Continue contractual requirements commensurate Maintenance programs have not been modified Sub-systems
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System Safety Assessment - Heavy Airtanker Program Heavy Airtanker Program System - Airworthiness Additional Local Mitigation Additional Local Mitigation Post Mitigation Value Outcome Mitigation Achieved? Yes or No Medium Medium Medium Mitigation Achieved? Yes or No Additional Local Mitigation Mitigation Achieved? Yes or No Medium Additional Local Mitigation Mitigation Achieved? Yes or No Severity Marginal Marginal Marginal Likelihood Remote Improbabl e Marginal Perform F&DT analysis IAW 25.571 for the tanker mission and require inspection programs and life limits based on that analysis. Remote Significant exposure to airframe stresses in the firefighting mission profile poses additional fatigue factors that shorten airframe life expectancy. Remote Outcome High Medium Perform prescribed engine maintenance and overhaul. Reduce overhaul intervals. Serious Engine Failures Serious Severity Catastrophic Critical A) Maintain a load monitoring system, and Incorporate the latest inspection technology. B) Maintain routine (daily) inspection program. Catastrophi Marginal c Airframe Fatigue Damage Likelihood Load limit excedence Frequent Continue contractual requirements commensurate with industry standards required by FAR 25.571 for aircraft continued airworthiness. Incorporate the latest inspection technology. Maintenance programs have not been modified to compensate for structural loads experienced in the fire mission. Continued Airworthiness Mitigation Remote Hazards Post mitigation Frequent Sub-systems Occasional Pre Mitigation Heavy Airtanker Program System - Contract Process Outcome Medium Post Mitigation Value Severity Implement airtanker modernization and evaluation criteria in contracts including but not limited to: performance, sustainable airframes, contractor offered technology, damage tolerant design and technology. Critical Mitigation Likelihood Post mitigation Remote Outcome High Severity Contract Incentive Aging of the airtanker fleet includes 50 year old aircraft Catastrophic Hazards Frequent Sub-systems Likelihood Pre Mitigation Heavy Airtanker Program System - Mission Environment Post Mitigation Value Outcome Serious Medium Severity Critical Critical A) Ensure high level recon is completed prior to commencing low level flight. B) Manage radio communication. C) Proper aircraft configuration. D) Reduce exposure time in low level. E) Consult sectional chart/hazard map, consult ground personnel/other aircraft. F) Request a leadplane. Occasional Conduct simulator refresher training. Demonstrate IFR capability during FS checkride. Remote Outcome High Severity Catastrophic Mitigation High CFIT due to low level operations Frequent Flight Profile Catastrophic Lack of proficiency/experience for IFR flights. Likelihood Hazards Probable Sub-systems Likelihood Post mitigation Pre Mitigation Heavy Airtanker Program System - Facilities 1 Outcome Medium Post Mitigation Value Severity Ensure micro motion meters have been calibrated. Vendor and government personnel review mixing procedures. Marginal Mitigation Likelihood Outcome Severity Post mitigation Remote Overloading and mixing errors Serious Tanker Bases Hazards Critical Sub-systems Occasional Likelihood Pre Mitigation Revised 2011 Heavy Airtanker Program System - Human Factors Additional Local Mitigation Additional Local Mitigation Post Mitigation Value Mitigation Achieved? Yes or No Outcome Mitigation Achieved? Yes or No Mitigation Achieved? Yes or No Additional Local Mitigation Serious Serious Serious Additional Local Mitigation Mitigation Achieved? Yes or No Severity Critical Critical Likelihood Occasional Critical Address airtanker pilot training and proficiency to reduce frequency of accidents. Aircraft performance planning for successful outcome in a high rate of descent, level off, and climb out profile. Occasional Provide additional food and administrative support. Adhere to duty limits. Improve the management model for national deployment of the fleet. Add more airtankers. Occasional Outcome High Mitigation High Severity Catastrophic Critical Post mitigation A) Vendors have instituted training programs such as CRM, risk management, and flight safety with the intent to standardioze cockpit procedures. B) Increase the scope and complexity of the NAFA program, enhance the McClellan training center for fire environment. High Target fixation and tactical maneuvering errors. Catastrophic Mission Induced Stress The limited number of airtankers has resulted in more frequent travel and change of duty station, which increases stress and has a negative effect on crew quality of life. Probable Pilot Proficiency and Lack of fire mission training and Lack of proficiency flight time. Training Frequent Hazards Probable Sub-systems Likelihood Pre Mitigation Heavy Airtanker Program System - Policy, Procedure, and Doctrine Administration Post Mitigation Value Outcome Medium Medium Severity Marginal Likelihood Marginal Enforce QA program for improved oversight of the contracted fleet. Remote Provide program oversight to assure risk is at lowest practical level. Improve crew risk management. Remote Mitigation High Outcome Post mitigation High Severity Critical Operator's lack of quality assurance and inspection program results in non compliance with contract airworthiness standards. Critical Quality Assurance and Inspections "Can do" philosophy has fostered aviation programs with high risk operations. Probable Agency Culture Hazards Probable Sub-systems Likelihood Pre Mitigation Heavy Airtanker Program System - Technology Outcome Low Post Mitigation Value Severity Develop new technologies for the mission such as glass cockpit, synthetic vision, electronic target identification, lazer targeting, etc. Negligible Mitigation Likelihood Post mitigation Occasional Outcome Medium Severity HAT underutilized resulting in task saturation Marginal Human Aided Technology Hazards Likelihood Sub-systems Occasional Pre Mitigation Heavy Airtanker Program System - Training 2 Outcome Medium Post Mitigation Value Severity Increase the scope and complexity, and fund the development and implementation of fire simulation training in the flight environment for contract and agency personnel. Marginal Mitigation Likelihood Post mitigation Occasional Severity Outcome Serious Flight crew lacks currency / proficiency in fire environment. Critical Fire Mission Training Hazards Occasional Sub-systems Likelihood Pre Mitigation Revised 2011
