104. Safety fundamentals
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104. SAFETY FUNDAMENTALS
References:
[a] OPNAVINST 3500.39A, Operational Risk Management
[b] OPNAVINST 5100.23F, Navy Occupational Safety and Health (NAVOSH) Program
Manual
[c] OPNAVINST 3750.6R, Naval Aviation Safety Program
[d] OPNAVINST 4790.2H, Naval Aviation Maintenance Program (NAMP), Vol. I
[e] OPNAVINST 5102.1C, Mishap Investigation and Reporting
[f] NAVEDTRA 14325, Basic Military Requirements
[g] NAVEDTRA 14014, Airman
[h] Local Directives and Standard Operating Procedures
[i] http://www.safetycenter.navy.mil
[j] NAVAIR 00-80T-105, CV NATOPS Manual
[k] http://www.vnh.org/NHB/NHBHome.html
[l] NAVAIR 00-80T-109, Aircraft Refueling NATOPS Manual
.1 Discuss the concept of ORM. [ref. a, ch. 1]
* Operational Risk Management is a systematic, decision-making
process used to identify and manage hazards that endanger naval
resources. ORM is a tool used to make informed decisions by providing
the best baseline of knowledge and experience available. Its purpose is
to increase operational readiness by anticipating hazards and increase
the potential for success to gain the competitive advantage in combat.
ORM is not just related to naval aviation; it applies across the warfighting spectrum
.2 Explain the following as they apply to ORM: [ref. a, ch. 1]
a. Identifying hazards
Begin with an outline or chart of the major steps in the
operation or operational analysis. Next, conduct a preliminary hazard
analysis by listing all of the hazards associated with each step in the
operational analysis along with possible causes for those hazards.
b. Assessing hazards
For each hazard identified, determine the associated degree of
risk in terms of probability and severity. Although not required, the
use of a matrix may be helpful in assessing hazards.
c. Making risk decisions
Develop risk control options. Start with the most serious risk
first and select controls that will reduce the risk to a minimum
consistent with mission accomplishment. With selected controls in place,
decide if the benefit of the operation outweighs the risk. If risk
outweighs benefit or if assistance is required to implement controls,
communicate with higher authority in the chain of command.
d. Implementing controls
The following measures can be used to eliminate hazards or reduce
the degree of risk. These include engineering controls, administrative
controls, and personnel protective equipment.
e. Supervising
Conduct follow-up evaluations of the controls to ensure they
remain in place and have the desired effect. Monitor for changes, which
may require further ORM. Take corrective action when necessary.
.3 Discuss the purpose of the NAVOSH Program. [ref. b, ch. 1]
* The primary objective is to preserve human and material resources.
The program enhances operational readiness by preserving the resources
used in accomplishing the naval aviation mission. The human resources
include professional pride, high morale, physical well being, and life
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
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itself, all of which are susceptible to damage and destruction caused
by mishaps. Material resources include property, which may be damaged
by an aircraft mishap including naval aircraft, ships, facilities, and
weapons.
.4 Discuss the purpose of the Naval Aviation Safety Program. [ref. c,
ch. 2]
* PURPOSE OF THE PROGRAM
The Naval Aviation Safety Program enhances operational readiness
when it preserves the lives and enhances the well-being of its members
by protecting the equipment and material they need to accomplish their
mission. The Naval Aviation Safety Program supports every aspect of
naval aviation. Knowledge gained here may assist other safety efforts.
The program may, therefore, yield benefits and preserve resources far
beyond its intended scope.
* OBJECTIVE OF THE PROGRAM
1. The Naval Aviation Safety Program succeeds by preventing damage
and injury. Potential causes of damage and injury under human control
are termed hazards. The goal of the Naval Aviation Safety Program is to
eliminate or control hazards.
2. The Director, Air Warfare Division (CNO (N78)) is responsible for
naval aviation safety and the safety of assigned surface ships.
.5 State the purpose of the personnel injury/death/occupational illness
report. [ref. e, ch. 1]
* Record keeping and reporting is vital to provide safety
information to Department of the Navy (DON) and Department of Defense
(DOD). These records and reports are required by federal law and
provide information to identify unsafe acts and conditions, and apply
corrective measures. With the inception of electronic reporting,
mishaps or incidents that previously were only locally recordable, and
not reportable outside the command, are all now in the reportable
category, since all electronic entries are transmitted to the Commander,
Naval Safety Center (COMNAVSAFECEN) mishap database. Besides material
damage, fatalities and disability mishaps, data must also be collected
on time away from work, light, limited, and restricted duty injuries
and occupational illnesses for preventive efforts. Therefore all
recordable mishaps are to be reported electronically to COMNAVSAFECEN.
.6 Discuss how the following causal factors contribute to aviation
mishaps: [ref. c, ch. 6]
a. Human: Human error causes an alarmingly high number of mishaps.
