1-212 th Aviation Regiment SAFETY Accident Trends Accident Prevention PL Procedures SOP Close Call...

1-212 th Aviation Regiment SAFETY Accident Trends Accident Prevention PL Procedures SOP Close Call Program Topics of Discussion

1-212 th Aviation Regiment SAFETY FY05 Class A 2 Class B 0 Class C 3 (2 material failure) Class D 6 (1 material failure) FY06 Class A 0 Class B 1 Class C 1 Class D 3 (1 material failure) Battalion Accidents

1-212 th Aviation Regiment SAFETY FY07 Class A 1 Class B 0 Class C 3 (2 ground, off-duty) Class D 3 (1 bus/pick up on flight line) Class E 1 (reach pendant broke) FY 08 Class D 1 (Bird Strike) Battalion Accidents

1-212 th Aviation Regiment SAFETY FY 09 Class B 1 ( Blade Strike @ Monroeville) Class D 2 (Search light, Bird Strike) Class E 7 (Search + landing lights, Birds, ENG Failure ) FY 10 Class D 1 (LTE, Overtorque) Class E 2 (#1 ENG Fire Light, ENG Failure) Battalion Accidents

(H) Stabilator damage found on post flight 26-JUL-05Crusader 90 86-24475 (E) Bird strike. Right chin bubble and foot plate 13-OCT-04 LSI $1,233.01 69-16226 OH-58 LSI Air Class E w/ damage UH-60 E Air (H) Stabilator contact w/ gnd. Evasive maneuver04-APR-05Crusader 89$8,392.0086-24514UH-60EAir (M) Windshield cracked, anti-ice23-MAR-05Crusader 43$3,760.3285-24440UH-60EGDN (M) Broken tail wheel assembly08-FEB-05Crusader 44$19,491.6186-24565UH-60EAir (H) Stabilator contact with gnd. Terrain flt decel18-JAN-05Wise$7,941.7587-24613UH-60EAir (H) Tail wheel damage during ground taxi29-OCT-04Eagle 47$12,638.0084-24024UH-60FAirClass D (M) Engine failure in-flight28-JUN-05Gustafson$117,44671-20513OH-58LSIAir (H) Fractured foot during PT test28-APR-05FergusonLost daysN/A EGND (H) Cracked ribs, bruised lung during motorcross12-FEB-05KoberLost days 69-16307 EGND (H) Rolled ankle while washing car12-DEC-04BumgardnerLost daysHHCGND (H) T/R tree strike, NVG, FS XXI02-DEC-04Crusader 83$75,171.2486-24565UH-60EAirClass C Class B (H) Uncommanded left yaw, D, BCS, FSXXI 29-MAR 05 Crusader 63 $6,600,00 81-23551 UH-60 E Air (H) Tower & wire strike (IPC) 12-FEB-05 Eagle 54 > $2M 86-24574 UH-60 F AirClass A RemarksDateCall SignECODTail # A/C TypeUNITAir/Ground FY 05 Accidents Air E E UH-60 86-24575 $4,324.14 $133.00 Crusader 57 Crusader 66 16-APR-05 (H) Landing light / WOW switch. Roll-on. BCS, Day AirLSI OH-58 PendingSamari 1404-APR-05(M) Hot start. Replaced engine N/A 85-24404 $1763.64 (H) Stabilator contact with gnd. Recovery of roll-on Air E UH-60 85-24443 Pending Crusader 63 19-SEP-05(H) SEF hover, broken tail wheel, day, FSXXI

1-212 th Aviation Regiment SAFETY November 4, 2006, Class-C Accident Tip of thumb cut off using home table saw. human error November 6, 2006, Class-C Accident Broken wrist from falling off a horse, off duty. February 12, 2007, Class-D Accident. Damage to tail yoke assembly by over controlling pedals with a broken tail lock pin. Pilot didnt recognize it was broken as the switch still indicated locked. Human error March 10, 2007, Class-A Accident UH-60A, While performing a roll on landing the aircraft touched down with nose left of center. Right strut snapped under sideward pressure. May 3, 2007, Class-D Accident. Lowe shuttle bus collided with ACLC pickup while bus driver was executing a left turn. The driver failed to see the oncoming traffic. Human error July 11, 2007, Class-D Accident. Bird strike with TH-67, damage below windscreen. FY 2007Accident Rate

