REPUBLIC OF SINGAPORE AIR FORCE SAFETY … RSAF, for accident prevention purposes. Use of...

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FOCUSR E P U B L I C O F

S I N G A P O R E A I R F O R C E

S A F E T Y M A G A Z I N E

Birdstrike!

Cognitive Biases The Man in Unmanned Flying

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IN THIS ISSUE

Achieving 20,000 Accident-Free Hours

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article shares an insight of 112 SQN’s path to 20,000 accident free flying hours.

As you read the articles, take a moment to reflect on the unexpected nature of the emergencies, and how you would have handled it if it had happened to you. During such moments, we – the man-in-the-loop – must fall back on the fundamentals and training received to adequately respond to the situation. These examples highlight the need for us to remain vigilant and to always take our training seriously, only then can we be the strongest link and prevent a mishap from occurring.

CONTENTS

EDITORIAL BOARD

Chairman

COL Philip Chionh

MembersLTC Danny Koh Keng SengLTC Ong Choon HuiLTC Chew Pang Teck JinME6 Amos Yap Keng YongMAJ Marcus WooCPT(DR) Aaron ChuaMS Audrey Siah Yushu

FOCUS is published by Air Force Inspectorate, HQ RSAF, for accident prevention purposes. Use of information contained herein for purposes other than accident prevention, requires prior authorisation from AFI. The content of FOCUS is of an informative nature and should not be considered as directive or regulatory unless so stated. The opinions and views in this magazine are those expressed by the writers and do not reflect the official views of RSAF. The contents should not be discussed with the press or anyone outside the armed services establishment.

FOCUS magazine is available on these sites:Internet: http://www.mindef.gov.sg/rsafIntranet: http://webhosting.intranet.defence.gov.sg/web/AirForce/AFI/index.htm

Cognitive Biases

Birdstrike!

The Man in Unmanned Flying

Achieving 20,000 Accident-Free Hours

Safety Activities

4 PICS 1 WORD

Crossword Puzzle

EditorCPT Chiam Dao Wei

Assistant EditorsME3 Vidianand Das PanickerREC Goh Zhen Kang

Design by JAB Design Pte Ltd

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FOREWORD

COL Philip ChionhHead Air Force Inspectorate

Cert No: 2007-2-1606SS ISO 9001:2008

Cert No: OHS. 2007-0179BS OHSAS 18001:2007

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I n this issue, our aviation psychologist shares an informative article on cognitive biases that we are subjected to when using

mental shortcuts, as well as some strategies to cope. We have a harrowing recount where a birdstrike at low level shattered the canopy of the aircraft and how the trainee pilot and her instructor managed to land the aircraft safely.

Our UAV pilots also share the challenges of operating an aircraft while not being physically inside it and how the crew were able to recover the UAV when an unexpected failure struck. The last

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F O C U S M A G A Z I N E — F E B 2 0 1 7 — I S S U E 9 0

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I NTRODUCTIONAs the well-known proverb goes, to err is human. 70% to 80% of aviation accidents are caused, at

least in part, by human error. A perennial question exists – “Why do humans make mistakes, and how do we eliminate human error?” Mistakes may occur due to innate limitations in our human capacity to process information. This is especially evident in the operational environment of aviation, where the mental workload is high, with time pressures, risk and uncertainty involved. In such situations, there is an inclination for one to utilise mental shortcuts often unconsciously in decision-making. While the use of such shortcuts allows us to make snap decisions, reliance on them in the

absence of a self-check mechanism may result in cognitive biases, which may cause inaccuracies in perceiving the environment. As a result, errors in decision-making occur.

Take the example of two of our incidents where the helicopters did not land in their assigned landing points (LPs). In both situations, the captain and co-pilot had misidentified the LPs, and landed the aircrafts in the wrong locations.

If we look deeper into what led to these mistakes, we realise that it was a series of events which led the aircrew to form an erroneous understanding

of the situation. In both incidents, prior mistakes in navigation made by the captain and co-pilot had resulted in cues which led them to perceive that their identified LPs were correct.

These initial errors were missed and the team then assumed that the LPs which they first sighted were correct, because their features were in line with what they were looking out for. There were alternative sources of information they could have looked at when making their decisions, which they did not.

For example, in one of the cases, the co-pilot had correctly plotted the LP position on a hardcopy map, which he could have used in identifying the assigned LP. Here, a mental shortcut was utilised, where the aircrew only looked out for information which confirmed their understanding of the situation. They did not pay attention to other sources of information which could provide disconfirming evidence.

Psychological literature provides evidence of various biases which are found to be consistently demonstrated in various settings. Here, some of these biases, which can occur in the context of military aviation are summarised.

