWR prior to using their
  facilities and equipment.

35
Fatigue Case Study

• An E-5 went to a bachelor party until midnight,
  slept five hours, the went to work. Toiled all
  day, then went on leave.
• Drove 120 miles to a party and boogalooed until
  three oclock in the morning. Slept for an hour
  on this way back, ran errands all day, met some
  friends for a midnight game of paintball that
  lasted once again until that magical hour of
  0300.
• Headed home at 0445. Pulled over within 30
  minutes to stretch and yawn.
• He then got back behind the wheel, fell asleep on
  a causeway, veered off the road and ran into two
  guard rails. His pickup truck when airborne and
  splashed down into the bay below.
• The sailor came to, released his seat belt,
  crawled through a broken window and swam to a
  pylon. Fortunately, a passing motorist had seen
  the drama and called emergency services.   

36
Legally drunk line
37
Is this your Commanding Officer?
CAREER
PEOPLE
OPS
MANPOWER
HEALTH
PROGRAMS
FRP
FAMILY
MAINTENANCE
SAFETY
TRAINING
COMBAT READINESS
ALL these tasks involve managing risk!
38
ORM Risk Management Not Risk Avoidance

• Easy, common-sense process
• Mind-set
• Way of life On and Off Duty
• Operating discipline
• Process must be taught
• Must institutionalize ORM its not today

YOU CANT ORM SOMETHING THATS STUPID, TO
SOMETHING THATS SMART!!!
39
ORM Where we want to be
We will manage risk to operate by following a
standardized and institutionalized common model
of ORM application and assessment across the
fleet.
Integrate risk management concepts across the
fleet as part of every decision made and every
action taken by every Sailor and DON Civilian
employee on and off duty
40
Lots of Time Time No Time
Resources To Plan
Charts/Flips Ships/aircraft (Systems
Safety) Instructions 3710, 5102, 4790 Approach
Plates Equipment (PPE) Training NATOPS
SOPs Briefings Local CO Guidance Local Course
Rules OJT
Mission Execution Change Management (Environment,
Mission, Emergency Procedures, Crew
Change) Equipment/Systems Degradation
Mission Task Accomplishment
In Depth
Deliberate
Time Critical
RESOURCES
Assess What is Going on Balance Your Options
Communicate Risk Intentions Do Debrief To
Improve
5 step process ID Hazards Assess Hazards Make
risk decisions Implement Controls Supervise
Reach Back for Resources
41
Risk Assessment System

• TRACS Total Risk Assessment and Control
• Proactive, intuitive, easy-to-use web-based
  application
• Allows user to assess, manage and report on
  hazards, risks, and controls.
• Utilizes library construct to store completed
  risk assessments
• Private and Public
• Searchable
• All data transmitted between you and TRACS is
  made secure by SSL
• TRACS server is restricted to .MIL users only

42
Travel Risk Planning System (TRiPS)

• Delivered to the Naval Safety Center for Fleet
  use in 2006 based on ASMIS-2 Army Safety
  Management Information System
• A click away on http//www.safetycenter.navy.mil
• Provides ORM trip assessment and actual mishap
  cases relevant to planned trip. Risk
  values/models based on NTSB data
• Trip map, times, distances and other products
  improve supervisor interaction CBT course
  content designed to help change behavior

43
Travel Risk Planning System
TRiPS usage increasing.
44
Recommendations to Improve Safety

• Naval Safety Center Website - Tools Are There!
• Traffic Safety Toolbox
• Web-Enabled Safety System (WESS) Online mishap
  reporting / database
• Leave and Liberty Risk Assessments
• Establish a SOLID Welcome Aboard, Sponsorship/
  Mentorship Program.
• First impressions are lasting ones
• On and Off duty activities must be addressed
• Identify High-Risk personnel within your
  command.
• Engage leadership with subordinate personnel
• Provide awareness training on the popular
  high-risk activities participated by your crew
  and mentor high-risk personnel
• Identify motorcyclist, confirm required training
  is complete add additional training requirements
  where appropriate

45
Recommendations to Improve Safety

• Be Proactive and Involved.
• Schedule a Culture Workshop / Safety Survey
• Distribute Safe Ride taxi cards
• Conduct safety stand-downs when needed and
  pre-holiday
• Require TRiPS and leave chit risk assessments
  prior to authorizing leave
• Maintain high-visibility within command.
• Enforce Established Standards defined command
  safety policy
• Treat every mishap the same (PMV/Off-Duty
  Fatality hurts command as much as an Operational
  Fatality)
• Correct safety deficiencies immediately
• Hold yourself and your personnel ACCOUNTABLE
• Expect what you INSPECT.
• Verify command policies are understood and
  followed
• Demonstrate daily commitment to safety. If its
  visibly important to you it will be to your crew.

46
HAZREP Culture Where Weve Been

• Reversing the trend to not report an incident
• Safety Awards are based on lack of incident
  reporting
• ISIC driven recognition is based on staying
  out of the lime light
• Command/Family environment of keeping
  embarrassing things within the command
• FITREP/EVAL and advancement fears, will
  reporting hurt my career?

