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The USAF Safety Process


xaarman

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At my last unit, if we wanted to read a safety report, the safety shop printed them out with the caveat to personally hand them back later that day or the next day for accountability. I just in processed to a new unit and they flat out refused to even pull it up saying we had to have a "need to know" which is determined by Wing Safety to the squadrons, and then there will be a mass brief to the squadron.

This strikes me as odd... I pulled up 91-204 and got this:

3.7.2. Limiting Release within the Air Force. Safety officers and their staffs, duly appointed safety investigators, AFSC personnel and AF/SE and his or her staff, are authorized access to and use of privileged safety information based on their safety duties. Other Air Force officials, when their duties include mishap prevention and when it is necessary to develop, take, or review preventive actions, may obtain access to privileged safety information.

This the new norm or an AETC FTU "perk" ?

Edited by xaarman
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At my last unit, if we wanted to read a safety report, the safety shop printed them out with the caveat to personally hand them back later that day or the next day for accountability. I just in processed to a new unit and they flat out refused to even pull it up saying we had to have a "need to know" which is determined by Wing Safety to the squadrons, and then there will be a mass brief to the squadron.

This strikes me as odd... I pulled up 91-204 and got this:

This the new norm or an AETC FTU "perk" ?

That is your FSO being a little over-cautions about protecting privileged information.

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At my last unit, if we wanted to read a safety report, the safety shop printed them out with the caveat to personally hand them back later that day or the next day for accountability. I just in processed to a new unit and they flat out refused to even pull it up saying we had to have a "need to know" which is determined by Wing Safety to the squadrons, and then there will be a mass brief to the squadron.

That's asinine. Your job as an aviator is all the "need to know" that moron needs.

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"Need to know" pertains to any aviator not wishing for history to repeat itself. Any Safety Officer not willing to give SIB info is either too lazy or missing the point. I might not agree that they should print a copy, but a quick briefing (or at least pulling it up on a computer) is their job. Get the answers you want, discuss with other 'privileged' persons, and learn. SIBs aren't created for the safety shop to keep them under wraps.

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Sweet crap.

I did the safety thing. Run this up to the Wing FSO. If the Wing balks, go to the MAJCOM. Withholding something until the "wing gets briefed" is idiotic.

There is NO REASON they are withholding, other than their own ignorance.

Chuck

Edited by Chuck17
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Sweet crap.

I did the safety thing. Run this up to the Wing FSO. If the Wing balks, go to the MAJCOM. Withholding something until the "wing gets briefed" is idiotic. I was in AK when SITKA 43 went down. We had the report the day it was released, and then a week later it was briefed to us.

There is NO REASON they are withholding, other than their own ignorance.

Chuck

2. As a former wing chief of flight safety for both an FTU and the same deployed wing as the mishap MC-12, I can tell you that anyone stating you can't read the report or know of the findings until some mass brief down the road is an idiot. If I was your wing SEF, I'd personally make sure you had access to read it...but unfortunately I've moved beyond the safety realm.

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At my last unit, if we wanted to read a safety report, the safety shop printed them out with the caveat to personally hand them back later that day or the next day for accountability. I just in processed to a new unit and they flat out refused to even pull it up saying we had to have a "need to know" which is determined by Wing Safety to the squadrons, and then there will be a mass brief to the squadron.

This strikes me as odd... I pulled up 91-204 and got this:

This the new norm or an AETC FTU "perk" ?

I'm an AETC FTU instructor and our FSO's allow us to review privileged information on safety mishaps.

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I cannot imagine any reason your safety shop wouldn't release that information to its pilots. Before making stupid decisions, people needs to ask themselves "how would I explain this decision to my boss and his boss" when the poop hits the fan. If you can't answer that, you may want to reconsider your decision.

Example: An SIB is released with data that could have prevented the same event from happening again, but for some reason the FSO decides not to release the report for an additional 3 weeks, and the same event happens again.

Boss: "So, we had the same mishap happen again....tell us again why you didn't release the report to your squadron for three weeks?"

FSO: (crickets)

I haven't read the report, so I don't know if this particular report has any information that could prevent future events, but either way as an FSO, I would want this information out soonest! But, maybe he does have a good answer for his boss...good luck!

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Sweet crap.

I did the safety thing. Run this up to the Wing FSO. If the Wing balks, go to the MAJCOM. Withholding something until the "wing gets briefed" is idiotic. I was in AK when SITKA 43 went down. We had the report the day it was released, and then a week later it was briefed to us.

There is NO REASON they are withholding, other than their own ignorance.