Human error is part of nearly every mishap. It includes those personnel
who may have maintained or repaired equipment or even the worker at the
factory where a part was manufactured. Human error involves both
physical and mental factors including ergonomics (design of the
workplace), physical strength of the individual, physical stress, and
mental factors including the person's attitude, behavioral factors, etc.
b. Material: Consider all material failures and malfunctions
thoroughly, whether the failures or malfunctions occurred because of
faulty design, defective manufacture, or repair. Most mishaps blamed on
material failure may really involve maintenance factors or human error.
Created by LTJG KyungNho "TACO" Kim
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.7 Define the following aircraft mishap severity classes: [ref. c, ch.
4]
a. Class A: The resulting total cost of reportable material property
damage is $1,000,000 or more; or an injury or occupational illness
results in a fatality or permanent total disability.
b. Class B: The resulting total cost of reportable material or
property damage is $200,000 or more, but less than $1,000,000; or an
injury or occupational illness results in permanent partial disability;
or three or more personnel are inpatient hospitalized.
c. Class C: The resulting total cost of reportable material or
property damage is $10,000 or more, but less than $200,000; a non-fatal
injury that causes any loss of time beyond the day or shift on which it
occurred; or a non-fatal illness or disease that causes loss of time
from work or disability at any time (lost time case). For reporting
purposes, reportable lost workday Class C mishaps are those which
result in 5 or more lost workdays beyond the date of injury or onset of
illness (exceptions apply).
d. Class D: The resulting total cost of reportable material or
property damage is less than $10,000 or a non-fatal injury (no lost
time or first aid case) that does not meet the criteria of a Class C
mishap.
.8 Define the following aircraft mishap categories: [ref. c, ch. 4]
a. Flight mishap (FM). This category encompass those mishaps which
result in $20,000 or more damage to a DOD aircraft or UAV or, the loss
of a DOD aircraft or UAV - when intent for flight for DOD aircraft or
UAV existed at the time of the mishap. Other property damage, injury or
death is irrelevant to this classification.
b. Flight related mishap (FRM). Those mishaps which result in less
than $20,000 damage to a DOD aircraft or UAV -when intent for flight
existed at the time of the mishap and, additionally, $20,000 or more
total DOD and non-DOD damage or a reportable injury or death occurred.
c. Aircraft ground mishap (AGM). Those mishaps in which the intent
for flight did not exist but a DOD aircraft or UAV was lost, or more
than $20,000 damage was sustained by a DOD aircraft or UAV, or DOD or
non-DOD property was damaged in the amount of $20,000 or more, or a
reportable injury occurred.
.9 Discuss the composition and purpose of the Aircraft Mishap Board.
[ref. c, ch. 2]
1. An Aviation Mishap Board must investigate every naval FM, FRM, and
AGM, then report on them as this instruction directs. Each aircraft
reporting custodian shall maintain at least one standing Aviation
Mishap Board (AMB).
2. Composition.
a. Appointment of AMBs. The aircraft controlling custodian or the
designated appointing authority shall appoint AMB members by name and
in writing. On all Class A Mishap Investigations, appoint the senior
member from commands not involved in the mishap - preferably from
outside the expected endorsing chain. The senior member will be a Naval
Aviator or Naval Flight Officer (A commander or lieutenant colonel or
above), a graduate of the ASO or Aviation Command Course, or have other
suitable training or qualifications acceptable to the aircraft
controlling custodian. On other mishaps the senior member may be from
the reporting custodian and of any rank senior to the Pilot in Command
and Mission Commander.
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Reviewed by LTJG Robert A. Wainscott
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b. Basic AMB Composition. The following applies to AMBs under all
conditions, except direct enemy action:
(1) Members of Aviation Mishap Boards shall be drawn from the
ranks of commissioned officers on active duty in the U.S. Navy or U.S.
Marine Corps. Officers on Exchange Duty from other services (U.S.A. or
foreign) may serve on AMBs, but may not be the senior member. Chapter 6
describes the requirements for inter-service participation on AMBs.
Enlisted personnel with the rank of E-6 and above may serve on AMBs for
UAVs.
(2) Minimum AMB membership shall consist of four officers drawn
from the command's standing board: an ASO (NAVPGSCOL ASO course
graduate), a flight surgeon, an officer well-qualified in aircraft
maintenance, and an officer well qualified in aircraft operations.
(3) The senior member of each AMB shall be a Naval Aviator or
Naval Flight Officer. The senior member of a Class A mishap board has
message releasing authority for Mishap Data Reports and SIRs. All other
senior member functions will remain the same as outlined in this
instruction.
(4) Sometimes an appointing authority may not have enough
qualified personnel in the command, may be operating in a remote
location, or for other reasons be unable to field a complete AMB. In
such cases, one may appoint AMB members from outside the command. For
instance, with no flight surgeon assigned, it is altogether proper to
borrow one from another command.