47
HAZREP Culture Where We Want to Be

• Establish an open environment for reporting
• Fleet Education on DON NSC Objective
• Instruction revision
• Training to encourage fleet support during
  surveys
• Potential Safety Hotline for anonymous
  reporting
• Encourage and reward reporting of hazards,
  near-misses, and lessons learned
• Improve/revise incentives
• Identify leading indicators, maximize
  awareness, and prevent similar mishaps in the
  future
• Create measures of effectiveness to grade
  environment for hazard reporting
• Database capabilities

v OPNAVINST 3750.6R Ch 4 rewrite
v OPNAVINST 1650.28A recognizes HAZREP
submissions for Safety S
48
Aviation Hazard Reports
Hazreps submitted
12 Jun
FISCAL YEAR
49
VP Safety Reporting

• 222 HAZREPS released to the fleet in FY07
• (13 of all USN/USMC reporting came from 25
  VP UICs)
• 131 released this FY (through Jun 12, 08)
• On track to exceed prev FY
• Model community for safety info sharing
• Diligent Ground Mishap reporting
• LWD Average above the fleet average due to
  responsible reporting, indicates a conscientious
  safety establishment that reports vice remaining
  silent.

50
What We Do for the Fleet

• ON THE ROAD
• Safety surveys
• ORM unit training
• Mishap investigations
• PCO briefings
• Safety Seminar/Safety Symposium
• NAVOSHENVTRACEN Safety Occupational Health
  Training
• AWARENESS
• Fleet Analysis
• Magazines printed/distributed (473,000 copies)
• Interactive CDs
• Acquisition process in-roads
• Safety advisories
• Customer information requests
• (3,600 database queries per month)
• Safety Center web page

51
Whats a Safety Survey?

• One-day assessment provided by the Safety Center
• Survey teams improve your crews awareness in
  mishap prevention and safety deficiencies
• One-on-One hands on training with your crew.
• Static Appraisal

A day in the life of my squadrons safety
programs!
52
NSC WebsiteYour Valuable Resource
www.safetycenter.navy.mil
53
Our Magazines Reach Every CommunityTell Your
Story
MECH (1961) 17,124 copies SAFE-Mech_at_navy.mil

• Focus on time-critical ORM
• Includes basic and advanced concepts
• Real-life scenarios and analysis
• Success stories, lessons learned from fleet
  units
• Tools, references and links
• On the street - July 2007

SEASHORE (2004) 30,442 copies SAFE-SeaShore_at_navy.
mil

• Detailed users guide
• Includes FAQs, guidance for common problems
• Flow chart of complete reporting and QA process
• Covers both 3750 and 5102 topics, incl. aviation,
  motor vehicles, explosives, diving, OSH and
  parachute
• Distribution of 3K copies to 1,560 addresses in
  July 2007

APPROACH (1955) 16,183 copies SAFE-Approach_at_navy.m
il
54
Data Collection / Dissemination

• An integrated system to web enable the data
  collection and information dissemination safety
  business processes for Navy Marine Corps.
• Allow data transfer with DOD, other Services
  other systems with a stake in safety
• Allow safety customers direct access, on-line,
  to safety data to target mishap prevention.

DATA FUSION BENEFITS THE FLEET!
55
QuickSeries Guides

• Resource-intensive flip books
• Data, guidance, tools, reference material
• Well-received by fleet
• Sent on request
• Motorcycle rider guide in work

56
Where We Are Today
FY07 vs. FY03 22 drop in fatalities 52 drop in
cost
The news in not all good We have exceeded last
years costs!!
232
241
214
217
182 85 USN 97 USMC 489M
124 71 USN 53 USMC 507M
NUMBER OF FATALITIES
114 USN 127 USMC 607M
113 USN 101 USMC 925M
103 USN 114 USMC 864M
106 USN 126 USMC 999M
As of 23 Jun 08
OUR ENDSTATE GOAL IS ZERO!
NSC Data 24 June 08
NHA Symposium. April 14-17 2008
57
Our Goal
58
Contacts and Resources
Naval Safety Center Website www.safetycenter.nav
y.mil PMV/Recreation Fatalities Statistics
http//www.safetycenter.navy.mil/execsummary/defau
lt.htm Culture Workshop/Best Fleet
Practices/Lessons Learned http//www.safetycenter.
navy.mil/culture/default.htm Traffic Safety
Toolbox http//www.safetycenter.navy.mil/ashore/mo
torvehicle/toolbox/default.htm Strategic
Planning/Marketing Derick.Nelson_at_navy.mil or
757-444-3520 x 77243 Focus Groups/Traffic
Safety/Off-Duty Priority Initiatives Traffic
bonnie.revell_at_navy.mil or 757-444-3520 x
7138 Community Partnerships dan.steber_at_navy.mil
or 757-444-3520 x 7137