2. Executive Safety Course Course presented by Col Robert Diduch, National Safety Officer Mr. Frank Jirik, NHQ, Safety Chris Hamm, CAP-USAF, Director of Safety

3. Alaskan Grown

4. Helicopter Pilot

5. 2 nd Chance

6. Overview Scope SMS - Preview Good, Bad, Ugly in Notifications and Mishap Reviews What is a “Safe” Commander Mishaps and the Media Conclusion

7. Scope

8. – Introduction: Safely directing complex organizations, like Civil Air Patrol, requires an understanding of the program requirements and a safety mindset that is acquired by prior planning, ORM, and constant situational awareness. This is a key function of the corporate official in the wing. Safety requires vigilance to ensure the proper education and prevention oversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensure subordinate commanders’ recommendations for remedial training are accomplished.

9. Scope – Introduction: Safely directing complex organizations, like Civil Air Patrol, requires an understanding of the program requirements and a safety mindset that is acquired by prior planning, ORM, and constant situational awareness. This is a key function of the corporate official in the wing. Safety requires vigilance to ensure the proper education and prevention oversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensure subordinate commanders’ recommendations for remedial training are accomplished.

10. Scope – Introduction: Safely directing complex organizations, like Civil Air Patrol, requires an understanding of the program requirements and a safety mindset that is acquired by prior planning, ORM, and constant situational awareness. This is a key function of the corporate official in the wing. Safety requires vigilance to ensure the proper education and prevention oversight reaches all of our members in appropriate and relevant methods. When our organization fails to be compliant, the wing commander is a key individual in supporting investigations. A wing commander’s responsibility is to ensure subordinate commanders’ recommendations for remedial training are accomplished.

11. Col Brandon Rocks!

12. SMS Preview

15. This really happened.

16. The Notification File the Mishap Notification – Form 78 Account: While flying an approach into XYZ airport that was VFR day, with winds from the east, CAP flight 4173, a C182 retractable gear flown by expert pilot Phillip Flysalot, CAP ID 123456, flying a stabilized approach, with all normal engine systems, landed smoothly, but upon stopping realized that the landing gear was not locked down.

17. The Notification X

18. Col Stokes Makes it happen!

19. The Notification File the Mishap Notification – Form 78 Account: Gear up landing (C182RG) occurred at XYZ airport. No injuries.

20. The Notification

21. Col Rosendahl Ice’s ‘em!

22. The Mishap Review The Mishap Review Officer is Appointed – Select someone that isn’t: Unskilled Slow to get stuff done Biased or history of being opiniated, or dishonest Close friends with the member(s) involved

23. The Mishap Review The Mishap Review Officer is Appointed – Consider selecting: Someone from a different wing or region A trained mishap review officer Perceived of high character and professionalism Readily available

24. Mishap Review Mistakes BUT NOT TOO FAST

25. Mishap Review Mistakes TOP 10 10. Uncooperative People or System 9. Conflicting Objectives 8. Surface Causes Only 7. Politics 6. Unskilled Mishap Review Officers 5. Interview Biases / Untruthfulness 4. Untimely Mishap Review 3. Mishap Reviewer Biases 2. Ineffective Corrective Action 1. Not Reviewing Close Calls (Near Misses, Safety Deviations)

26. Your Turn

27. We’ll be back in the air in ‘no time!’

28. The Mishap Review The Mishap Review (Form 79) Factual Narrative: The pilots flying the C182RG aircraft did have a smooth landing as noted by the straight marks in the fuselage of the aircraft. No one was injured. The pilot and crew were long time CAP veterans and are very skilled. The gear was not lowered. This was a Form 5 check ride. The check ride was not completed.

29. The Mishap Review XX

30. The Mishap Review The Mishap Review (Form 79) Factual Narrative: The flight crew of this C182RG aircraft did not utilize the proper checklist or execute the before landing checks required. Sterile cockpit procedures were not observed. The gear up audible was checked and functioning. Checklists in the aircraft were available. Safety education currency was up to date on two of three crewmembers. What would you expect to see?

31. Col Mathews Rules!

32. The Mishap Review The Investigation – Form 79 Recommended Corrective Action: Assess the Pilot the $500 deductible. Caution the crew on listening for the landing gear audible. Replace the checklists with a laminated copy for better use. Recommend crew be returned to full flight status.

33. The Mishap Review XXX

34. The Corrective Action The Mishap Review (Form 79) Corrective Action: Flight crew received remedial ground instruction on checklist use and crew communications responsibilities. The Pilot, the two CAP Check Pilots, received unique recertification in their positions of responsibility and demonstration of crew communication be required. The aircraft be checked by maintenance to ensure required warning notifications are operational. The unit maintenance officer ensure the proper checklists are available within the aircraft. FRO re-education on flight release responsibilities to ensure non-compliant members in safety education are not allowed to participate in CAP activities. What would you expect to see?

