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Navy Aims to Curtail Aviation Mishaps Caused by Crew Error 

10  2,000 

by Sandra I. Erwin 

The U.S. Navy’s plan to improve safety in aviation will emphasize the need to reduce “human error,” said Rear Adm. Frank M. “Skip” Dirren Jr.

If human errors that result in mishaps were lowered by 50 percent during the next five years, the Navy would save 250 lives and $1 billion, said Dirren, who is commander of the Navy Safety Center. He spoke during the Tailhook Association’s annual convention, in Reno, Nev.

Human errors are those committed by air crews, supervisors and by maintenance and facilities personnel.

In the 1995-1999 period, Navy and Marine Corps aircraft were involved in 155 so-called class A mishaps. Those are mishaps that involve loss of life or at least $1 million in damage. Of those 155 accidents, 85 percent involved human error.

Even though the accident rate so far in 2000 is on an upswing, compared to 1999, the Navy, over the long term, is experiencing fewer mishaps, Dirren said. The service lost 22 planes in 1999. But 50 years ago, the Navy was having 54 mishaps per 100,000 flight hours. That number went down to 1.9 (for Navy and Marine Corps combined) in 1999.

“It’s easy for us to say ‘there’s a problem with the air crew,’” said Dirren. But that is not the case, he stressed. “These are first rate aviators. ... They have to do things that older aviators never had to do or didn’t have the capability to do.”

The 1995-99 period was by far the “best years” for naval aviation safety, said Dirren. Nonetheless, those 155 mishaps over five years cost the United States $4 billion and 1,000 deaths.

For the 1995-99 period, Navy and Marine Corps aviators had 506 flight mishaps, including class A and less serious ones. From that total, 366, or 72 percent, were caused by human error, according to charts published by the Navy Safety Center.

For all U.S. military services combined, 80 percent of flight mishaps are caused by human error.

For the Navy, one third of those human errors involve rule violations, said Dirren. That problem is more acute in the rotary-wing fleet, he said. “We have to do much better at explaining the rules.”

Dirren believes the Navy could reduce human errors up to 50 percent by 2006. That would save 250 lives and $1 billion.

“The biggest issue today is how to reduce human error,” Dirren said. In the F-14 Tomcat fleet, for example, three out of four mishaps in the last five years were related to pilot or supervisor mistakes. For the EA/6B Prowler electronic warfare fleet, about two-thirds of mishaps are caused by crew error. The same percentage applies to the S-3 Viking anti-submarine warfare community.

The AV-8B Harrier—a single-engine attack jet that can take off vertically and hover—has a mishap rate of 12 per 100,000 flight hours, among the highest in the U.S. military aviation community. But only one-third of Harrier mishaps are caused by human error, Dirren said. “Two-thirds [of the mishaps] are related to the aircraft failures.” He believes that the Harrier engines are severely stressed by the hovering function. “It’s important for us to do everything we can to reduce the mishap rate in the AV-8B,” he said, because its replacement, the Joint Strike Fighter (JSF) also will be a hovering jet with a single engine.

The JSF program is developing a conventional take-off version for the Air Force, a carrier-capable variant for the Navy and a vertical take-off and landing (VTOL) configuration for the Marine Corps and the U.K. Royal Navy. The VTOL JSF was designed to replace the Harrier in about 10 to 15 years.

In the JSF, Dirren said, “We’ll have the same issues as the AV-8B.” Earlier this summer, more than one hundred of the Marine Corps’ 140 Harriers were grounded after a crash in Yuma, Ariz., which was caused by engine problems. Some of those Harriers have been returned to service since the accident.

Dirren believes that, in order to prevent the JSF from experiencing the problems witnessed in the Harrier, it should be spared unnecessary weight. “If we are going to buy JSF with a single engine, then we should not start adding things, because you are going to start flying that engine apart. I think that is what happened to the AV-8.”

The carrier-based JSF presents another challenge, which is a return to single-engine warplanes. Today’s F-14 and the F/A-18 have two engines, and many of the pilots who will be flying JSF will have flown mostly two-engine planes.

The Navy decided to buy a single-engine JSF for budgetary reasons, and because it believes the new JSF engines are more sophisticated and safer than previous ones, said Dirren. “My personal opinion is that two-engine airplanes—like twin-piloted or twin-crew airplanes—do better, based on statistics.” Two brains, two sets of eyes, two engines have better odds than a single one, he said.

The JSF engines “are better than they used to be,” Dirren said. He is worried, however, that, over time, more weapons and systems will be added to the airplane, which will stress the engine. “So you start closing in the margin. ... Adding weight affects performance.

“If we are going to buy JSF with a single engine, we have to be smart about how we manage the mission, the weight, the accoutrements that go on that airplane.”

Chip “Big Bird” McNees, former F-14 pilot and currently JSF program manager at the Boeing Company, said the Navy should not underestimate the transition from twin- to single-engine airplanes.

“When it comes to flying single-engine airplanes, there are considerations, I won’t fool you,” he told aviators at Tailhook. “You fly the airplane differently, when it comes to in-flight emergencies.”

