WHAT DO WE NEED TO FIX?
TOPIC: PROTECTION READINESS.
DISCUSSION: Protection readiness is:
"The ability of personnel and equipment to efficiently, effectively, and safely perform their mission in the operational environment. This ability is determined by: self-discipline of individual soldiers; enforcement of standards by leaders; individual/collective training to standard; procedures/standards that are clear and practical; and support activities/operations that are to standard."
Director of Army Safety
Human error causes approximately 80 percent of all training and combat accidents. These mistakes happen for a number of reasons. Most can be avoided if proper risk management techniques are used. The sources of human error accidents can be traced to shortcomings in the five elements of readiness.
Individuals who know the standard and are trained to standard, but elect not to follow the standard cause 48 percent of the errors. Soldiers fail to follow the standard for a number of reasons: attitude, overconfidence, haste, fatigue (self-induced), and alcohol or drugs.
Eighteen percent of errors are due to leadership; that is, leaders that know the Army standard, but do not enforce it. Deficiencies in direct, unit command, and higher command supervisional techniques are all contributors. Leaders must be ready, willing, and able to enforce known standards.
Individual and leader failures account for two-thirds of all errors. These two readiness shortcomings are attitude-based and indicate a poor command climate for protection.
Training shortcomings cause 18 percent of all errors. Soldiers are often not trained to a known standard because of insufficient, incorrect, or nonexistent training on a given task at either the schools or unit, or the soldier does not have the required experience.
Unclear, impractical, or nonexistent standards and procedures cause 8 percent of all errors.
The last source of human error is support. Accounting for 8 percentof human error, support is defined as equipment or materiel that is improperly designed or not available; an unit has an insufficient number or type (MOS) of personnel; or has inadequate maintenance or facilities or services.
An infantry battalion had convoyed to an assembly area in preparation to be airlifted. The Air Force crew had difficulty getting the S-1 section's vehicles -- two HMMWVs with a water buffalo between them -- loaded and properly secured on the C-130. When the crews finished loading and securing the vehicles and cargo, they let the passengers board. "There were 10 of us, and there wasn't much room," says the NCOIC. "I warned my guys, 'Don't sit around these vehicles; I don't trust them.' I had a clerk move from between the water buffalo and the rear HMMWV. As the aircraft started to taxi, I woke another soldier who was lying in the rear of the forward HMMWV with his legs hanging out the rear of the truck and had him move his legs inside the vehicle." Just as the C-130 lifted off the ground, the water buffalo broke loose, rolled back, and slammed into the rear HMMWV, breaking its chains and causing both to slam into the rear ramp of the aircraft. The aircrew quickly alerted the flight crew. The pilot immediately set the aircraft back down and braked hard. Both loose vehicles rolled forward, slamming into the truck in the front of the cargo bay. "There was no serious damage to the vehicles," said the NCOIC, "but I was glad that our soldiers had not been between the trucks or trailers." |
LESSON(S): By recognizing a hazard and doing something about it, this NCO prevented almost-certain serious injury or death. Because he enforced the standards, this unit was able to go on and accomplish its mission. Most of the time, when leaders enforce standards by on-the-spot correction, the reward is just the personal satisfaction of knowing that we have done our job as leaders. We never know for sure that our action had a tangible return of protecting a soldier from injury or equipment from damage.
TOPIC: MOST PROBABLE HUMAN ERROR PROBLEM AREAS.
