USCG Auxiliary Aviation Safety Event Discussion October 2014

USCG Auxiliary Aviation

Safety Event Discussion

USCG Auxiliary Aviation

Safety Event DiscussionOctober 2014

Who Are These People And Why Are They Important To Us!

Who Are These People And Why Are They Important To Us!

• Auxiliarists Skip and Madeline Mau• Auxiliarists Richard and Linda Smilgoff• Auxiliarists Duffield and Rene• Auxiliarists Anderson, Huhne, Nappi and

Polimeni• Auxiliarist Feig• Auxiliarists Frank and Frederika Lizak• Auxiliarists Purvis and Fuller

July 1984July 1984

• New Hope, NY• Piper PA-23-160; N4167P• Two Auxiliarists were departing for a

Safety Patrol of southeastern Lake Ontario when their twin-engine aircraft experienced an engine malfunction in the left engine. It subsequently crashed.

• Auxiliarists Skip and Madeline Mau are dead.

January 1989January 1989• Chicago, IL• Piper PA-28-180, N16375• The pilot and two observer/trainees were on a

flight along the Lake Michigan shoreline. After about 23 min of flight, while approaching to land at Chicago, the pilot reported an engine problem of unknown origin. He attempted to land in a parking lot at a water filtration plant. After clearing the roof of a building, the plane turned & subsequently collided with a retaining wall at the edge of the parking lot. The pilot was seriously injured.

• Auxiliarists Richard and Linda Smilgoff are dead.

September 1989September 1989

• Escondido, CA• Beech A35; N566B• While on a routine patrol the crew encountered

a thick cloud layer. After initiating a climb on course, the pilot lost control of the airplane at 7100 feet and it entered a right descending spiral. During the uncontrolled descent, just prior to ground impact, the outer 1/2 or the right wing separated due to overstress.

• Auxiliarists Duffield and Rene are dead.

May 1990May 1990• At sea off of Davis Park, NY• Bellanca 17-31A; N7SF• This crew was on a routine training flight and

departed on what was to have been a local area training flight for the U.S. Coast Guard Auxiliary. There was no further contact with the airplane, and it was reported overdue about 6 hrs after takeoff. Recorded radar data showed that the airplane had flown out over the ocean after takeoff, and after some maneuvering reversed course. At no time was the airplane above 500 ft. Three days later, parts of the airplane were found washed up on a beach.

May 1990May 1990

• Two passenger bodies were recovered; the pilot and the remaining passenger were not. Examination of the wreckage indicated that the airplane had impacted the water at high speed while structurally intact. The pilot had reportedly suffered a head injury within the previous 48 hrs, and had been complaining of pain on the left side of his head.

• Auxiliarists Anderson, Huhne, Nappi and Polimeni are dead.

January 1992January 1992• 28 miles south of Key West• Cessna C-172; N121L• The aircraft was on patrol when a little over 3 hours into the

flight, the pilot reported that the engine began to miss. Attempts to correct were unsuccessful. The condition continued & the aircraft began to shake violently and oily smoke entered the cockpit. The pilot ditched the aircraft and it sank in 2,500 ft of water. Both occupants exited with no injuries but the passenger reportedly lost his lifejacket during the egression. The observer perished after the crash. He had undergone a cardiac triple bypass in Nov of 1989, & was taking medication for high blood pressure & diabetes.

• Auxiliarist Feig is dead.

June 1997June 1997• Avon Park, FL• Grumman American AA-5B; N28297• Two Auxiliarists were returning from a Coast

Guard Auxiliary Conference in Fort Lauderdale, Florida. The airplane was observed at about 100 to 125 feet in the traffic pattern. It was seen to make a very steep left turn, lose altitude, and then hit the ground. Examination of the airframe, flight controls, engine assembly, and accessories, revealed no evidence of a pre-crash mechanical failure or malfunction. Low ceilings and poor visibility were reported at the airport.

• Auxiliarists Frank and Frederika Lizak are dead.

February 2001February 2001• Florida Keys• Piper PA-32-300, N99WD • The aircraft was conducting a night intercept training

mission (posing as a drug smuggling plane) with a Coast Guard HU-25 from Air Station Miami. The accident pilot stated that it was getting a bit hazy and informed the Coast Guard pilot that he would be breaking off and turning to the north to get separation for another intercept. After some more communications between the two aircraft, there was no other radio communications with the Piper.

• Radar data at about 0100 revealed multiple turns at 1600 AGL. The last recorded hit was at 1500 AGL.

February 2001February 2001

• Examination of the airframe, flight controls, engine assembly and accessories, vacuum pump and flight instruments revealed no evidence of a pre-crash mechanical failure or malfunction. However, only the tail of the single-engine aircraft was in one piece, indicating that the plane slammed into the sea at a high rate of speed.

• Auxiliarists Purvis and Fuller are dead.