1-212 th Aviation Regiment SAFETY FY05 Trend Analysis 10 Class A E w/ damage Human Error Aviation Accidents UH-6010 of 10 Tactics 6 of 10 Aircraft Tail 8 of 10 Recent MOI Grad 8 of 10 FSXXI 8 of 10 IP on Controls 5 of 10 Guest IP 4 of 10 NVG 3 of 10

Trends 1-212 th Aviation Regiment SAFETY UH-60 engine failures OH-58 hot starts Cold Wx Blade strikes/Stabilator Strikes Situational awareness Scanning / Clearing aircraft Crew coordination Airspace Post flight

UH-60 Roll On E 1-212 AVN For Accident Prevention Purposes Only

Summary of Event Date: 31 March 2004 Time: 1525 Hrs Location:Stinson Stagefield Synopsis: While performing a roll on landing during Flight School XXI, the main rotor blades contacted the tail rotor drive shaft. Remarks: Class B ($467,000 ECOD)

UH-60 Tail Rotor Strike E 1-212 AVN For Accident Prevention Purposes Only

Details of Event Date: 02 December 2004 Time: 2055 Hrs (NVG) Location: RT 186 (EV879557) Synopsis: While turning during a 15ft AGL hover, the crew of a UH-60 felt a vibration coming from the tail of the aircraft. The crew flew the aircraft approximately 60 meters away then turned to see they had struck a tree. Inspection revealed damage to all tail rotor blades and the stabilator. Class C Accident, $75,171.00 damage

035 deg 114 deg / 60m 081 deg / 92m 060 deg / 75m 072 deg / 32m 220 deg / 55m

SAW DUST

Distance Estimation Site (North Hover Area) LOWE AHP

45 30 S W E N 45 degrees, 3 disk (not to scale) 30 degrees, 3 disk (not to scale) Lowe AHP Distance Estimation Site Site enables IPs to train and demonstrate safe distance estimation cues for the UH-60 to aid in clearing the tail. Also aids on recognizing proper formation distance of 3 disk for multiship purposes Distance measured from cockpit to tail +

UH-60 Stabilator Damage E 1-212 AVN For Accident Prevention Purposes Only

Summary of Event Date: 04 April 2005 Time: 2047 hrs Location: RT 367 (16R EV 985373) Classification: Class D ($8,392.00) Remarks: Health Usage Monitoring System (HUMS) installed

Summary of Event Synopsis: While conducting a terrain flight deceleration in conjunction with an evasive maneuver, during Initial Entry Rotory Wing (IERW) NVG training, the stabilator of the UH-60 contacted the ground. The flight crew was unaware of the ground contact and continued the mission. During post flight inspection the crew did not inspect the stabilator. Inspection by maintenance personnel the following morning revealed damage to the trailing edge of the stabilator.

TM 1-1520-237-10 para 9.12.b With pitch attitude beyond 25 there is the possibility of ground contact with the stabilator trailing edge.

BACKGROUND UNIT: E Company, 1-212 th Aviation Regiment EQUIPMENT: UH-60A DATE/TIME: 29 MAR 05 / 0817(L) LOCATION: TAC X RESULTS: Aircraft Destroyed COST: $6,600,000 MISSION: Individual Aircrew Training, UH-60 Basic Combat Skills Training

Board Synopsis Human ErrorTraining Failure. That is, the Instructor Pilot (IP) through lack of experience and training, perceived an emergency situation (left yaw as loss of tail rotor thrust) and responded with an inappropriate procedure for the perceived emergency. This caused the aircraft to impact the ground, destroying the aircraft and injuring the occupants.