DISCUSSION: Research has found that there are seven frequent types of accidents which occur during the normal duty day, during training exercises, and during combat operations. These types of accidents are all caused by the five readiness shortcomings previously discussed. These readiness shortcomings have led to approximately 50 problem areas that have consistently caused accidents in exercises and operations in garrison, at the local training area, at the Combat Training Centers (CTCs), during large-scale training exercises, and in operations such as DESERT SHIELD and DESERT STORM. The most critical of these problem areas are:
- DRIVER
ERROR (WHEELED VEHICLES)
- Excessive Speed
- Following to Close
- CREW ERROR (TRACKED VEHICLES)
- Before/During/After Operation (PMCS) Checks
- Crew Coordination and Communication
- WEAPONS HANDLING ERROR
- Unauthorized Use or Handling of Duds
- Assembling/Cleaning/Disassembling (Improper Clearing)
- MAINTENANCE ERROR
- Improper Use of Tools and Equipment
- Improper Lifting
- MATERIEL HANDLING ERROR
- Improper Techniques
- Environmental Hazards
- COMBAT SOLDIERING ERROR
- Improper Parachute Landing Falls (PLFs)
- Traversing Terrain under Adverse Environmental Conditions
- Camouflaging
- NIGHT CREW ERROR (ROTARY WING)
- Scan
- Coordinate
- Excessive Speed
The following vignettes are examples of critical problem areas:
A DRIVER OF A HEMMT WAS PART OF A CONVOY. HE BEGAN SPEEDING TO CLOSE THE GAP BETWEEN HIS VEHICLE AND THE TRUCK AHEAD. NOT REALIZING THE CONVOY HAD STOPPED, HE REAR-ENDED THE TRUCK. |
DURING A ROAD MARCH, THE CONVOY CAME TO A SUDDEN STOP. THE HEMMT DRIVER HAD FAILED TO MAINTAIN AN INTERVAL LARGE ENOUGH TO MAKE A CONTROLLED EMERGENCY STOP AND COLLIDED WITH THE VEHICLE IN FRONT. |
AN M1A1 LOADER FAILED TO ENSURE THE HATCH WAS LOCKED OPEN BEFORE THE TANK MOVED. THE HATCH CAME DOWN WHILE THE VEHICLE WAS MOVING, INJURING HIS HAND. |
WHILE WAITING FOR THE TANK TO BE REFUELED, THE TC DECIDED TO MOVE THE MAIN GUN TUBE. HE FAILED TO CONFIRM THAT CREWMEMBERS WERE CLEAR BEFORE ELEVATING THE TUBE (POSITIVE COMMUNICATION). WHEN THE GUN WAS ELEVATED, THE BREACH STRUCK THE GUNNER IN THE KNEE, FRACTURING HIS KNEECAP. |
A SOLDIER WALKED FROM A HALTED CONVOY TO AN ABANDONED ENEMY FIGHTING POSITION AND RETURNED CARRYING AN MLRS BOMBLET. THE BOMBLET EXPLODED IN HIS HANDS, KILLING TWO SOLDIERS AND INJURING ANOTHER. |
A SOLDIER WAS CLEANING THE LOWER RECEIVER GROUP OF HIS M16A2 WITH A WEAPONS CLEANING BRUSH. THE BRUSH ENGAGED THE TRIGGER AND THE WEAPON DISCHARGED WOUNDING HIS LEG. THE WEAPON HAD NOT BEEN PROPERLY CLEARED. |
A SOLDIER WAS CUTTING A PLASTIC CABLE WITH THE KNIFE BLADE POINTING TOWARD HIM. WHEN THE CABLE SNAPPED, THE SOLDIER LOST CONTROL OF HIS ARM, AND THE KNIFE STABBED HIM IN THE EYE. |
WHEN LIFTING A TRAILER TIRE, A SOLDIER FAILED TO GET HELP, AND STRAINED THE MUSCLES IN HIS FOREARM. |
A SOLDIER FAILED TO DRINK SUFFICIENT FLUIDS IN THE EXTREME HEAT AND SUFFERED DEHYDRATION. |
WHILE PARTICIPATING IN A NIGHT TACTICAL PARACHUTE JUMP, A SOLDIER FAILED TO KEEP HIS FEET AND KNEES TOGETHER. WHILE HITTING THE GROUND, HE TURNED HIS ANKLE AND WAS LOST FOR THE REMAINDER OF THE TRAINING EXERCISE. |
A SQUAD WAS CONDUCTING A PATROL AT NIGHT IN ADVERSE WEATHER CONDITIONS. AS THE SOLDIERS WALKED DOWN A HILL, THEY SLIPPED ON THE WET ROCK. SEVERAL SOLDIERS WERE INJURED. THE PATROL LEADER FAILED TO MAKE ADJUSTMENTS FOR TERRAIN AND WEATHER CONDITIONS. |
WHILE ON TOP OF A LANCE MISSILE CARRIER (M667), A SOLDIER FAILED TO MAINTAIN THREE POINTS OF CONTACT. AS HE REACHED DOWN TO RETRIEVE CAMOUFLAGE NETTING, THE SOLDIER LOST HIS BALANCE, FELL OFF THE VEHICLE AND INJURED HIS BACK. |
DURING CLIMBOUT FROM A TAKEOFF ON A NVG TRAINING FLIGHT, BOTH THE PILOT AND THE COPILOT OF A UH-1H CHANNELIZED THEIR ATTENTION INSIDE THE AIRCRAFT TO TURN ON AND SET THE RADAR ALTIMETER (WHICH SHOULD HAVE BEEN DONE BEFORE TAKEOFF). NEITHER PILOT MONITORED ALTITUDE OR OBSTACLE CLEARANCE. AS A RESULT, THE AIRCRAFT WAS ALLOWED TO DESCEND INTO TERRAIN. |
WHILE ON A NIGHT-UNAIDED TACTICAL MISSION IN MARGINAL WEATHER, AT 100 FT ABOVE WATER, AN OH-58 PILOT IN COMMAND (PIC) ATTEMPTED TO FLY OUT OF A THUNDERSTORM. WITHOUT DIRECTING ASSISTANCE FROM THE COPILOT FOR INSTRUMENT CROSSCHECKS, THE PIC ATTEMPTED SEVERAL TASKS BY HIMSELF: RADIO CALLS, INSTRUMENT CROSSCHECKS, AND RESETTING FORCE TRIM. AS A RESULT, THE PIC BECAME TASK-SATURATED, DID NOT NOTICE THE LOSS OF ALTITUDE, AND ALLOWED THE AIRCRAFT TO DESCEND INTO THE WATER. |
LESSON(S): Commanders should focus prevention efforts on the most probable problem areas rather than all possible problem areas.



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