COGNITIVEBIASES

AEROMEDICAL CENTRE

ARTI

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Ms Vera LimShu Ping

Aviation Psychologist

Source: philmackinney.com

CONFIRMATION BIASThis occurs when one seeks and focuses on evidence that confirms one’s understanding of the situation (also known as a “mental model”) and ignores disconfirming evidence. In the earlier example provided where the LPs were misidentified, confirmation bias had influenced the decision-making process. The aircrew could have actively sought alternative cues to further test if their understanding of the situation was correct, instead of being reliant on only cues which confirmed their understanding. If left unchecked, confirmation bias can result in fatal consequences.

The U.S. Navy example in 1988 illustrates this, where the USS Vincennes mistakenly shot down an Iranian commercial jet, resulting in many deaths. Several pieces of information had contributed to the interpretation that the unknown aircraft spotted by the Vincennes was hostile: Intelligence reports of enemy activity received by the Vincennes had potentially led to the crew expecting hostility and increased vigilance.

Furthermore, cues and signs presented by the commercial jet reinforced the strong mental model. For instance, it seemed to be emitting Identification Friend or Foe (IFF) signals which suggested that it was a military aircraft (investigations later showed that the signals were emitted by another Iranian military aircraft which was picked up by the IFF system). The commercial jet had also failed to respond to radio warnings, and was not flying in the centre of the air corridor, as commercial aircraft normally do.

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Doing It Right Always!OVERCONFIDENCE BIASThis occurs when one overestimates the accuracy of his or her own knowledge and actions. When making decisions, a shortcut that we tend to utilise is in assuming that our existing knowledge is correct. If we do not check our assumptions, it may lead to risks being taken at the expense of safety. Overconfidence may also result in an illusion of invulnerability, which is the belief that bad things may occur to others but not oneself. In the RSAF, there have been several similar occurrences of equipment or jerry-cans being topped up with the wrong fuel (e.g. diesel instead of petrol). We note that these errors occurred in team settings. Due to overconfidence, personnel did not cross-check that

their teammates did the task correctly. Furthermore, as the task was a familiar one, which was done many times previously, it had led to beliefs that errors were unlikely to occur. Clearly, we see that overconfidence can seep into even the most simple and routine tasks. In flying, errors have also occurred as aircrew let their guard down during the domestic phases of flight.

These biases are just a few amongst the many that are known in literature. While we are unable to completely eliminate biases, it is important for us

to acknowledge that they exist, and work towards strategies which can help us make better decisions. Here are some recommendations.

BUILDING KNOWLEDGE AND EXPERIENCEAs poor decisions tend to result from a lack of knowledge and experience, it is important for one to have strong expertise so as to be able to make better decisions. With greater expertise, there is a lower likelihood of relying on assumptions and making superficial judgements. Compared to novices, experts have more mental models in mind. These form alternative templates from which they can start from to spot problems, identify the

underlying causes of issues and evaluate courses of action. Hence, it is important for one to build deep expertise through being exposed to a variety of scenarios and operational conditions. In the RSAF, personnel are equipped with knowledge and skills through extensive and robust scenario-based training. Open sharing of lessons learnt is also encouraged at both the unit and organisational levels, to learn from others’ experiences. For novices, this is especially important in increasing the pool of mental models that they can draw from amidst their limited experiences.

ANCHORING BIASThis occurs when one places too much emphasis on early evidence or information in decision making, and makes insufficient adjustments subsequently. Particularly when workload is high, people are inclined to adopt a mental shortcut where they rely on their initial plans instead of considering new information in the situation. Across various aviation settings, there have been cases of flight into adverse weather when conditions were unsuitable, due to reliance on initial favourable weather forecasts. For example, in the RSAF, a near controlled flight into terrain (CFIT) incident which happened

in 2007 may have resulted from this bias. Rapidly deteriorating weather occurred as the incident aircraft was preparing for landing. While the aircrew could have taken alternative courses of action in the situation, (e.g. executing a go-around to an alternate airfield, or wait out the weather), they decided to press on with landing, which resulted in the near CFIT. For this incident, the aircrew could have anchored their decision based on initial plans to land at the specified airfield, which led to them to press on even when conditions later on were unfavourable.

"Relying too heavily on an initial piece of information

and failing to continue considering reasonable

alternatives."

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Controllers of 202 SQN manning up for daily operations.

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Watching the skies

HARNESSING TECHNOLOGYBeyond what the individual can do, organisations can also make use of enhanced human-system interfaces which can help personnel to better make sense of situations. For example, computerised decision aids can be utilised to overcome the challenges faced by operators.

Systems that use artificial intelligence can select and present information that an experienced operator would normally look at, and provide suggestions on courses of action. Such tools can provide more novice decision-makers at all experience levels with greater situational awareness, hence allowing them to make more informed assessments.

AWARENESS OF BIASES AND TRAINING TO IMPROVE DECISION-MAKINGAs the saying goes, the first step towards change is awareness. It is important for us to be aware that we are susceptible to biases. One can consciously work towards being more careful in considering alternative explanations for a situation.

