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xaarman

The USAF Safety Process

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As a former Safety guy, I'm not sure the guys in that office are driving the boat. My guess would be higher ups that either want to do some CYA or control the data to shape the report to their liking. IIRC, the 4 star could change causal factors to just about anything before the report is sent out to the masses. The AF Safety Center could put the causal factors back where they belong but the report is filed and never sent back out afterward. Other than that, it makes no sense to not take advantage of the mistakes of others to prevent mistakes in the future.

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The safety folks are worried about protecting/ keeping privilege. A decent fix would be hosting the videos/presentations on afsas via streaming, without requiring short term tab access. There's got to be a way to do that securely right?

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Re timeliness: I've been a Class A SIB BP and a few other roles...the instant we believed releasing info was necessary to prevent future mishaps, we sought the MAJCOM/CC's permission to put the fix in place (Mx action, TO change, etc).

Contrary to popular opinion, you probably do not instantly need to know what happened. If you're really interested in flight safety, go read the 91 series, and go to ASPM/AMIC and become a safety officer.

Safety reports are full of very sensitive info and are not for the curious. That's what AIBs are for.

ETA: I routinely look up reports and TELL the curious/interested what happened, without releasing privileged info. That's what safety offices SHOULD be doing.

Edited by Learjetter
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The notion of "privileged" went out the window as far as I'm concerned when I read the account that AMC/CC used info from a safety investigation to justify overruling the results of an FEB.

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Anyone read Approach magazine? Why doesn't the AF have something like that?

If you're referring to a service-wide magazine, we use to have Wingman, but it was recently cancelled.

1. Get something out to the community in a timely freaking manner. The DVR/DFD are decoded pretty quickly, and we generally have a good idea of what the hell happened within 48 hours or so. Isn't there a preliminary safety message put out that soon anyway? The NTSB gets a basic report out pretty early, and it is usually about 95% accurate after the final report comes out. And before anyone says "things can change," then I say so what. Then we can change what we learned if the final report is that much different from the initial one.

The preliminary safety message (within 24 hours) is generally nothing more than an OPREP that states only facts (location, ranks, aircraft type and tail number, general mishap category). The time limit for investigations is 30 days - barring no extenuating circumstances - which really isn't that long of a time period to wait to hear what happened. As was mentioned previously, if something is discovered that is imminent hazard to aircrew, it WILL be immediately released. IMO, the reason the NTSB releases so much information so quickly on accidents is because of public scrutiny and media. Neither of those plays a big part on Air Force mishaps, so we do it under our timeline.

2. Give everyone with access to the portal access to safety reports. Maybe a semi-sanitized version. I should be able to access these lessons from my hotel room, downrange, or wherever. I shouldn't have to go back to my home unit and then beg and plead with the safety office, only to be denied about 50% of the time anyway by the "I have a secret" weenies. I just don't get how it will somehow hurt operations, safety, or privilege by allowing the broader community to have access to safety reports. NTSB reports are not only open to the flying community, but they are open to anyone with an internet connection.

You’re missing the point of the report. You can’t have a “semi-sanitized” report that has any sort of findings – this would make it privileged, and therefore FOUO, and therefore subject to the restrictions of safety reports. Releasing these FOUO reports has nothing to do with hurting operations, it has do to with protecting the concept of privilege for those who are subject to investigation by safety reports. If the reports are leaked publicly, that information could in theory be used in legal or other matters for which it was not intended (again - that is the point of the AIB) . Unfortunately, the reports are kept close hold for the same reason you have to take IA training every 12 months that is geared towards the lowest common denominator – because some people are stupid, and when given the chance, they will email it out or upload it to YouTube. That all being said, your safety office isn’t doing their job if they're not working to get you reports and/or briefings.

3. As I mentioned before, have a condensed, user friendly document, PPT, and animation on said safety portal, available to anyone with a CAC card. Someone mentioned how the C-5 animation was leaked out and how bad that was, and how we have to be careful with "raw data" like that without the safety guys there to "interpret" it for us.

I agree 100% that these should be more easily accessible (by Safety shops), but again not to the average Joe. On the occasions when we wanted to brief mishaps, it took a lot of prodding and justification to the safety center -- it is unnecessarily painful. But the reason for not making it available to everybody has nothing to do with the safety guys interpreting it, it has to do with the concept of privilege and safeguarding that information.

IIRC, the 4 star could change causal factors to just about anything before the report is sent out to the masses. The AF Safety Center could put the causal factors back where they belong but the report is filed and never sent back out afterward.

The convening authority (4-star MAJCOM CC) cannot change casual factors, but he can reject the report and/or make the SIB go back and research other areas. The report is never "sent out," it is uploaded into AFSAS. Any changes following the final report (MOFE) or loaded into AFSAS. All versions of the report are maintained in AFSAS.