(5) In unusual or complex mishaps, the AMB may benefit from
having officers with specific expertise as members. In such cases the
senior member should request the appointing authority assign these
additional members (a flight deck officer, perhaps, or an aerospace
physiologist) to the AMB.
c. Required Changes to Composition of AMBs. The following may
require adjustments in the membership of the AMB by the appointing
authority,
depending
on
the
circumstances
of
a
mishap
under
investigation:
(1) The senior member of each AMB shall be senior to the pilot in
command and mission commander involved. The appointing authority, with
the concurrence of controlling custodian, may waive this requirement in
isolated cases where compliance would require unreasonable measures.
(2) For manned aircraft mishaps, at least one member of the AMB
shall be a pilot who is NATOPS-qualified in the model aircraft involved.
(3) Personnel directly involved in a mishap shall not serve on an
AMB conducting an investigation of that mishap.
(4) Members whose personal interest in a mishap might conflict
with the objective and impartial performance of their duties shall not
serve on the AMB investigating that mishap.
(5) Do not allow someone who may be called upon to endorse the
SIR to sit on the AMB investigating the mishap.
d. Insufficient AMB Membership
(1) Sometimes AMB members are involved in mishaps. Address plans
for
such
eventualities
(particularly
important
for
detachment
operations) in pre-mishap planning.
(2) When, despite their best efforts, appointing authorities find
themselves with too few members to constitute a board, they may:
request relief or waiver from investigating and reporting the mishap,
or request help with the investigation from the controlling custodian.
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104. Safety fundamentals
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.10 Discuss the safety precautions to be observed when:
* Self explanatory
a. Working in confined spaces [ref. b, ch. 27]
b. Working near or utilizing electrical equipment [ref. b, ch. 24]
c. Working in spaces with high noise levels [ref. b, ch. 18]
d. Working with flammable (paints, solvents, etc.) [ref. b, ch. 20]
e. Working near compressed gases [ref. h]
f. Working with composite materials/beryllium [ref. b, ch. 17]
g. Lifting heavy objects [ref. k]
h. Working in RADHAZ areas [ref. b, ch. 22]
i. Working with/near asbestos [ref. b, ch. 17]
.11 Discuss the safety precautions to be observed during a fire. (e.g.,
space security, evacuation routes, mustering, etc). [ref. g]
* Self explanatory
.12 Discuss the safety precautions which must be implemented aboard
your ship/station to prepare for severe weather or when severe weather
is being experienced. [ref. g]
1. NORMAL WEATHER CONDITIONS
In general, the following procedures apply when securing aircraft
under normal conditions:
1. Plane captains of landing aircraft stand by with tie-downs on
the flight deck in a designated area. They join their aircraft as they
are being parked. If an aircraft is moved to the hangar bay below, its
plane captain should board the elevator with it if he can do so safely.
2. Aircraft-handling crews stand by in a designated area during
recoveries and act as chock men while aircraft are being taxied and
parked. They put on the initial tie-downs and are assisted by the plane
captain when possible.
3. When the aircraft reaches the final spot, the director will
signal the pilot of the aircraft to lower its tail hook. This
automatically straightens the nose wheel to center. Some aircraft must
have the nose wheel aligned to center manually.
4. The plane captain connects the ground wire and installs wing
fold jury struts, parking harness and batten boards, engine and cockpit
covers, and tie-downs needed other than the initial tie-downs put on by
the aircraft-handling crews. Detailed procedures for securing a
specific aircraft are found in the maintenance instruction manual (MIM)
for that aircraft.
2. HEAVY WEATHER PROCEDURES
The procedure for securing aircraft during heavy weather differs very
little from that used in normal weather. The main difference is that
more tie-downs are used. All flight control surfaces are secured with
battens, and controls inside the aircraft are secured. When extremely
heavy weather is anticipated, as many aircraft as possible are spotted
on the hangar deck. The remainder are spotted in the fly 2 (center) and
fly 3 (aft) areas of the flight deck. Avoid securing aircraft athwart
ship and in the heavy weather spot. Aircraft remaining on the flight
deck should be spotted inboard along either side of the center line of
the deck. Leave a clear area around the perimeter of the flight deck.
If possible, spread the wings on the aircraft that are spotted on the
flight deck. For special instructions on securing an individual
aircraft, refer to the aircraft's specific maintenance manual. When the
ship is not at flight quarters or during heavy weather conditions, the
Created by LTJG KyungNho "TACO" Kim
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104. Safety fundamentals
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Air Department is required to maintain a security/integrity watch on
the flight deck and hangar deck to ensure that each aircraft remains
properly secured. The watch must be especially alert for loose or
broken jury struts, tie-downs, battens, chocks, engine intake/ exhaust
and canopy covers, any leakage, or hazardous conditions. Extreme
caution is necessary when you handle aircraft in heavy weather.