Chuck

Last time I asked wing safety to send me a report via email (encrypted) they said the MAJCOM said no way... Called MAJCOM, they asked for my email address.

I'm an AETC FTU instructor and our FSO's allow us to review privileged information on safety mishaps.

No shit, that is what it is for!! Why is this so difficult for some Safety people to understand?

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I'm glad to hear this attitude from so many safety officers. One of my greatest frustrations flying in the Air Force has been the secrecy surrounding safety investigation results.I have never once walked into my safety office, shut the door and successfully been allowed to access and read a safety report. I find it incredibly frustrating that I have easier access to top-secret information than the results of a safety investigation. Mostly the issue is manning, as our safety offices rarely have anybody qualified; this means we are dependent on Wing safety representatives who are not forthcoming or accountable to SQs.

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If you have wings or are actively training to earn a set of wings, there should be absolutely no reason why you can't walk into your wing safety office to view an official SIB report. Anyone who turns you away isn't doing their job. Period.

I'll add that perhaps if members of the MC-12 community had been encouraged to visit their safety shop to get read in on recent (past few years) C-12 and MC-12 mishaps, this tragedy could have been avoided. I know because I was SEF at the mishap wing and there were lessons learned that I personally investigated two years ago that could directly contribute to preventing this years' Class A. It's very upsetting to me that safety reports are treated like TS when their sole purpose exists to "spread the word".

Edited by Hueypilot
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For the ASO's in the group, is there a way for other sevices that fly a similar airframe to get eyes on the report?

Agree with all the positive comments. If you wing safety or any other aviation safety personnel are witholding information on the basis of "Need to Know" they are in the wrong job! Command influence has no place in an aviators or cremember's needing to have a full understanding of an event regardless of the accident classification. However if an investigation is in progress, that's the only rationale for keeping a lid on preliminary information. Once the investigation is completed and Issues, Findings and Recomendations are completed it is imperative that all crews or interested individuals should be briefed. In the case where individuals involved are available, they should share the experience with unit, squadron, wing members in an open forum of discussion. The purpose is "Accident Prevention and Lessons Learned"

http://www.ntsb.gov/investigations/reports_aviation.html

http://www.asias.faa.gov/pls/apex/f?p=100:93:0::NO:::

https://rmis.safety.army.mil/RMISRegistration/NewUser.aspx

A few ways to access accident investigation data.....those looking for C-12 specifics (Army Aviation obviously has the most data available).

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I'm glad to hear this attitude from so many safety officers. One of my greatest frustrations flying in the Air Force has been the secrecy surrounding safety investigation results.I have never once walked into my safety office, shut the door and successfully been allowed to access and read a safety report. I find it incredibly frustrating that I have easier access to top-secret information than the results of a safety investigation. Mostly the issue is manning, as our safety offices rarely have anybody qualified; this means we are dependent on Wing safety representatives who are not forthcoming or accountable to SQs.

I thought I was the only one who thought this way. If folks are not being allowed to read the SIB reports, please ask your safety office what the point of a SIB is in the first place. Hint: To Prevent Future Mishaps. I really don't "get" the flight safety culture in the AF. It seems like incidents, big and small, get swept under the rug and are not to be talked about. I didn't realize the amount of 'minor' stuff that was happening on a monthly basis until I started digging around in AFSAS. There is a lot to be learned from reading AND teaching what is in these reports. It can be as simple as telling your crews that incident X happened last week, be sure to check that the pitot covers are removed or whatever. You don't have to go into detail.

Another great tool is the ASAP program. http://www.safety-masap.com/ Crews should not only be participating in these reports, but reading as well.

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Wait til you hear this, pilots in the 427th (Beale's MC-12 squadron) who asked to see the report are being told to wait 3 weeks until the squadron is briefed.

WG/SE has paper copies if you want to read it. Also, I'm pretty sure SQ/SE will let you read the report, the SQ is just doing an "official" brief in 3 weeks. I admit, when I heard the reason for the 3 week delay, I thought it was pretty absurd, but ultimately I suppose it's the CC's decision when to brief his SQ...

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I'm glad to hear this attitude from so many safety officers. One of my greatest frustrations flying in the Air Force has been the secrecy surrounding safety investigation results.I have never once walked into my safety office, shut the door and successfully been allowed to access and read a safety report. I find it incredibly frustrating that I have easier access to top-secret information than the results of a safety investigation. Mostly the issue is manning, as our safety offices rarely have anybody qualified; this means we are dependent on Wing safety representatives who are not forthcoming or accountable to SQs.