Re timeliness: I've been a Class A SIB BP and a few other roles...the instant we believed releasing info was necessary to prevent future mishaps, we sought the MAJCOM/CC's permission to put the fix in place (Mx action, TO change, etc).

Contrary to popular opinion, you probably do not instantly need to know what happened. If you're really interested in flight safety, go read the 91 series, and go to ASPM/AMIC and become a safety officer.

Safety reports are full of very sensitive info and are not for the curious. That's what AIBs are for.

ETA: I routinely look up reports and TELL the curious/interested what happened, without releasing privileged info. That's what safety offices SHOULD be doing.

Shack on all of this.

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Agree with what you are saying. The main point is that the individual safety offices need to develop root causes of each SIB from the recommendations and disperse that info throughout their respective wings.

I think as a whole, if there is an obvious safety of flight issue....the AF sends guidance thru FCIF/TO change, but the inference of SIB info wrt to each specific airframe is not disseminated to the masses appropriately. That being said, there needs to be action from both the SE office and also line aircrew (mainly IPs) to emphasize the findings and fixes to the info in each SIB report during spin up.

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Agree with what you are saying. The main point is that the individual safety offices need to develop root causes of each SIB from the recommendations and disperse that info throughout their respective wings.

If the safety offices aren't doing this... what ARE they doing?

I was the safety guy for a weapons squadron - an additional duty on top of being an ADO and Phase Manager - I built countless SIB-related briefs to keep the bros informed on the safety issues/incidents/investigations in our little corner of the AF. It wasn't all that difficult, and was always well received.

So what gives? Are safety shops too busy with other safety-related taskers that they can't do one of their primary jobs - keep the fliers informed? Are they deployed?

Not an accusation, just a question...

Troubling to hear stuff like that.

Chuck

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We don't give the FSOs the most effective tools they need to get the squadron flyers the lessons from a mishap. We give them AFSAS reports. We should give them the simulator recreation, with CVR, and brief the convening authority gets. You learn more from just seeing what happened in the recreation that you do in the report. The C-17 stall over Guam, the C-17 crash in Alaska, the C-5 crash at Dover, the MC-130H crash in Albania, the U-28 crash in DJ and the MC-12 crash in Afghanistan all have very powerful and informative videos that recreate the cockpit instrumentation, the relative aircraft position, and the exact crew coordination and communication that occurred. It is excruciating to listen to when you know the crewmembers, but it is an extremely effective teaching tool that will prevent future mishaps. We are allowing AFSEC and MAJCOM privilege policy, not law, to restrict our education and limit prevention. This needs to change now. The unacceptable way we handled the MC-12 mishap info clearly shows that.

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All valid, and think Liquid was spot on. There are some barriers due to the restrictiveness, but also think the info is available...but under a shitload of obstacles that are unnecessary.

Spinning up aircrew in a new airframe that was rapidly procured...the FTU needs to have an emphasis on pushing out the info from past SIBs, but also new aircrew need to seek that info...and that's regardless of airframe. I can somewhat understand the displacement of info of guys that used to be in the MC-12 that are no longer there...but if a pilot is in that current airframe he/she needs acces (whatever kind).

Champ- not saying this doesn't happen at every safety shop or FTU, but don't think it is an emphasis when it should be as a whole.

Liquid- the only part I disagree with is the aspect of training post-SIB.

I am with you that all the products produced from an SIB would give extremely more insight to all crew members in a community, but there needs to be a better answer than that. FTUs need to train based off the information gained from those SIBs or we are repeating previous incidents.

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Re timeliness: I've been a Class A SIB BP and a few other roles...the instant we believed releasing info was necessary to prevent future mishaps, we sought the MAJCOM/CC's permission to put the fix in place (Mx action, TO change, etc).

Contrary to popular opinion, you probably do not instantly need to know what happened. If you're really interested in flight safety, go read the 91 series, and go to ASPM/AMIC and become a safety officer.

Safety reports are full of very sensitive info and are not for the curious. That's what AIBs are for.

ETA: I routinely look up reports and TELL the curious/interested what happened, without releasing privileged info. That's what safety offices SHOULD be doing.

Have to disagree and say this is the root of the problem. We do need to know, and half assing the report and giving AIB info is next to useless. Case in point, the C-17 crash in Alaska. Safety's response was "we don't do airshows, that accident does not apply to us." BS! There are so many CRM examples, Halo effect, expectation analysis, etc etc (I don't want to get in specifics, mods feel free to edit) that it is obvious the SE office was wrong.

