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THE MAGAZINE OF AIR MOBILITY COMMAND

ASAP  |  LOSA  |  MFOQA  |  CRM/TEM

Aviation Safety Action Program (ASAP) Reports:

Why Should I File One?

By MR. BILL KROUSE, AMC Ops RAMS

Today’s aircrews grew up in a “why” society. Why should I do this? Why is this important? Why should I care? It is not surprising; people are bombarded daily by social, visual, and audio media at an unprecedented level with information that often conflicts, frequently directs a change in behavior, or requires additional effort to comply. Pure survival skills dictate the need to question, verify, and interpret everything.

This article provides verifiable evidence on multiple levels for WHY having an active ASAP program to proactively report actual as well as potential safety issues and/or concerns is beneficial to the U.S. Air Force. The success already achieved by the current program, operating at such a low power setting, is amazing. Who knows what can be achieved when the throttle is pushed to the firewall!

First, an active ASAP program will provide leadership, trainers, and aircrews with an aggregate view of issues affecting the safe and efficient execution of the mission. For example, of the 3,200+ ASAPs submitted, 13.4 percent were related to altitude deviations. Add the number of ASAPs related to navigation errors and the rate jumps to 19.7 percent. These ASAPs show a fairly even mix of automation errors, communication breakdowns between crew members and ATC, task saturations, and poor CRM/TEM skills.

This flight analysis highlights areas to monitor for leadership, provides trainers with the “meat” to emphasize the importance of why certain techniques are used to mitigate specific threats, and enables aircrews to not only “chair fly” specific mission profiles but also consider how they would address the threats the ASAP submitters encountered. None of these benefits are available if aircrews don’t submit ASAPs.

An active ASAP program enriches the search tool incorporated in the ASAP software to allow an individual to search for and likely find numerous ASAPs about a specific event, location, or MDS. For example, your mission is scheduled for an ERO so you search the ASAP database and find 23 related ASAPs. Perhaps, if your mission is planned for a “quick turn” through Charleston AFB, you find there are 72 ASAPs in the system related to activities at Charleston. Finally, maybe you are a new C-21 crew member; you search the ASAP database for MDS specific issues and find 71 ASAPs associated with the C-21.

The real bonus of an active ASAP program is that issues are quickly addressed! AMC has dedicated resources—the Ops RAMS branch—with the mandate to review each ASAP submission by the next working day. After redacting all information that may identify the submitter, the submission goes to the appropriate agency on the staff responsible for that area of operations. The Ops RAMS branch continues monitoring each submission, tracking it through the staff and developing a coordinated response to post on the AFSAS scoreboard. Because there are times the Ops RAMS branch needs to contact the submitter to ensure the staff understands the issue (and not for punitive reasons), providing your contact information is recommended.

While some issues are tracked for trending purposes, many result in actionable changes that aircrews can see.

Example 1

With the number of lithium-ion battery fires on civilian airlines increasing, an ASAP submission questioned when the AMC staff would address this hazard. The staff totally agreed with the submitter’s concern and jumped on getting fire-suppression bags out to the field. In the rush to make this equipment distribution happen, the bags were deployed before the checklist and instructions were developed. A subsequent ASAP highlighted this fault, which prompted AMC A3 and A4 staff to initiate the development of usage instructions, storage responsibilities, and product ownership validation.

Example 2

Another ASAP submission involved a C-17 passing through Yokota AB on the Diego Channel mission. Yokota Airfield Management consistently assigns C-17s to parking spot C7 or C9. Per the Giant Report, the weight bearing capacity (WBC) of those two parking spots is 197,000 pounds. The problem is that particular C-17 channel normally arrives around 350,000 pounds and departs at 480,000 to 550,000 pounds. With only an airfield manager’s waiver, limited by regulation to a 50 percent increase of the reported WBC, the aircrew was concerned for the safety of the aircraft. Because of the ASAP, AMC Airfield Management worked with PACAF and the Yokota airfield manager to investigate this submission. Initial recommendations from the Civil Engineering assessment were to replace the existing concrete slabs with new 18” slabs to meet appropriate WBC requirements. Until then, C-17s will not utilize these spots.

Example 3

This final example highlights the complexity of airlift missions and why aircrews need to keep their head in the game. An aircrew landed at its en route cargo pickup location to find the cargo was double what they expected, forcing a reduction in the Block 10 fuel load to enable the aircraft to take off. The aircrew also had weather in Europe that did not allow for a legal second alternate. TACC directed the aircrew to take off with the decreased Block 10 fuel load and to divert to its planned alternate if unable to make up the 6,000-pound fuel reduction. Feeling pressured to launch and with little chance of making up the missing fuel, the aircrew declared “safety of flight” and terminated missions for the day. The Ops RAMS branch promptly contacted the TACC and found poor internal communication between the DO, Senior, and Flight Manager led to the aircrew perceiving that the Senior was directing the aircrew to take off without a legitimate destination (i.e., insufficient fuel) and alternate. The intended directions were to have the aircrew work with the Flight Manager to obtain a legal alternate, update weather en route, and make a final decision on whether it would be safer to divert to a legal alternate. This ASAP allowed the TACC to review its mission execution processes to ensure miscommunication on this level does not occur again.

ASAPs have highlighted many unsafe practices, inefficient techniques, and issues previously unknown to leadership. ASAPs have highlighted MDS specific issues, such as:

  • SATCOM linkage failures in the C-5M: Resulted in a Working Group to track and mitigate.
  • Faulty C-17 fuel probes: Prompted a Crisis Action Team to evaluate the extent of the issue and develop interim procedures to use until a fix can be developed.
  • C-130J weight and balance issue: Resulted in a Combat Offload Method B that highlighted the manufacturer improperly transferred the weight and balance charts from the C-130H to the C-130J instead of creating a new weight and balance charge to account for the extra pallet position in the C-130J.

In addition, ASAPs have identified safety issues specific to a single location, like the lack of RCR knowledge by the Navy tower controllers at Lakehurst NAS, the incorrect taxi-line issue at Kandahar, and the “Dips” issues in Scottish airspace.

The ASAP program provides the submitter with instant access to individuals who can fix the issue. It also provides fellow aircrews with real-life examples of mistakes and the events that led to error, arming them with knowledge and tools to help avoid similar errors. The potential power of the ASAP program is incredible, and the move to incorporate the ASAP program into the AFSAS safety system will allow searching both the mishap and ASAP databases.

The upgrade of the ASAP program to a mobile app, scheduled for a 2018 release, will allow aircrews to draft their ASAP submissions on their smart devices and tablets (EFBs) at any time, in any location, without a live network connection and then submit them later when they have connectivity.

The future of the ASAP program relies on aircrews highlighting safety issues and errors. The benefits mentioned here are just a small sample of the potential “Safety Bonanza” waiting to be unleashed. Put your fears away and get into the game. Like the famous WWII Uncle Sam poster read: “We Need Your ASAP!”