For example, to reduce fixation on a single solution, one can apply the “crystal ball” method – in pretending that a crystal ball has shown that one’s explanation for a situation is wrong, and trying to come up with a different explanation. While this strategy may not be suitable for time-pressured environments, it is good practice to consciously

adopt it in everyday situations. With practice, it can come to mind more easily when required, in critical situations with time constraints. For the case of the pilots who had identified the wrong LPs, to improve decision-making in future, they could integrate the abovementioned method in their training, to consciously question and test their assumptions. The RSAF has in place training conducted by psychologists, which aims to equip personnel with skills in decision-making and in performing under pressure (e.g., the Adaptiveness, Innovativeness and Resilience (AIR), as well as Human Factors workshops).

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ABOUT THE AUTHOR

Ms Vera Lim is an Aviation Psychologist with the Aviation Psychology Branch, in Air Force Medical Service. She began her career with the RSAF in 2014 as an aircrew selection, organizational diagnosis and human factors specialist. She graduated with a Bachelor of Social Science (Honours) in Psychology from the National University of Singapore.

BIRDSTRIKE!

150 SQUADRON

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CPT Tung Wanrong

Pilot

I NTRODUCTION11 October 2016 was one eventful day that left a vivid memory. It was the day bird

strikes were seen in a new light. It was the day the deafening windblast was heard. It was the day the wind chills were felt right through the bones. It was the day the intense raw blood and remains were smelled. It was the day of experiencing flying in an open-top aircraft at 450 knots (~830km/hr) and 500 feet above the ground. No one said convertible flying would be anything of such.

MISSIONSlightly after 3pm that afternoon, HONDA, formation of two aircraft, took off for an air-to-ground sortie to perform basic surface attacks. The first pass was conducted uneventfully. However, during the second pattern, on the Base leg, just prior to the turn for the Initial Point (IP), at 500’AGL and 450KCAS, the incident happened.

BIRDSTRIKEBefore initiating the turn, I looked out on the right to visually identify the initial point. When I turned back, a large flock of birds appeared at close range. Before I knew it, that dark shadow loomed overhead. The next moment, my head jerked backwards and a splash of red was observed on the blast-shield that separated the forward and aft cockpits. In an instant, countless thoughts ran through my head. Did the birds get sucked into the engine? Is the aircraft still flyable and under control? What was this loud whooshing sound?

My instructor immediately took over the controls, set the aircraft on a climb and checked that the engine parameters were good. The birds had penetrated the canopy and hit my helmet and visor. The forward portion of the canopy shattered into pieces and was blown off. Bird remains splattered on the blast-shield and obscured the backseat’s forward field of view.

CONCLUSIONDuring the course of our RSAF duties, there is a need to make timely and effective decisions. There is little room for error, as mistakes made can have severe consequences. While man can be the strongest link to prevent errors, this can only be possible if steps are taken to mitigate innate biases. Individuals need to actively play a part to deepen their knowledge and adopt different perspectives in understanding issues.

There is also a need for organisational structures and processes to be put in place, to equip personnel with the skills and tools to make good decisions, even under stressful and challenging circumstances.


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CONSIDERATIONSMy instructor’s consideration was to get above the minimum safe ejection altitude quickly. He informed the Flight Lead of the emergency and declared a MAYDAY call. My instructor shouted over the intercoms, “I have control!” but could not hear my response. The airflow through gaps between the blast-shield and the instrument cowling was causing a louder whooshing sound in the aft cockpit.

The sight of a blood covered blast-shield and the inability to hear me made my instructor deduce that we were in a bad situation. He immediately started to point the aircraft towards the nearest divert airfield to land the aircraft as soon as possible. The airfield at this time was approximately 13Nm Southwest of our position.

DECISION-MAKINGWhile tracking towards the divert airfield and after slowing down the aircraft (with a commensurate reduction in windblast), my instructor was finally able to communicate with me. He clarified with me on the extent of damage to the canopy and whether my forward view was clear. My instructor continued to slow the aircraft down while assessing the extent of damage to the airframe. He made the assessment that there were no damages to the control surfaces of the aircraft.

We were fast approaching the extended centerline of Runway 27. My instructor lowered the landing gear and started to turn the aircraft and lined up on a 6Nm Finals for Runway 27.

DIVERSIONThankfully, the tower controller was quick to respond and provided clear and calm instructions. Due to the requirements of the emergency, my instructor coordinated with the controller to perform a straight-in approach to land on the reciprocal runway when Runway 09 was in use. ATC was very expeditious in coordinating the emergency recovery by clearing all other traffic in order to give us priority to land.

LANDINGWith the aircraft configured and clearance to land obtained, all I had to do was to put the aircraft on the ground safely. We relied on our fundamentals, remained composed, and focused on flying the aircraft. Very shortly, we were over the runway and landed safely.