UH-60 Tower Strike F 1-212 AVN For Accident Prevention Purposes Only

Summary of Event Date: 28 February 2005 Time: 2257 hrs Location: 16R FV 13584971 Synopsis: While in low level flight at 100 kts, on an IPC NVG mission, the UH-60 struck an unlit radio tower. The crew felt a sharp jolt followed by severe vertical vibrations. During the emergency (forced) landing the aircraft struck wires and came to rest on its left side. Remarks: Class A (>$2M).

Radio Tower Power Line A/C N

Broken Poles

BACKGROUND UNIT: UH-60 -- F Co, 1-212 th Aviation Regiment OH-58 LSSI, Tactics Division, Shell Field EQUIPMENT: UH-60A, OH-58C DATE/TIME: 11 May 06 / 2253(L) LOCATION: 16R FV76387079 (Elba AL.) RESULTS: Two Aircraft Moderately Damaged COST: $376,903.13 + $65,352.00 = $442,255.58 MISSION: Individual Aircrew Training, UH-60 Instructor Pilot Course and OH-58 Basic Combat Skills

RT 216 400m

1-212 th Aviation Regiment SAFETY

FACTOR ANALYSIS ENVIRONMENTAL: Not Contributing MATERIEL: Not Contributing HUMAN: Present & Contributing

PRESENT AND CONTRIBUTING: (Human Error Individual Failure) Both aircrews failed to detect another aircraft that was closing on their position while in the terminal area of the landing site Both Aircrews failed to ensure that adequate scanning techniques were used in vicinity of the landing site That is, they failed to Maintain Airspace Surveillance while performing terrain flight FINDING - 1

PRESENT AND CONTRIBUTING: (Suspect Human Error Individual failure) During NVG terrain flight to RT 216, the UH-60A and OH-58C aircrews did not hear the other aircraft transmitting on the assigned RT frequency. FINDING - 2

PRESENT AND SUSPECT CONTRIBUTING: (Human Error Individual failure) Both Aircrews failed to ensure proper radio procedures were followed. Mandatory "1K call" required by the 1-212th SOP was not accomplished at the correct location in order to advise other traffic in the vicinity of the RT. Accomplishment of this call may have alerted the other aircraft vicinity of the RT of his presence FINDING - 3

UH-60 Roll On E 1-212 AVN For Accident Prevention Purposes Only

While conducting a roll-on landing at Skelly Stagefield in a UH-60A during Initial Entry Rotary Wing training, the instructor pilot (IP) failed to take appropriate action to correct an unsafe condition. That is, when the pilot trainee (PT) improperly manipulated the flight controls, the IP allowed the flight condition to deteriorate beyond acceptable limits contrary to guidance in TC 1-237. As a result, in the ensuing crash, the aircraft was destroyed, the instructor pilot (IP) received fatal injuries, and three PTs received minor injuries. Roll On, Class A, 10 MAR 07

SE NW SW NE SS W W E E NN

1. 2. 3.4. Aircraft touches down nose high, heading left of centerline Right main landing gear touches down hard with minimal collective and aft right cyclic inputs. Main rotor blade contacts and severs tail rotor drive shaft Right main landing gear drags right until strut snaps off Rotors contact ground and aircraft yaws to the right 540 degrees, breaking off the tail section in the 2 nd 180 degrees

W W E E N N S S NW NE SW SE

Tailboom Tail Rotor Gearbox SE NW SW NE SS WW EE NN AFT Troop Seat

FY 09 Accident Pictures

1-212 th Aviation Regiment SAFETY Down and Safe An aircraft with an emergency that has landed without any damage to the aircraft, civilian property, or any injuries. Must be released by competent maintenance personnel to the PC depending on circumstances prior to recovery. The following are examples of down and safe. engine chip light master caution light with no other indications low fuel indications weather boost off conditions ECU will not go out of LOCKOUT Hydraulics off Tail wheel pin broken** Engine failure (when no visible damage occurs) Completion of an AAAR or AAAR worksheet is required to be filed at the appropriate Basefield Operations. The release authority for the crew is the PIC. SOP

