Farewell toCapt. Zip Rausa

ApproachThe Navy and Marine Corps Aviation Safety Magazine

Are CRM Refreshers Necessary?

2018, Vol. 62 No. 2

Approach

CONTENTSThe Navy & Marine Corps Aviation Safety Magazine

2018 Volume 62, No. 2

RDML Mark Leavitt, Commander, Naval Safety CenterCAPT Roger L. Curry Jr., Deputy CommanderCMDCM Baron L. Randle, Command Master ChiefNaval Safety Center (757) 444-3520 (DSN 564) Publications Fax (757) 444-6791Report a Mishap (757) 444-2929 (DSN 564)

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14Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Approach (ISSN 1094-0405) and (ISSN 1094-0405X online) is published quarterly by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Approach is available for sale by the Superintendent of Documents, P.O. Box 979050, St Louis, MO 63197-9000, or online at: bookstore.gpo.gov. Telephone credit card orders can be made 8 a.m. to 4 p.m. Eastern time at (866) 512-1800.Periodicals postage paid at Norfolk, Va., and additional mailing office. Postmaster: Send address changes to Approach, Code 022, Naval Safety Center, 375 A Street, Norfolk, VA 23511-4399. Send article submissions, distribution requests, comments or questions to the address above or email to: SAFE-Approach@navy.mil.

On the cover:A Sailor assigned to the aircraft carrier USS John C. Stennis (CVN 74) directs an MH-60S Sea Hawk helicopter assigned to the “Chargers” of Heli-copter Sea Combat Squadron (HSC) 14 to take off from the ship’s flight deck. (Photo by Mass Communication Specialist 3rd Class William Ford)

Pages

4.Gliding Into Trouble by ENS Erik Bergstrom

6. Single Engine Consideration by LT John Lyles

8. Not Seeing the Forest for the Trees by LT Nathan Rice

10. No HYDs, No Problem by LCDR Adam Green

12. An Uncomfortable Place To Be by Kristi Hansen

14. Something for Zip by Peter Merskey

16. Bravo Zulu

18. Why Must I Sit Through Another CRM Refresher by LT Jim Dundon

20. Loss of SA Makes Sense by LT Andrew Miranda PhD.

Kimball Thompson, Deputy Director CAPT William Murphy, Aircraft Operations

edward.thompson@navy.mil Ext. 7226

william.j.murphy@navy.mill Ext. 7203

All Analystsafe-code11@navy.mil Ext. 7811

Nika Glover-Ward, Editor juanika.glover@navy.mil Ext. 7257

Approach Staff

Aviation Safety Programs Editorial Board

CONNECT WITH US

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2 Approach

FROM THE EDITOR

Editor, Approach and MechNaval Safety Center

This issue is our first official back to print issue. While the magazine has still been available online, we decided to bring those articles that had been online but not printed into print so those writers could have print copies.

As many of you know, Approach as well as the other publications here at the Naval Safety Center have faced some major growing pains during the past year. Society as a whole, simply doesn’t favor printed products the way it once did. However, one of the main reasons we questioned wether we could continue to print is because the staff has decreased dramatically. Alan Lewis and John Williams, our former visual information specialists have retired. These guys were at the Safety Center for decades and they will be greatly missed.

During my tenure on the Approach staff, John and Allan have been like fathers as well as mentors to me. Both of their designs, illustrations and information graphics have made the magazine visually appealing as well as informa-tive. There are plans to bring in new people to our staff as later down the line. I’m not sure in what capacity they will be working, but as always our goal is to please our readers.

One of the items we’ve been seriously discussing is

scholarly papers. I often get request to publish academic papers and we’ve never had room for them in Approach considering most are 10 pages or more. However, we’re considering the idea of publishing them on our publication website. We’d love to hear your feedback on this subject. If we get enough interest, we will start publishing those papers and open it for peer reviews. If you have a better idea, we’d love to hear it.

Also, after much inquiry, we decided to bring the Raven back. You will find it on this cover hidden in plain sight. Happy hunting.

As always, if you’d like to be added to our distribution list please email your request to SAFE-Approach@navy.mil or SAFE-Mech@navy.mil.

Interested in writing for Approach-MECH? Please use the following guidelines when submitting articles.

1. If you have already written your article and are famil-iar with our magazines, simply e-mail it to one of the email addresses below:

Approach: SAFE-Approach@navy.milMech: SAFE-Mech@navy.mil2. If you aren’t familiar with our magazines, here’s more

detailed information:send in Microsoft Word document format.FONT: Courier NewSPACING: Double spaced (1 space after period)FONT SIZE: 11 pointsNECESSARY INFO: Include a proposed headline, the full

byline of the author (rank, first, and last name), and the unit the author is with.

3. When you email your article, please use the author’s name as the filename. Give us the author’s full name and a mailing address so we can send a certificate of appreciation and a copy of the issue that the article will appear in.

Our surveys consistently show that readers like articles written by their peers, and they like to read about true-life events and experiences. Your effort keeps others from having to learn the hard way. Therefore we want your letters, feed-back, and comments.

We want honest appraisals and realistic solutions. Our staff is always open to new ideas, so don’t be afraid to try something different. We also want your input. Send your let-ters, opinions, viewpoints, and comments to safe-mediafdbk@navy.mil.

WRITERS WANTED

Bravo Zulu Submission GuidelinesInclude a smooth narrative of the event, names

and ranks of the nominees, and endorsements from the command safety officer and CO.

Approach and Mech BZs must include endorse-ments from squadron CO and appropriate wing or MAG CO.

Send an action photo of the candidate(s) on

the job or crew with the nominee(s) identified in the photo. Photos must be high-res (300 dpi), saved as a JPG. A phone number should also be included.

We cannot work the BZ until we have all these “pieces.” Forgetting the chops delays processing the nomination and its publication.

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Approach

VT-27 is a primary flight training squadron stationed in Corpus Christi, Texas. VT-27 conducts hundreds of training missions each week producing future naval

aviators. Many Navy outlying fields (NOLFs) and working areas are used in the process of training these new aviators. On June 8, 2016, LT Howell and ENS Joula were flying back to Corpus Christi from one such NOLF and nearly encountered a catastrophic surprise. Both the instructor and the student were confident in the training achieved thus far. They just needed to return their T-6B to NAS Corpus Christi and finish a success-ful flight.