3. COLD WEATHER PROCEDURES
Handling aircraft during cold weather operations is extremely
difficult. Keep as many aircraft on the hangar deck as is possible
during extremely cold weather. Keep the flight deck clear of ice and
snow. The following methods, gear, and equipment for snow and ice
removal are often used:
1. Mobile equipment removal—some aircraft tow tractors may be
fitted with snowplow blades or with rattan or wire rotary brushes.
2. Manual removal—conventional methods include brooms, crowbars,
shovels, wooden mallets, and scrapers. Use compressed air to blow snow
from pockets. Use firemain water at 100 psi and steam lances for
undercutting ice. Use deck scrapers and auxiliary hot-air heaters to
clear flight-deck equipment, such as wires, sheaves, arresting gear,
and elevators, of ice. Use normal deck procedures in cold weather, but
considerably more time is required because of the excessive hazards
involved. Use battens on control surfaces. Jury struts and cockpit
covers are recommended. Tie-down the controls inside the aircraft to
eliminate the chance of movement of outer control surfaces. Aircraft on
ice or snow should always be moved slowly. Avoid using the brakes as
much as possible when turning aircraft.
.13 Describe the purpose of the Navy's Tag-Out Program. [ref. b, ch. 24]
* ENERGY CONTROL PROGRAM (LOCKOUT/TAGOUT)
a. Purpose: This chapter establishes Navy policy and minimum
procedures for locking out or tagging the sources of energy to
equipment or systems under the requirements of reference 24-1 and the
minimum performance standards of reference 24-2.
b. Scope and Application: The requirements of this chapter apply to
the control of energy during servicing and maintenance of machinery and
equipment ashore. These requirements apply only when the unexpected
energizing or movement of machinery/equipment or the release of energy
during the maintaining or servicing of such equipment/machinery could
cause injury to personnel and/or property damage.
Reference 24-1. Title 29 Code of Federal Regulations (CFR) 1910.147
of 13 Feb 96, The Control of Hazardous Energy (lockout/tagout), latest
revision, and Title 29 CFR 1910.332 of 6 Aug 90, Electrical-SafetyRelated Work Practices
http://www.access.gpo.gov/nara/cfr/waisidx_04/29cfr1910_04.html.
Reference 24-2. American National Standards Institute (ANSI)
Standard Z244.1-2003, American National Standard for Personal
Protection Lockout / Tagout of Energy Sources-Minimum Safety
Requirements (NOTAL), http://www.ansi.org.
.14 Discuss the following first aid procedures: [ref. f]
a. Removing a victim from an energized circuit [ch. 14]
* Rescuing a person who has received an electric shock is likely
to be difficult and dangerous. Use extreme caution or the rescuer may
also be electrocuted. Don’t touch the victim’s body, the wire, or any
other object that may be conducting electricity. Some procedures you
might use to rescue a person who’s received an electric shock are as
follows:
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
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* Look for the switch first of all, and if you find it, turn off
the current immediately. Don’t waste too much time hunting for the
switch; however, every second is important.
* If you cannot find the switch, you should try to remove the
wire from the victim with a dry broom handle, branch, pole, oar, board,
or similar non-conducting object.
* It may be possible to use dry rope or dry clothing to pull the
wire away from the victim.
* You can also break the contact by cutting the wire with a
wooden-handled axe, but that is extremely dangerous because the cut
ends of the wire are likely to curl and lash back at you before you
have time to get out of the way. When you are trying to break an
electrical contact, always stand on some non-conducting material, such
as a dry board, newspaper, or clothing.
Administer artificial ventilation immediately after freeing the
person from the wire if the electric shock caused breathing to stop.
Check the victim’s pulse, since electric shock may also cause the heart
to stop. If you do not feel a pulse, immediately administer CPR. Get
the victim to a medical facility as soon as possible.
b. Treatment for shock [ch. 14]
* Keep an injured person warm enough for comfort, but do not let
the victim become overheated. The best position to use to prevent or to
treat shock is one that encourages the flow of blood to the brain. If
possible, place the injured person on his or her back on a bed, a cot,
or a stretcher. Raise the lower end of the support about 12 inches so
that the feet are higher than the head. If you can’t do that and it’s
possible, raise the feet and legs enough to help the blood flow to the
brain. Sometimes it’s possible to take advantage of a natural slope of
ground and place the victim so that the head is lower than the feet.
* If you have any doubts about the correct position to use, have
the victim lie flat on his/her back. The basic position for treating
shock is one in which the head is lower than the feet. Do the best you
can under the particular circumstances to get the injured person into
this position. In any case, never let a seriously injured person sit,
stand, or walk around.
c. Treatment for burns [ch. 14]
* The most effective immediate treatment of burns and of pain is
as follows:
1. If the burn area covers less than 20% of the body, immerse the
burned area in cold water, or apply cold compresses if immersion is
impracticable. Cold water not only minimizes pain but also reduces the
burning effect in the deeper layers of the skin. Gently pat dry the
area with lint-free cloth or gauze.