While I wouldn't mind Safety School, not all pilots want to go that route - yet they still have perfectly valid reasons to wanting to know the causal factors and how they can apply to their flying. Did you never do Lessons Learned at the end of every formal brief in pilot training?

Edit: Thank you Liquid, glad to hear you share the same views as the majority of us here on this issue.

Edited by xaarman

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Perhaps I'm not communicating well. I'll try again for xaarman: you do not need to see the recreations, listen to the CVR, watch the HD video of the T-38 mishap, even if you fly T-38 aircraft. You do not need the crews 72 hour and 7 day histories. You do not need to listen to the spouse interviews, or see the crash site photos, or read the autopsy reports. You don't need toxicology, or school transcripts, or training records, or FEFs. You don't need to read the SIB deliberations, the metallurgy reports, or the human factors analysis.

You DO need to know what happened, and what's being done to prevent recurrence, in AFSAS final report detail. Which is why if you ask, I'll let you read the final and/or MOFE for ANY mishap.

Even more importantly, the SIB has to do its job and put forth meaningful, effective recommendations to prevent recurrence...and the MAJCOM must implement them rapidly.

The system won't work if privilege fails. And it's a very very good system, and works well.

ETA: grammar buffoonery

Edited by Learjetter
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And it's a very very good system, and works well.

Basically every other poster in the last several pages of this thread would beg to differ.

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Perhaps I'm not communicating well. I'll try again for xaarman: you do not need to see the recreations, listen to the CVR, watch the HD video of the "xxx" mishap, even if you fly That aircraft. You do not need the crews 72 hour and 7 day histories........

The system won't work if privilege fails. And it's a very very good system, and works well.

Who are you to decide what I need to correctly ascertain the lesson? What if 7 day history is part of the problem? The system is terrible and doesn't work at all.

TS is required for my job; somehow I'm professional enough to keep those secrets; why do you think I would go post on YouTube if I saw the recreation?

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... you do not need to see the recreations, listen to the CVR, watch the HD video of the "xxx" mishap, even if you fly That aircraft. You do not need the crews 72 hour and 7 day histories. You do not need to listen to the spouse interviews, or see the crash site photos, or read the autopsy reports. You don't need toxicology, or school transcripts, or training records, or FEFs. You don't need to read the SIB deliberations, the metallurgy reports, or the human factors analysis.

I have seen it and lived it, on both sides of the Class-A investigation -

I agree that crews don't need all the private tab-access personal information stuff, but they do need to be able to read an SIB report (and some of that stuff is usually included - photos, transcripts, video, etc). If the SIB is out, crews have every right to come to safety, sit down and read it. All of it, at least what is released... And if safety can get the tapes, they should play them. I'm not saying start handing out SIB reports. I am saying be up front with info for the crews, and show them what you can if you are asked.

That being said, MOST dudes want the cliffs notes version. They want to know what happened and why, how it effects them, how they can use the findings to make themselves safer pilots. But when a guy comes to safety and says "I want to read the SIB", it is not the safety officer's job to pass judgement on what the lowly crewdog gets to read. If you can read it, they can read it. Brief them on privilege, document that you gave them a copy of the SIB and follow up to get it returned. Or if you still dont trust them, let them read it in your presence.

This hyper-control of information, fear-of-god bullshit comes straight from the AF Safety Center. I disagreed with it when I went through the courses, and I still disagree with it. "Toe-ing the line" and deciding who "needs to know" what information is garbage, and safety offices continue to hide behind it.

And that's why people are angry - it is a continued lack of trust in people and aircrew. The comparison between TS-SCI and AFSAS access is spot on. As is the assertion that privilege or protection is out the window... If some general wants to burn you, they will.

Chuck

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I don't understand what's so damn hard about this. If a crewmember walks into the safety office and asks to see the results of a SIB, the FSO should bring it up on their computer, let the member read/watch/listen to EVERYTHING, remind them that it is privileged information, then let them get back to their job a little wiser than before. Nothing leaves the safety office, or gets uploaded to youtube, and no privileged info gets compromised. How fucking difficult is that?

We are all professionals and we constantly complain about not being treated that way by our senior leaders whenever we're battling the latest nanny policy pushed out by big blue. If my example above isn't happening, well, now we've managed to fail at treating EACH OTHER like professionals, too. We need to pull our collective heads out of our asses and fix this ASAP.

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You learn more from just seeing what happened in the recreation that you do in the report. The C-17 stall over Guam, the C-17 crash in Alaska, the C-5 crash at Dover, the MC-130H crash in Albania, the U-28 crash in DJ and the MC-12 crash in Afghanistan all have very powerful and informative videos that recreate the cockpit instrumentation, the relative aircraft position, and the exact crew coordination and communication that occurred. It is excruciating to listen to when you know the crewmembers, but it is an extremely effective teaching tool that will prevent future mishaps.

