2008 Infared Program Assessment
Serious
Proper training/procedures
Coordination with maintenance personnel and
repair stations
Follow SOPs
Perform FCFs when applicable, coordinate with
maintenance technician; if possible take
maintenance technician on FCF
Improbable
Critical
Medium
Update the equipment/design for standardization
& Train to the new equip. & Maintain currency in
all A/C, Standardize fleet to same make aircraft
Improbable
Marginal
Medium
Post
Mitigation
Value
Medium
Medium
Low
Marginal
Marginal
Negligible
Remote
Improbable
Occasional
Mitigation
Achieved?
Yes or No
Outcome
High
Install and utilize satellite up-link capability
Additional Local Mitigation
Medium
Medium
Coordinate with all staffs on modifications prior to
the installations, refresher (preseason) mission
training and equipment calibration
Critical
High
Update the equipment/design for standardization,
train to the new equipment, maintain currency in
all A/C, standardize fleet to same make aircraft
Remote
Serious
Training, Pre and post season avionics checks
High
Severity
Outcome
Medium
Keep your cell phone handy (and charged up).
Have the required 2 "D" cell flashlight working
and charged. Have a spare hand-held VHF-AM
radio. Training on emergency procedures.
Medium
Non-Standard Aircraft
Mitigation
Serious
Not performing Functional Check Flight (FCF)
before releasing aircraft after maintenance
(when applicable)
Post Mitigation
High
Severity
Critical
Critical
Critical
Negligible
Critical
Marginal
Catastrophic
Marginal
Undocumented open discrepancies
Catastrophic
Remote
Occasional
Maintenance providers (lack of skilled
technicians/repair stations)
Frequent
Nitrogen servicing (Improper technique), not
wearing proper PPE and ultimately causing
personal injury
Frequent
Increased exposure to land/take-off to hand-off
immagery
Frequent
Electrical Interface (A/C Mods)
Frequent
Non-Standard (type/lay-out/location) of
equipment
Occasional
Erroneous read-outs from the equipment
Occasional
Loss of electrical power
Remote
Avionics
Hazards
Frequent
Sub-systems
Likelihood
Pre Mitigation
Likelihood
System: Flight Operations
Serious
Medium
Serious
Critical
Negligible
Catastrophic
Remote
Frequent
Occasional
IR Equipment
Standarization
1
Critical
Medium
Marginal
Improbable
Maintenance
Completed 2008
System: Flight Operations (cont.)
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Mitigation
Achieved?
Yes or No
Outcome
Additional Local Mitigation
Medium
Low
Low
Additional Local Mitigation
Medium
Severity
Negligible
Negligible
Catastrophic
Catastrophic
Likelihood
Remote
Observe fueling; confirm loading.
Improbable
Observe fueling; sump fuel as required.
Improbable
Testing and relocation of system components to
correct the interference; for future modifications
include testing for interface interference.
Improbable
Outcome
Serious
Catastrophic
Correction to existing modification; coordination
and testing of future modifications.
High
Improper fuel loading
Fuel
Mitigation
Serious
Marginal
Frequent
Bad Fuel
Remote
Modifications
Hazards
Post Mitigation
Serious
Severity
Frequent
Increased exposure to mid-air collision due to
necessity of turning off TCAS during mission
because of interference between TCAS and IR
equipment.
Sub-systems
Catastrophic Catastrophic
Likelihood
Effects of modifications that decrease aircraft
capabilities causing additional crew
workload/exposure/performance issues(fuel
burn, flight planning)
Remote
Pre Mitigation
System: Environmental
Post
Mitigation
Value
Outcome
Serious
Serious
Medium
Medium
Medium
Medium
Severity
Critical
Critical
Marginal
Catastrophic
Marginal
Critical
Likelihood
Occasional
Improbable Occasional
Remote
Improbable
Remote
Outcome
High
High
Medium
Serious
Medium
Severity
Serious
Moderate (plus) turbulence
Critical
Critical
Topography
Improbable Occasional
Marginal
Critical
Catastophic
Marginal
Preflight briefing, PIREPS, Fly different altitude or
out of area
Probable
Maintain Situational Awareness, File IFR, Train
and remain proficient
Frequent
IR Technician reports, PIREPS, Debrief other fire
air ops crews (lead plane, airattack, etc…) Fly out
of column
Icing equipment (aircraft) failing
Contolled flight into terrain
2
Preflight checks of icing equipment, proper
maintenance of icing equip.