The crew had completed the landing pattern work at NOLF Goliad and was flying a southerly heading under normal course rules back to NAS Corpus Christi (KNGP) at 2100’ mean sea level (MSL) and 240 knots indicated airspeed (KIAS). The aircraft checked in with approach as they neared the Corpus

Christi area. Corpus approach responded that they had traffic at their one o’clock at approximately five to seven miles with type and altitude unknown. LT Howell scanned his multi-func-tional display and saw no traffic matching this description on his traffic collision avoidance system (TCAS). LT Howell called back to Corpus approach and reported negative contact. Corpus approach advised that the aircraft was not squawking and was moving northeast at approximately 70 KIAS.

The flight crew subsequently received another call from Corpus approach stating that the traffic was now at their 12 o’clock and at 1.4 miles. After scanning in front of them, neither LT Howell nor ENS Joula could acquire the traffic. As they continued to search for the traffic, they heard the aural tones, “Traffic! Traffic!” from their TCAS. LT Howell then saw a yellow dot on the TCAS that indicated that the traffic was 100 feet directly below. Immediately LT Howell took the controls while verbalizing, “I have the controls,” and initiated a climb of about 300 feet. He then rolled right wing down to get back on

BY ENS ERIK BERGSTROM, VT-27

Gliding Into Trouble

4 Approach

altitude. Both LT Howell and ENS Joula scanned back toward their 8 o’clock and saw a shiny, white aircraft with an unusually long wingspan flying away from them.

Due to the unique nature of the aircraft, VT-27 was able to track it down. Although the pilot did not wish to speak with the squadron, the president of the glider club was happy to discuss the incident. The aircraft was a powered civilian glider from a field nearby. During this incident, the pilot was flying in glider mode as opposed to powered mode. He switched off all nonessential equipment in order to maximize the aircraft’s battery life. He deemed that the transponder was nonessential and is not required in class golf (class G) airspace, which is void from air traffic control jurisdiction. It is believed that once the glider pilot saw the T-6 coming toward him, he switched on his transponder. This allowed the T-6 crew to get the TCAS hit which helped them avoid the glider.

This event highlights the importance of the see-and-avoid principle while operating visual flight rules regardless of air

traffic control (ATC) services. In this case, ATC alerted the T-6 crew of the other traffic, however, that may not always be possible. Aircraft are not required to have a transponder while flying in class G airspace, so the glider was not violating any rules. Although both aircraft were in compliance with all appli-cable rules, a mishap still nearly occurred. Since the incident, coordination between the glider club and VT-27 has reduced the risk significantly by making both parties aware of when, where and how each organization is operating in the area.

Navy aircraft flying in South Texas are not alone. Civilian aircraft will continue to be flying alongside the Navy aircraft with varying levels of skilled pilots. Civilian aircraft often do not operate in the same manner as military aircraft, making it crucial that all aviators be extra vigilant as well as communi-cating with ATC when appropriate. As we conduct our military training, it is crucial that we are aware of the other aviation operation in our vicinity. This awareness may be the only thing keeping us (or them) from gliding into trouble.

Gliding Into Trouble

Three T-6B Texan II aircraft bank toward Naval Air Station Whiting Field to help celebrate the arrival of the 148th and final T-6B aircraft to serve as part of VT-5’s primary training fleet. (Photo by Ensign Antonio More)

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Single engine considerations are discussed in depth in the F/A-18 community. Around the boat we place emphasis on emergency catapult fly-away,

emergency gear extensions, and single engine recovery procedures. Ashore, operating in the R-2508 of east-ern California, the divert field is often predicated on whether an engine fails east or west of the Sierra Nevada Mountains. I thought I had a good handle on single engine considerations until I had an engine fail while in port observation on a KC-135 over Northern Iraq.

The flight that day began like all the rest. After exe-cuting the first vul of close air support, I exited the area as a single for yo-yo tanking and climbed to rendezvous with the KC-135 at 26,000 feet. After a few moments in port observation, I began to hear the thumps and bangs associated with an engine stall, followed shortly by a loss of thrust and the aural “engine right, engine right”.

With a quick glance to my left display, I confirmed the engine stall suspicion with an R ENG STALL caution displayed and I executed the immediate action item of placing the right throttle to idle. The engine stall cleared which was verified through normal engine indications and the removal of the R ENG STALL caution. Given my altitude and configuration, I elected to advance the throttle in order to salvage some sort of performance as the jet began to decelerate.

Each throttle advance brought further engine stalls and it became clear the engine would not be useable for the remainder of the flight. Once the emergency was under control, I communicated the situation to my flight lead in order to determine the most logical course of action. Our standard conventional load (SCL) produced a drag count of 125, which put me at 500 pounds above the maximum range fuel number to the primary divert in Kuwait, which was roughly 550 nautical miles from our current position. The fuel number that we referenced was based on a medium cruising altitude of 25,000 feet and would get the jet on deck with a conservative 2.0K pounds of gas vice the actual bingo which would end up with 1.5K on deck.

The fuel number, however, is calculated with two good engines but unfortunately I only had one and was therefore unable to maintain 25,000 feet. I figured the options were limited to either receiving fuel from our current tanker or diverting to Baghdad International Airport (BIAP). Given the current geo-political situa-tion, the latest threats to aircraft assessments and the absence of Hornet maintenance support at BIAP, I con-cluded that the most favorable option was to receive gas from the KC-135 at my right 2 o’clock, provided I could

gather the thrust required to stay in the basket. Once the decision to stay with the tanker was made,

I quickly realized that, with my energy decreasing and nearly half of my advertised thrust, I will be unable to tank at the current altitude. As I communicated my emergency to the tanker, the crew altered course, alti-tude and airspeed to satisfy my need for fuel.

We figured 17,000 feet would be a good starting point for a single engine tanking attempt. Once the tanker started their descent, I needed afterburner (AB) on the good motor to gain the airspeed I had lost in the decision making process.However as the tanker leveled off at 17,000 feet and slowed to 250 knots, I was able to deselect AB and give the Iron Maiden another shot. Using only the good motor to maneuver, I was able to pump up above single engine divert numbers to Kuwait and started my 500-mile trek. During the last final portion of my refuel, my lead was able to join and we coordinated a section divert to the field.