Did this happen? If so when.?I know a C-5 stalled over Deigo and there is a great CRM video for that. Just asking if this was a type-o.

Edited by Butters
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Did this happen? If so when.?I know a C-5 stalled over Deigo and there is a great CRM video for that. Just asking if this was a type-o.

2 on this, never heard of a C-17 stall over Guam.

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Not a typo, just a screw up. I meant the C-5 stall over Diego. It was one of the first simulator recreation videos with CVR and it scared the shit out of me when I watched it. All pilots and crewmembers can learn from other MDS mistakes. We shouldn't limit it to similar aircraft/aircrew only, and we absolutely should include FTUs. Mishap prevention is the goal, not limited distribution.

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Perhaps I'm not communicating well. I'll try again for xaarman: you do not need to see the recreations, listen to the CVR, watch the HD video of the "xxx" mishap, even if you fly That aircraft.

explain.png

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The system won't work if privilege fails. And it's a very very good system, and works well.

The only part of your post I really agree with (and Toro's post) is about protecting privilege. I think we all see the benefits and appreciate the process that achieves that. However, the rest of the system is, more or less, horribly ineffective in terms of getting important stuff to the guys who need it.

Again, I am not blaming you, Toro, Huey, or any other safety officers for this buffoonery. Like most stupid things, it comes from above and is sanctioned from above. But all you guys are doing is regurgitating the company line about how important privilege is and how the process works. I think we all know how the process works, or shall I say doesn't work. And all the 'need to know' shit just comes off as the safety culture in the USAF as one big game of I Have a Secret.

I think that instead of just reading everyone the standard lines that are taught in ASPM, we need to think outside the box and try to change some of the ways we communicate this, and hopefully people like Liquid can help achieve this. If 90% of the guys on this thread think the current system is inefficient and crappy, that should say something.

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I'll pile on to say I also believe privilege has been compromised to the point that I will not participate in the AF safety process if involved in an incident.

Nobody has mentioned the C-17 guy who's SIB was released to the special prosecutor during his court martial.

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Perhaps I'm not communicating well. I'll try again for xaarman: you do not need to see the recreations, listen to the CVR, watch the HD video of the "###" mishap, even if you fly That aircraft. You do not need the crews 72 hour and 7 day histories. You do not need to listen to the spouse interviews, or see the crash site photos, or read the autopsy reports. You don't need toxicology, or school transcripts, or training records, or FEFs. You don't need to read the SIB deliberations, the metallurgy reports, or the human factors analysis.

You DO need to know what happened, and what's being done to prevent recurrence, in AFSAS final report detail. Which is why if you ask, I'll let you read the final and/or MOFE for ANY mishap.

Even more importantly, the SIB has to do its job and put forth meaningful, effective recommendations to prevent recurrence...and the MAJCOM must implement them rapidly.

The system won't work if privilege fails. And it's a very very good system, and works well.

A lot has already been posted, but I wanted reply as well - I do want to hear the CVR recordings... What information did get out and how could it have been communicated better? I would love the 72 hour and 7 day look back histories! Do any of those factors also apply to me? Can they apply to me in the future? How about my crew members? Are there common characteristics that caused maybe, a lack of sleep contributing to the fatigue, say perhaps arguing with the wife? Details matter in aviation.

The accident about memorizing checklist items has explicitly contributed to me becoming more mechanical with my checklists. The C-17 is an example about adherence to TO parameters, even when you know the aircraft can do more. I can go on and on about how every accident has lessons learned.

I was flying with a student last night, at night, in the weather, who looked up and said "Woah, I had no idea we were in a turn still." We had a great discussion on how every pilot is vulnerable, and then tied it into the F-16 crash that was just released.

Thanks for preaching the HHQ line, but it's bunk. The "I have a secret" game is robbing us fantastic airmanship education tools, which the consequences could be dire. I agree the system won't work if privilege fails, but I have a TS/SCI clearance, wings on my chest, and fly long days full of fatigue and/or with unqualified crew members. The system is there to be safer, let it be used.

Edited by xaarman
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I'll pile on to say I also believe privilege has been compromised to the point that I will not participate in the AF safety process if involved in an incident.

Nobody has mentioned the C-17 guy who's SIB was released to the special prosecutor during his court martial.

Well, that's a different side of the privilege coin.

There's the protection of the Safety Process side: protecting data from making its way into litigation. This is where we are going Full Retard.

Then there's the protecting YOU side: which has been shredded wholesale over the past few years. If you are involved in an incident, you are Bud Holland incarnate and therefore should be burned at the stake.

No, I don't blame you.

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