Pressure to complete the mission regardless of
the Wx
Smoke Column
Mitigation
Just say NO! Education/Training of the ground
personnel regarding go-no-go situations. Preflight
planning. Give options.
Flying in bad weather
Weather
Post Mitigation
Preflight planning;Just say NO (accept the fact
that the mission cannot be completed)! PIREPS,
Call local area, change priority of mission flight,
Equip monitoring (i.e., Wx Radar, Storm scope,
XM radio, etc.)
Remote
Hazards
Occasional
Sub-systems
Likelihood
Pre Mitigation
Completed 2008
System: Airports
3
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Outcome
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Medium
Additional Local Mitigation
Medium
Medium
Medium
Severity
Critical
Critical
Critical
Critical
Critical
Catastrophic Catastrophic
Catastrophic
Critical
Critical
Catastrophic Catastrophic
Likelihood
Remote
Improbable Improbable Improbable Improbable
Improbable
Improbable
SA, CRM, Communication, Training of support
personnel
Improbable
SA, CRM, TCAS, Communications, A/C lighting,
training, parking tenders, familiar with the airport
Improbable
SA, communicattions, CRM, UNICOM, PIREPS,
aircraft lighting, TCAS,
Improbable
TCAS, SA, CRM, Training, Communications,
Chose another airport
Remote
Preflight planning. Performing approach briefings,
training/profeciency, current charts, CRM, Do
NOT land if conditions are such that it is unsafe to
make a safe visual approach and landing
Remote
High
Serious
Medium
Serious
Serious
Serious
Outcome
Severity
Catastrophic
Critical
Critical
Critical
Critical
Catastrophic Catastrophic
Serious
Unqualified Personnel (ground/ramp or agency)
leading to misfueling, hazardous parking,
leading to damage to the aircraft or injury to
personnel
Preflight planning. Performing approach briefings,
training/profeciency, current charts, CRM
High
Support
Personnel
ATIS UNICOM, visual cues, preflight planning
Serious
Incursions on the runway and parking areas
NOTAMS, ATIS, Local traffic, Tower, UNICOM
Serious
No Tower-pilots operating without radio or
wrong frequency-Possible midair
Perform performance calculations/preflight
planning, NOTAMS
Serious
Congested, task saturation of controller and/or
pilots/crew, midair possibility
Check the AFD, NOTAMS, local traffic, Tower,
Serious
Occasional
Remote
Not having an IAP leading to a CFIT
Remote
Airspace
Unfamiliar with the missed approach
procedures (MAP), leading to CFIT
Remote
IAP
Lighting systems are inop/inadequate leading to
a short landing/go-around, CFIT
Remote
construction hazards/equipment
Perform fly-by, contact personnel on ground to
check field, air-drop, install gun on nose of
aircraft
Catastrophic
Runway length is not appropiate for the
aircraft's capabilities
Preflight planning, instrument approaches, refusal
of delivery point, landing during daylight hours
Catastrophic Catastrophic
Limitations
Mitigation
Critical
Airport surface condition is not conducive to
landing resulting in damage to aircraft
Post Mitigation
Critical
Collision with wildlife on the runways leading to
damage/injury of personnel or property
Occasional Occasional
Location
Remote
Mountainous Terrain-Unfamiliar, leading to
CFIT,
Occasional Occasional
Hazards
Occasional Occasional
Sub-systems
Likelihood
Pre Mitigation
Completed 2008
System: Personnel
4
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Outcome
Low
Medium
Medium
Medium
Low
Medium
Additional Local Mitigation
Low
Low
Low
Low
Low
Severity
Marginal
Negligible
Critical
Marginal
Marginal
Negligible
Negligible
Negligible
Negligible
Negligible
Likelihood
Negligible
Critical
Catastrophic Catastrophic
Critical
Critical
Catastrophic
Frequent
Frequent
Frequent
Frequent
Remote
Serious
CRM, communications, training and education,
take additional time off to recover, see the
Doctor, support from other factions
Remote
Medium
Flying with known physiological conditions
leading to degraded decisions, and hazardous
mistakes
Remote
Critical
Qualified and mission profecient personnel
operating/maintaining the equipment.
