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TESTIMONY OF 
 REAR ADMIRAL RICHARD E. BROOKS
UNITED STATES NAVY
COMMANDER, NAVAL SAFETY CENTER

 BEFORE THE
COMMITTEE ON ARMED SERVICES
UNITED STATES HOUSE OF REPRESENTATIVES

REGARDING DEPARTMENT OF THE NAVY 
AVIATION SAFETY PROGRAM

FEBRUARY 11, 2004

Mr. Chairman and distinguished members of the House Armed Services Committee, I am Rear Admiral Dick Brooks, Commander of the Naval Safety Center. Together with my Marine Corps colleague, Brigadier General Helland, I am here to present the current state of Naval aviation safety. 

As we look to our past performance in aviation safety we have made significant reductions in our mishap rates over the past five decades. To put this in perspective, in 1954 naval aviation (this includes the Navy and Marine Corps) was averaging fifty-four mishaps per one hundred thousand hours; as of the end of FY 03 the rate was 2.42. Truly a dramatic decline but it also represents historical performance.  There is a common theme however between what we accomplished many years ago and what we are working to achieve today. Our aviation efforts then, as today, were and are designed to save lives, our most precious asset, preserve resources in the form of the valuable equipment entrusted to our men and women, and enhance our combat readiness. 

TREND ANALYSIS

By defining aviation mishap rates as those number of mishaps per one-hundred thousand flight hours, I believe it is important to focus on historical trends over time rather than individual years in isolation. Such a trend analysis provides tangible evidence of the existence of a viable aviation safety program.  A safety program that always faces challenges due to the high-risk nature of flight operations, but has also shown many successes.

It is equally important to conduct an analysis of mishap characteristics in order to provide a focus for those areas required for correction and intervention. While today we are at an all-time low for mishap rates, we are not content with historical successes and are continually working to reduce mishaps even further. To accomplish this, the first step is a review and analysis of the causes of our mishaps. As we look back over the past five years, 83 percent of our class A flight mishaps were due to human error (either aircrew, maintenance personnel or supervisory). In addition, 36 percent involved some form of material failure. (Since mishaps generally involve multiple factors these percentages add up to more than 100 percent.)  Once we analyzed the causes of our mishaps, we worked to identify those areas that would have the largest impact on reducing our number of mishaps. These include leadership, training and education, resources, and technology (both what is available today and emerging in the future).

MISHAP DATA COMPARISON

Before I discuss some of our accomplishments and programs in these areas, let me first provide an overview of how successful our safety programs have been. The following is what the Navy has saved in terms of Class A aviation flight mishaps and aviation fatalities, and the associated cost savings. There are many ways to compare these savings and I've chosen ten, five, and one year comparison periods. First a comparison of the ten-year period from FY94-03 to the period from FY84-93: During FY94-03 there would have been 106 additional class A flight mishaps, 132 additional fatalities and an additional $3B in cost had the mishap and fatality rates in FY94-03 showed no improvement over FY84-93. 

Looking at a more recent five-year comparison for the same statistics, comparing FY99-03 to FY94-FY98 we "saved" 9 class A flight mishaps, 14 lives and $541M. Looking at the last two 12-month periods (3 Feb 2002 - 3 Feb 2003 vs. 3 Feb 2003 - 3 Feb 2004) the Navy had 6 fewer class A flight mishaps, 13 fewer fatalities, and a savings of $287M. These trends indicate our aviation safety program is effective and having a positive impact where it counts most - savings lives and preserving valuable equipment and resources. 

LEADERSHIP, EDUCATION, AND TRAINING

In my opening remarks I mentioned leadership, education and training as key focus areas. In January 03, Commander, Naval Air Force, developed and instituted an Operational Risk Management (ORM) and Fundamentals Campaign designed to prevent and reduce aviation mishaps. Included in this campaign are the following steps:  1) Each aircraft type/model/series established a standing Operational Risk Management review board to conduct community-wide risk assessments, with a focus on human factors to address human error; 2) Each senior community type wing commander established a monthly publication/message from the senior community type wing to promulgate identified hazards and available risk controls, and to heighten safety and ORM awareness of community issues; 3) Type wing commanders review community-wide flight briefs and standard operating procedures on a routine basis, and revise them as necessary; 4) All deployable aviation squadrons complete a formal Naval Safety Center-sponsored cultural workshop during the at home period, with non-deployable units completing a workshop once every two years; and finally, 5) All aviation squadrons complete Command Safety Assessment (CSA) and Maintenance Climate Assessment surveys (MCAS) offered by the School of Aviation Safety in Monterey, Calif. 

