Col. Itai Alon - Chief of Quality Control Administration

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1 ATASC 8 Col. Itai Alon - Chief of Quality Control Administration The Safety Conference recently held in Israel was the continuation of the Israeli initiative already begun in the 1990s. The Conference is usually attended by representatives of all the military branches operating aircraft in the United States. The last two Conferences were attended by representatives of the Canadian Air Force as well. On average, this Conference is held every year-and-a-half and each is lead by a different military branch. The last Conference was the eighth in number and the second led by the Israeli Air Force. This time the Conference was organized by the Center for Air Safety Center (at the Fisher Institute for Air and Space Strategic Studies) with the participation of the Israeli Air Force Aviation Safety Research Center (ASRC). The Conference had originally been scheduled for the spring of 2002, with the participation of a large number of people, including representatives of the Defense Industries and even representatives of commercial airlines air safety organizations. In light of the security situation in Israel at the time, there were a great number of cancellations, and the Conference was postponed to the end of that year. Although there was no change in the security situation in Israel, our American and Canadian colleagues changed their policies and decided to come despite the situation and as a show of solidarity with the Air Force and the State of Israel. The most senior participant in the Conference was Three-star General Hess, Commander of the American Air Force Safety Center. He was accompanied by veteran safety personnel. The participation of O.C. Air Force in the Conference and his meeting with General Hess in his office significantly affected the atmosphere at the Conference and reflected the importance that the Air Force Senior Command attaches to air safety. It should be mentioned that many of the safety organizations in the United States comprise both uniformed and civilian personnel specializing in various professions in the sphere of safety. This kind of structure provides better representation from the "field", representation that changes according to the traditional mobility of military personnel from role to role as well as the preservation of information and long-term specialization of civilians serving in the organization. To our delight, many of those who came to participate in the Conference were seasoned specialists, military personnel who had seen combat in those places in which the United States was involved in recent years in the Gulf and in the Balkans as well as researchers and medical personnel specializing in safety. Generally speaking, the Conference served as a platform for the presentation of information, cooperation on ideas and plans in the sphere of safety. As anyone knows who deals with flying in general and safety in particular - knowledge is power, information is the fuel that spins the wheels of the safety machine. Almost every action, every plan, every idea - is based on information accumulated in one way or another in the safety information apparatuses. The American branches, ten times larger than our own Air Force, base themselves mainly on information gathered following actual accidents. In view of the fact that we do not enjoy the privilege of learning solely from accidents, we in Israel have developed the familiar system of information collecting and the debriefing following incidents of almost hit. The system is deeply rooted in the culture of the Israeli Air Force and arouses considerable envy among our counterparts. One must remember that it is not all that simple to adopt a system like this in large and veteran organizations. The last Conference, because it was smaller in scope, allowed for more direct acquaintance with its participants. The transfer of information in this Conference, over and above the fact that it was from a primary source, was directly between the participants. There can be no doubt that in this manner we saved considerable time and acquired information from a primary source on the use of medications on long-range operations and in around-the-clock combat. I shall not enter into other areas in which the process was shortened because of the ability to receive information and discuss it directly with professional colleagues. I am certain that other subjects will be mention in this issue. One must remember that despite the differences between the various branches in the United States military and our own the similarities still outnumber the differences. We operate the same platforms, the people who operate the platforms grapple with problems very much like our own, it's just that each of them does it in his own language. In conclusion, I should once again like to point out the great appreciation we have for the participants who came to Israel in such a difficult period when so many stay away from our country. After a lecture on the geopolitical situation, including flying along the border line, several holders of key position returned to the United States and Canada with a better understanding of the situation in Israel. ±

2 THE SAFETY PICTURE IN THE AIR FORCES Compiled by Major Eldad Introduction The safety picture in various air forces and the issues concerning them were presented at the opening of ATASC 8. The Israeli Air Force The data refer to 100,000 flight hours. The major prevention programs for the Quality Control Administration for the year 2003 encompass several subjects. The first is the training of commanders in the areas of human resources in the framework of Raqi'a Command and Control. The second deals with transport flying in proximity to civilian flying. The intention is to utilize safety information in extending the perimeter and broadening the areas of training flight. The use of the safety information apparatus will expand and improve including improvement of investigation and presentation of data. There are also plans to broaden and deepen the introduction of the CRM in the transport and helicopter dispositions and its introduction to the combat disposition. In order to improve the utilization of capabilities around the clock, changes are being made in the rules of rest and sleep as well as the introduction of alertness improvement pills in long-range flights and high payload flying. The United States Air Force In the course of the past year there were 35 serious accidents in which 19 planes were destroyed and 22 crew members were killed. Human error was given as the main factor in 24 of these incidents. An increase in the number of helicopter accidents, nine as opposed to none in the previous year, and this was the largest number of helicopter accidents recorded in the past 33 years. In addition nine unmanned aircraft In the course of fighting in Afghanistan, there were eight serious accidents, seven of the due to human error. The multi-annual graph is similar to that of the Israeli Air Force graph, in other words, a dramatic decrease that levels off in the 1990s. An important fact is that although last year was the second worst year in the last decade regarding the number of severity of the accidents, "only" 19 planes were lost, and that is almost the lowest number ever (in planes were lost). On the other hand, there was an increase in the number of those killed as opposed to nine the previous year, mainly because 13 people were killed in two accidents involving C-130s. In addition, one can see that the rate of accidents in the combat disposition is larger in comparison to the rest of the Air Force. Of the 35 accidents this year, 68% were involved in operations, 26% in administration and command, 3% technical and 3% other.