2. If the burn area covers more than 20% of the body, apply
sterile, dry bandages. Aspirin is also effective for the relief of pain.
Continue treatment until no pain is felt when the burned area is
exposed to the air. Burn victims require large amounts of water, which
should be slightly salted. Because of the nature of the injury, most
burns are sterile. Therefore, the best treatment for uninfected burns
is merely to protect the area by covering it with the cleanest
(preferably sterile) dressing available. Some actions that should not
be taken when dealing with burns are as follows:
* Never apply ointments to a burn or use petrolatum gauze.
* Don’t attempt to break blisters or to remove shreds of tissue
or adhered particles of charred clothing.
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
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* Never apply a greasy substance (butter, lard, or Vaseline™),
antiseptic preparations, or ointments. These may cause further
complications and interfere with later treatment by medical personnel.
d. Treatment for bleeding [ch. 4]
* Blood is circulated throughout the body by three different
kinds of blood vessels. 1. Arteries, which are large vessels that carry
the blood away from the heart 2. Veins, which are large vessels that
carry the blood back to the heart 3. Capillaries, which form a
connecting network of smaller vessels between the arteries and the
veins
* Hemorrhage (escape of blood) occurs whenever there is a break
in the wall of one or more blood vessels. In most small cuts, only
capillaries are injured. Deeper wounds result in injury to veins or
arteries. Bleeding severe enough to endanger life seldom occurs except
when arteries or veins are cut.
* The only way to stop serious bleeding is by the application of
pressure. In practically all cases, bleeding can be stopped if pressure
is applied directly to the wound. If direct pressure doesn’t stop the
bleeding, pressure should be applied at the appropriate pressure point.
In those very rare cases where bleeding is so severe that it cannot be
controlled by either of these methods, pressure can be applied by a
tight constricting band. The actual procedures you should use to stop
bleeding are shown in chart on pages 14-10 and 14-11. Read Reference.
e. Treatment for heat exhaustion [ch. 14]
* To treat heat exhaustion victims, you should treat them as if
they were in shock.
* Loosen the clothing; apply cool, wet cloths.
* Move the victim to either a cool or an air-conditioned area,
and fan the victim.
* Do not allow the person to become chilled.
* If the victim is conscious, administer a solution of 1 teaspoon
of salt dissolved in a quart of cool water.
* If the victim vomits, don’t give any more fluids.
* Transport the victim to a medical facility as soon as possible.
f. Treatment for frostbite [ch. 15]
* Frostbite and immersion foot are serious injuries that can
happen even when you’re wearing enough clothing to stay fairly
comfortable. Frostbite usually affects the hands, face, or feet, and it
most often occurs on windy, very cold days. Affected parts of the body
turn stiff, pale, and numb. To prevent frostbite, keep exposed parts of
the body as warm as possible and maintain circulation. If frostbite
occurs, treat the affected part immediately by placing it in contact
with a warm part of your body. Cover it with your hand or put frozen
fingers inside your clothing. Don’t rub the affected parts; that could
result in damage to frozen tissue.
* Immersion foot is the swelling of the foot accompanied by
numbness and pallor (lack of color) or discoloration. Immersion foot is
caused by poor circulation in the legs, particularly when the foot
remains wet for several days. To prevent immersion foot, exercise the
ankles and toes for a few minutes several times each day. Keep your
feet warm, dry, and elevated as much as possible. Unlace your shoes or
take them off. If you have no dry socks or wrappings for your feet, put
them under the arms or in the lap of a shipmate. Never treat immersion
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104. Safety fundamentals
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foot by rubbing. As with frostbite, tissue damage may result. Rewarming
is the only proper treatment.
104.15 Discuss the following:
a. Sight conservation [ref. b, ch. 19]
b. Battery safety [ref. g, ch. 7]
c. Foot protection [ref. b, ch. 20]
d. Head protection [ref. b, ch. 20]
e. Toxic material protection [ref. b, ch. 20]
f. Hazardous material label [ref. b, ch. 7]
g. Electromagnetic radiation hazards [ref. b, ch. 22]
h. Hearing conservation [ref. b, ch. 18]
* Self explanatory
.16 Discuss the following services provided by the Naval Safety Center:
[ref. i]
* Access the web site: http://www.safetycenter.navy.mil
a. Periodicals
b. Messages
c. Surveys
d. Web site
.17 Define the following terms as used in aviation maintenance
publications: [ref. d, ch. 1]
a. Warning: refers to a procedure or practice that, if not correctly
followed, could result in injury, long term health hazards, or death.
b. Caution: refers to a procedure or practice that, if not correctly
observed, could result in damage to or destruction of equipment.
c. Note: refers to a procedure or condition that requires emphasis.
d. FYI, The concept of word usage and intended meaning that has been
adhered to in preparing this instruction is as follows:
(1) "Shall" means procedure is mandatory.