Remote
Serious
Unqualified IR technicians leading to damage to
aircraft and/or personnel
Occasional
High
Critical
Qualified and mission profecient personnel flying
the aircraft, adequate staffing levels.
Remote
Critical
Unqualified personnel flying the aircraftResulting in: CFIT, emergency procedures,
incidents, accidents
Improbable
Probable
CRM & teambuilding training for all IR systems
staff; open communications; pre/post season
meeting to include all factions of IR systems staff;
AARs; clearly defined policies, procedures & roles
(Infrared Operations Guide).
Logisitical issues with non-co-located personnel
leading to additional exposure of
flight/landings/take-offs ultimately leading to
fatigue/stress/damage/injury to the aircraft and
or personnel
Improbable
Personnel dissention between factions of the IR
"System" leading to stress and anxiety, resulting
in degraded decision making and ultimately
possible damage/injury to aircraft or personnel
Stress and fatigue from insufficient staffing
levels leading to the can-do/will-do attitudes
Improbable Improbable Improbable
High
Co-locate personnel at single base/unit, RON at
single location
Occasional
Outcome
High
High
Serious
High
High
High
Staff and budget at appropiate levels, support the
crews decision to manage workloads that are
commencerate with the staffing levels
Mission pressure from other factions
(dispatch/fire teams), leading to fatigue, anxiety,
harried decisions leading to hazardous
mistakes
Training
Medical
Severity
Education/training, attending the IMT/dispatch
meetings, ensuring open communication between
IMTs, dispatch and coordinators, AARs
(debriefings)
Critical
Training, CRM, Support of crew decisions, neutral
person (arbitrator) to share
issues/disputes/conflict resolution
Mission pressure from management, leading to
fatigue, harried decisions leading to hazardous
mistakes
Critical
Education/Training, CRM, communications,
tailgate sessions/AAR (after action review,
debrief)
Trans-cockpit authority gradient, junior
crewmember not confident in speaking up
about a hazard
Frequent
Training, CRM, sleep-power naps, support of
crew decision to decrease duty day
Fatigue-Acute, errors due to fatigue (SA)
Occasional Frequent
Scheduling management (reduce duty hrs and/or
flight time), sufficient staffing levels, sleeppower naps, Training, CRM, support of crew
decision to decrease duty day,
Fatigue-Cronic, errors due to fatigue (SA)
Human Factors
Mitigation
Remote
Hazards
Post Mitigation
Occasional
Sub-systems
Likelihood
Pre Mitigation
Completed 2008
System: Personnel (continued)
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Mitigation
Achieved?
Yes or No
Outcome
Additional Local Mitigation
Serious
Medium
Additional Local Mitigation
Medium
Likelihood
Severity
Critical
Critical
Marginal
Leadership training, participation in pre/post
meetings of IR system staff.
Remote
Education and training; implement CRM; knowing
and employing personnal limitations
Occasional
Use of shuttles, most alert crewmember drives
Remote
Outcome
Critical
Catastrophic
Lack of skilled leadership/managerial skills in
supervisors and upper management leading to
stress/anxiety of crews resulting in errors and/or
degraded decision-making skills.
Critical
Management
Serious
Severity
Occasional
Incidents or errors caused by physiological
challenges (circadian rhythem deviations,
vision, fatigue)
Night Ops
Mitigation
High
Likelihood
Accidents while driving to lodging after mission
completion late at night.
Post Mitigation
High
Hazards
Frequent
Sub-systems
Probable
Pre Mitigation
System: Policy
5
Post
Mitigation
Value
Outcome
Low
Low
Negligible
Remote
Medium
Low
Negligible
Severity
Negligible
Clearly defined policies, procedures, and roles
(Infrared Operations Guide); Have IR Ops Guide
approved by line officer authority.
Marginal
Improbable
Critical
Occasional
Procedures that do not reflect the entire IR
system leading to ambiguity in the decisions
Ill-defined policy that need to be made, adding stress and
and procedures anxiety to the crew's workload ultimately leading
to hazardous decision making with possible
damage/injury to aircraft or crew
Likelihood
Qualified and mission proficient personnel flying
the aircraft, adequate staffing levels.