Emergency services then assisted us to egress from the aircraft. I had never felt so relieved to be able to step back on firm ground. Subsequent checks showed that the birds had impacted the forward cockpit canopy, left engine intake, vertical stabiliser, top surface of the fuselage and leading edges of the wings.

REFLECTIONSAfter reflecting back on the incident, several lessons were derived from it. From the damage of my flight gear, I learnt the importance of properly donning Personal Protective Equipment, as without them, I would not have been able to come out of the incident physically unharmed. Although the temperature on the ground was a comfortable 16°C, the effects of wind chill at high speeds brought that temperature to sub zero conditions. The sudden change in temperature came as a bit of a shock while dealing with the birdstrike.

Extent of damage to the helmet

Secondly, the effects of air load can aggravate structural damage of the aircraft. A small dent on one of the panels on the leading edge of the wing quickly degraded to a point where rivets holding that panel broke off and the panel almost flew off.

Lastly, noise affects the ability to communicate well in a multi-crew or multi-aircraft environment. This in turn makes emergency handling much more complicated, especially if the severity of the emergency cannot be communicated clearly for the correct actions to be adopted.

It also adds additional stress to the crew who are used to operating in a quiet and air-conditioned environment. It affects the ability to concentrate on the flying and reduces overall performance.

This highlights the importance of our training, especially when it comes to emergency handling. Constantly training under various dynamic profiles improves our ability to handle emergencies better.

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Throughout the course of my training, we practiced emergency handling extensively in the simulators and conducted numerous table top discussions during safety days. Through the daily FAIR/GAIR sharing, we learnt about the different birdstrike incidents, of which we discussed in detail. We were taught about how to handle birdstrikes, be it during maneuvers or during the short final to land – where it could hit, what could happen, how serious it might be. However, I did not expect a birdstrike of such severity to happen to me.

Immediately after the birdstrike, time seemed to stop momentarily. I heard a loud whooshing of the wind blast, felt the cold air whipping across my neck, and saw a bloody mess around me. What had happened? Why was I feeling all this? I was momentarily stunned. But I observed that the engine indications were still in the normal range and that gave me some comfort. The aircraft was still under control. I looked around me and saw the broken canopy.

It was then that it struck me, I was flying without a canopy. I tried to communicate with my instructor, however I could barely hear myself, much less my instructor. Many thoughts ran through my mind, could I make it home safe? Was my instructor alright? How bad was the damage? Is this it?

The experiences learnt at training helped in managing my composure at that point in time. I calmed myself down and told myself to focus. We need to land the aircraft. That's what's of utmost importance.

The tough training certainly played a part in preparing us well for emergencies. It instilled the preparedness and composure that were essential when faced with a complex situation.

I am grateful for the countless discussion and practices that equipped me with the skills to handle an actual emergency. As a trainee, the instructors wasted no time in giving us various

scenario-based training and ensuring that we can make sound judgments and decisions as the captain of the aircraft. All these helped me to better manage the aircraft under the unusualsituation faced during the birdstrike.

CONCLUSIONFrom this incident, we learnt never to take preparations and considerations of contingencies lightly. Emergencies may strike during any phase of flight. We have to be able to handle them with composure and decisiveness.

ABOUT THE AUTHOR

CPT Tung Wanrong is a pilot who just graduated from the Fighter Wings Course at 150 SQN. She is presently posted to Fighter Group. She graduated from University College London with a Bachelor of Science in Economics, and New York University with a Masters in International Politics and Business.

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HOW UAVS ARE FLOWNThe H450 UAV was the first advanced UAV procured as part of the 3rd Generation Singapore Armed Forces transformation. Significant improvements over legacy Searcher UAV systems include more robust software designs and increased automation. The incorporation of automation alleviates the UAV Pilot’s load in ‘flying the unmanned aircraft’, so that he can spare greater capacity in ‘flying the mission’. In an ideal operating scenario, UAV Pilots need only to send commands to the UAV to hold it in a certain profile at a certain waypoint rather than turning multiple knobs or pushing and pulling sticks to manage throttle settings, pitch and roll attitudes.

While the level of human input in flying the UAV is reduced, it is not eliminated. UAV’s launch and recovery operations continue to be done manually. The E-CoP performs the takeoff and landing with manual inputs to the control surfaces. The E-CoP flies the UAV with assistance from the internal crew (PIC and I-CoP) who provide readouts of air

speed, altitude and heading, even though the E-CoP himself is also trained to assess these parameters visually in the event of flight emergencies.

Even as the I-CoP primarily flies the UAV with the assistance of the flight computers’ autonomous logic, all H450 UAV Internal Pilots are also trained to fly the UAV using manual inputs to the control surfaces in the event of flight emergencies. This is necessary for safe flight of the UAV should the autonomous logic fails for any reason.