1-212 th Aviation Regiment SAFETY Down with Suspected Damage/Injury When an aircraft has landed with the possibility of damage or personnel injury: (a) The following incidents are examples of down with suspected damage and can be released by the Battalion Commander. spike knock (once confirmed by maintenance) bird strikes hot start overspeed over temp over torque (b) The following incidents are categorized as down with suspected injury and can only be released or transported by FLATIRON. sick flight personnel smoke and or fumes in the aircraft Any injury that occurs during flight duties after takeoff Completion of an AAAR or AAAR worksheet is required to be filed at the appropriate Basefield Operations. SOP

PL Notification 1-212 th Aviation Regiment SAFETY CCC Flat Iron BN Initial Responder ATC OPS

1-212 th Aviation Regiment SAFETY Secured area An area, which provides sufficient protection to preclude vandalism or unauthorized tampering with the aircraft. The following are considered secure areas: (a) Military airfields, which are operational or have a monitor/guard during non-operational hours. (b) Any area, which has military personnel or civilian police on duty as monitors/guards. (c) Stagefields will be considered secure areas as long as a stagefield crew (ATC operator) is on duty or during hours of operation as depicted on Fort Rucker Form 196, Stagefield and Support Requirements. Secure Airfield An airfield that has a tower that is staffed by military personnel and is operational. Example If an aircraft is left at an airfield, other than a basefield, that has a tower staffed by military personnel and is operational, the responsibility of security is transferred to the tower personnel, who are required to remain on site until a guard arrives, thereby maintaining uninterrupted aircraft security. SOP

1-212 th Aviation Regiment SAFETY Logbook Entries following a PL: Prior to recovery of aircrews, the aircraft must be marked with chemsticks and a write-up entered on the DA Form 2408-13-1. The entry will state, chemstick markers placed on tail rotor and windshield, along with a write-up explaining the deficiency. The aircraft key will be returned to the basefield operations upon return. Crash Control: PLs for other than low fuel and weather require notification of Cairns Crash Control. No one may interrupt the crash system sequence once a PL has been declared. The aircrew, cover ship, AMC, or ATC will not reject flatiron. PL aircraft will not be moved unless released by maintenance personnel or the Battalion Commander or designated representative as applicable. PC/IP Responsibilities: The PC will remain with the PL aircraft at unsecured locations until relieved by maintenance or a guard. SOP

1-212 th Aviation Regiment SAFETY AAAR/ACR Requirements: 1. After making a PL, aircrews will report to their Basefield Operations and complete the DA Form 2397-AB (AAAR) IAW the example posted in operations. The AAAR will be completed by the IP/PC anytime after the starter is energized and an unscheduled termination occurs, regardless of whether or not a PL is declared. It is incumbent of the PC that the AAAR or AAAR worksheet is completed at appropriate Basefield Operations, as soon as practicable after the incident. 2. An aircraft landed due to a weather PL will complete the AAAR with aircraft recovered or aircraft secured at, and give location. 3. A complete form to include Page 2 is required anytime damage or injuries exist. 4. Completion of an Aircraft Condition Report (ACR) is required anytime scheduled maintenance is not completed properly, aircraft condition is not flyable, and the starter switch(s) have not been pressed. SOP

1-212 th Aviation Regiment SAFETY Downed Aircraft Site: The crew of the first aircraft discovering an accident/incident will orbit the area not lower than 500 AGL, squawk emergency, and contact HUB/ATC, giving approximate location and request that radar position be marked and reported to Crash Control. The aircraft will continue to orbit as long as practical, or until FLATIRON, THE BATTALION SAFETY OFFICER / DESIGNATED REPRESENTATIVE, or a MAINTENANCE recovery aircraft arrives. Extreme care will be exercised if landing is necessary to render emergency assistance to the downed aircrew. Aircraft landing at the crash site will ensure adequate safe landing area remains for FLATIRON. Pilots will monitor frequencies 30.10 FM and 139.450 and 243.0 UHF. Solo aircraft may be relieved by any aircraft with two rated aviators onboard or any aircraft with an Instructor Pilot onboard. SOP