35. If you can’t think, someone already HAS! A quick fix to a CAP Van?

36. If you can’t think, someone already HAS! No frost issues here

37. If you can’t think, someone already HAS! Where is the nosewheel?

38. If you can’t think, someone already HAS! Hey cadet, pass me your flashlight.

39. If you can’t think, someone already HAS! Don’t scratch my door when you get in.

40. If you can’t think, someone already HAS! Cadets always have chips!

41. The Corrective Action The Mishap Review (Form 79) Wings Corrective Action: THESE PILOTS WILL NOT ACT AS PIC OF CAP AIRCRAFT OR AS MEMBERS OF CAP AIR CREW EXCEPT TO COMPLETE THE FOLLOWING REMEDIAL TRAINING, GIVEN BY A XXWG OR XXR CHECK PILOT EXAMINER: A MINIMUM OF 1 HOUR OF INSTRUCTION IN EACH OF THE FOLLOWING AREAS: 1. STABILIZED APPROACHES 2. NIGHT LANDINGS 3. EMERGENCY PROCEDURES. CHECK PILOT INVOLVED IN THIS MISHAP MUST SUCCESSFULLY ACCOMPLISH ALL MANEUVERS FROM FRONT RIGHT SEAT. PILOTS MUST SUCCESSFULLY COMPLETE AN ADM COURSE THAT MEETS FAA WINGS STANDARDS IN ORDER TO RETURN TO FLYING STATUS. UPON COMPLETION OF REMEDIAL TRAINING AS ENDORSED BY THE CHECK PILOT EXAMINER, PILOTS MUST PASS A SPECIAL FLIGHT CHECK GIVEN BY A CHECK PILOT DESIGNATED BY XXR/CC. AFTER SUCCESSFUL SPECIAL FLIGHT CHECK, RECOMMEND RETURN TO CAP FLYING STATUS. ALL XXWG CHECK PILOTS WILL RECEIVE GUIDANCE FROM XXWG/CC TO CONFINE MANEUVERS DURING CHECK RIDES TO PUBLISHED CAP FORM 5.

42. What is a Commander? A Commander IS: He/She is THE Safety Officer – Not just the authority, but the person that is responsible for everyone’s safety He/She is THE Safety Program Manager – A strong program is led. He/She is THE Risk Manager – They do not walk by risk without correcting it. Not saying anything really says, I condone this.

43. Pyramid Theory Bodily Injury Vehicular Aircraft Nat'l Total 010 1 21 9 42 38518 89 Nat'l Total 34178492201763260692 Accidents Incidents Minor Mishaps 1 20-50 600 Data FY08 – FY10 AccidentsIncidentsMinor Mishaps *Data Current as of 2/10/2010 Broken Program

44. Pyramid Theory Bodily Injury Vehicular Aircraft Accidents Incidents Minor Mishaps 1 20-50 600 Data FY11 – present AccidentsIncidentsMishaps *Data Current as of 2/10/2010

45. Mishaps and the Media In all mishaps that involve the FAA or NTSB, NHQ Safety signs in as “Party to the Investigation.” By federal law, the FAA or the NTSB Investigator in charge (IIC) becomes the voice of all information related to the mishap. Civil Air Patrol is bound by this same federal law to not disclose information and to direct all media inquiries to the IIC. It should be assumed the FAA or NTSB is involved in all mishaps until otherwise confirmed by NHQ Safety.

46. Summary Scope Practical Exercise Good, Bad, Ugly in Notifications and Mishap Reviews Mishaps and the Media What is a “Safe” Commander

47. Closing Comments Safety should be: A positive environment without any obstacles for disclosure and discussion Foster a willingness to share and learn Safety should be proactive not reactive Should be supported at all levels of leadership and integrated in all CAP programs Safety should be easy to navigate If you think it, it can be done.

48. Remember The Leader You See In The Mirror Each Morning. The answer is before you. Who can change the Safety Culture of CAP?

49. Questions? Where is the next mishap going to occur? Please feel free to send your questions and comments directly to the National Safety Team and NHQ Safety @ safety@capnhq.gov QUESTIONS?

50. Contact Information Col Bob DiduchFrank Jirik National Safety OfficerSafety, CAP NHQsafety@capnhq.gov 609-731-5600800-227-9142 ext. 232 907-350-7559 cell safety@capnhq.gov