(2) "Should" means procedure is recommended.
(3) "May" and "need not" mean procedure is optional.
(4) "Will" indicates futurity and never indicates any degree of
requirement for application of a procedure.
.18 Discuss the role of the ship/station Industrial Hygienist, in
aviation maintenance operations. [ref. b, ch. 8; ref. i]
* Navy industrial hygiene personnel anticipate, recognize,
evaluate, and make recommendations to control unacceptable workplace
exposures. Exposure assessment of Navy workplaces requires a sound,
logical strategy and shall be based on references 8-2 through 1.1.1.
Inform the Secretary of Defense on 8-5. The purpose of such a strategy
is to accomplish at least four goals:
(1) To assess potential health risks faced by Navy personnel by
understanding their exposures, to differentiate between acceptable and
unacceptable exposures, and to control unacceptable exposures.
(2) To establish and document a historical record of exposure
levels for Navy personnel and to communicate exposure monitoring
results.
(3) To ensure and demonstrate compliance with safety and health
exposure criteria.
(4) To provide a basis for medical surveillance examinations.
Reference 8-1. OPNAVINST 5100.19D, of Dec 05; Navy Occupational Safety and Health (OSH)
Program Manual for Forces Afloat
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104. Safety fundamentals
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http://www.safetycenter.navy.mil/instructions/afloat/510019D.htm.
8-2. DODI 6055.5 of Jan 89, Industrial Hygiene and Occupational Health
http://www.dtic.mil/whs/directives/corres/pdf/i60555wch1_011089/i60555p.pdf.
8-3. Industrial Hygiene Field Operations Manual of Dec 04, NEHC Technical Manual,
NEHCTM6290.91-2, http://www-nehc.med.navy.mil/ih/ihfom.htm.
8-4. AIHA “A Strategy for Occupational Exposure Assessment”, latest revision (NOTAL)
http://www.aiha.org/.
8-5. “DOD IH Exposure Assessment Model of January 00,” DOD Industrial Hygiene
Working Group Report 2000-1.
https://www.denix.osd.mil/denix/Public/News/Army/DOHP/Occhealth/Documents/IHEAM/ih
asses smodelv8.html.
104.19 Discuss the flight deck/line safety precautions applicable to
the following:
a. Flash photography [ref. h]
b. Flight deck clothing [ref. j, ch. 2]
c. Hazards of turning main rotor blades and rotor blade downwash [ref.
j, ch. 4]
d. Hazards of turning tail rotor blades [ref. j, ch. 4]
e. Ship maneuvering [ref. h]
f. Cold/heavy weather operations [ref. h]
g. Aircraft movement hazards [ref. j, ch. 6]
h. REMOVE BEFORE FLIGHT warning flags/streamers [ref. h]
i. Trip hazards associated with flight deck/hangar deck [ref. h]
j. Divisional/hangar/elevator doors [ref. h]
k. Weapons elevator hatches [ref. h]
l. AESS hatches/stations [ref. h]
m. Aircraft fueling [ref. l]
n. Fuel, oil, and hydraulic leaks [ref. h]
o. Weapons/chaff [ref. j, ch. 6; app. C]
p. Emergency landing [ref. j, ch. 5]
q. Night operations [ref. h]
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
Page 11 of 15
MORE AMB INFO
a. Responsibilities.
Mishap investigation and reporting responsibilities of AMB members
take precedence over all other duties.
(1) Aircraft or UAV reporting custodians, paragraph 107k.
(2) Senior member, AMBs, paragraph 107m.
(3) Members, AMBs, paragraph 107n.
b. Organization for Investigation
(1) The Standing AMB. The program requires reporting custodians
appoint in writing and maintain a standing AMB. Paragraph 206b requires
a minimum of four members with experience and knowledge in the
specialized fields of safety, aeromedical, operations, and maintenance.
The AMB's senior members must be sure their boards are trained and
ready to investigate mishaps.
(2) Changes in Board Membership. When changes in Board membership
are necessary, it is the senior member's responsibility to recommend to
the appointing authority appropriate changes of AMB membership to
comply with this instruction. The senior member may also recommend
additional members be seated if the investigative effort requires. For
example, in a mishap involving Aviation Life Support Systems, the
senior member may recommend the assignment of a local AMSO to the Board.
(3) Use of Board Members. The senior member may excuse any member
from active participation in the investigation if that individual's
particular skills are no longer needed. The individual retains board
membership until removed by the appointing authority
c. Conduct of the Investigation. NAVAIR 00-80T-116, Vols. I-II,
Technical Manual, Safety Investigation Techniques; and Aviation Safety
Programs, Aircraft Mishap Investigation Notebook tells how to conduct a
naval aviation mishap investigation.