As the hurt bird, I took the administrative lead and my flight lead coordinated with air traffic control (ATC). During the next hour and a half, while we flew south toward Kuwait, I was able to get partial thrust out of the right engine allowing me to fly close to the max range profile. We coordinated with the E-2 controlling the south portion of Iraq, and they were able to get a tanker to meet us in southern Iraq. It’s now night and as we joined the compressor stalls returned at almost anything above idle making for a colorful rendezvous. My flight lead received gas since I was now well above my bingo number to the divert field and the ship was expecting her back at the boat after dropping me off.

My flight lead dropped me off and I landed unevent-fully in Kuwait where the maintenance detachment discovered a bad inlet temperature probe, which caused the engine to improperly schedule fuel, resulting in mul-tiple compressor stalls. The inlet temperature probe was replaced in a few hours and I was able to make the final recovery of the night on board the ship.

Too often, situations like this end poorly or are made harder than they need to be because of poor commu-nication and headwork. After the initial shock of the emergency subsided and the procedures completed, the coordination and decision making between flight mem-bers and outside agencies was crucial to the successful transit and safe recovery. By breaking down this emer-gency into manageable parts, the flight members were able to make correct and timely decisions that ultimately resulted in the safe recovery of a single engine Hornet back to a friendly airfield.

Single Engine ConsiderationsBY LT JOHN LYLES, VFA-94

6 Approach

An F/A-18 Hornet assigned to the Mighty Shrikes of Strike Fighter Squadron Ninety Four (VFA-94), flies over the Western Pacific Ocean during flight operations.( U.S. Navy photo by Mass Communication Specialist 3rd Class Elizabeth Thompson)

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Upon waking for my noon to 8 p.m. alert shift, I was informed that we would be launching to search for what might be a self-propelled semi-submersible (SPSS) in the area. Crown jewel or unicorn, it was a high value target that everyone was getting spooled up (including me, my co-pilot, our aircrewman and Coast Guard observer). We briefed, conducted a preflight check on our trusty SH-60B, spun up and requested green deck.

“Gauges green, cautions clean,” I said when a final visual check of the cockpit looked exactly the same as the previous 96 days at sea. After the landing safety officer (LSO) released the beams of the rapid securing device (RSD) and gave us a green deck, I repeated, “Gauges green, cautions clean.”

As my copilot picked us up into a hover, I noticed that our turbine gas temperature and gas generator turbine speed (TGT and Ng) both seemed higher than normal. They were still in the green range within the vertical instrument display system (VIDS). Everything else looked good. As we came up and aft, away from the flight deck and out of ground effect, both TGT and Ng momentarily fluctuated into amber and then back to green several times.

I thought, “This is a bit high, but we’re in limits. It’s been

over a week since I’ve flown Red Stinger 107, maybe she just burns hotter.” We pedal turned into the wind and completed our takeoff. Climbing to 500 feet, I took the controls while my heli-copter second pilot (H2P) completed the post-takeoff checklist, including crunching the numbers for the engine health indicator test (HIT) checks. A few moments later and heading in the direction that Gary wanted us to search, my H2P said the HIT checks were calculated within limits. “Good,” I thought, “she’s just burning hotter.”

Twenty minutes into the flight and with no luck yet finding the SPSS, I glanced at the gauges to ensure things were going as well as they seemed. Everything was green and clean, but some-thing was out of place. The No.1 and No.2 ENG ANTI-ICE ON advisory lights were both illuminated.

I remember thinking how weird that was. I could not ever remember seeing them during this phase of flight. I looked up to the overhead console and confirmed that both ENG ANTI-ICE switches were off and the DE-ICE MASTER switch was in manual.

I knew what NATOPS said about determining if there was a malfunctioning anti-ice/start bleed valve, so I figured I could

FOR THE TREESBY LT NATHAN RICE, HSL-49

Things were smooth during the fourth month of my HSL-49 Helicopter Aircraft Commander (HAC) cruise. It was a 4th Fleet Counter Trans-national Organized Crime (CTOC) deployment embarked in USS Gary (FFG 51), and the detachment was running astonishingly well. Our officer in charge (OIC) had recently called everyone together for

a few meetings about complacency. We hadn’t run into any major problems, but we were in the stretch of cruise where we felt confident. Things were good.

NOT SEEING THE

FOREST

8 Approach

simply pull power to above 94 percent Ng to see if the lights extinguished. However, both 94 percent and 95 percent were still on. There was no change to 96 percent. Puzzled, I reduced collective. I asked my copilot if he had noticed anything I was missing, but he was just as puzzled. Then I told him to pull out the big NATOPS. He read aloud the section in Chapter 2 on how the valves operate and how to determine if they were malfunctioning.

As our troubleshooting progressed, we ensured circuit break-ers were in and looked for a rise in TGT after manually selecting engine anti-ice ON for both engines. There was no rise in either engine.

The gauges were all green and well within limits. The HIT check numbers were in. All we had were two advisory lights that should not have been illuminated. I decided that it was very unlikely that both engine anti-ice/start bleed valves were malfunctioning simultaneously. Since the HIT checks were in, it

was more than likely a wiring issue. “Maybe the harnesses aren’t properly seated or a cannon plug is loose,” I said.

Since we were not able to fix our dilemma, we did some time-critical ORM and discussed the issue at hand. Whether or not it was a wiring or indication problem, we had to assume the worst by figuring that the valves had somehow failed.

If they had failed in the open position, they would be robbing 18 percent of available torque from each engine. If they had failed in the closed position, we could flame out an engine during low-power settings, such as during practice auto rotations or quick-stops.

Because of the possible power loss, we talked about how we might drop rotor speed while getting into a power-required-ex-ceeds-power-available situation during landing. To alleviate the problem, I said “I’ll take the approach and landing.” We also discussed that being lighter in fuel would help us. The most dangerous part of the flight with this power-loss malfunction would have been during the takeoff, when our fuel tanks had been full.

Concerned with the possible flame out during low power set-

tings, we agreed that we would be cautious with the collective and not do anything aggressive, such as a quick-stop.

We continued the flight and found no sign of the elusive SPSS. Flight quarters was sounded, numbers passed, and my one approach and one landing happened without incident.

After our maintainers inspected the aircraft, they told us we would be shutting down and not relaunching. While in the main-tenance shop to log the flight and write up the discrepancy, my copilot started to log the HIT check in the aircraft discrepancy book (ADB).