SUBJ: AIR STATION SUPPORT FOR CG AUXILIARY AVIATION SAFETY TRAINING EVENT

SUBJ: AIR STATION SUPPORT FOR CG AUXILIARY AVIATION SAFETY TRAINING EVENT

• 1. The Auxiliary Aviation program has experienced five significant mishaps since July, 2014. These mishaps occurred in different regions with no identifiable common causal factors. Luckily, all Auxiliary air crews involved have avoided serious injury. However, air facility damage ranged from minor to total loss.

SUBJ: AIR STATION SUPPORT FOR CG AUX AVIATION SAFETY TRAINING EVENT


• 2. The National Commodore of the Auxiliary, in concurrence with the Office of Auxiliary and Boating Safety (CG-BSX) and the Assistant Commandant for Capability (CG-7), has issued a mandatory Safety Training Event for all Auxiliary Aviation personnel. This event will be accomplished prior to 31 October 2014 and will include completion of the mandatory tasks outlined in the attachment. Auxiliary members unable to attend in person or participate via webinar may satisfy this mandate by watching a recorded version of the required training session. Recordings will be made available through the Auxiliary District Flight Safety Officer (DFSO) and District Staff Officer (DSO-AV), and completion of the tasks will be recorded via AUXDAT



• 3. Air Stations are encouraged to host the safety training event and are directed to provide Command Cadre representation. It is highly recommended that the Air Stations Commanding Officer, Operations Officer, Flight Safety Officer (FSO) and unit Auxiliary Liaison(AUXLO) attend the safety event. It is also encouraged that the event be open to all interested unit members. Station commands, FSOs and AUXLOs are encouraged to reach out to their regional Auxiliary counterparts to offer coordination and assistance. However, it should be highlighted that this event is coordinated, led and primarily delivered by the DFSO/DSO-AV.



• 4. Commencing on 1 November 2014, orders will not be issued to any Auxiliary Aviation member whose completion of the training has not been recorded in AUXDATA. The Unit Auxiliary Aviation Coordinator shall verify training with the Auxiliary Training Officer prior to issuing orders to ensure compliance.

SUBJ: AIR STATION SUPPORT FOR CG AUX AVIATION SAFETY TRAINING

EVENT

SUBJ: AIR STATION SUPPORT FOR CG AUX AVIATION SAFETY TRAINING

EVENT

• 5. It is not recommended that this event be combined with any other Air Station training. It is recommended that Air Stations offer to host the event, but that is not mandatory if another facility makes better logistical sense.

• 6. CG-711 POCs: LCDR Jeffrey Dorwart and LCDR Paul Beavis.

• 7. CAPT Tom McDevitt, Acting Chief, Office of Aviation Forces sends.

• BT• NNNN

Recent EventsRecent Events– An off-airport landing due to engine roughness – no

damage or injuries;– An off-airport landing due to engine failure – major

damage, minor injury;– A case of temporary pilot incapacitation – no damage

or injuries;– The unintentional inflation of a 54-man life raft in an

aircraft on the ground – major damage, no injuries; --Pictures to follow--

– A long landing from an instrument approach in which the airplane exited the end of the runway and flipped over – major damage, minor injuries.

Interrupting the TrendInterrupting the Trend

• The current trend is unacceptable and unsustainable in a professional and disciplined organization. Normalization of deviation is not an acceptable standard. Decreased pilot proficiency, faulty aeronautical decision-making, violation of Coast Guard standards, and non-compliant attitudes contribute to unacceptable deviations.

• Human Error is the greatest casual factor in aviation mishaps.

• So what can we do about this?

Interrupting the TrendInterrupting the Trend

• It starts with you! Each and everyone one of us.

• Look in the mirror and consider how you approach things.

• Be HONEST & critical of what you see.• Are you current? Do you need some training?• Aircraft commanders, you set the tone for the

crew.

Interrupting the TrendInterrupting the Trend• Does your pre-mission brief layout functions

and responsibilities on each mission?

• Do you understand exactly what your role is?

• Are you allowed to carry out your role?

• Do you use CRM/ORM effectively?

• Why not? What do you do about it?

• Post Mission Brief?

• Use your DFSO! This is confidential.

Operational Risk Management (ORM)

Operational Risk Management (ORM)

• Factors are– Aircraft Performance – right facility for job?– Pilot Proficiency– Human Limits – are you current and

proficient?• Are your adequately rested? OTC meds?

– Environmental Conditions – Weather, crew makeup

How does it apply to me?

Are all members of the crew reviewing the changing circumstances of the mission?

Just CultureJust Culture

• Errors: When personnel commit errors, the normal human response is embarrassment, shame, and disappointment. The appropriate leadership response is to support and console personnel that commit those errors. Consoling includes verbal and candid discussion in an empathetic and supportive environment. Over time, uncorrected errors tend to become at-risk behavior.