Having all squadrons measure their existing safety climate is one of the key drivers of the CNAF ORM Fundamentals Campaign. Both the CSA aircrew and MCAS maintainers' surveys are taken online, and offer commanding officers a web-based tool to provide direct feedback of the perceptions of safety within the organization. These tools were developed through research funding at the Navy and Marine Corps School of Aviation Safety at the Naval Postgraduate School in Monterey. To date more than 75,000 service members from more than 700 commands and organizations have participated in CSA and MCAS. Further in the area of education and training, the School of Aviation Safety annually educates approximately 700 Navy, Marine Corps, and Coast Guard officers. Educating our aviation leaders, coupled with safety research, are critical elements the school provides for proactively approaching mishap reduction. 

In response to Secretary of Defense Rumsfeld's memorandum of 19 May, 2003, which challenged us to, "Reduce the number of mishaps and accidents rates by at least 50 percent in the next two years" we have taken additional steps. In September 2003 we established the Navy and Marine Corps Safety Council with an Aviation Safety Committee to address aviation specific areas and look for new and innovative ways to reduce mishaps. The Naval Safety Center and this committee developed an aggressive aviation mishap-reduction plan that is currently executing a Plan-of-Action-and-Milestones (POAM) to achieve the 50 percent reduction goal. The plan emphasizes leadership, communication, and accountability: All critical factors for meeting mishap-reduction goals.

This plan's guiding precepts include an Operational Risk Management-based assessment of high-risk evolutions that result in questionable readiness and tactical returns, and eliminating any cultural mindset that mishaps are the cost of doing business. As MGEN Hess mentioned in his statement we are also fully engaged in the DSOC process and I serve as the Vice Chair of the Aviation Task Force.  

Once again in the area of education and training, all Navy and Marine Corps squadrons are required to have safety surveys with periodicity determined by deployable status. A safety survey consists of a team of Naval Safety Center professionals who analyze a squadron/unit, scrutinizing operational, training, maintenance, and administrative procedures and identifying the unit's strong points as well as where they need improvement.  Mandatory safety culture workshops also will be instituted with a frequency as that of squadron surveys. Culture workshops are comprised of a smaller team than a safety survey (usually two officers and one senior enlisted sailor). This team spends one and a half days immersed within a squadron's normal operational routine observing normal procedures, conducting spontaneous interviews, and holding three or four group discussions broken up by rank. As with the more in-depth safety survey the result is a written and verbal debrief to the CO of the strengths and weaknesses of the command as well as recommendations of how to address any potentially unsafe trends.

HUMAN FACTORS

As aircraft have become more reliable, humans have played a progressively more important causal role in aviation accidents. Consequently, the Naval Safety Center Aeromedical Division is working to address the highly complex issue of human error. In that regard, a Human Factors Analysis and Classification System (HFACS) has been developed and subsequently adopted for the Navy and Marine Corps as an accident investigation and analysis tool. The Aeromedical Division, Naval Safety Center, uses this as an analytical tool for our existing Aviation Mishap Database. By aligning human causal factors within the HFACS taxonomy, we can address trends in human performance as related to human error, possibly associated with perception, adverse mental or physiological states, or simply skill-based in nature. Taking the taxonomy out of the cockpit (looking at "other than aircrew causal factors"), we are able to analyze supervisory and/or organizational influences, which may have induced or influenced the mishap. This information will be used to analyze human performance and related causal factors to help understand--and ultimately reduce-mishaps.

AVIATION MAINTENANCE

In April 2003, The Naval Safety Center instituted an annual Aviation Maintenance Safety Conference to make sure maintenance initiatives and procedures are uniformly practiced throughout the Navy. These annual conferences provide a fleet-wide forum for promulgating and sharing aviation maintenance safety information. The goal is to improve readiness and mission effectiveness through increased awareness of mishap-reduction techniques, safety education, clarifying the Naval Aviation Maintenance Program (NAMP), ensuring compliance with SOPs and Navy Occupational, Safety and Health initiatives and regulations.

LEGACY AND AGING AIRCRAFT

We continuously embrace emerging technologies and innovative training for aviators and maintainers as we strive to meet the 50-percent mishap-reduction goal, and to get the most from our aircraft. To date, despite ages of many different Navy and Marine Corps aircraft, the statistics are a testimony to our many successes in safely maintaining and flying our legacy aircraft. Rigid inspection cycles-monthly, quarterly, annually, and required inspections based on engine hours-result in fully mission-capable and safe operation of our aircraft, despite their age.

It is often not aircraft age that necessarily intensifies aircraft maintenance, but shipboard operations-general exposure to the elements, and the stresses of arrested carrier landings and launches-which pose challenges to maintaining aircraft whether they are new in the inventory or are legacy platforms. However, our strict standards keep them safely flying, or on the ground if the situation warrants.