Remote
Training, CRM, sleep-power naps, support crew
decision to decrease duty day
Improbable
Outcome
High
Critical
High
Critical
Unqualified personnel flying the aircraftResulting in: CFIT, emergency procedures,
incidents, accidents
Scheduling management (reduce duty hrs and/or
flight time), sufficient staffing levels, sleeppower naps, training, CRM, support crew decision
to decrease duty day
Duty Day
Qualifications
Mitigation
Serious
Critical
Fatigue-Acute, errors due to fatigue (SA)
Post Mitigation
Serious
Frequent
Severity
Fatigue-Cronic, errors due to fatigue (SA)
Frequent
Hazards
Occasional
Sub-systems
Likelihood
Pre Mitigation
Completed 2008
System: Flight Operations
6
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Additional Local Mitigation
Medium
Low
Low
Serious
Low
Medium
Medium
Outcome
Severity
Negligible
Negligible
Marginal
Remote
Improbable
Critical
Catastrophic
Maintain situational awareness; training; file IFR
Occasional
Maintain currency and proficiency; Do not allow
non-current crewmembers to fly missions
Catastrophic
Negligible
Likelihood
Improbable
Outcome
Filing IFR; preflight planning; if you encounter
IMC inadvertantly fly instruments and exit IMC
conditions
Improbable
Catastrophic
Catastrophic
Ensure clear communications prior to drop--no
drop if no communications; follow established
drop procedures
Improbable
Critical
Marginal
Remote
Controlled flight into terrain (CFIT)
Carry back up hand-held radio in the survival kit;
cell phones available
Improbable
Occasional
Remote
Lack of currency and proficiency
Improbable
Instrument
Flying
Inadvertant flight into IMC Conditions
Low
Catastrophic
Negligible
Chance of striking person or property with drop
tube because of a lack of clear communications
during air drop
Communication
High
Frequent
Losing radio communications
Education and training; implement CRM;
Recognize and operate within personal
limitations.
Low
Negligible
Incidents or errors caused by physiological
challenges (circadian rhythm deviations,
impaired vision, fatigue)
Serious
Severity
Occasional
Night Ops
Check aircraft data cards and pilot qualification
cards
Medium
Likelihood
CWN/Other A/C
Use of uncarded aircraft and crew. Failure to
follow policy/safety recommendations resulting
in use of pilots who are not proficient or current
for the mission. Using aircraft that may have
exceeded inspection and or component
replacement deadlines.
Mitigation
Serious
Hazards
Post Mitigation
Medium
Sub-systems
Remote
Pre Mitigation
Completed 2008
System: Flight Operations (continued)
Post
Mitigation
Value
Mitigation
Achieved?
Yes or No
Outcome
Additional Local Mitigation
Catastrophic
Medium
Training, Situational Awareness, CRM, clear and
positive air to ground communications, IAPs, Use
radio altimeter, Determine criteria for go-no go
situations/decisions. Drop only during clear VFR
conditions.
Serious
Medium
Severity
Ensure crew is adequately trained. Maintain
Situational Awareness. Be sure communications
are clear between air-ground personnel. employ
data transfer via satellite, No communications-NO
drop
Catastrophic
Catastrophic
Likelihood
Ensure crew is adequately trained. Maintain
Situational Awareness. Be sure communications
are clear between air-ground personnel.
Improbable
Improbable
See and avoid, Use TCAS
Remote
Outcome
Serious
Serious
Catastrophic
Catastrophic
Catastrophic
File IFR, TCAS, Situational awareness, visual
scanning
Serious
Severity
Remote
Non-radar/uncontrolled airspace-unknown
aircraft, possible mid-air collision
Mitigation
Serious
Likelihood
Congestion, mid-air collision potential
Post Mitigation
High
Hazards
Remote
Sub-systems
Remote
Pre Mitigation
Low/slow flight profile in delivery of air drop
resulting CFIT
7
Catastrophic
Catastrophic
Delivery of
Imagery
Air drop tubes striking an object or person
causing damage or personnal injury
Probable
Medium
Medium
Catastrophic
Catastrophic
Improbable
Improbable
Hot hand-offs resulting serious injury or death
Remote
Airspace
Completed 2008