AUTOMATION - REDUCING BUT NOT ELIMINATING HUMAN INVOLVEMENTToday’s automation software is more robust than before, but it still has its limits. While it can complete computations and spot patterns much faster than humans can, it is woefully inadequate in handling scenarios that were not predefined. The ability to deal with uncertainty and unpredictability is largely a human attribute.

THE MANIN

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CPTLi Yichuan

I NTRODUCTIONOn 12 May 2016, a Hermes 450 (H450) Unmanned Aerial Vehicle

(UAV) was planned for an airborne check. Immediately after takeoff, on Upwind, the UAV started to experience uncommanded pitch oscillations. “MASTER CAUTION” flashed across the screens on the Ground Control Station (GCS). Messages indicating that both the Rate Gyro Units (RGU) on the UAV had failed were displayed in the GCS. RGUs measure the rate of change in the pitch, roll, and yaw axes and are used to regulate the UAV’s flight profile. This was an unfamiliar and abnormal situation that had never been experienced in the H450 UAV fleet.

The crew assessed that they had sufficient controllability to land the UAV on the runway and concurrently declared “MAYDAY”. Subsequent actions were closely coordinated between the Pilot-In-Command (PIC), Internal Co-Pilot

(I-CoP) and External Co-Pilot (E-CoP) to land the UAV. The UAV eventually landed heavy due to the uncommanded pitch oscillations, resulting in the port side landing gear shearing off. The entire event, from take-off to landing, was over in less than 3 minutes.

Though some damage was sustained on the airframe, the outcome would have been catastrophic if not for the strong system knowledge, decisive action, good teamwork and calm execution of emergency actions by the crew. The ‘Man’ in the loop saved the day in a situation that the autonomous systems of the UAV was not designed to handle.

While the H450 UAV is in itself unmanned, virtually every aspect of UAV flying i.e launch, transit, mission execution, and recovery – is dependent entirely on the man on the ground to ensure safe execution of UAV operations.

MAJTan Xi Jie

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Flight computers continue to suffer from “garbage-in, garbage-out” problems. When it receives erroneous inputs and does not recognise it, the commanded output by the flight computers to adjust to this erroneous input can put the UAV in a more precarious situation. To give an example: if the altitude measured by the UAV is stuck at 10,000ft, the UAV will not stop its descent when the UAV Pilot commands a change in altitude to 9,000ft, until it crashes onto the earth’s surface. Timely human intervention is therefore required to prevent a catastrophic mishap from occurring. This requires active monitoring of flight parameters by the Man on the ground, to recognise deteriorating situations as well as a keen understanding of the autonomous control logics and to apply appropriate inputs to recover the UAV quickly.

While UAV Pilots need to rely on the UAV’s built-in automation to fly the UAV, to spare greater capacity to manage the mission, they can ill-afford to delegate the responsibility of flight safety to these computers. UAV Pilots must continue to possess extensive understanding of the automation logic of these computers. They must maintain superior awareness of the air traffic in the airspace they operate in. Otherwise, if the automation technology fails on a less than perfect day during a flight, this can easily lead to task saturation, deterioration of the flight situation, and thereafter an accident. It is therefore imperative that we continue to pay sufficient focus to the flying fundamentals of our UAV Pilots, such as the strengthening of system knowledge and emergency handling capabilities.

REL ATIVE SENSORY ISOL ATION - READING THE WORLD THROUGH A STRAWTactile sense, in the form of visual and auditory somatogyral indications, is extremely important to pilots of manned platforms. Cockpit sights, sounds, and smells are critical to build a pilot’s situational and emergency awareness.

While manned pilots typically take this tactile sense for granted, this is a luxury that is not accorded to UAV Pilots. UAV Pilots fly their UAVs in relative sensory isolation. The only visual cues a UAV Pilot can rely on are through the UAV’s mission camera, which covers a very limited field of view. This is much like having to make sense of the world while peering through a straw. And even then, you don’t get to see everything that a pilot on-board could otherwise observe. Emergencies can appear out of the blue and catch pilots unaware.

To mitigate this challenge, UAV Pilots have to rely on other means to increase their situational awareness of the UAV health state and the airspace they operate in. This means scanning their instruments diligently and correlating them to determine

if an abnormal situation is developing. For example, any unusual changes in altitude, rate of climb and angle-of-attack could be correlated to turbulence. This also means monitoring ATC radio transmissions closely to have better awareness of the air traffic situation.

The emphasis of daily training is in strengthening fundamental skills, such as instruments scanning and monitoring ATC transmissions, to ensure the UAV Pilots’ high situational awareness. Sharpening system knowledge also enhances the UAV Pilots’ ability to make sense of the parameters they see during flights. Using simulators, we drill our UAV Pilots to detect anomalous behaviour quickly despite the lack of tactile feel. The ability to recognise that something is wrong with the UAV and to arrest any further deterioration in the situation is critical for our UAV Pilots, especially in local flying where the airspace is constrained and near to densely populated areas, and therefore the margin of error is extremely small.