(1) The Investigative Effort. The amount of investigative energy
expended in discovering the causes of mishaps has nothing to do with
the amount of damage they cause. Your job is to identify the hazards
associated with the mishap. A complex or mysterious mishap may require
extensive investigative efforts; a simple, well-defined mishap might be
investigated with minimal effort. The extent of the investigative
effort depends on the senior member's desire.
(2) Collection of Evidence. It is impossible to accurately
predict what kinds of evidence should be collected under what
circumstances in every mishap investigation. For this reason, we rely
on the AMB senior member's judgment.
(3) Medical Evidence. Because medical evidence is quickly lost,
we must immediately notify the AMB flight surgeon when a mishap occurs.
The flight surgeon is primarily concerned with medical, physiological,
social, behavioral and psychological factors which may reveal mishap
causal factors.
(a) Pre-Mishap Planning. The flight surgeon shall participate
fully in AMB pre-mishap planning, including planning for the collection
of medical evidence. (See appendix 2B, Pre-Mishap Plan Checklist.)
(b) Physical Examinations. Regardless of his/her military
service affiliation, the first flight surgeon on a mishap scene, or the
one to whom mishap victims are brought, shall immediately perform
examinations and laboratory procedures required by the flight surgeon's
service. However, the parent service of the victims must delineate
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
Page 12 of 15
unique requirements and assume responsibility for the aeromedical
portion of this investigation as soon as possible.
(c) Radiographs. They shall perform Radiology studies as
clinically indicated. Full spinal x-rays are required after all
ejections, bailouts, and crashes with or without suspected back
injuries.
(d) Biological Samples. In all Class A and Class B mishaps and
when necessary following Class C mishaps and incidents with potential
to meet defined naval mishap limits, biological sampling shall take
place immediately after the mishap. The importance of this knowledge is
unrelated to the severity of the mishap. Include biological sampling
policies which conform to current Navy and DOD directives in every PreMishap Plan. Take enough blood and urine specimens for blood alcohol,
carbon monoxide, drug screen, hemocrit, hemoglobin, glucose and
urinalysis testing. Freeze and store an aliquot of each specimen for at
least 90 days following the mishap for verification or for other
studies as may be necessary later.
(e) Pathological Studies. Conduct an autopsy, including full
body x-rays, whenever a fatality occurs as a result of a naval aviation
mishap.
(f) Drug-Assisted Interviews and Hypnotic Techniques. Drugassisted interviews and hypnosis are prohibited without the specific,
written authority of CNO (N78). These interviews and techniques will be
authorized only when critical safety-related information cannot be
obtained any other way and the subject agrees voluntarily. When
authorized, the procedure shall be conducted by a member of the medical
department qualified in the procedure, with the AMB flight surgeon in
attendance. Other attendees are discouraged. (The value of these
efforts is suspect and the probability of getting false, inaccurate,
and misleading information from them must be considered.)
d. Deliberations. As the AMB collects evidence it must begin to attach
significance to that evidence and decide what part it may have played
in the mishap. The SIR format provides a guide for the deliberations of
the Board. The SIR outline reflects a pattern of deductive reasoning:
- What the Board knows (paragraph 10, Evidence).
- Reasoning of the Board (paragraph 11, Analysis).
- Deductions of the Board (paragraph 12, Conclusions).
- The Board's recommendations to prevent recurrence of the mishap,
or damage and injury occurring during the mishap (paragraph 13,
Recommendations).
(1) Analysis and Causal Factors. The AMB must analyze the
evidence available to them in order to determine the causes of the
mishap. The resulting list constitutes the causal factors of the mishap.
Causal factors have three elements which (1) describe the people or the
equipment, and (2) define the actions or the events, and (3) tell why
this causal factor contributed to the mishap.
Defining these elements is essential for determining the cause of
the mishap. Thus, causal factors fall into two general classifications:
human and material.
(a) Human Factors. Determining how people contribute to mishaps
is of obvious importance. To describe fully and to understand human
factors requires us to identify the elements: WHO, WHAT, and WHY in
each occurrence. It is not enough to describe the human portion of
mishaps as "personnel error," or "pilot technique". Such labels are not
nearly detailed enough to encompass the entire cause of a human factor
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
Page 13 of 15
mishap; they fail to explain why the event happened. Normally, there
are few questions about WHAT occurred; usually it is self evident: A
gear-up landing is just that. Likewise, the WHO lends itself to quick
identification: the pilot. Still, the most significant element, from
the standpoint of prevention, is missing: the WHY. This is the element
that lends itself to remedial action. Flight surgeons are trained and
thus must always have a role in the identification and analysis of
human factors.
