LACKLAND AIR FORCE BASE, TEXAS -- Note: Long before the Air Force Safety Center stood up at Kirtland Air Force Base, N.M., on Jan. 1, 1996, Airmen were sharing their lessons learned in a variety of safety publications such as Aerospace Safety, Aerospace Maintenance Safety, Air Force Driver, among others. During a year-long commemoration of the safety center's 20th anniversary, the Public Affairs Office will highlight previously-published articles and reprise historic Rex Riley cartoons to emphasize that long-standing safety practices and lessons learned remain relevant to the mishap prevention program of today's Air Force.
Serious accidents can cause real anguish and suffering so real and vivid that persons involved or nearby bystanders rarely forget them. An accident without injury though is more like a bloodless, painless fakery of television “violence”--perhaps without real purpose in the drama and therefore easy to forget. We all remember the C-141 midair incident over the South Atlantic, but how many other incidents “almost” occurred that went unreported?
In the real Air Force, there is a danger in brushing off incidents that do not hurt, harm, or damage. When these incidents (or “near misses” as we call them) happen, we should immediately run the red warning flag up the pole. Because a non-injury accident is like a 104-degree fever, it’s a positive sign or symptom that something is wrong.
Sometimes we misdiagnose or completely fail to diagnose the symptoms of near misses, because luck or blind chance saved us from injury. We have all been flying along, exactly where we’re supposed to be, and have seen another aircraft whose pilot thinks he/she is exactly where he/she is supposed to be, and suddenly has to take some kind of evasive action. We may tend to shrug it off and forget the near miss with a casual kind of ignorance. Hopefully everyone agrees that it’s not a good practice to rely on luck for effective accident prevention.
I was on departure from a forward operating base, turning left on the departure. A C-17 was inbound on the arrival. We were both aware of the other’s presence, and the controller had given us different altitudes so that no problem should arise. However, the next thing we see is the C-17 in a LEFT bank, slicing through our altitude. It happened so fast, we couldn’t take any evasive action (and the C-17 should have taken a RIGHT turn!). Bottom line, we missed one another. We continued, now VERY alert, to Ramstein. But 8 hours later, who wants to fill out paperwork? The problem worked itself out, right? Additionally, you ask yourself, “Was it my fault? If I report it, I may be exposing myself.” Regardless of the guaranteed immunity a safety report gives you, EVERY CREW MEMBER HAS A RESPONSIBILITY TO FELLOW AIRMEN TO REPORT ANY SUCH INCIDENT!!
One of the best ways to eliminate the likelihood of future close calls is through effective root cause analysis and effective corrective action taken on near misses. The near miss may have occurred on approach, maneuvering for departure, or even at altitude. In these days of reduced vertical separation minimums, the tolerances are much tighter; therefore our vigilance needs to be even sharper. It’s best to learn the real lessons from these near misses, since they are very likely to continue to occur repeatedly until an accident occurs. The primary responsibility of reporting near misses lies with the aircraft commander. The AF Form 651, Hazardous Air Traffic Report, is the primary means of passing the critical information from any unusual occurrence. It may seem to the basic crew member that as long as there was no harm, there’s no need to report it. However, any information collected today, can prevent a mishap tomorrow.
There was a study done many years ago that found for every serious or disabling injury reported, there were about 10 injuries of a less serious nature, 30 property damage incidents, and about 600 incidents (near misses) with no visible injury or property damage.
How can you help? Report each and every near miss incident to your safety office immediately in order to help prompt investigation and follow-up actions that will reduce the potential for future near misses. Safety officers must rely upon you and your fellow Airmen to report these to them, as they just can’t see everything.
If you are involved with or witness a near miss incident, remember that you or your crew members may not get a second injury-free chance to hoist that red warning flag up the pole. Do your part to help make the skies safe for everyone involved. Report those near misses to your flight safety officer immediately! (Reprinted from Flying Safety Magazine, October 2007)