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FATIGUE MANAGEMENT - DEALING WITH LONG ON-STATION TIMESThe human ability to stay alert, think clearly, and communicate can deteriorate rapidly with fatigue. While fatigue management is a commonly addressed issue in aviation, the problems with fatigue are particularly acute in UAV flying. UAVs typically have very long endurance and UAV missions tend to be long. Today, our H450 UAVs can fly more than 12 hours. This is significantly longer than a typical fighter mission of approximately 1-2 hours. Intelligence, Surveillance and Reconnaissance missions can also be mundane – staring at the same piece of land for an extended period of time. Long on-station times, coupled with monotonous missions exacerbate the risks of fatigue.

One of the key tools in fatigue management is in flight scheduling, to minimise the effect of adverse pilot physiological states. UAV training flight periods for each pilot are typically not planned to exceed a continuous block of 3 hours for internal pilots and 1 hour for external pilots. Sufficient breaks are also planned for UAV Pilots to further mitigate the risks of fatigue.

Operating with a two-man internal flying crew concept, the PIC and I-CoP, also mitigates the risks of fatigue. The PIC and I-CoP help to check on each other’s physiological states before, and during the flight.

CONCLUSIONUnmanned flying is not devoid of human inputs, and this is not likely to change in the near future. Some level of human oversight and intervention continues to be necessary to address the inherent limitations of any automation software. Strong UAV Pilot fundamentals in system knowledge, and emergency handling are prerequisites to effective human oversight and intervention in UAV operations.

The safety risks and challenges of UAV flying can be unique - managing complacency from relatively robust but imperfect autonomous control systems, relative sensory isolation from not being physically on the UAV, and fatigue from long on-station times. Despite these unique risks and challenges, what remains constant in aviation is that man will ultimately determine if these risks and challenges are exacerbated or mitigated. A well-trained and highly disciplined pilot has the ability to mitigate these unique risks and challenges. Such a pilot, maintaining superior situational awareness, making a systematic, informed, and measured decision with information provided by UAV technology will make for safer flying for all aviators, including unmanned ones.

ABOUT THE AUTHORS

CPT Li Yichuan is a H450 UAV Pilot and a qualified UAV Instructor in 116 SQN. CPT Li is presently the Unit Safety Officer. He graduated from Murdoch University with a Bachelor of Commerce in Banking and Finance.

MAJ Tan Xi Jie, is a H450 UAV Pilot. He is currently a student at the Goh Keng Swee Command and Staff College. MAJ Tan served as Officer Commanding in 116 SQN and Force Transformation Officer in Joint Plans and Transformation Department. He is a recipient of the SAF Merit Scholarship. He graduated from Carnegie Mellon University with a Bachelor of Science in Electrical and Computer Engineering and from Stanford University with a Master of Science in Management Science and Engineering.

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ACHIEVING 20,000 ACCIDENT-FREE

HOURS

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I NTRODUCTION112 SQN celebrated her “20,000 Accident-Free KC-135R Hours” milestone on 9

Dec 2016. The achievement represented 16 years of flying operations, and could only have happened because of a strong safety culture, made up of robust processes and the commitment of her people.

There are several approaches through which we can strengthen and promote a strong safety culture within the RSAF. Two catchy mnemonics are the “DST” and “OMW” approaches to safety from the Air Combat Command Safety Office. DST refers to “Discipline”, “Survival Instinct” and “Tribal Mentality”, whereas OMW refers to “Own the Issues”, “Message must reach the Ground” and “Walk-the-Ground”. In this article, I will elaborate on how DST and OMW relate to safety.

DISCIPLINE IN SAFET YSupervisors and leaders must communicate effectively about the dire consequences of not adhering to established processes. Personnel must have strong knowledge of procedures, and demonstrate a strong commitment to safety. When a culture of discipline is established, it contributes to safe outcomes as everyone can be counted on to do the right thing, even when no one else is watching.

SURVIVAL INSTINCTTo make a rapid, complex and specific response to environmental stimuli that does not allow the time for lengthy deliberations or discussions, one can only count on Survival Instinct. Drawing parallels from the “Fight or Flight” response, decisions are made almost instinctively because of the collective experience that the individual has amassed over the course of his/her professional career. Such time-critical decisions can only be

MAJDan Ho

THROUGH A STRONG SAFETY CULTURE

made correctly if strong fundamentals have been inculcated in him/her through a robust training programme and strong safety culture.

TRIBAL MENTALIT Y In the Air Force, though everyone has a specific role to play, we fight as a system. Thus, we need to work collectively, and adopt a Tribal Mentality. We need to watch out for each other and be the last line of defence if something goes wrong. Crew Resource Management (CRM) best demonstrates this tribal mentality in the RSAF’s flying operations. CRM covers a wide spectrum of knowledge, skills and attitudes. These consist of communications, problem solving, decision making, and teamwork.

