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Execute the plan: since summer 2005, the MPR Force has reaped the benefits from reinstituting a back-to-the-basics from which focuses on using naval-aviation fundamentals and the tenets of ORM to prevent mishaps
Approach, Nov-Dec, 2006 by Drew Kenny
The Maritime Patrol and Reconnaissance (MPR) Force is involved in an ongoing effort to reasess our vulnerabilities, identify risks, and implement controls to prevent mishaps. As this self-evaluation continues, we have identified two weak areas we must focus on and improve: using existing tools properly and fully exercising our collective responsibility to monitor and report violations.
Commander Patrol and Reconnaissance Group, RDML Brian Prindle, stated in a recent safety message that "following the plan the first time, every time, is our path to continued success, and will improve our safety culture across the force." Simply put, he said we need to "execute the plan."
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Since summer 2005, the MPR force has reaped the benefits from reinstituting a back-to-the-basics campaign, which focuses on using naval-aviation fundamentals and the tenets of ORM to prevent mishaps. Despite these successes, the MPR Force has had their fair share of close calls, incidents resulting in a hazrep, and a Class C-flight mishap that involved an aircraft departing the runway during landing roll-out. Well-instituted safety programs, emphasis from command leadership, open lines of communication, and safety stand-downs can help squadrons address hazards and mitigate risks, but real progress in safety and risk management comes from learning and energetically applying the lessons of failure.
Near-misses have been called the hidden seeds of the next disaster. The MPR Force is working to identify and eliminate all these hidden seeds, and we want to share three simple, proactive measures we're using with the MPR Force to prevent the next incident and properly execute the plan.
1. Increase reporting of miscues using hazreps.
2. Use more formal and rigorous aircrew-training-record reviews as a risk-management strategy.
3. Increase recognition and commendation of personnel executing procedures by the book.
These measures are positive actions to develop a more proactive, not reactive, safety culture. Just talking about one's safety culture will not develop what RDML Prindle has termed "a critical mass of proactive safety thinkers."
When everyone on our flight lines, hangar decks, aircraft, and those who plan the evolutions and look for ways to mitigate risks become proactive thinkers, then procedural non-compliance never will go unnoticed and never will fail to be corrected. Without a critical mass of people, we will continue to subject ourselves to the random mishap or hazard. The MPR Force knows these measures to improve our behavior will make us better. The effort we take now to eliminate causal factors to prevent mishaps and to avoid costly losses certainly will save time, pain, and money in the future. We want to reduce the need for less efficient reactions.
Our leadership believes there never has been a more important time in the community's history for increased focus on robust, proactive, communication-rich, and ORM-centric programs that emphasize the right balance between reporting our errors and upholding a high standard of personal accountability and responsibility. One such program is reporting our errors through hazreps, via the web-enabled safety system (WESS). Hazrep reporting across naval aviation has declined seriously over the past decade, and this also was true for the MPR Force. However, during FY06, MPR hazrep submissions dramatically increased. This increased reporting is a positive sign we are willing to openly communicate so others can benefit. We can avoid reoccurrences, and we proactively can address potential mishaps and their causal factors.
Hazreps afford squadrons an opportunity to discuss pertinent issues and to offer feedback and suggestions on how to improve. Hazreps are used during hangar-flying training sessions by both experienced and inexperienced personnel to facilitate ORM and CRM discussions before being challenged with circumstances similar to those where others have gone astray. Completing a hazrep reinforces that everything we do and say with respect to safety is vital. A hazrep also emphasizes individual accountability, so all hands clearly know what is expected of them. We never must waver in expectation or execution of the plan.
In addition to conventional hazreps via WESS, the MPR Force uses "visual hazreps," which are short PowerPoint presentations, using digital pictures to enhance retention of lessons learned from the hazrep incident. Visual hazreps are distributed across the MPR Force as incidents occur, and they also are discussed in working-group sessions and formal presentations during commander's conferences, operational-advisory groups (OAGs), and similar community forums.
As we follow through on our collective responsibility to monitor and report errors, we expand our awareness scan so human error doesn't go unnoticed. We have reassessed the effectiveness of our aircrew-training programs to make sure complacency hasn't set in to a point where we simply are going through the motions. Complacency easily can lead to overlooking an individual's negative tendency, which, if identified and remedied, can prevent a mishap.
