A Safety Perspective on How the Past Informs the Present (and Future)

A Safety Perspective on How the Past Informs the Present (and Future)

By VADM Dean Peters, USN (Ret.)

Regarding the aspect of human error, I think back to my time as an H2P in 1986. At the time, I was reluctant to discuss any aspect of flight operations that was dangerous or even unusual. This was the era before crew resource management and well before the concept of flight debriefings. The old adage of “better to die than look bad” was unfortunately in full effect, and it was not unusual for near-misses to become real mishaps. Only then would procedures be changed or training altered to address unnecessarily dangerous scenarios. Because of the advent of CRM and flight debriefings, there now exists a formal venue to bring forward concerns and observations, no matter how small. But it still takes courage, humility, and a time investment to bring forward these observations and concerns. As a squadron CO, I understood the value of “True Confessions” and made it an important topic of weekly wardroom training. In all honesty, I was reluctant to share my own close calls that might cast my image in a poor light. I was the CO and had to set the example. I could not be seen as having failed, as that would constitute weakness. Only later would I overcome this false perception and start setting the right example by admitting mistakes so that I and others could learn. Setting this “right” example also opens the door for others to be more transparent, and in this way, the team, the squadron, the organization all get better.

Regarding the aspect of material failures, such as the damper line that caused the tragic Loosefoot 616 mishap, I can only say that there is a deep support structure of engineers and logisticians primed to attack suspected material issues. A few years ago, NAVAIR began attacking quality issues on both new components and repaired items, as reported in quality deficiency reports. Filling out the maintenance action form (MAF) is the first step. And if a condition exists that causes alarm, it’s important to get the word out through all available means. A call to PMA-299, the H-60 Program Office, will also start the process moving.

An example from the fixed wing community highlights the use of the latest technology for solving material failures, and also illuminates the power of providing feedback, however small. A few years ago, physiological episodes (PE’s) were Naval Aviation’s number one safety concern. Marine Corps and Navy fighter squadrons were experiencing historic numbers of PE’s, degrading mission completion, and driving readiness issues. The aviators were at risk of serious medical issues and confidence in the aircraft was a real problem. A coalition of stakeholders across multiple organizations finally produced solutions that drastically reduced PE’s in the fighter squadrons and in the training command. Although there were many factors to this reduction, one important element was the use of machine language and artificial intelligence. There is a NAVAIR command in Orlando, FL – Naval Air Warfare Center Training Systems Division – that had established a machine learning and artificial intelligence team and they took on the task of analyzing PE’s for the F/A-18E/F Community. Their efforts involved the ingestion of every known MAF associated with the environmental control system (ECS). Squadrons participated by increasing their documentation of all possible material failures, and by providing as much information as possible on flight regimes and material condition. Through machine learning algorithms, the engineers at Orlando were able to reliably predict when components of an ECS System would fail, by squadron, by bureau number. The F/A-18 Program Office coordinated the feedback of this information to CNAF and the fleet with increasingly beneficial results. I share this case study because it highlights the importance of maintenance-related feedback. It is not a waste of time. In fact, it is essential – with or without slick techniques like artificial intelligence.

Ultimately, I’m confident that the rotary wing community will adopt an increased focus on feedback, both for the human side of near-misses and for the material side. There was another article in the Summer 2022 edition of Rotor Review that reinforces the power of learning through transparent selfassessment and the imperative to build learning teams that embrace frank discussions of performance in order to build a winning culture and high-performance Navy. The article was from the On Leadership series by Admiral Bill Lescher, then Vice Chief of Naval Operations. Like Admiral Lescher, I am confident that today’s generations of aviators and maintainers will build a learning culture and take the rotary wing community to the next level.