To specifically address the issue of aging aircraft Naval Air Systems command (NAVAIR) stood up an Aging Aircraft Integrated Process Team (AAIPT). The program's purpose is to develop effective solutions to combat the effects of aging aircraft on operational readiness. The scope of this effort includes analyses of failure modes and sustainment issues. It involves coordination with multiple competencies and program offices to focus on systems across the NAVAIR spectrum. The team is tasked with identifying aging problems, quantifying the costs/risks associated with each problem through application of cost tools, and providing information to NAVAIR Program teams for implementing effective solutions. The AAIPT also facilitates integration of other promising, developing technologies.  Additionally, this AAIPT serves as a primary member on the Joint Council on Aging Aircraft, which was founded in September 2002. The council focuses on joint aging aircraft, product-oriented issues and process improvements, which capitalize on, and optimize, the effectiveness of the Agencies Aging Aircraft Effort through leveraging/sharing knowledge, joint projects/program and executive advocacy. Membership includes all uniformed services, along with the FAA and NASA. The products these teams deliver concentrate on monitoring and operating legacy aircraft to ensure that cost/risk benefits are balanced with safety and readiness.   

TECHNOLOGY

Shifting to current and emerging technologies, some longer-term initiatives include studies of successful civilian programs and converting them to military use such as Military Flight Operations Quality Assurance, or MFOQA, which will assist our on-going programs for analyzing human error with digital flight and maintenance data capture-and-display for mishap prediction and intervention and scenario realization training. MFOQA is particularly noteworthy, as it has proven successful during recent flight demos with F/A-18 fixed wing, and SH-60 rotary, aircraft. MFOQA allows for rapid download and playback for animated Windows environment; it offers pilot debrief and maintenance control download information after every flight.   Data is infinitely selectable with high fidelity animation and requires minimal aircraft hardware. It has a proven capability and was funded as a demonstration project for FY 2004 and 2005.

We are also continuing research for new programs and emerging technologies such as the Tactile Situation Awareness System (TSAS), which is a tactile vest with nodes that accurately make a pilot aware of aircraft movement and motion. We also are working on an emerging Operational Risk Management Assessment System (ORMAS), which is a conceptual risk-assessment tool that relies on existing data to determine the degree of risk a command faces in different situations, based on known risk factors.  Still in its infancy, we believe it will eventually be capable of identifying training risks, using data analysis to look at mishap predictors and safety-related leading indicators (operational and personnel tempo, flight hour excesses or shortages, qualifications and their currency, cultural factors, maintenance and manning strengths or weaknesses, and training deficiencies).  

One other technology I want to mention is our project to Web enable the current mishap-reporting and data-collection system in use at the Safety Center. Our current system is Naval Safety Center-centric, time-consuming, and labor-intensive. As a result, personnel at the Safety Center must input the majority of safety data, process data queries and conduct the analysis of our extensive mishap data. Our new web based system, the Web-Enabled Safety System (or WESS), will put the reporting system on the WEB for all authorized Navy, Marine Corps and DoD customers.  Aviation commands will have the ability to directly input mishap data into WESS and use an extensive library of canned and ad hoc reports to query the system and develop effective and timely mishap avoidance strategies. This web-based system will truly streamline our safety business process and put timely and relevant information in the hands of those who need it most.

RESOURCES

As for resources and naval aviation's commitment to safety, the funding line for safety-related systems has also increased. Recognizing the need to maintain warfighting capability in concert with safe operation, the DoN has invested in safety-related improvements and activities to support our Naval Aviation. To complement a timely recapitalization program that encompasses more than $11B a year in procurement and associated RDTEN, the Navy has provided more than $1.4B in FY05 to target specific improvements in the safety and reliability of our legacy fleet. In addition to safety investments in collision avoidance and ground proximity warning systems, other funded priorities include such programs as EA-6B Outer Wing Panel and Center Wing Section replacements, P-3 Special Structural Inspections, and Center Barrel Replacements for the F/A-18, as well as numerous communication/avionics and engine upgrades across a myriad of platforms. Total investment in this area is planned to exceed $6B over the FYDP.

CONCLUSION

Mr. Chairman, we believe naval aviation's overall safety programs and safe operating practices are a "natural consequence" of a winning organization that is dedicated to safe operations. Our trends indicate such, and our efforts continuously focus on prevention. Our safety culture does not accept loss of life or equipment, or maintaining the status quo, as a cost of doing business. Rather, we approach aviation safety with the belief that one mishap is too many and that all mishaps are avoidable. Initiatives like those I have described and our push to find and adapt other programs that will further reduce mishaps will ensure "Safety First, Mission Always" and maintain a naval aviation culture of safety through readiness. Thank you again for the opportunity to appear before you today.