A minute later, he sheepishly broke the silence and admitted that he was wrong on his earlier HIT check calculations and that both engines were “way out”. In the heat of the alert launch, he subtracted the reference engine temperature from the actual temperature instead of the other way around. I was frustrated with him but more so with me at the sudden realization that engine anti-ice was on for both engines during the entire flight.

Upon further maintenance troubleshooting, we discovered that inexplicably both engine anti-ice valves had failed in the open (or ON) position, regardless of the cockpit switch setting. I had flown nearly three hours as aircraft commander in a degraded aircraft, without ever appreciating what the degradation was.

Even though we broke out the big NATOPS to read through Chapter 2 and used ORM to back ourselves up, I never consid-ered looking in either Chapter 12 or in the pocket checklist. Had I looked in the emergency procedures section of either, we would have been given the answer we needed: land as soon as practical.

The aircraft had been flying fine. I had thought the HIT checks were good and I had never considered it an emergency, but because of the 18 percent power loss we very well could have drooped and lost tail-rotor authority on takeoff.

This was a sobering thought, but more sobering was the complacency I had shown. Ignoring what the aircraft was trying to tell me: “No.1 ENG ANTI-ICE ON” and “No. 2 ENG ANTI-ICE ON”. I could not see the forest for the trees. Overall, it was a wake up call and a great lesson in complacency.

An SH-60B Sea Hawk helicopter assigned to the Helicopter Anti-Submarine Squadron Light (HSL-49) is flown during a routine mission. (Photo courtesy of the U.S. Navy)

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Flying on the first day out of port is typically avoided for a whole host of reasons. However, after many days of transit and upon completion of our first port call of deployment on

the lovely island of Guam we were eager to get back into the air. My EWO and I were scheduled for a good-deal, daytime tactical intercept flight. It was a one-hour cycle and the weather was clear except for a thin cloud layer between 2,000 and 5,000 feet MSL.

While executing an abort maneuver during the first intercept, the aircraft was at about 9,000 feet MSL and approximately 450KIAS when we received a master caution with displayed HYD5000, HYD 2A and HYD 2B cautions. My first thought was “this is why we don’t fly the first day out of port”. However, after processing the cautions we immediately called “knock it off” and brought the right throttle back to idle. I initiated a climb and slowed down while we broke out the pocket checklist (PCL) to start working through the problem.

After realizing that the left engine just became our new best

friend, we started formulating a game plan for our recovery. Cyclic operations require a few added levels of coordination depending on the severity of the emergency. In the EA-18G Growler, the HYD 2A and 2B systems powers half of the flight controls and all of the systems needed for a normal landing (i.e. landing gear, nose wheel steering, and normal brakes). Due to the quickness with which we received both cautions (no reservoir level sensing (RLS) system indications) we suspected a blown hydraulic line, which meant we also lost our emergency braking and fuel probe extension system.

Once the dust settled from the initial indications, we had our wing man join on us for a visual inspection. Everything looked normal so we began flying a maximum endurance profile to the carrier to conserve fuel (at the time we had 11k, which was well above ladder) and started talking to the ship via J-Voice A to inform them of our emergency and to get our Pri-fly rep in the tower to start coordinating for recovery. This emergency was going to require us to emergency extend the landing gear with

BY LCDR ADAM GREEN, VAQ-133

No HYDS, No Problem

Petty Officer 3rd Class Alexis Rey, from Stratford, Conn., conducts pre-flight checks on an EA-18G Growler. (U.S. Navy photo by Petty Officer 2nd Class Ryan Kledzik)

10 Approach

No HYDS, No Problemno way to raise it once it was down. The good news was that every aircraft carrier in the Navy comes equipped with arresting gear unlike some airfields, so braking wasn’t going to be much of an issue. The bad news was that fuel quickly becomes an issue when the only option is executing a dirty bingo profile. Tanking with the landing gear down was not going to be an option due to the fact that our fuel probe extension and emergency extension relies on hydraulic fluid from the HYD 2B system (now empty). Fortunately for us, we were not operating blue water. The nearest divert (Andersen Air Force Base on Guam) was only about 80 miles away.

The tower representative coordinated with the Air Boss, informing him of the nature of our emergency, the requirement for a tow out of the wires, and our inability to raise the hook. Meanwhile, we verified all steps were completed from the PCL, informed the ship of our plan to come down last for a straight-in approach, ran the dirty bingo numbers, and passed that we would need to stay mid-range on the power in the wires until we were

chocked. Tower informed us that they would manually push us out of marshal and clear us to blow down our landing gear at the appropriate time, which enabled us to conserve as much fuel as possible. We flew a standard day straight-in with no issues.

If I were to choose when to have a HYD 2A/2B failure I couldn’t think of a better time. We had lots of fuel, decent weather and a divert airfield close by. The HYD emergency did not require us to shut down the right engine, so we were able to fly a normal approach. The discussion to have in your ready room is two-fold. First, what actions and coordination need to be per-formed in this situation and with whom? Second, what thought processes, crew resource management, and decision making need to occur in the cockpit with night time, blue water operations, or single engine considerations? Despite all of our coordination there was still confusion on the flight deck about why we were not at idle in the wires and not raising our hook. It only takes one broken link in this long chain of events to turn a well-executed emergency into a SIR.

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The master caution went off as the jet started to fly away and the light in the gear handle accompa-nied with a continuous beeping tone immediately caught my attention. Worried that my gear had not come up, I tried to double check my airspeed to find that the airspeed box in the heads up display (HUD) was empty. Not entirely sure what was wrong at the time, I continued to climb until I was sure I was nowhere near the water. Passing 5,000 feet, the radar altimeter (RADALT) kicked off and I lost my altitude reference as well. Glad that I still had some horizon left, I called for assistance and started to cycle through my displays. I had an AIR DATA caution and an associated air data computer (ADC) MUX fail on the BIT page. My worst nightmare of a standby recovery at the boat was finally occurring and to make matters worse the marine layer was moving in and the moon was nowhere in sight.

