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<a href="http://www.mca-marines.org/gazette">www.mca-marines.org/gazette</a> 13 M a r i n e C o r p s G a z e t t e • M a y 2 0 0 9 Forrestal (CV 59), in 1955; deploy- ment of mirror (now optical) landing systems in 1957; initiation of the re- placement air group concept, now known as fleet replacement squadrons (FRSs), in 1958; implementation of the Naval Aviation Maintenance Pro- gram in 1959; introduction of the Naval Aviation Training and Operating Procedures Standardization Program in 1961; creation of the Aviation Safety School in 1965; elevation of the avia- tion safety officer to department head level in 1975; initiation of the Squadron Safety Program in 1978; and system safety designated aircraft in 1981. In the two decades since I joined my first squadron the mishap rate has hovered around an average of 2.1 per 100,000 flight hours. Despite imple- mentation of programs, such as aircrew coordination training/crew resource management (ACT/CRM) in 1991 and operational risk management (ORM) in 1997, we have had no clear trend of a significantly consistent mishap rate reduction in those two decades. Some would argue that based on this two-decade trend we’ve reached the floor of safety improvements. Oth- ers contend that we can still achieve significant mishap rate reductions through improved awareness and inter- vention strategies but that a major cul- tural change and paradigm shift will be required to get there. On 23 May 2003, then-Secretary of Defense Don- ald H. Rumsfeld challenged the heads of the military departments to a 50 percent reduction in the mishap rate by the end of fiscal year 2005 (FY05). The Class A flight mishap rate had nearly doubled from an alltime low of 1.3 in 2001 up to 2.4 by the end of 2003.2 The FY06–11 Strategic Planning Guid- ance (SPG) further extended this goal to a 75 percent reduction from the FY02 baseline by the end of FY08. Four years after the Secretary’s chal- lenge we have yet to reach these goals. The trend had been in the right direc- tion through FY07 as seen in Figure 2, but 2008 looks like it might end that favorable trend. Trend analyses from mishap investi- gations have shown that human error is now the most significant contributor to mishaps. Causal factors have in- cluded skill-based errors, ACT/CRM failures, and violations of policy and procedures. Our current safety toolbox, while well populated and very effective, is not good enough to consistently break through the 2.0 floor of today’s mishap rate. Many of the tools we use are reactive. Mishap investigation re- ports and hazard reports are written after the fact, after an incident has oc- curred or a hazard has elevated itself. Other tools, such as ORM, are proac- tive, but they rely heavily on human perceptions and fail to fully capitalize on available data. New tools are needed that will help us use data to “see” these human error causal factors as they occur so that we can predict the hazard or incident and intervene before it re- sults in a mishap. One such tool is flight operations quality assurance, or FOQA (pro- nounced foe-qua), which has been used by the commercial aviation industry Figure 1. Figure 2.
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