Risk Management Magazine

Search for Articles

Latest Articles

Looking Forward

Looking Forward

Reversing the fourth-quarter aviation safety trend

Looking Forward


Commanding General
U.S. Army Combat Readiness Center
Fort Rucker, Alabama


The Army closed fiscal year (FY) 2019 with the fewest manned flight fatalities on record, a reflection of the Aviation Branch’s tenacious approach to safety and commitment to continuous improvement.

Overall, aviation Class A-C mishaps continued a downward trend during FY19, with a nearly 40 percent reduction from FY18. Class A-C flight mishaps (58) and rates (5.54 per 100,000 flying hours) were the lowest in the past 10 years. Due to Armywide emphasis, ground taxi mishaps fell from four Class A’s in FY18 to zero. Most importantly, aviation mishap fatalities decreased from six in FY18 to two. These achievements conclude the safest five-year period in Army Aviation history and place us on a solid foundation as we begin the new decade.

However, we still have work to do. In the first quarter of FY20 alone, the Army experienced four Class A mishaps with five resulting fatalities. This figure exceeds the total number recorded in FY19, and Class A mishaps are on track to surpass each of the past five years. This difficult start to the new year reminds us how quickly our environment can change and the need for continuous, ruthless adherence to risk management protocols at all echelons of our formations.

The U.S. Army Combat Readiness Center remains steadfast in its role of leading Armywide loss prevention efforts and serving as your enduring “backside” support. We continue to disseminate the latest mishap summaries, trend analysis, aviation near miss brief and other safety materials to your safety officers, as well as placing them on our website (https://safety.army.mil). Our goal remains the same — to get in front of mishaps through predictive analysis and drive them to zero.

With that in mind, I ask each of you to begin turning your focus to an alarming trend in Army Aviation that has, unfortunately, proven reliably consistent. The graph below depicts Class A mishaps relative to flight hours, by quarter, for each of the past five years.

As you can see, Class A mishaps have almost doubled during the fourth quarter of each fiscal year (with the exception of one) since FY15. In other words, we are experiencing nearly 50 percent of our Class A mishaps during the fourth quarter of every fiscal year. The graph also shows that flight hours for the fourth quarter remain relatively consistent with the other three quarters, so it is difficult to attribute this trend to increased OPTEMPO during the fourth quarter or end-of-year execution of unit flight hour programs.

The USACRC continues to analyze this problem from multiple perspectives. While fourth quarter mishap data from the past five years does not reveal any appreciable trends, this time period is ripe with risk factors that, when aggregated, present a complex situation increasing the chance for mishaps. We are looking closely at the impact of environmental and training factors, along with the summer permanent change of station and leader change of command cycles to see if personnel and leadership turbulence, usually more pronounced later in the third quarter, has a residual safety effect in the fourth quarter.

We know from history and our own experience that risk increases significantly during transitions, whether it be the transition between distinct operations and phases or the transition from one leader to another. Seasoned Army leaders understand that establishing relationships and a shared understanding with supporting and supported units decreases confusion, misinformation and mishaps. Thus, we tend to be very deliberate in planning the transitions between commanders, ensuring sufficient time for onboarding briefings, touch points with certain staff functions, and even equipment inventories. But how deliberate are we with aviation safety officer (ASO) transition plans? Some recent feedback from the field indicates a lack of face-to-face handoff and, even worse, no continuity files for incoming ASOs. Personnel turbulence is nothing new in the Army, so we must anticipate and plan for it. If commanders emphasize, receive back-briefs on and make modifications to ASO transition plans, not only will the quality of those hand-offs improve, so will the unit risk profile.

As we think about leader transitions, particularly during periods of high personnel turbulence, consider that new leaders in positions of risk acceptance might be initially unable to holistically assess hazards in their new unit, installation or mission role. Limiting their risk acceptance authority the first several weeks as expectations are set and relationships built is one measure to ease the transition. Established ASOs and instructor pilots (IPs) can typically help the commander make good crew mix decisions, but those new to the unit will be unaware of numerous, potentially harmful, factors. In concert with the higher headquarters commander, it makes good sense for senior aviation officers, ASOs and IPs to limit new personnel as mission briefers and/or mission approval authorities for a predetermined onboarding time and for scenario-based mission approval training, as programmed into the unit standing operating procedure. This will allow leaders to train the force on how to identify, assess and mitigate risk and ensure standardization of the mission approval process across the breadth of a formation. Finally, new commanders might consider implementing tactical and training imperatives, deliberate mission briefings and rehearsals at their level for a set amount of time to assess and appreciate the level of rigor within existing mission planning and risk management processes.

I hope these recommendations are the start of an engaging dialogue within your formations about how we prepare for success in the fourth quarter. We know the challenge is coming. We have a clear, established trend the past five years. However, the collective critical thinking, discussion and sharing of best practices within our community will allow us to reverse this trend. Winning matters!

Readiness Through Safety!



  • 1 April 2020
  • Author: USACRC Editor
  • Number of views: 324
  • Comments: 0
Categories: On-DutyAviation

Theme picker