1. WHO. There are four kinds of people who can contribute to an
aviation mishap. They are: aircrew, supervisors, facilities and
maintenance personnel.
a. Aircrew. The people (including instructors) in the aircraft,
in the formation, or controlling the UAV, are listed under the aircrew
factor classification. We must identify their contributions to the
mishap - whether or not they survived.
b. Supervisory. People in command and operations -related support
– up and down the chain of command – fall into the supervisory factor
classification. Consider the behavior of supervisors at every level,
their publications, and their policies, all of which may contribute to
a mishap.
c. Facilities Personnel. Classify errors committed by people
involved in air traffic control (tower, prifly, CATCC, etc.), runway
watches, aircraft or UAV ground handling, crash and rescue, and search
and rescue under Facilities Factors.
d. Maintenance. Errors committed by people engaged in the
production, servicing, or repairing of aircraft are listed under the
maintenance factor classification.
2. WHAT. The actions of those who caused the mishap are the “WHAT”
of a human causal factor. The WHAT is a hazard statement defining an
act of omission or commission which led to the mishap. Appendix L is
matrix
of
actions
performed,
or
not
performed,
by
the
four
classifications.
3.
WHY.
One
assumes
no
naval
aviation
professional
would
purposefully commit an act that would result in a mishap. Circumstances
like fatigue, lack of training, misinformation, and motivational
dysfunction may combine to create a situation that leads to a mishap,
but even negligence lacks the specific intent to cause damage or injury.
They are subdivided into six groups:
- Communication/Coordination
- Psychosocial
- Environment
- Performance
- Human Engineering
- Medical/Psychological
(b) Material Factors. Even in material failures, there may be enough
evidence for the AMB to identify human factors; someone misused
something, or did not maintain or service it, or designed it improperly,
or made or reworked it below standards. Even so, including material
factors in the set of mishap causal factors is important because, while
human factors are surely involved, the material factor is often the
weak link in the chain. It may be possible, for example, to redesign
and strengthen a part. On the other hand, there may be no evidence
supporting human factor involvement and a material failure may be the
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
Page 14 of 15
only possibility. Thus, we include material factors in this set of
mishap causal factors.
1. Component. The smallest, most specific part, assembly, or
system identified as having failed is the component.
2. Mode. How the component failed. Specifically, "WHAT" occurred,
is the Mode. Typical examples are: fracture (load bearing member broke),
stripped threads, jammed, leaked, etc.
3. Agent. The acts or events which led to the failure mode are
the agents. Typical examples are overload, fatigue, fire, or spalling.
These are the "technical" agents; each component failure must have, at
least, one "technical" agent. In addition, the AMB may discover further
"human factor" agents. These might include improper maintenance
procedures, poor design or improper aircrew procedures. We will address
"human factor" agents as separate causal factors (Aircrew, Supervisory,
Maintenance and Facilities), and will analyze the WHO/WHAT/WHY more
fully.
(2) Conclusions. AMBs must base their conclusions as to which hazards
caused the mishap, damage, or injury during the mishap, on all
available information and their own deductions. They may test the
conclusions under consideration with the question: "Absent this causal
factor would there have been a mishap?” You may use the terms "Hazard,”
"mishap cause and causal factor," and "causal factor of damage or
injury,” interchangeably.
(a) Mishap Causal Factor Determination. The SIR is the report of
the mishap causal factors determined by the AMB.
(b) Causal Factors of Other Damage and Injury Occurring during a
Mishap.
(c) Environmental Conditions.
(d) Noncontributory Hazards Discovered During the Investigation.
(3) Recommendations. AMBs should use the guidelines in appendix C when
formulating their recommendations, and test these recommendations with
the question: "If this had been done before the mishap, would these
additional
hazards
have
been
eliminated?"
Don't
include
any
recommendations that fail this test; rather, report them in a Hazard
Report.
* PRE-MISHAP PLANS: A pre-mishap plan describes - in advance - the
steps that must be taken when a mishap occurs. Anticipate all
reasonable eventualities and devise measures to cope with them.
Deficiencies may be identified through periodic drills designed to
ensure the plan's smooth execution when a mishap occurs. While the
content of a pre-mishap plan is largely at the option of the command,
plans for Navy and Marine Corps airfields and aircraft operating
facilities must address:
a. Coordination with local news media, area law enforcement
officials, civil fire and rescue agencies, the Environmental Protection
Agency (EPA), and the FAA.
b. Coordination with tenant commands to be sure required support
for engineering services, supply, medical assistance, and hazardous
material disposal will be available.
c. Coordination with nearby military aviation facilities to
clearly describe the geographic boundaries of responsibilities for
immediate responses to an aviation mishap
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott
104. Safety fundamentals
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d. Provisions for an immediate telephone report to the reporting
custodian of aircraft mishaps within the airfield's area of cognizance.
e. Plans to protect aircraft wreckage so that it remains
undisturbed for at least 24 hours.
f. Provisions for explosive ordnance disposal (EOD) services which will
render explosives in the aircraft wreckage safe and provide authorized
storage facilities.
Created by LTJG KyungNho "TACO" Kim
Reviewed by LTJG Robert A. Wainscott