System: Flight Operations 2008 Infared Program Assessment

Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Keep your cell phone handy (and charged up).

Medium

Medium
Remote

Remote
Critical

Critical
Have the required 2 "D" cell flashlight working and
Loss of electrical power
charged. Have a spare hand-held VHF-AM radio.
Training on emergency procedures.

Occasional

Marginal

Medium
Remote
Serious
Critical
Avionics Erroneous read-outs from the equipment Training, Pre and post season avionics checks

Improbable
Frequent

Marginal
Update the equipment/design for standardization,

Medium
Critical
Non-Standard (type/lay-out/location) of

High
train to the new equipment, maintain currency in
equipment
all A/C, standardize fleet to same make aircraft

Occasional
Negligible

Negligible
Frequent

Coordinate with all staffs on modifications prior to

Medium

Low
Electrical Interface (A/C Mods) the installations, refresher (preseason) mission
training and equipment calibration
IR Equipment

Occasional
Frequent

Serious
Critical

Critical
Increased exposure to land/take-off to hand-off
High

Install and utilize satellite up-link capability

immagery

Negligible
Frequent

Frequent
Marginal

Nitrogen servicing (Improper technique), not

Medium
Serious

wearing proper PPE and ultimately causing Proper training/procedures

personal injury
Catastrophic

Catastrophic
Occasional

Remote

Serious
Maintenance providers (lack of skilled Coordination with maintenance personnel and
High

technicians/repair stations) repair stations

Maintenance

Improbable
Occasional

Marginal

Marginal
Medium

Medium
Undocumented open discrepancies Follow SOPs
Catastrophic

Improbable

Not performing Functional Check Flight (FCF) Perform FCFs when applicable, coordinate with

Medium
Remote

Serious

Critical
before releasing aircraft after maintenance maintenance technician; if possible take
(when applicable) maintenance technician on FCF
Improbable
Frequent

Marginal

Update the equipment/design for standardization

Medium
Critical

High

Standarization Non-Standard Aircraft & Train to the new equip. & Maintain currency in
all A/C, Standardize fleet to same make aircraft

1 Completed 2008
System: Flight Operations (cont.)
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Effects of modifications that decrease aircraft

Negligible
Frequent

Marginal

Remote
Serious
capabilities causing additional crew Correction to existing modification; coordination

Low
workload/exposure/performance issues(fuel and testing of future modifications.
burn, flight planning)
Modifications

Catastrophic

Improbable
Increased exposure to mid-air collision due to

Negligible
Frequent
Testing and relocation of system components to
necessity of turning off TCAS during mission

High

Low
correct the interference; for future modifications
because of interference between TCAS and IR
include testing for interface interference.
equipment.

Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious
Bad Fuel Observe fueling; sump fuel as required.

Fuel

Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious
Improper fuel loading Observe fueling; confirm loading.

System: Environmental
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Preflight planning;Just say NO (accept the fact

Occasional
Probable

that the mission cannot be completed)! PIREPS,

Serious
Critical

Critical
High

Flying in bad weather Call local area, change priority of mission flight,
Equip monitoring (i.e., Wx Radar, Storm scope,
XM radio, etc.)

Occasional
Frequent

Just say NO! Education/Training of the ground

Serious
Critical

Critical
Pressure to complete the mission regardless of
High

personnel regarding go-no-go situations. Preflight

the Wx
planning. Give options.
Weather

Improbable
Marginal

Marginal
Medium

Medium
Remote

Preflight checks of icing equipment, proper

Icing equipment (aircraft) failing
maintenance of icing equip.
Occasional

IR Technician reports, PIREPS, Debrief other fire

Medium
Remote
Serious
Critical

Critical

Smoke Column air ops crews (lead plane, airattack, etc) Fly out
of column
Catastrophic
Catastophic
Improbable

Improbable
Medium

Medium

Maintain Situational Awareness, File IFR, Train

Contolled flight into terrain
and remain proficient

Topography

2 Completed 2008
Topography

Occasional

Marginal

Marginal

Medium
Remote
Serious
Preflight briefing, PIREPS, Fly different altitude or
Moderate (plus) turbulence
out of area

