R 152116Z AUG 11

ALCOAST 384/11
COMDTNOTE 3000
SUBJ: AVIATION SAFETY ASSESSMENT ACTION PLAN UPDATE
1. JUST OVER A YEAR AGO THE VICE COMMANDANT DIRECTED A JOINT DCMS/DCO
ASSESSMENT OF COAST GUARD AVIATION SAFETY FOLLOWING A TWO-YEAR PERIOD
OF ALARMING AND TRAGIC AVIATION MISHAPS.  DCMS/DCO CHARTERED A FIVE
COMPONENT STUDY OF ALL FACETS OF COAST GUARD AVIATION, WHICH PRODUCED
THE AVIATION SAFETY ASSESSMENT ACTION PLAN (ASAAP).  THE ASAAP
PROVIDED A CALL TO ACTION TO IDENTIFY AND ADDRESS THE ISSUES THAT
CONTRIBUTED TO THESE MISHAPS AND SUBSEQUENT LOSS OF 14 COAST
GUARDSMEN.
2. THIS STUDY TEAM COMPLETED AN EXHAUSTIVE "NOSE TO TAIL" ASSESSMENT
OF THE AVIATION SAFETY ENVIRONMENT EARLIER THIS YEAR.  ANALYSIS OF
THE MISHAPS DETERMINED THAT A NUMBER OF FACTORS COMBINED TO CREATE AN
ENVIRONMENT WHERE COMPLACENCY, RATE OF CHANGE, LACK OF FOCUS ON
AVIATION PROFESSIONALISM AND INCOMPLETE RISK MANAGEMENT UNDERMINED
THE OVERALL SAFETY POSTURE OF COAST GUARD AVIATION.
3. PRIOR TO THIS TWO-YEAR SPIKE IN MISHAPS, OUR AVIATION SAFETY
RECORD HAD BEEN OUTSTANDING. EVEN DURING THIS PERIOD, ON FLIGHTS WHEN
THERE WAS SIGNIFICANT OPERATIONAL RISK, OUR AIRCREWS CONSISTENTLY
DEMONSTRATED STRONG OPERATIONAL RISK MANAGEMENT.  HOWEVER, IN EACH OF
THE RECENT MISHAPS - WHEN THE PERCEIVED OPERATIONAL RISK WAS LOW -
LEADERSHIP LAPSES AND COMPLACENCY LED TO DISREGARD FOR SAFETY
POLICIES AND SAFEGUARDS THAT COULD HAVE PREVENTED THE MISHAPS.  THE
ASAAP IDENTIFIED IMMEDIATE ACTIONS TO ADDRESS THESE ISSUES AND
PROVIDED A PLAN TO PREVENT SIMILAR MISHAPS IN THE FUTURE.
4. OVER THE PAST YEAR, OUR ACTIONS INCLUDED:
     A. DUTY STANDING AVIATORS ARE NOW PRECLUDED FROM SIMULTANEOUSLY
PARTICIPATING IN GRADUATE EDUCATION PROGRAMS UNTIL MASTERING THEIR
CRAFT BY EARNING THE QUALIFICATION OF AIRCRAFT COMMANDER.
     B. A POLICY CHANGE ENHANCED THE USE OF FLIGHT PLANS TO IMPROVE
IN-FLIGHT ACCOUNTABILITY AND TRACKING.
     C. ATC MOBILE WAS TASKED WITH PROVIDING ANNUAL AIRCREW
INSTRUCTION SPECIFICALLY RELATED TO AIR OPERATIONS POLICY.
     D. WE HAVE INITIATED AN AVIATION SPECIAL MISSION PROGRAM REVIEW.
     E. WE HAVE CONDUCTED FOCUSED OUTBRIEFS OF THE ASAAP RESULTS AND
CRITICAL LESSONS LEARNED TO THE ENTIRE AVIATION COMMUNITY, AT SECTOR,
CUTTER AND AIR STATION CO CONFERENCES, ENGINEERING OFFICER
CONFERENCES AND OTHER OPERATIONS-RELATED VENUES.
     F. CG FLAG AND O6 AVIATORS HAVE PERSONALLY VISITED AND BRIEFED
EVERY AVIATION UNIT ON THE ASAAP FINDINGS.  SUBSEQUENTLY, AIR
STATIONS WERE TASKED WITH PROVIDING DEBRIEFS TO THEIR SERVICING
SECTORS.  SENIOR AVIATORS ALSO BRIEFED AREA AND DISTRICT STAFFS ON
THE FINDINGS.
5. BY ENGAGING WITH THE ENTIRE AVIATION COMMUNITY IN THIS MANNER, WE
HAVE GENERATED ENHANCED SITUATIONAL AWARENESS OF AN ARRAY OF SAFETY
AND RISK MANAGEMENT ISSUES, AS WELL AS THE TOOLS AVAILABLE TO ADDRESS
THEM.  AS A RESULT OF STRONG LEADERSHIP AT EVERY LEVEL WITHIN THE
AVIATION COMMUNITY, A COMMITMENT TO PROFESSIONALISM, AND IMMEDIATE
ACTIONS TAKEN TO ADOPT THE ASAAP RECOMMENDATIONS, WE RECENTLY PASSED
THE ONE-YEAR MARK SINCE THE LAST MAJOR AVIATION MISHAP. WE WILL
CONTINUE TO IMPLEMENT THE ASAAP RECOMMENDATIONS.
6. COAST GUARD AVIATORS HAVE A RICH HERITAGE OF BEING AMONG THE BEST
IN THE WORLD, ESPECIALLY FLYING IN THE MOST EXTREME, DEMANDING
CONDITIONS.  WE HONOR THAT HERITAGE BY SUSTAINING MISSION EXCELLENCE
AND ACHIEVING PROFICIENCY - THE MASTERY OF CRAFT BEYOND QUALIFICATION
- TO ENSURE SAFE AND EFFECTIVE OPERATIONS.  THAT DEMANDS LEADERSHIP,
MANAGING RISK, AWARENESS OF THE ENVIRONMENT, CONTINUOUS COMMITMENT TO
LEARNING AND MASTERING OPERATIONAL ARTS, INCLUDING POLICY,
REGULATIONS AND MISSION REQUIREMENTS.  THE OPERATIONAL CHALLENGES WE
FACE ARE SIGNIFICANT, AND FAILURE TO UNDERSTAND AND ADDRESS THE RISKS
CAN BE CATASTROPHIC. CONTINUED MISSION EFFECTIVENESS IS OUR
COLLECTIVE DUTY.
7. I AM PROUD OF YOUR EFFORTS. STAND A TAUT WATCH. SEMPER PARATUS.
8. ADM BOB PAPP, COMMANDANT, SENDS.
9. INTERNET RELEASE AUTHORIZED.