If you have your annual privilege training, you can request your own AFSAS account for read-only access. You may not print or redistribute the privileged information in AFSAS without properly sanitizing (arguably some reports can never be fully sanitized by the reg).

Depends on your wing safety office. YMMV.

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Another great tool is the ASAP program. http://www.safety-masap.com/ Crews should not only be participating in these reports, but reading as well.

This will take awhile to take off, but it really has the potential to be a great program. Unfortunately our current system only investigates things after something bad rather than the near miss.

For the ASO's in the group, is there a way for other sevices that fly a similar airframe to get eyes on the report?

Contact AF Safety Center at Kirtland, they can get a sanitized version released assuming the person you talk to isn't one of the Privilege=TS morons which is likely.

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  • 3 months later...

I think we overuse "privilege" protections. Our current safety system does not adequately use the information the SIB gathers to prevent future mishaps through education. However, I respect the rules and procedures that deliberately restrict the public release of safety board information and analysis. AIB information is for the public, the family and lawyers. SIB information is for the Air Force to prevent future mishaps by figuring out what happened without worrying about the threat of prosecution. Not a perfect system since convening authorities see both versions, but the protection of "privilege" has merit. However, we go overboard protecting the SIB information at the expense of mishap prevention.

I asked the safety center for the video of the C-17 crash during the airshow practice in Alaska. I was officially told I could not have that video (with tower footage, CVR and sim recreation) because it belonged to AMC/CC and was not intended for my use. So during my 1.5 hour long discussion to 600+ wing crewmembers about flight safety, flight discipline, risk management, CRM and standards, the Air Force Safety Center and AMC/SE thought I did not have a valid use for the video. Undeterred by bad decisions and bureaucracy, I got a bootleg copy of the video and showed it during my brief because it was an effective tool to discuss mishap prevention. I also showed the video of the MC-12 doing a barrel roll, an RPA landing mishap with horrible CRM, a CV-22 mishap and several recent ground mishaps.

I read this MC-12 AIB and attended the SIB VTC to (A)SECAF. I thought the AIB did a good job investigating the crash and I thought the findings were solid. I disagreed with some of the SIB findings and recommendations. Not appropriate to get into details here.

So, questions for this distinguished forum. Have any of you have seen the full MC-12 SIB brief, with CVR and simulator animation? Did your sq/wing safety shop brief the mishap with all of the tools available? Do you think we do an adequate job preventing mishaps through education gained from SIBs?

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I asked, was told it didn't apply to the kind of flying we do in AETC and thus would be unable to get a copy. Haven't seen, no briefing, and we could but about two years ago Safety went into a shut in with a major need to know justification thus inhibiting the ability to get safety reports. However,I believe this is leadership dependent, just very frustrating - not sure what HHQ guidance they were given (after the F-22 crash, was SIB was leaked which led to the settlement?)

Edited by xaarman
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I think we overuse "privilege" protections. Our current safety system does not adequately use the information the SIB gathers to prevent future mishaps through education. However, I respect the rules and procedures that deliberately restrict the public release of safety board information and analysis. AIB information is for the public, the family and lawyers. SIB information is for the Air Force to prevent future mishaps by figuring out what happened without worrying about the threat of prosecution. Not a perfect system since convening authorities see both versions, but the protection of "privilege" has merit. However, we go overboard protecting the SIB information at the expense of mishap prevention.

I asked the safety center for the video of the C-17 crash during the airshow practice in Alaska. I was officially told I could not have that video (with tower footage, CVR and sim recreation) because it belonged to AMC/CC and was not intended for my use. So during my 1.5 hour long discussion to 600+ wing crewmembers about flight safety, flight discipline, risk management, CRM and standards, the Air Force Safety Center and AMC/SE thought I did not have a valid use for the video. Undeterred by bad decisions and bureaucracy, I got a bootleg copy of the video and showed it during my brief because it was an effective tool to discuss mishap prevention. I also showed the video of the MC-12 doing a barrel roll, an RPA landing mishap with horrible CRM, a CV-22 mishap and several recent ground mishaps.

I read this MC-12 AIB and attended the SIB VTC to (A)SECAF. I thought the AIB did a good job investigating the crash and I thought the findings were solid. I disagreed with some of the SIB findings and recommendations. Not appropriate to get into details here.

So, questions for this distinguished forum. Have any of you have seen the full MC-12 SIB brief, with CVR and simulator animation? Did your sq/wing safety shop brief the mishap with all of the tools available? Do you think we do an adequate job preventing mishaps through education gained from SIBs?

