AV I ATI O N - M I S H A P S MV-22 Osprey
FY2019
FY19 marks the second year in a row with no Class A mishaps in the community. The community reported 34 mishaps, including two Class B, 21 Class C, and 11 Class D mishaps in FY18. The mishap rate increased over FY19 due to the increase in class C and D mishaps. Class C mishaps have increased by 20 percent and Class D mishaps have nearly tripled. Of these Class C and D mishaps, the most common causes were click stud disbanding and Blade Fold Wing Stow (BFWS) operations. Human factors were the leading cause for all mishaps. Based on mishap reporting, MV-22B leading mishap causal factor preconditions were: Teamwork Critical information not communicated Failed to effectively communicate Failure of crew/team leadership State of Mind Complacency Overconfidence Pressing Policy & Process Issues Provided inadequate procedural guidance or publications Purchasing or providing poorly designed or unsuitable equipment Organizational (formal) training inadequate or unavailable Mental Awareness Inaccurate expectations Not paying attention Distraction These are all factors that CRM or ORM, when used properly, can prevent. Whether flying or maintaining aircraft, you are never alone. When flying, there is a crew, and when performing maintenance, there are supervisors and inspectors who should be present during the task to act as checks and balances in the process to break the mishap chain. The MV-22 community has reported 52 HAZREPs for FY19; the trends include: • BASH • TFOA (blade fairing leading cause) • Unauthorized Laser Events (ULE) • Click Studs • BFWS
FY19 marks the second year in a row with no Class A mishaps in the community.
The Naval Safety Center Annual Report (2019)- Page 41