• At-Risk Behaviour: At-risk behaviour increases risk and leads individuals to unrecognized risk acceptance or justification. Constructive leadership response to at-risk behaviour is coaching, with a values-supportive discussion of safe behaviour. Coaching must be productive, and yield organizational learning and personal growth.


• Reckless choices: Reckless choices involve deliberate behaviour to accept unwarranted risk. Known reckless choices are clearly called out in education, training, policy, and workshops. In a just culture, an Auxiliary member who chooses to engage in a reckless choice should expect a level of personal and professional accountability.

Aux Air CultureAux Air Culture

• For our program, compliance and competency are the bare minimums.

• Excellence is what we seek.

• Flight Examiners have the duty and responsibility to insist on performance to the FAA and Coast Guard Standards.

AUX AIR ToolsAUX AIR Tools• The Flight Examining Board and the

Aviation Board are extremely useful tools for maintaining objectivity and keeping personalities out of our decision-making about our aviators. Please USE THEM as a robust tool for doing so. We must be open and transparent with each other about everything – including ourselves.

• The Coast Guard is and they expect the same from us.

Standards for Training and Operations


– Continuing Operational Risk Management in on-going operations

– CRM Principles– Aircraft systems knowledge and its importance– Weather minimums for patrols, stabilized

approaches, go-arounds– Currency -- day, night, Instrument flight conditions– Flight and duty limits - Importance of rest– Emergency egress review



– Standard crew complements for IMC operations and passenger transport

– Value of ATC Services and CG AirSta Ops – Don’t hesitate to call the ODO

– Pre-flight activities– Use of Check Lists– Spatial Disorientation– Review of aircraft performance and limitations,

including weight & balance– Engine Stop Policy– Careful determination of the cargo and its nature

and risks– Compliance with maintenance standards

Personal Self AnalysisPersonal Self Analysis

• All aviators must conduct a personal self-analysis regarding their ability to perform at the level required by the FAA Practical Test Standard, and recheck their commitment to the disciplines set by the FAA and the Coast Guard.

• This includes an attitude of professionalism to be able to self-select out of a flight when all conditions are not met for the safety of the mission.

Privilege of Auxiliary Flying

Privilege of Auxiliary Flying

• Flying for the Coast Guard is a privilege and not a right.

• When we are flying under orders we are part of the Coast Guard.

• We have a duty and responsibility for compliance and excellence, meeting and exceeding the expectations of the Coast Guard.

Privilege of the Auxiliary


• Must have FAA flight certificates• The aircraft offered for use Must be N registered.• CIM_16798_3E, Section A, Authority for Flights states:• Auxiliary aircraft, while assigned to authorized Coast

Guard duty, shall be deemed to be Coast Guard aircraft, public vessels of the United States, and vessels of the Coast Guard within the meaning of 14 U.S.C. § 646 and 647 and other applicable provisions of law. Subject to the provisions of 14 U.S.C. § 823(a) and 831, while assigned to duty, qualified Auxiliary pilots shall be deemed to be Coast Guard pilots.



• This does not exempt nor remove any FAA requirements.

• The Auxiliary aircraft are NOT public use.• The Public Use designation requires that

an LOA has be issued by the FAA to the specific aircraft.

• A log book entry is made reflecting this change.

• The aircraft is no longer available for personnel use.

Characteristics of Well Functioning Teams


• Purpose: Members proudly share a sense of why the team exists and are invested in accomplishing its mission and goals.

• Priorities: Members know what needs to be done next, by whom, and by when to achieve team goals.

• Roles: Members know their roles in getting tasks done and when to allow a more skillful member to do a certain task.

• Decisions: Authority and decision-making lines are clearly understood.

• Conflict: Conflict is dealt with openly and is considered important to decision-making and personal growth.



• Personal traits: Members feel their unique personalities are appreciated and well utilized.

• Norms: Group norms for working together are set and seen as standards for everyone in the group.

• Effectiveness: Members find team meetings efficient and productive and look forward to this time together.

• Success: Members know clearly when the team has met with success and share in this equally and proudly.

• Training: Opportunities for feedback and updating skills are provided and taken advantage of by team members.



• Is this how your crew operates?• If not, why not?• What have you done to fix it?• If so, what have you do to cement it?• Resources if you need assistance!

– DFSO – Confidential– ADSO-AV– DSO-AV

Procedure for CreditProcedure for Credit

• Make sure your name is on the Attendance Roster – **No Name = No Credit**

• AUXDATA Entry: Once completed, Safety Event Training will be recorded in AUXDATA as a task titled “Air Safety Seminar.” This task will be assigned to all five AUXAIR competencies to complete. This task can only be entered by the DIRAUX office. If not completed by 31 October 2014, members will go into REWK and will not be able to receive credit for AUXAIR missions.

DiscussionDiscussion

• What will you do to improve the safety of your operations?

• What road blocks do you have?

Documents

USCG Auxiliary Aviation Safety Event Discussion October 2014