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SouthwestCirrus.com Near-Miss Analysis Predicting and Preventing General Aviation Accidents
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SouthwestCirrus.com
Near-Miss Analysis
Predicting and Preventing General Aviation Accidents
SouthwestCirrus.com
Definitions
STEEP TURN
Excessive bank maneuver with massive loss of altitude
SouthwestCirrus.com
Definitions
STALL
A tactic used to explain higher AVGAS costs to the
mortgage company
SouthwestCirrus.com
Definitions
LAZY 8
SC Owner7 Mechanics
SouthwestCirrus.com
Definitions
DIVE
Local pilot hangout
SouthwestCirrus.com
Definitions
ANGLE OF ATTACK
Pickup lines frequently used at the DIVE
PILOT
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Definitions
SUITABLE LANDING FIELD
The good-looking one
SouthwestCirrus.com
Definitions
PRECISION APPROACH
Performed at a suitable landing field with
appropriate approach clearance
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Definitions
NEAR-MISS
A Near-Miss is an opportunity to improve safety, health, environmental impact and security of an operation based on
a condition or an incident with potential for more serious consequences.
- Wharton Risk Center
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
SouthwestCirrus.com
Incident/Accident Analysis
Identification
Reporting
Prioritization
Distribution
Causal Analysis
Solution Identification
Dissemination
Tracking
SouthwestCirrus.com
Safety Pyramid
Major Accidents
Minor Accidents
Incidents & Observations(Near-Misses)
- Bird, F.E. Jr, 1996, “Practical Loss Control Leadership”
NTSB Accident Database
ASRSNever AgainI Learned…
Individual PilotExperience
SouthwestCirrus.com
Identification
• What, Where, When
• Preceding circumstances
• Flight conditions
• Aircraft condition
• Flight plan / flight log
• Other remotely-related information
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Reporting
• You as Office of Primary Responsibility (OPR)• ATC / FAA?• Airport?• NTSB?• Manufacturer(s)?• Trainers?• Repair Station?• Others?
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Prioritization
• Life– Limb
• Environment– Economy
• Your priorities may not match other stakeholders
• Burden may shift, but not OPR
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Distribution
• All stakeholders need access to info
• OPR must take the lead
• ASRS?
SouthwestCirrus.com
Causal Analysis
• Direct and root causes
• Why?
• OK, then why that?
• OK, then why that?
DIRECT CAUSE
PROXIMATECAUSE
ROOT CAUSEPROXIMATE
CAUSE
ROOT CAUSE ROOT CAUSEPROXIMATE
CAUSE
ROOT CAUSE
ROOT CAUSE
SouthwestCirrus.com
Solution Identification
• Solution(s) for EVERY defined cause– Less than ideal solutions OK– “No solution for time being”
• Predetermine possible ancillary results
SouthwestCirrus.com
Dissemination
• Allocation of resources
• Action offices
• Limit to interested parties
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Resolution Tracking
• Employment/Resolution
• Continuous process improvement
Solution Identification
Implementation
Results DisseminationProcess
Improvement
SouthwestCirrus.com
Case Study
Subject: Electrical System
From: [email protected]
Date: 9/19/2005 7:12 pm
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)…
Subject: Electrical System
From: [email protected]
Date: 9/19/2005 7:12 pm
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)…
SouthwestCirrus.com
Case Study Analysis
• Reporting: pilot and repair station• Prioritization: High• Distribution: N/A?• Causal Analysis:
– 1) “Voltage regulator for 1 had blown”– 2) “Coupling for 2 was shot”
• Solution Identification: Replace Both• Dissemination: N/A?• Resolution Tracking
SouthwestCirrus.com
Case Study
Subject: Electrical SystemFrom: [email protected]: 9/19/2005 7:12 pmTo: [email protected]
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)
Fixed both, made it to Smyrna TN and Alt 1 comes on again! Voltage regulator again....hmmm. Found a field wire chafed and shorted against the engine, front right corner, fixed both and no more problems......
Subject: Electrical SystemFrom: [email protected]: 9/19/2005 7:12 pmTo: [email protected]
…As an aside, I had electrical trouble on the way to M3, left PMP heading North. Near Valdosta GA Alt 1 light came on. Didn't know or think to confirm, but was VMC daylight. Headed for Valdosta airport and on long final Alt 2 light comes on!! Made it to the ground, spent the night, scud run to Augusta in the AM, found that the voltage regulator for 1 had blown and the coupling for 2 was shot (so, where's that lottery win you mentioned?)
Fixed both, made it to Smyrna TN and Alt 1 comes on again! Voltage regulator again....hmmm. Found a field wire chafed and shorted against the engine, front right corner, fixed both and no more problems......
SouthwestCirrus.com
Case Study Analysis
• Incomplete causal analysisIncomplete solution identification
Repeat failure
• Distribution and Dissemination?
SouthwestCirrus.com
Near-Miss Analysis
• Be alert for “off-the-script” conditions
• Formalize analysis and solution tracking
• Report your results
• Critically analyze the results of others
• Eat good food, don’t litter, don’t talk to strangers, get plenty of rest, fly safe.