“CRM is concerned not so much with flying techniques and technical knowledge required to operate an aircraft but rather with cognitive and interpersonal skills needed to manage the flight”.

In a multi-crew environment, every position plays an important role that leads to mission success. When everyone is doing their job correctly, it will be a smooth ride. However, in the real world, people make mistakes. A mistake made during Air-to-Air Refuelling (AAR) is especially dangerous. AAR is a procedure that transfers fuel between 2 airborne aircraft, and requires the tanker and receiving aircraft to fly in close proximity, in excess of 290 knots, in order to establish an aerial contact between them. There are many things that could potentially go wrong during AAR and when things go wrong, there are procedures in place to contain the situation.

However, if the procedures are not carried out properly, a disaster could ensue. Without good Teamwork, Discipline and Professionalism of each position - Pilot, Co-Pilot, Navigator and Boom Operator - things can go awfully wrong in AAR.


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DISCIPLINE, SURVIVAL INSTINCT AND TRIBAL MENTALIT Y IN MANAGING A COMPLEX IN-FLIGHT EMERGENCY In Nov 15, our RSAF KC-135R was planned for an AAR training sortie with a RAAF C-17, en-route from RAAF Base Amberley to Darwin. Approximately halfway into the flight, and while the C-17 was tanking with the KC-135R, the Boom Operator heard a loud “POP” sound from outside the boom pod and observed hydraulic fluid spreading rapidly across the outer surface of the boom sighting window, affecting his visibility and causing him to lose sight of the C-17.

The boom operator’s training led him to promptly call a “Break Away” and the emergency procedure was executed, ensuring a safe separation was achieved between the aircraft. The crew, upon noticing that the hydraulic fluid quantity on the right hydraulic system had dropped from 4 to 2 gallons within a few seconds, elected to switch off the AAR pump to stop the running leak.

Emergency procedures were carried out in accordance with the flight manual and all affected external lightings were also switched off to minimise the risk of fire hazards. Making use of all resources available, the crew requested for visual inspections from the C-17.

Notably, with the loss of the right hydraulic system, the boom operator was unable to stow the boom via normal means. Emergency boom hoist procedures were subsequently carried out through crew coordination in order to stow the boom.

The crew declared a PAN call in accordance with the emergency matrix and continued towards Darwin as it had passed the equal time point (ETP) between Amberley and Darwin. En-route, the crew carried out a systematic review of the current situation and discussed considerations regarding how the complete loss of the right hydraulic system would affect the approach and landing.

Numerous hydraulic systems are dependent on the right hydraulic system in the KC-135R. These include the co-pilot’s instrument panel, outboard spoilers, flaps, co-pilot’s brakes, aft AAR pump,

nose-wheel steering, refuelling boom system, auxiliary power unit, and rudder power.

Without rudder power, the auto-pilot was unable to provide directional control to the aircraft, and the sortie had to be completed with the autopilot off for an extended duration. The co-pilot instrument panel had to be operated in emergency mode, utilising power from the engine-driven generator instead.

The loss of outboard spoilers made the aircraft more difficult to handle, especially at slow speeds on final approach. Flaps were also extended using a manual hand crank at a port in the cargo compartment. With risk mitigating measures put in place, the crew safely landed the aircraft in Darwin.

This is a fine example of a “Tribal Mentality” that drives great teamwork in handling an emergency. All members of the crew displayed high levels of discipline, technical knowledge, vigilance and situational awareness during the flight. This allowed them to work together as an effective team to safely handle the emergency.

The crew prevented a more serious situation from developing, which could have potentially resulted in a mishap. The crew ensured that the aircraft was recovered safely in spite of a major system malfunction that resulted in the loss of multiple flight control systems.

The training and survival instinct of the boom operator to promptly call for a “Break Away”, the discipline of the aircrew to strictly carry out procedures in place, and the great teamwork that comes from a tribal mentality, all contributed to a safe outcome for the team.

OWN THE ISSUES, MESSAGE MUST REACH THE GROUND, WALK THE GROUNDBy adopting a mentality to “Own the Issues”, tribe members are encouraged to look deeper into issues on hand and to adopt proactive measures to ensure they do not repeat others’ mistakes. By taking ownership, tribe members are always constantly reviewing processes and

procedures to improve safety.

Message Must Reach the Ground - The RSAF’s Safety Information System (SISII) has been in place since the early 90s to centrally manage safety lessons from flight and ground accidents/incidents. It is a very good tool through which to disseminate information about flight and ground hazards to stakeholders (i.e. RSAF aircrew/logisticians).

RSAF’s SISII is an intranet-based platform that individuals can easily and quickly use to upload, disseminate and access safety- related information. Important lessons from disseminated FAIRs/GAIRs are given emphasis by commanders, and applied to the specific operational context of each unit.