According to NATOPS, the ADC receives inputs from numerous sources and calculates accu-rate air data and magnetic headings. Information is supplied to the mission computers, the altitude reporting function of the IFF, engine controls, environmental control system, landing gear warn-ing, and the fuel pressurization and vent system. From a piloting standpoint, the loss of airspeed and barometric (BARO) altitude is disconcerting but to make matters worse, the velocity vector may become inaccurate after approximately 10 min-utes and the procedures call for the ATT switch to be placed in standby (STBY). For all of us who have become velocity vector cripples, this is a major degradation of one’s scan within the cockpit. The landing signals officer (LSO) sight picture is affected as well since the outside AOA indexers do not function.

I was directed to use ground speed as an air-speed reference until I could get my gear down and use the “E” bracket for AOA control. The deci-sion was made for me to return with the current recovery, so I had plenty of gas to fly around dirty. As my hopes of being mercifully diverted to North Island dwindled, I requested that a tanker join on me prior to descending through what had become a

black abyss. Standby instruments function nor-mally with an ADC failure, but flying steam gauges as my sole altitude reference until 5,000 feet was not my idea of a good time.

With the tanker on my wing, I found it easier to retain the lead vice flying form. It gave me a chance to get used to the standby sight picture on the HUD and take things at my own speed. My TACAN was intermittent and my tanker escort did an outstanding job of driving me around and backing me up on my altitude and rate of decent. He told approach that he would set me up on the straight in and that they could start directing us once we were lined up. Thankfully, the ILS was still functioning which significantly enhanced my reference points. The ILS and my wingman dropped me off on a decent start and Paddles was able to talk me into the wires.

Finally on deck, I was very thankful for the crew coordination that helped me get there safely. I was able to get help in quickly sorting out functioning reference points for airspeed and altitude. My wingman assisted in my descent and line up, and Paddles put the finishing touches on a flight that I would rather never repeat.

Although I had practiced standby approaches at the field, I was not expecting the lack of VSI in the HUD and the inability to use auto throttles that came with a full ADC failure. In addition, this failure reiterated the importance of referencing 10 degrees of pitch attitude with the waterline symbol coming off of the cat. If my cat shot had occurred just a couple of minutes later I would have launched without a visible horizon and with a questionable velocity vector. Not a comfortable place to be.

My next set of carrier qualification workups will definitely incorporate ADC failures in the simu-lator. Up to this point, I have always just selected STBY on the HUD to simulate a standby approach. Unfortunately, as mentioned above, this does not completely imitate the totality of systems lost. Practice, a knowledgeable representative and some help from paddles is essential in turning a bad night into an earned meal at midrats.

AN UNCOMFORTABLE PLACE TO BEBY LT KRISTI HANSEN, VFA-113

It was going to happen eventually. All good things come to an end, and my incredibly lucky run of avoiding display issues at the boat came to a screeching halt on a “pinky” cat shot two weeks into our composite training unit exercise (COMPTUEX).

12 Approach

AN UNCOMFORTABLE PLACE TO BE

A pilot assigned to the Stingers of Strike Fighter Squadron One One Three (VFA-113) is directed into launch position. (U.S. Navy photo by Mass Communication Specialist 2nd Class Aaron Burden)

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After more than 30 years at the helm of Wings of Gold, Captain Zip Rausa is stepping down from the editor’s chair. He retired from active duty in 1986 and quickly took on this new position after two full tours as the editor of Naval Aviation News, then as head of Navy Publications and finally, working on the staff of the 75th Diamond Celebration of Naval Aviation. Coupled with his earlier experiences as a combat Naval Aviator, with two deployments aboard the USS Coral Sea (CVA-43) with VA-25 at the height of Rolling Thunder, including time over the embattled Marine bastion at Khe Sanh as well as missions over Laos. Captain Rausa has certainly had his share of action both in the cockpit and in the planning rooms of several Navy maga-zines.

A native of Hamilton, New York, and a graduate of Middle-bury College in Vermont where he played several positions on the school’s baseball team. Zip, as he is widely known to his many friends and associates alike, is a man of unquenchable energy and dedication. He still enjoys a game of senior basket-ball and participates in an occasional round of Senior Olympics in various parts of the country. He also happens to be more than a passable writer.

After going through Aviation Officer Candidate School and earning his Navy Wings of Gold in 1959, he found himself in the cockpit of one of the Navy’s most iconic aircraft, the Douglas AD Skyraider. This large and powerful single-engine attack bomber had entered service too late to see action in World War II but more than made up for it in Korea five years later followed by service in Southeast Asia until 1968. Zip cut his teeth in Spads, as the Skyraider came to be known, in VA-85 aboard the USS Forrestal (CVA-59), the first of the so-called super carriers. He made several Mediterranean cruises before a shore tour and his first tour with the Navy’s oldest periodical Naval Aviation News. The last deployment, 1967-1968, was the last combat cruise of a U.S. Navy squadron flying single-seat A-1s. If you want to read about one of his more unusual missions, read The Route 9 Problem by retired Army Lieutenant Colonel Dave Stockwell. We recently reviewed the book in Wings of Gold.

During this time, he met Neta Irene Lloyd, a flight atten-dant for Eastern Airlines. They married in 1967 and have five children, two boys and three girls. The first boy, nicknamed Zeno, followed his father’s example and earned his Wings of Gold, becoming an F/A-18 Hornet driver and eventually taking command of VFA-97, and like his father, seeing combat, but this time in Southwest Asia. With all their children married, Zip and Neta are enjoying eight grandchildren, who also promise to do great things.

omethingZip hit the ground running when he took over Wings of Gold

and assumed other duties required by the Association of Naval Aviation (ANA). He enjoyed it all because all these activities kept him deeply involved with Naval Aviation. His enthusiasm combined with his intimate knowledge of the subject were in-valuable in his new position as well as allowing him to converse with members at the same level. He had logged more than 4,000 hours and nearly 600 arrested landings. He had also logged time in two light attack squadrons in the Naval Air Reserve, flying the A-4 with VA-45 as an instrument instructor and the A-7 with VA-304 as the squadron officer-in-charge. He was a senior officer in the Training and Administration of Reserves (TAR) program and while flying Spads in Vietnam was one of a select group of TARs in combat.

Something a little more intangible was how Zip worked with authors, often first-time writers of all ranks. He seldom refused an article and patiently worked with new writers to bring their articles up to the standards required by an experienced maga-zine editor and writer.

