U.S. Army Reserve
Fort Carson, Colorado
After 24 years in Army aviation and six more as a civilian helicopter emergency medical services pilot, I recently returned to the military community as a Department of the Army civilian (DAC) aviation safety inspector. In just six months on the job, I discovered a trend that has not changed since I first left the Army — the lack of near-miss reporting.
The civilian aviation safety culture is much more transparent. Civilian pilots are highly encouraged to self-report incidents and focus on a learning culture that acknowledges the fact that all humans are subject to error. Capturing minor mistakes or missteps identifies trends and improves processes before it leads to a catastrophic event. The addition of cameras monitoring cockpit operations compels pilots to pay more attention to detail and always follow procedures. Although no system prevents human error, civilian programs take a more aggressive approach in regard to near-miss reporting.
Army Regulation (AR) 385-10, The Army Safety Program, defines a near miss as a “potentially serious accident or incident that could have resulted in personal injury, death, or property damage, damage to the environment and/or illness but did not occur due to one or more factors.” Although we frequently read about near misses in Army safety-related publications, there are still many unreported near misses that, if reported, could help prevent an accident, serious incident, or loss of equipment or life.
Examples of a near miss could be missing a step in a checklist, finding foreign object debris on an aircraft or not following the technical manual procedure during scheduled or unscheduled maintenance. Although these might seem like simple mistakes or menial discoveries, if not reported in a timely manner, over time they could have catastrophic impacts. Lack of reporting does not constitute a safe culture.
According to AR 385-10, Soldiers and DACs at all levels will “report Army accidents, near misses, and hazards in their workplace as soon as possible to their supervisor or leader.” Most of the near misses I discovered were maintenance-related tasks that were not reported in a timely manner nor reported to the supervisor or the safety officer. How were they discovered? By walking the line numerous times a day, engaging Soldiers and conducting regulatory monthly safety inspections.
There may be many reasons why Soldiers do not report near misses, including some may not receive proper training, leader supervision is lacking, embarrassment or complacency. In our case, luck prevailed and no serious incidents occurred. But how long will luck last before a catastrophe occurs?
As a new safety officer, I had numerous tools at my disposal to identify discrepancies and provide feedback to supervisors and civilian technicians to encourage a more proactive safety culture. Upon assignment, I went right to work reviewing historical documentation for the safety department. The unit had just completed an Aviation Resource Management Survey (ARMS) inspection, so the results were organized and well-documented. Although the safety department did well on the inspection and the paperwork was in place, the program was lacking attention from a long-term administrator due to an extended vacancy in the position.
During my first 90 days on the job, AR-385-10 and the ARMS checklist became my best friends in understanding the 5 W’s of the unit safety program. I discovered the lack of reporting and other safety-related items that required attention. Here are the lessons learned:
- In-processing safety brief. Although the bare-bones brief was in place and met inspection criteria, details needed to be added to address all areas of safety and in greater detail, such as highlighting specific safety-related training and standard operating procedures (SOPs) specific to the individual job requirements. Since civilian and dual-status personnel turnover is less frequent in a Reserve organization, updated information should also be incorporated into monthly training so everyone receives information on updated SOPs.
- Monthly safety meetings. After discovering many unreported near misses, “Reporting Incidents and Accidents” training was completed for all personnel. All near-miss reporting (formally reported or not) is immediately brought to the supervisor’s attention and briefed at each monthly meeting for common knowledge and lessons learned. Work leads and supervisors have to advocate safety, enforce SOPs and hold personnel accountable for not reporting. Pre- and post-work briefs and end-of-day briefs are highly encouraged to discuss issues while still vivid in everyone’s mind.
- Monthly safety inspections. Required monthly inspections identified trends in procedural and supervisory issues. Procedural issues such as lack of reporting were addressed through training and updating SOPs accordingly. Supervisory issues were addressed at the personal level through verbal or written counseling.
- Hazard log (HAZLOG). Items that cannot be fixed immediately and are recurring issues are transferred to the HAZLOG, assigned responsibility, and tracked, briefed and updated until completion. If a common trend is discovered, define the problem and find and implement a solution.
- Follow up. Just because a procedure is updated on paper doesn’t mean it is effective. Evaluate the controls that are put in place to ensure they are effective and actually fix the problem. If not, redefine the problem and repeat the process.
Don’t let an accumulation of near misses lead to your next mishap. Get ahead of the chain of events, be proactive and protect the force through diligence and professionalism. Most items discussed in this article were derived from AR 385-10 and are regulatory items. Additionally, maintain the most current copy of the ARMS checklist as a guide and reference to manage your safety program.