Hornet mishaps … what's the answer?

Approach, June, 2003 by Matthew Bartel

Unless you've been taking an exceptionally long re-rack this year, you've noticed the FA-18 safety record hasn't been good. Through the halfway point of this fiscal year, we've had 10 Class A mishaps, nine of which were flight mishaps, and one aviation-ground mishap. At this rate (7.26), FY03 will be the worst year in the history of the Hornet. What makes this year so different?

First, here's a general overview of the recent mishaps:

* 18 Oct 02, VFA-41, FA-18F. Midair collision during AIC. Both pilots saw each other.

* 31 Oct 02, VFA-125, FA-18C. Ramp strike on night approach by replacement pilot. Near idle for five seconds in the groove.

* 03 Nov 02, VFA-34, FA-18C. Controlled flight into terrain (CFIT) during a routine circle-the-wagons on an NVG-bombing-smokes mission.

* 14 Nov 02, VMFAT-101. FA-18D Out-of-control flight (OCF) during BFM.

* 20 Nov 02, VFA-125, FA-18C Ground fire during low-power turn.

* 18 Dec 02. NSAWC, FA-18A. Aircraft crashed after fuel starvation during AIC.

* 06 Jan 03, VFA-97, FA-18C. Aircraft landed right of runway, struck arresting gear in one-sixteenth-mile visibility in fog.

* 17 Jan 03, VFA-25, FA-18C. Aircraft departed end of runaway after aborted go-around.

* 17 Jan 03, VMFA-225, FA-18D. Material failure during FCF, with one engine shut down.

* 18 Feb 03, VFA-147, FA-18C. OCF during BFM.

So what do all of these mishaps have in common?

Preliminary data suggests all but one mishap involved human error. Considering, on average, 80 percent of Class A mishaps involve human error, we're outdoing ourselves this year--shooting nearly 100 percent. Some people might say these mishaps are the "cost of doing business." For anyone in the safety world, and that includes you, those four words are what we're fighting against. If we accept mishaps as an expected result of our job, we harbor a bias toward allowing those mishaps to occur. The data suggests all but one of this year's mishaps could have been avoided. So how?

ORM

ORM has been tossed around the fleet as the new buzzword to save us from ourselves. The truth is, ORM is common sense, defined. We use ORM every day, in every decision we make, but we don't realize it. Whenever you say, "Is this going to hurt?" or "How can this bite me later?" you've used ORM. The fact that ORM has been institutionalized confuses many people; don't let a simple process become more complex. Our leadership is trying to bring ORM down to earth.

The first ever T/M/S ORM conference was held at NAS Lemoore, Calif. on 3-4 March. Fleet operators and safety experts met to discuss how to identify, prevent and manage risks in the FA-18 community. The meeting was successful and will be a semiannual event.

The FA-18 safety system has problems: many people perceive the system is solely reactionary. People only show their safety colors after a spike like we're currently seeing. It's ironic that when the fleet sees safety the most is when the system is not working. Safety has the impossible task of justifying itself by proving a negative. If the system works, nothing seems out of the ordinary. If the system doesn't work, as now, then safety becomes visible. Here is some insight into how the safety system and, specifically, the Safety Center is looking out for you.

200-pound heads and hardware

Safety officers look for items that concern fleet aviators and, every six months, compile a top-10 list. Magically, those items are collated into a fleetwide top-10 list. The process is not magic; it's called the Systems Safety Working Group (SSWG).

Every six months, the 200-pound heads who built the airplane get together with fleet operators, industry reps, and safety folks from around the country to talk about fleet concerns. Their emphasis is on engineering solutions to risks--how to design a better airplane. The hierarchy for risk is:

1. Design a foolproof systems.

2. Add safety devices.

3. Include a warning system.

4. Implement procedures and training.

Items three and four are less desirable because they include the human element, which is prone to error. The SSWG has tackled numerous problems in the Hornet, including hydraulic pumps, aileron hinges, MLG failures, and engine-bay-fire issues. Solutions to these problems result in seamless operations in the fleet. The statistics indicate the SSWG has been unusually effective, considering this year's material-failure rate versus the human-error rate.

Human error--the software

What's the best way to avoid problems? Awareness. If you know the danger, avoidance is easier. The Safety Center has compiled data from the inception of the Hornet. This database has catalogued every mishap. We use this information to identify trends, predict risks, and try to prevent mishaps.

What systems will fail and cause a mishap? The short answer is the Mk-1, Mod-0, brain-housing group. The biggest risk out there is you. Every aviator knows he's bulletproof;s mishaps happen to those unlucky enough to not be as good as you. I'm sure when you read SIRs of recent mishaps, you've said, "How could someone be that stupid?"