I teach in AETC and saw the PowerPoint after the SIB was released. The briefer flew MC-12's at this location and gave us some background on the mission, crew compliment, etc that the SIB didn't have in their brief. I can say that at least in the MAF we do use SIB's for changes to prevent the same mishap from happening. We're starting to see changes in the KC-135 world due to the Shell 77 mishap. We were also shown the full C-17 Elmo crash brief, to include the unedited version of the video.

I don't agree with keeping SIB information within a MAJCOM and not sharing. Lessons can be learned from all with unfortunate events like these.

I asked, was told it didn't apply to the kind of flying we do in AETC and thus would be unable to get a copy. Haven't seen, no briefing, and we could but about two years ago Safety went into a shut in with a major need to know justification thus inhibiting the ability to get safety reports. However,I believe this is leadership dependent, just very frustrating - not sure what HHQ guidance they were given (after the F-22 crash, was SIB was leaked which led to the settlement?)

If you have wings on your chest, then you have a need to know to an SIB.

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I'm not an Air Force pilot, but I've been a civilian pilot for over a decade now, and have had friends and colleagues die in aviation incidents. In every instance, I learned something.

The ODNI has been working for several years now to break down stovepipes within the IC, and foster information sharing and collaboration. The idea being that sharing intelligence within the IC ultimately leads to a safer America (and warfighter), and it allows us to better understand threats from a multi-INT perspective. It took 9/11 for people to realize that stovepipes weren't working.

It's incomprehensible to me that an Air Force pilot would be prohibited from accessing and using the findings from an accident that took the lives of fellow Airmen. How fucking short-sided is that? This information should be readily available to every Aircrew member, potentially MX, Intel and OSS folks as well. Nobody is spitting on graves; this information could literally save lives in the future. I hope it wont take an air safety 9/11 for the Air Force to change course.

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So, questions for this distinguished forum. Have any of you have seen the full MC-12 SIB brief, with CVR and simulator animation? Did your sq/wing safety shop brief the mishap with all of the tools available? Do you think we do an adequate job preventing mishaps through education gained from SIBs?

Nope, we got briefed on it by our Wing and squadron safety guy (happened to be the same dude while we were downrange i.e. he was our deployed SQ/SE but works at WG/SE at home). Not sure the access he had or what materials/videos/animations he had seen or not seen.

Would love to see the full monty though since our community has a particular vested interest in how to safely and effectively fly the MC-12 airframe...

Edited by nsplayr
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Do you think we do an adequate job preventing mishaps through education gained from SIBs?

Pretty big "NO" from me. Here is what surprised me the most: out of the ~100 items on the multiple pre-deployment checklists I had to accomplish (many including CBTs such as cultural sensitivity, foreign language modules, sexual harassment, OPSEC, etc), not one of those items was "Sit down and read the three Class B-E mishap reports from MC-12's in the past." All past in-flight mishaps were related to stalls while in orbit with the autopilot on. I would say 90+% of the deployed pilots have not read these, and wouldn't you agree that they would be the most important readers of such reports? I'd say that's a pretty big failure at multiple levels. Not to mention after arriving to deployment, we have another 20+ item reading list, and guess what is still absent from the reading list?

Edited by TLAR
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Pretty big "NO" from me. Here is what surprised me the most: out of the ~100 items on the multiple pre-deployment checklists I had to accomplish (many including CBTs such as cultural sensitivity, foreign language modules, sexual harassment, OPSEC, etc), not one of those items was "Sit down and read the three Class B-E mishap reports from MC-12's in the past." All past in-flight mishaps were related to stalls while in orbit with the autopilot on. I would say 90+% of the deployed pilots have not read these, and wouldn't you agree that they would be the most important readers of such reports? I'd say that's a pretty big failure at multiple levels. Not to mention after arriving to deployment, we have another 20+ item reading list, and guess what is still absent from the reading list?

I wish an O-10 would read your comment TLAR. Our priorities are all messed up. Fix those and the AF may get back on the right track.

Edited by WABoom
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So, questions for this distinguished forum. Have any of you have seen the full MC-12 SIB brief, with CVR and simulator animation? Did your sq/wing safety shop brief the mishap with all of the tools available? Do you think we do an adequate job preventing mishaps through education gained from SIBs?

No. Why the fuck would our safety shop show us stuff related to flying safety? I get the same looks that other guys here do when I ask the safety office for the low down / video / report on one of these accidents. It's like I just asked a CIA officer to show me his Rolodex or something.

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