And on that last point, Zip has his own books, including his memoir Gold Wings, Blue Sea, published by the Naval Institute in 1981. Zip told in his own intimate, crisp style. His other books include biographies of such Naval Aviation personalities as engineer and designer Ed Heinemann, whose credits include creating a number of great aircraft like the A-3 Skywarrior, A-4 Skyhawk and the A-1 Skyraider. The two men were close, so

BY PETER MERSKY

for ZipS

Left: Captain Zip Rausa and his wife Neta proudly pose with their son Cmdr. Zeno Rausa at his outgoing change of command of VFA-97.

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close that Heinemann asked Zip to come out to California just before he died in 1991. The same closeness was also evident when R.G. Smith, internationally known illustrator of aircraft, asked Zip to work on his biography. All of these books are highly recommended for their story and for the coverage of such im-portant aviation personalities’ lives.

Zip is a quiet and dedicated sort. He always puts his full ef-fort and concentration into any project he is working on. These qualities show in his dedication to the two Navy magazines he edited for such long and productive times, Naval Aviation News and Wings of Gold. ANA was fortunate to have such a man for as long as we did. He will be missed.

A note of thanks for the following people who knew Zip on different deployments and offered photographs from different cruises. Mrs. Louise Rigney, whose husband, retired Command-er Steve Oltmann was a junior air intelligence officer with VA-81 aboard the 1962-1963 Forrestal cruise. She let us use a few of her late spouse’s photos.

Retired Captain Louis R. Mortimer and his wife Margaret worked on retrieving the VA-25 lineup photo from that deploy-

ment’s cruise book. Captain Mortimer was an air intelligence/photo interpretation (PI) officer with VFP-63 during that cruise and always remembered the colorful men of VA-25 and enjoyed spending time in their ready room.

Authors Note: Shortly after this article was published, Captain Rausa passed away on the evening of January 4, 2018, surround-ed by his family after being diagnosed with a particularly viru-lent form of leukemia. He had checked into Walter Reed Hospi-tal at Bethesda, Maryland in late December 2017. Zip had been the Washington representative for the Naval Safety Center with an office in the Pentagon in the mid-1980s. The Safety Center was then commanded by RAdm. Jerry Breast, USN. Zip will be missed as a friend, Naval Aviator, and as a particularly talented writer and editor. He would have been 82 on January 21st.

EDITOR’S NOTE: This article originally appeared in the Naval Aviation News magazine. Cdr. Peter B. Mersky, USNR (Ret), was a writer then editor of Approach magazine from March 1984-June 2000.

Cruise book photo of VA-25, 1967-1968, aboard USS Coral Sea (CVA-43). Zip is standing, fifth from right. At this time, he was a TAR—training, administration, reserve—one of the few such reserve officers in combat.

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Bravo Zulu

Sailors and Marines Preventing Mishaps

LCpl Chase L. RemyDuring a training evolution at Marine Corps Air

Station Camp Pendleton, LCpl Remy was con-ducting fueling operations when a fellow Marine began running behind the aircraft towards the spinning tail rotor. LCpl Remy reacted quickly and effectively, sprinting towards the Marine and pushing him to a safe distance prior to impacting the tail rotor. His assertiveness and rapid reac-tion were pivotal in preventing the serious injury or death of a fellow Marine. For LCpl Remy’s swift action and high situational awareness he was awarded an impact Navy and Marine Corps Achievement Medal.

An AH-1Z Cobra helicopter assigned to Marine Light At-tack Helicopter Squadron (HMLA) 267 takes off from the Harpers Ferry-class amphibious dock landing ship USS Pearl Harbor (LSD 52) during deck landing qualifications. (Photo by Mass Communication Specialist 3rd Class Kelsey J. Hockenberger)

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For all the qualified aircrew out there, I am certain you have asked yourself the same question several times during your aviation career. You might think these lessons are

always the same; the mistakes are the same, so why do I have to do this again? After all, I’m not that guy I read about in all those safety stand-downs and yearly refreshers we’ve conducted over the years, those lessons are for the other guys that just don’t get it. Right?

To better understand the scope of the situation, let me give you some background. I have been an instructor pilot since my first squadron in 2006. I was fortunate to be selected to instruct at the P-3 FRS in Jacksonville, Fla. I departed that tour to a one-year flying IA in Afghanistan and returned to the P-3 community for my Department Head tour. My last year there was spent as the maintenance operations officer and senior pilot. Being generally successful at those endeavors and amassing over 2,500 flight hours, I never thought I’d be the author of “another CRM article.”

So here’s what happened on the flight: We were scheduled for a 3 a.m. brief for an anti-submarine warfare event. It was mine and my commanding officer’s last flight in the squadron and in all likelihood our last flight in a P-3. It was kind of a big deal. The tactical portion of the flight was uneventful and we checked off station for transit back to NAS Jacksonville. During the transit, we obtained ATIS, confirmed NAS was landing runway 28 and reporting a solid cloud layer from 2,000 to 4,000 feet. We requested radar vectors for a PAR to runway 28 and began a normal approach to the active runway. When directed, we descended to 2,000 feet and the controller informed us we were on a base leg for the PAR. At 2,000 feet we were below the cloud layer and saw we were being vectored to runway 10 instead of the expected 28. We queried the approach controller who confirmed his mistake. He asked if we wanted vectors back around for 28 or to enter the downwind for runway 28 with the tower. We elected to chop and enter the tower pattern for runway 28. Had I elected to remain IFR, as we had briefed during the approach, I would

Why Must I Sit Through Another CRM Refresher?

BY LT JIM DUNDON, VP-26

LCDR Robert Peters, gives a briefing to service mem-bers. (Photo courtesy of the U.S. Navy)

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have avoided the worst mistake of my career. While established in the left downwind for runway 28 I could

see that we were alone at the field. Having radios tuned to both tower and approach confirmed this. We were clearly VFR at NAS Jacksonville, where I have seven years of experience in the pattern and was intimately familiar with the obstacles in the local area.

I asked the CO if his family was on site for his final flight, and he said they were. Wanting to make this memorable for the CO that had given so much to the squadron over the past two years, I elected to ask the tower for a low approach to runway 28 followed by a mid-field downwind. I continued the approach turn at 25 degrees AOB with maneuver flaps at 190 knots. I confirmed with my copilot that the gear was up and repeated I wanted her to ask for a mid-field downwind.