1-212 th Aviation Regiment SAFETY USAAVNC Form 1891 Dated FEB 2009 BN OPS 255-4033 (Lowe) / 255-4157 (Shell) BN SAFETY 255-4372 BN SAFETY Cell (334) 470-7635 HUB Radio 255-8431/8435

1-212 th Aviation Regiment SAFETY Crew Endurance: Maximum duty hours per day 12 Maximum factored flight hours per duty day 8 Maximum factored flight hours per 7-day period 40 Maximum factored flight hours per 30-day period110 NOTE 1: Factors applying to aircraft time flown: Day/SFTS1.0 Contact/Combat Skills/Terrain Flight1.5 Spanish/MTP1.5 Night /Instrument/Hood/NVG2.0 3:1 Flight2.0 NOTE 2: The Battalion Commander is the extension authority and is the only person that can authorize deviations of any crew endurance factors. SOP

1-212 th Aviation Regiment SAFETY The individual aviator will ensure he does not exceed crew endurance limits. The individual aviator is the final authority when fatigue is a factor for flight. The duty day begins when the aviator departs his place of residence enroute to duty and ends when he is released from duty. Crewmembers will receive at least 10 hours of off duty time between duty days. Crewmembers will receive at least 10 hours off between shift changes from AM/PM to Nights or from a Night schedule to an AM/PM schedule. SOP

1-212 th Aviation Regiment SAFETY Student Pilots: Students will not factor their individual flight times. Flight time, including OR/CP time, will not exceed 6.0 hours daily. IERW NVG PI time will not exceed 2.5 hours per training day. IPC and AQC will not exceed 4.0 hours of NVG time per training day. SOP

1-212 th Aviation Regiment SAFETY Any tools or maintenance equipment found in or around the helicopter will be reported to ACLC immediately. Do not move the FOD until ACLC has completed their inspection. All personnel are required to police the aircraft and the immediate area around the parking pads for objects that could create a FOD hazard. Report significant FOD hazards to the Battalion FOD Control Officer or Safety Officer as soon as possible to help prevent recurrence of similar problems. Dont leave FOD (cans, papers etc.) behind. FOD

1-212 th Aviation Regiment SAFETY FOD EXAMPLES

The program was developed to fill the gap between accident reporting and the avoided accident to identify hazards prior to an accident occurring Prior to the program, the first time a hazard was recognized was when an accident occurred Close Call Program

Hazards are reported via a sheet located in all briefing and debriefing rooms The unit ASO is responsible for collection and database entry The applicable ASO reports to the commander any new hazards or spikes of a particular hazard Close Call Written On Close Call Sheet Annotated in database Database Searched Weekly Risk is Determined Awareness Conducted Reporting & Tracking

What this gives the Commander

Random Hazards The command is made aware of new hazards and the risk management process can be implemented Driven Hazards The command is made aware how their policies or procedures may be causing unwarranted risk The command can make a risk decision based upon the data and adjust policies or procedures accordingly What this gives the Commander

An MS Access based database Can data mine info based on the completed fields: Location Time Task The Close Call Database

Queries of specific hazards Provides objective data to leaders Commanders Tools

Falcon View Overlay: Allows data to be displayed visually Crew briefings / Awareness TNG Commanders Tools

Falconview 10

Advantages Ease of use Performance metric Identifies previously unknown risk Provides Historical Continuity Instills sharing not shying Disadvantages Requires active participation by unit members Additional work for ASO or designated assistant. Advantages vs. Disadvantages

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1-212 th Aviation Regiment SAFETY Accident Trends Accident Prevention PL Procedures SOP Close Call...

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