southwestcirrus.com near-miss analysis predicting and preventing general aviation accidents
TRANSCRIPT
![Page 1: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/1.jpg)
SouthwestCirrus.com
Near-Miss Analysis
Predicting and Preventing General Aviation Accidents
![Page 2: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/2.jpg)
SouthwestCirrus.com
Definitions
STEEP TURN
Excessive bank maneuver with massive loss of altitude
![Page 3: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/3.jpg)
SouthwestCirrus.com
Definitions
STALL
A tactic used to explain higher AVGAS costs to the
mortgage company
![Page 4: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/4.jpg)
SouthwestCirrus.com
Definitions
LAZY 8
SC Owner7 Mechanics
![Page 5: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/5.jpg)
SouthwestCirrus.com
Definitions
DIVE
Local pilot hangout
![Page 6: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/6.jpg)
SouthwestCirrus.com
Definitions
ANGLE OF ATTACK
Pickup lines frequently used at the DIVE
PILOT
![Page 7: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/7.jpg)
SouthwestCirrus.com
Definitions
SUITABLE LANDING FIELD
The good-looking one
![Page 8: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/8.jpg)
SouthwestCirrus.com
Definitions
PRECISION APPROACH
Performed at a suitable landing field with
appropriate approach clearance
![Page 9: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/9.jpg)
SouthwestCirrus.com
Definitions
NEAR-MISS
A Near-Miss is an opportunity to improve safety, health, environmental impact and security of an operation based on
a condition or an incident with potential for more serious consequences.
- Wharton Risk Center
![Page 10: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/10.jpg)
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
![Page 11: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/11.jpg)
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
![Page 12: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/12.jpg)
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
![Page 13: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/13.jpg)
SouthwestCirrus.com
Incident/Accident Analysis
Identification
Reporting
Prioritization
Distribution
Causal Analysis
Solution Identification
Dissemination
Tracking
![Page 14: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/14.jpg)
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
![Page 15: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/15.jpg)
SouthwestCirrus.com
Identification
• What, Where, When
• Preceding circumstances
• Flight conditions
• Aircraft condition
• Flight plan / flight log
• Other remotely-related information
![Page 16: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/16.jpg)
SouthwestCirrus.com
Reporting
• You as Office of Primary Responsibility (OPR)• ATC / FAA?• Airport?• NTSB?• Manufacturer(s)?• Trainers?• Repair Station?• Others?
![Page 17: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/17.jpg)
SouthwestCirrus.com
Prioritization
• Life– Limb
• Environment– Economy
• Your priorities may not match other stakeholders
• Burden may shift, but not OPR
![Page 18: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/18.jpg)
SouthwestCirrus.com
Distribution
• All stakeholders need access to info
• OPR must take the lead
• ASRS?
![Page 19: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/19.jpg)
SouthwestCirrus.com
Causal Analysis
• Direct and root causes
• Why?
• OK, then why that?
• OK, then why that?
DIRECT CAUSE
PROXIMATECAUSE
ROOT CAUSEPROXIMATE
CAUSE
ROOT CAUSE ROOT CAUSEPROXIMATE
CAUSE
ROOT CAUSE
ROOT CAUSE
![Page 20: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/20.jpg)
SouthwestCirrus.com
Solution Identification
• Solution(s) for EVERY defined cause– Less than ideal solutions OK– “No solution for time being”
• Predetermine possible ancillary results
![Page 21: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/21.jpg)
SouthwestCirrus.com
Dissemination
• Allocation of resources
• Action offices
• Limit to interested parties
![Page 22: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/22.jpg)
SouthwestCirrus.com
Resolution Tracking
• Employment/Resolution
• Continuous process improvement
Solution Identification
Implementation
Results DisseminationProcess
Improvement
![Page 23: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/23.jpg)
SouthwestCirrus.com
Case Study
Subject: Electrical System
From: [email protected]
Date: 9/19/2005 7:12 pm
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)…
Subject: Electrical System
From: [email protected]
Date: 9/19/2005 7:12 pm
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)…
![Page 24: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/24.jpg)
SouthwestCirrus.com
Case Study Analysis
• Reporting: pilot and repair station• Prioritization: High• Distribution: N/A?• Causal Analysis:
– 1) “Voltage regulator for 1 had blown”– 2) “Coupling for 2 was shot”
• Solution Identification: Replace Both• Dissemination: N/A?• Resolution Tracking
![Page 25: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/25.jpg)
SouthwestCirrus.com
Case Study
Subject: Electrical SystemFrom: [email protected]: 9/19/2005 7:12 pmTo: [email protected]
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)
Fixed both, made it to Smyrna TN and Alt 1 comes on again! Voltage regulator again....hmmm. Found a field wire chafed and shorted against the engine, front right corner, fixed both and no more problems......
Subject: Electrical SystemFrom: [email protected]: 9/19/2005 7:12 pmTo: [email protected]
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)
Fixed both, made it to Smyrna TN and Alt 1 comes on again! Voltage regulator again....hmmm. Found a field wire chafed and shorted against the engine, front right corner, fixed both and no more problems......
![Page 26: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/26.jpg)
SouthwestCirrus.com
Case Study Analysis
• Incomplete causal analysisIncomplete solution identification
Repeat failure
• Distribution and Dissemination?
![Page 27: SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents](https://reader036.vdocument.in/reader036/viewer/2022062806/5697bf701a28abf838c7d9bd/html5/thumbnails/27.jpg)
SouthwestCirrus.com
Near-Miss Analysis
• Be alert for “off-the-script” conditions
• Formalize analysis and solution tracking
• Report your results
• Critically analyze the results of others
• Eat good food, don’t litter, don’t talk to strangers, get plenty of rest, fly safe.