We flew down the runway in this configuration at 200 feet and asked the tower for the mid-field downwind which they approved. I rolled the aircraft to 30 degrees and started a climb for the downwind. My path over the ground took me directly in front of our hangar where the CO’s family was watching. We had just passed the family gathering when my speed was comfortably below 190 knots. I selected approach flaps in the climb to down-wind for an uneventful, full stop landing.

That memorable flight for my CO’s family resulted in a field

naval aviator evaluation board (FNAEB) for a flight discipline violation. During the course of the investigation I was dismayed that I had violated some of the most basic tenets of CRM that I’ve been taught my entire career; the same ones I worked so hard as senior pilot to instill in junior pilots. While I’m sure there are numerous combinations of errors that occurred during this maneuver I will highlight a few here in this article.

First and most obvious, my decision making during this flight was flawed. In the P-3 community and I’m sure elsewhere we often say, “don’t do anything dumb, dangerous or different.” While setting up on the downwind and evaluating the traffic pattern, weather, and landing environment. Alarm bells should have been shrieking in my head that this approach was definitely different and non-standard. I might want to think twice about this decision.

The second failure highlighted was the horrible communica-tion I fostered in the aircraft during that approach. I was again shocked when I learned that my copilot and flight engineer thought I was flying a low approach in reference to a maintenance discussion we had during the transit home. My third pilot, not in the seat, thought we were landing and had just missed noticing the gear coming down. I further complicated the situation by not giving my intentions to the commanding officer who was on the

aircraft. At any point during this event, if I had properly commu-nicated my intentions to the flight station/crew and ensured I received the requisite feedback from them on my decision this chain of events could have been avoided.

Lastly, I would highlight assertiveness. Again, during the process of the board’s investigation the determination was made that the copilots on my flight were not assertive enough with respect to our interactions in the cockpit and did not challenge my decision to conduct the low approach. The reader might be quick to agree, but I would challenge each of you to think about a time you flew with an instructor at a training command or your plane commander or the commanding officer and possibly let them conduct a maneuver that wasn’t necessarily dangerous but definitely non-standard. Thinking back on my career I know there were other situations like that for me. I think it is import-ant to continually reaffirm that junior pilots be assertive, but it is also imperative that each senior pilot instructor. Understand their role in fostering the right environment to allow that student or junior officer to speak up. My fear in this situation is my rela-tionship as the senior pilot and instructor for both of my copilots, compounded by the poor communication fostered during this approach, led them to assume that I had the situation under control, and it was my decision alone.

I have always understood since the day I received my

qualification as a patrol plane commander (PPC) and mission commander that the safe conduct of the flight and mission are my responsibility. When I was setting up and coordinating this maneuver I knew that I was not going to come close to max performance of the aircraft or exceed my skill level with respect to flying the aircraft in a configuration I had not briefed. I thought at the time I had adequately considered the weather, obstacles, other aircraft and runway environment and concluded that I could safely conduct the maneuver. But the discussion of what, where and how you fly a multi-piloted aircraft can’t end inside the PPC’s head. There were several opportunities that I could have empowered any member of my crew to help me avoid a really bad decision. During this whole process and investigation I learned many hard lessons about myself. Most importantly I learned how quickly a snap decision in the cockpit coupled with terrible com-munication can go horribly awry despite your best intentions.

At the end of this I sincerely hope my community walks away with a positive lesson in CRM yet again. There are old pilots and there are bold pilots…and I never intended to be either. This was the first flight discipline FNAEB in MPRA in the past 15 years. Fortunately, we’re all walking away from this able to con-tinue on with our flying careers. Fair tailwinds, following seas, and solid CRM to all of you.

During the course of the investigation I was dismayed that I had violated some of the most basic tenets of CRM that I’ve been taught my entire career; the same ones I worked so hard as senior pilot to instill in junior pilots.

““

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Loss of SA Makes SenseBy LT Andrew Miranda, PhDWhen it comes to understanding how the mind works,

“situational awareness” (SA) seems to have us covered. It has become the all-encompassing concept; applicable to every aspect of the human experience. For example, aviators are typically encouraged to maintain SA during pre-flight briefs. I have heard that losing SA can cause human error, especially when one is complacent. Others have claimed to improve my SA when sending me helpful information via email by concluding the message with “FYSA.” I have even heard it mentioned during the classiest of our cultural outlets, sports talk radio, when the host admired a quarterback’s SA. Noth-ing is off limits. SA: the alpha and the omega.

We all seem to understand what we mean when we say it, especially since the term kind of explains itself. We all have a general understanding of the term “situation” (unless we’re talking about Mike “The Situation” Sorrentino on MTV’s Jersey Shore, then we’re all very confused).

We all are “aware” because we are capable of conscious thought with our own minds, I think. So why question SA as a concept? Why bother discussing a term we all already know so well? Because these tendencies only fuel the misconception that SA is a well-defined term and that we all understand it the same way. Consider this article my attempt to wreak some truth by presenting and exposing three important myths surrounding SA.

Myth #1: SA is defined as “when perception equals reality”

This is classic definition-by-substitution. In other words, this definition might as well read, “when awareness equals situation.” Definition-by-substitution just tells us the same thing with different words and certainly does not give us understanding. Nevertheless, this is the most common definition I have come across during military training, so let’s unpack it.

Practically speaking, we already have a term for when our perceptions do not equal reality: they’re called “visual illu-sions.” Take a look at the Café Wall illusion as an example:

We see the grey horizontal lines as tilted and the rows of squares appear as alternating wedges stacked on top of each other. But once you measure the image, you learn that the “reality” is the grey lines are parallel and all black squares are the same size. Whenever we see something messed up, our brains automatically tidy up the mess to help us make sense of it. Most of the time this cleaning process goes completely unnoticed. This is a normal part of how the mind works and it will continue to function this way, even after you stop reading this article and go about your daily life. The Café Wall illusion, and visual illusions in general, demonstrate that our minds are not a perfect mirror of the outside world.