A junior officer at the conference asked McNees what he would recommend doing in case of engine failure with the JSF. “Should you try to ‘dead stick’ it?” asked the junior aviator. “I wouldn’t be that brave,” said McNees. “I’d give it back to the taxpayers, and go and get me another one.” ‘Dead sticking’ an airplane, in aviator-speak, means gliding the plane into a landing position. Military aviators agree that such a maneuver only would work with light airplanes, not with jet fighters.

Cost of Losses
In 1954, said Dirren, the Navy lost 776 airplanes, an average of two a day. But even though fewer planes are lost in accidents today, the cost of naval aircraft has gone up so much that the financial implications of mishaps are more significant than ever, he explained. “We lost 22 in 1999. But those 22 airplanes were worth 10 times what the 776 airplanes were worth in 1954,” he said. The A4 Skyhawks were $240,000 a copy. Today’s premier naval fighter-bomber, the F/A-18E/F, costs $57 million.

Back in those days, said Dirren, such high rates of mishaps were acceptable and viewed as “the cost of doing business.”

The decline in the number of accidents is attributed to better designed airplanes, improved avionics and more proficient pilots, who undergo more hours of flight training, said Dirren. Other factors that improved safety in naval aviation were the introduction of angled decks on carriers and the advent of the so-called NATOPS program. NATOPS stands for Naval Air Training and Operating Procedures Standardization program, which sets rules and regulations governing safe and correct operation of naval aircraft. Aviators, in jest, say NATOPS means “Not Applicable To Our Present Situation.”

The mishap rate through August 16, 2000, was 1.99, with 26 mishaps (18 for the Navy and eight for the Marine Corps). At this pace, fiscal year 2000 would end with a higher rate than the 1995-99 rate of 1.97 (155 mishaps). The Navy’s mishap rate for that four-year period was 1.58 and the Marine Corps’ was 3.2.

Dirren explained that safety concerns differ between legacy and modern aircraft. The popular F8 Crusader, which served during the 1960s and 1970s in the Vietnam War, was an unsafe plane by today’s standards. “Many argue that the F8 was the best fighter ever,” said Dirren. But the F8’s mishap rate was 14.3 per 100,000 flight hours. The F/A-18 E/F’s mishap rate is 3 per 100,000 flight hours.

The mindset that losing airplanes and pilots is “just the cost of doing business” is not acceptable any more, Dirren said. “One death a year is not OK,” said Dirren. “That is how we fly today.”

Marine Corps aviators experience a higher mishap rate that their Navy counterparts, said Dirren. “Part of it is the culture. They fly tough missions, having to protect Marines on the ground.” They also have more accidents because they fly the AV-8, said Dirren.

Even though the F/A-18 has the lowest mishap rate in naval aviation, it has been involved in accidents where pilots literally flew into the ground. This is called “controlled flight into terrain,” said Dirren, and it’s the “leading killer of the F/A-18.” The Navy has installed ground proximity warning devices to try to prevent these accidents. “It’s not great but it’s a start,” he said.

One way to improve the safety record for the F/A-18 fleet would be to cut back on the pilot’s workload, said Dirren. “He has an enormous amount of things to do. We have to get [the air crews] some help.”

Additionally, he said, “We have to change the way we buy airplanes” so safety is not short-changed. “It used to be that when an airplane was bought and safety devices were added, during budget drills, the safety systems were cut and we wouldn’t find out until much later.” That doesn’t happen any more, said Dirren. Any safety-related budget cuts have to be approved by a three-star and two-star officer review panel, who agree that, if any cuts are made, they are accepting the risk that would result from not buying that equipment. “That policy has been in place for nine months, and there hasn’t been a signed one yet,” said Dirren. “We think that is a healthy way to do business.”

Since Operation Desert Storm, in 1991, said Dirren, both the Air Force and the Navy have adopted some of the safety policies implemented by the U.S. Army, which cut its aviation mishap rate by 400 percent since the Gulf War. The Army’s “operational risk management,” Dirren said, has been incorporated into Navy/Marine Corps aviation. “The other services stole the Army’s program.”

Operational risk management, he explained, “is about leadership.” It teaches air crews how to balance the need to accomplish a mission against the risk involved, and helps them decide how far to go.

Dirren refuted suggestions that cutting back on training flight hours would be one way to curtail mishaps. “That is idiotic. ... That is not how it works.” Keeping an adequate number of flight hours is important not only because they are needed to train aviators, but also because fewer flight hours means more disgruntled pilots who may choose to leave the Navy if they don’t get enough flying time.

“Retention is not just about money. But about flying enough hours,” said Dirren. “It’s about bringing the fun back to naval aviation.”

The most frequent cause of death in the Navy today is not aviation mishaps, but automobile accidents, said Dirren. “Where we hurt people is not in aviation, but on the highway.” Naval officers who die on active duty are more likely to die in an aviation accident. But that is not the case for enlisted sailors and Marines, for whom the most prevalent causes of death are automobile accidents and suicide. Suicide is the second highest cause of death among all enlisted personnel in the U.S. armed services.

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