Additionally, RSAF Safety Days (RSDs) provide a monthly opportunity for all to discuss and internalise important messages from recent FAIRs/GAIRs. By adopting a two-way approach in talking about safety, commanders are better able to improve existing safety processes.

It is also important for commanders to “Walk-the -Ground”. Doing so allows commanders to have a better sense of whether messages and guidance cascaded down are internalised. Walking the ground also entails conducting spot checks to ensure compliance, and provides an excellent opportunity for commanders to identify latent issues that may otherwise be left unresolved.

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SAFETY ACTIVITIES

CAF Quarterly SafetyForum 04/16Changi Air Base (West) Auditorium

20 JAN 2017

CONCLUSION While technological advancements can greatly enhance flight safety, they cannot identify all human errors and prevent them from happening. Therefore, it is paramount that humans in the loop are ingrained with a strong commitment to safety.

It is important to maintain a strong safety culture through the open sharing of incidents and wrong doings, confronting hard truths instead of shying

ABOUT THE AUTHOR

MAJ Dan Ho is currently the Deputy Command Safety Officer and Transport Group Safety Officer, ACC HQ. He is a Navigator by vocation and has vast operational experiences in both 112 and 122 SQN, spanning 9 and 5 years respectively.

away from problems and issues. Everyone has a responsibility to maintain a strong safety culture, and to guard against its erosion.

To continually improve the safety culture, we need to adopt the correct approach and mind-set to safety. As long as we focus on the tasks at hand, demand high standards, and continually adopt the “DST” and “OMW” approaches to safety, the achievement of accident free hours is a natural outcome.

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AFI conducted the 02/16 RSAF Safety Officers’ Course from 15 to 30 Nov as part of RSAF’s ongoing effort to build a strong safety culture. 31 officers, including one officer from the RMAF, successfully completed the course. The course aims to equip all personnel with the knowledge and tools to contribute towards safety at the workplace.

RSAF Safety Officers’ Course 02/16 Air Force Training Command

15 NOV – 30 NOV 2016

C3 Group Annual Safety WorkshopAir Force Training Command

24 NOV 2016

Helicopter Group Annual Safety WorkshopSembawang Airbase Officers’ Mess

1 DEC 2016

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4 PICS 1 WORD CROSSWORD

B O A P T I E

S R G L N T S

V I E F K P N

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1: Pierre-Yves Beaudouin / Wikimedia Commons

2: “Weightlifting” by juliev, flickr.com3: “Tire Toss” by NAVFAC, flickr.com4: From Pixabay.com

5: “linked” by Anjan58, flickr.com 6: “Internet1.jpg” by Rock19977: Wikimedia Commons8: “Chain link” by imjane, flickr.com

Permission granted by LOTUM GmbH to publish 4 Pics 1 Word in FOCUS.

The images used on this page are licensed under Creative Commons and links can be accessed via the digital version of this issue.

What word can you derive from the 4 pics? Across

2. However, if the procedures are not carried out properly, a __________ could ensue

5. It can come to mind more easily when required, in ________ situations with time constraints

6. These consist of __________, problem solving, decision making, and teamwork

8. He informed the Flight Lead of the emergency and declared a __________ call

9. This is a fine example of a “Tribal Mentality” that drives great __________ in handling an emergency

11. Timely human __________ is therefore required to prevent a catastrophic mishap from occurring

12. They must maintain superior __________ of the air traffic in the airspace they operate in

14. The ability to deal with uncertainty and __________ is largely a human attribute

15. This occurs when one __________ the accuracy of his or her own knowledge and actions

18. Confirmation bias had __________ the decision-making process

Email your answers with your Rank/Name, NRIC, Unit and Contact details to AFI (ME3 Vidianand Das) before 21 April 2017. All correct entries will be balloted and 3 winners will receive S$30 worth of NTUC Fairprice vouchers each.

The crossword puzzle is open to all SAF personnel except personnel from AFI and members of the FOCUS Editorial Board.

Ans

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: "ST

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FOCUS #89

WINNERS

19. The outcome would have been __________ if not for the strong system knowledge

20. We relied on our __________, remained composed, and focused on flying the aircraft

Down

1. We drill our UAV Pilots to detect anomalous behavior quickly despite the lack of __________ feel

3. My instructor’s consideration was to get above the minimum safe __________ altitude quickly

4. With risk __________ measures put in place, the crew safely landed the aircraft in Darwin

7. Clearly, we see that __________ can seep into even the most simple and routine tasks

10. We have to be able to handle them with composure and __________

13. Rapidly __________ weather occurred as the incident aircraft was preparing for landing

16. Supervisors and leaders must communicate effectively about the dire consequences of not __________ to established processes

17. I looked out on the right to __________ identify the initial point

CPT Pravin S/O Loganathan, GBAD SCHCFC Neo Yu Chen, SA, ATDLCP Benjamin Lim, MP Br, HQ AFMS

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