At a deeper level, human beings have pondered the rela-tionship between perception and reality for more than 2,000

years. The Ancient Greek philosopher Plato was obsessed with asking these types of questions (e.g. “How are we able know what we know beyond our own physical sensations?”) and would create stories to challenge the idea that human perception, and the mind in general, can perfectly interpret the outside world. These stories and his teachings laid the groundwork for Western philosophy and are still influential today. Take, for instance, the following critique of “reality” from an accomplished military captain and one of the great thinkers of all time: Morpheus from The Matrix, “What is real? How do you define ‘real’? If you’re talking about what you can feel, what you can smell, what you can taste and see, then ‘real’ is simply electrical signals interpreted by your brain.”

The perception-reality conundrum is among the types of problems that philosophers, theorists, psychologists, and a whole bunch of people who had difficulties getting dates in high school are still working to solve. If we are indeed audacious enough to claim that our perceptions are capable of equaling reality, we should probably make a couple phone calls to announce the news that we have solved a mystery spanning more than two millennia and can explain what it means to exist as a human being. Otherwise let’s drop this definition and reconcile the fact that the perception-reality question is slightly more complicated.

Myth #2: There is an accepted definition of SAIf the current definition we are using for SA is unaccept-

able, then the next logical question is, “What is the defini-tion of SA?” Well there is not a clear answer to that question either. The concept of SA originated in the field of human factors, which is a field of study covering subjects such as vision, attention, cognition, and other topics sure to sedate most college students. The definition most commonly cited in this field was originally coined in 1995 by Dr. Mica Ends-ley, former Chief Scientist of the U.S. Air Force and current president of SA Technologies. That definition is as follows:

“The perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.”

This definition is typically simplified to the 3 levels of SA: Perception, Comprehension, Projection. This version of SA is also the one typically taught in human factors courses and is the most popular among casual consumers of human factors research. But among the human factors experts and professionals who live and breathe these concepts, it’s as controversial as asking someone of their political beliefs or if pineapple belongs on pizza.

The Endsley definition of SA is a major point of conten-

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Loss of SA Makes Sensetion within the human factors community. Many of the experts have voiced strong opinions that this term has outlived its usefulness and become something it was never intended to be. During the last 20-plus years, numerous experiments, studies, and papers have been produced by fiercely passionate human factors experts arguing that the concept of SA is unhelpful and that the common misunderstandings do more harm than good. Specifically, some say the definition resembles too much of the misguided “perception equals reality” notion addressed in the previous myth. Others claim the definition does not do enough to emphasize the importance of context (e.g. tools, task demands, overall environment), which is essential to achieve a better understanding of how the mind works. Lastly, this defini-tion has been criticized mostly because of reasons I will get to in the 3rd myth.

The debate over SA came to a head in 2015 when the Journal of Cognitive Engineering and Decision Making, an academic publication covering human factors topics, published a special issue titled “Reflections and Commentaries on Situation Awareness.” It featured 13 articles from 19 different authors, all sharing strong views on a topic they care about very deeply. Here are three titles of articles and their authors, who happen to be among the prominent leaders in human factors:

• SA Anno 1995: A Commitment to the 17th Century by Roel van Winsen and Sidney Dekker

• Let the reader decide: A paradigm shift for situation awareness in sociotechnical systems by Neville Stanton and others

• Situation awareness misconceptions and misunder-standings by Mica Endsley

After reading the special issue, one thing is clear: the concept of SA remains unclear. These articles were written by the people who immerse themselves in SA research and theory. And if these experts were unable reach a consensus on how to define the concept, then the term is much more confusing that we think and likely being misused. If the researchers were to solve this problem and reach an agreement on a definition, that may provide us with better understanding. But it still would not address the dangers existing in the final myth.

Myth #3: “Loss of SA” can be causal to a mishapThousands of pages have been written about the idea that

“human error” as a conclusive cause to accidents and mishaps is unhelpful. Despite this perspective, “Loss of SA” has unfortu-nately evolved into an acceptable explanation for human error

Quartermaster Seaman Christopher Szkaradnik operates the Office of Naval Research-funded Situational Awareness System (SAWS) aboard the aircraft carrier USS Dwight D. Eisenhower (CVN 69). ( (U.S. Navy photo by John F. Williams)

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Cmdr. Andrew Schulman, executive officer of Amphibious Construction Battalion (ACB) 1, briefs 172 reservists assigned to ACB-1 during a Battalion field training exercise. The exercise increases situational awareness and readiness for expeditionary operations. (U.S. Navy photo by Mass Communication Specialist 2nd Class Brian P Caracci)

in the aftermath of these incidents. In this regard, the term is grossly overgeneralized. The strongest proponents of SA have even said the term is too often carelessly applied as a simple explanation for a complex event. In one of those 2015 special issue articles mentioned earlier, Dr. Endsley herself wrote that “the construct of SA is not about providing a post hoc label for explaining human error and never was.”

When SA is considered as perception equaling reality, and then later applied to help explain the cause of a mishap, it becomes 100% pure, uncut hindsight bias. By telling individuals involved in a mishap that they caused a mishap because they “lost SA,” it’s the same as saying “we know now more than you knew then.” It prevents us from obtaining a deeper understand-ing of the decisions, actions, or inactions that made sense to them at that moment in time.

Only after the fact can we piece together the “reality” their perceptions should have seen coming, giving us an easy answer to what happened. Also, because the eight syllables in “situa-tional awareness” lends more intellectual credibility than the three syllables in “they oopsied,” it’s understandable that the

term is so attractive. So there you have it. “Loss of SA” becomes a go-to for explaining mishaps because it is easy and attractive. Two characteristics that will surely inhibit safe practice, in both complex operations and romantic encounters.

I hope this article made a meaningful impression. It is important to scrutinize and challenge the words and concepts we so casually use every day. If not, we end up in an Emperor’s New Clothes situation, where we imagine something must be true simply because everyone else imagines it to be true, thus making us too afraid to speak up. I love that story not only because it ends with everyone staring at a naked man, but also because it was an innocent child who didn’t know any better that shouted the truth.

The keys to preventing future mishaps due to a lack of proper supervision are increased communication and coordi-nation. If the Sailor and the leader are communicating (SQ2C checkpoint) about the pending task and the various leaders are coordinating their efforts at a higher level (night orders), then the entire command will benefit through the preservation of combat readiness and the saving of lives.

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“When situational awareness is considered as perception equaling reality, and then later applied to help explain the cause of a mishap, it becomes 100% pure, uncut hindsight bias. .” – LT Andrew Miranda PhD

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