3 The American Naval Air Force and Marine Corps From the historical point of view, the situation is identical here, as well. The historical rate of accidents in the air force/marines: Things were not good in the naval branch this year either, and there has been an increase in the number and rate of accidents in comparison with the multi-annual average in general and the previous year in particular. The increase is further underscored by the fact that the previous year had been the second in quality in Naval Air Force history and the best in the history of the Marine Corps. Thus far, no one has been able to put his finger on the cause of this because it was put down to all the possible elements: materials, maintenance, human error and administration/command. Of the 22 accidents in the Air Force, 18 were the result of human error, 13 of them by air crews. In the Marines, 13 of the 15 accidents were put down to human error, 11 of which were caused by members of the air crews. In both cases the percentages are the same, as much as 6%, to the average relative contribution over the past five years. According to a study conducted among 7,800 air crews and 17,000 maintenance personnel the field tends to "blame" budgetary problems: cut-backs in the number of personnel, both in the sphere of flying and the sphere of maintenance result in increased loads. Cut-backs in manning and training resulted in manning problems and increasing mistakes particularly those involving special skills. A tight-fisted maintenance policy also contributed to problems of materials and maintenance. The list of steps taken to improve safety includes investment in simulators and central information apparatuses, improvements in training, increasing skills, introduction of danger management, enforcement of standards and increased inspections and balances. The Coast Guard The Coast Guard Air Force has about 200 aircraft that clock about 100,000 flying hours a year. The division is: about 25 combat planes, about 30 transport planes and the remainder helicopters. They also have about 230 boats and about 1600 small craft. Accident Graph: Because of the small numbers, it is difficult to extract significant statistics, however once can see that on average there are roughly one medium level accident and one serious accident a year. No trends

4 emerge from this, but an examination of the less serious incidents reveals that there has been about a 15% annual decrease in flying accidents over the past five years. Generally speaking in the Coast Guard, especially in its maritime fleet, there has been an increase in the number of less serious accidents arising in part from changes that were made in the system of reporting the incidents and partly to the substantial increase in the number and variety of activities in the wake of the 11th September attacks. One may conclude from the structure of the Coast Guard and its safety trends that the main emphases and activities in the coming year will be in the devoted to safety in sailing and in land transport. (see following report) The Canadian Air Force The Canadians did not submit a safety picture of their own but rather presented the structure of their Flight Safety Administration. This is very similar to the structure of the flight section of the Quality Control Administration, with the Prevention Branch, including information apparatuses, and the Investigation Branch. Similar to our Air Force, but different from the American Air Forces, in the Canadian Air Force the only incidents investigated are those that involved "almost hit", with each serious incident comprising a team fitted to that incident in coordination with staff personnel and field personnel. They are also assisted by semi-civilian laboratories in Ottawa. The Prevention Branch, like in Israel, is divided into sections in keeping with the various dispositions. Data on safety incidents are gathered by a computerized system similar to the one in the Ministry of Defense. Publications and debriefings are disseminated over the Internet as well as in the three-monthly safety pamphlet. The Air Force is in the process of absorbing rules of damage control and quality assurance as well as upgrading its information apparatus. Summary As may be seen from the graphs, historically the safety picture is the same in all the Military Branches. The dramatic decrease in the 1970s that abated at the end of the 1980s and the beginning of the 1990s, and since then has leveled out at a more or less constant rate of between 1.5 and 4 accidents per 100,000 flying hours. It would appear that the great progress made possible with the improvement of the reliability of the aircraft, the introduction of avionic apparatuses which contribute to safety, rules of safe flying in training and, mainly, changes in awareness and norms have achieved these ends. The question now facing all of us is "How to "go beyond the straightway" or at least how to keep up the progress. There is the danger among all of those involved that maintaining the existing variety of activities alone, without adopting new ones, will not succeed in even maintaining the existing level of safety, to say nothing of decreasing the accident level. It appears that for everyone, including us, the next step after we have assimilated danger control is to deal with the human factors which contribute to these accidents happening. This includes focusing the investigation on the human factors involved

5 in accidents and incidents, introduction of CRM in the combat disposition as after introducing them into the helicopter and transport dispositions, instructing the commanders in identifying and dealing with general or individual human factors etc. (Explanations of tables) Rate of accidents by decade (according to the rate for each 100,000 flying hours Rate of accidents in the present decade (amount of accidents in blue) Rate of accidents in the last decade: ROAD ACCIDENTS In addition to dealing with flight safety, the Safety Centers and the Quality Control Departments also deal with ground safety. One of the issues very much troubling everyone is the matter of road accidents, in which the situation grew worse this year for all of us. For example, in the American Fleet, of 1000 deaths occurring in all the various kinds of accidents in past five years, 569 were killed in road accidents, and in the Coast Guard, 59 out of 94 deaths in the past nine years were the result of road accidents. Following is a graph showing the rate of those killed in the United States: In the Coast Guards, six military personnel were killed in road accidents this year, which puts the rate at seven killed per 100,000 people. In the Israeli Air Force, by comparison, seven people were killed in road accidents this year. The Marine Corps has the youngest and most inexperienced personnel, and this, most likely, influences the number of those killed in road accidents. The Navy is concerned mainly with personnel stationed for the most part at sea, and tries to "compensate" them for this when they are on leave. The American Air force has the most stable and most veteran personnel, and this is also connected with the fact that they are usually stationed in permanent bases which enable the Air Force to maintain follow-up and prevention programs more efficiently, but nevertheless, this year, for the third year in succession the situation has worsened. All of the military branches have instituted danger control apparatuses in connection with road accidents, as well. However, there is a feeling that the methods are more efficient in road trips taken in connection with work, and are unobserved as soon as personnel leave their bases during free time and on leaves, as can be seen in the following graph:

6 Causes of death in road accidents in the Air Force and the Marine Corps in the past three years:

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