3 Completed 2008
System: Airports
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Catastrophic
Occasional

Medium
Remote

Critical
Preflight planning, instrument approaches, refusal

High
Mountainous Terrain-Unfamiliar, leading to CFIT,
of delivery point, landing during daylight hours

Location

Improbable
Occasional

Medium
Serious
Critical

Critical
Collision with wildlife on the runways leading to Perform fly-by, contact personnel on ground to
damage/injury of personnel or property check field, air-drop, install gun on nose of aircraft

Improbable
Medium

Medium
Remote

Critical

Critical
Airport surface condition is not conducive to
Check the AFD, NOTAMS, local traffic, Tower,
landing resulting in damage to aircraft

Improbable
Occasional

Medium
Serious
Critical

Critical
Runway length is not appropiate for the aircraft's Perform performance calculations/preflight
Limitations capabilities planning, NOTAMS

Improbable
Occasional

Medium
Serious
Critical

Critical
construction hazards/equipment NOTAMS, ATIS, Local traffic, Tower, UNICOM
Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious

Lighting systems are inop/inadequate leading to

ATIS UNICOM, visual cues, preflight planning
a short landing/go-around, CFIT
Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious

Unfamiliar with the missed approach procedures Preflight planning. Performing approach briefings,
IAP (MAP), leading to CFIT training/profeciency, current charts, CRM
Catastrophic

Catastrophic
Improbable
Occasional

Preflight planning. Performing approach briefings,

Medium
training/profeciency, current charts, CRM, Do NOT
High

Not having an IAP leading to a CFIT

land if conditions are such that it is unsafe to make
a safe visual approach and landing
Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious

Congested, task saturation of controller and/or TCAS, SA, CRM, Training, Communications,
pilots/crew, midair possibility Chose another airport
Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious

Airspace No Tower-pilots operating without radio or wrong SA, communicattions, CRM, UNICOM, PIREPS,
frequency-Possible midair aircraft lighting, TCAS,
Occasional

Medium
Remote
Serious
Critical

Critical

SA, CRM, TCAS, Communications, A/C lighting,

Incursions on the runway and parking areas
training, parking tenders, familiar with the airport

4 Completed 2008
 Unqualified Personnel (ground/ramp or agency)

Occasional

Medium
Remote
Serious
Critical

Critical
Support leading to misfueling, hazardous parking, SA, CRM, Communication, Training of support
Personnel leading to damage to the aircraft or injury to personnel
personnel

5 Completed 2008
System: Personnel
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Scheduling management (reduce duty hrs and/or

Frequent

Marginal

Medium
Remote
Critical
flight time), sufficient staffing levels, sleep-

High
Fatigue-Cronic, errors due to fatigue (SA)
power naps, Training, CRM, support of crew
decision to decrease duty day,

Negligible
Frequent

Remote
Critical
Training, CRM, sleep-power naps, support of crew

High

Low
Fatigue-Acute, errors due to fatigue (SA)
decision to decrease duty day

Occasional
Trans-cockpit authority gradient, junior

Medium
Remote
Serious
Critical

Critical
Education/Training, CRM, communications,
crewmember not confident in speaking up about
tailgate sessions/AAR (after action review, debrief)
a hazard

Catastrophic
Frequent

Marginal
Mission pressure from management, leading to Training, CRM, Support of crew decisions, neutral

Medium
Remote
High
fatigue, harried decisions leading to hazardous person (arbitrator) to share issues/disputes/conflict
mistakes Catastrophic resolution

Education/training, attending the IMT/dispatch

Occasional
Human Factors
Frequent

Marginal
Mission pressure from other factions

Medium
meetings, ensuring open communication between
High

(dispatch/fire teams), leading to fatigue, anxiety,

IMTs, dispatch and coordinators, AARs
harried decisions leading to hazardous mistakes
(debriefings)

Negligible
Frequent

Staff and budget at appropiate levels, support the

Remote
Critical

Stress and fatigue from insufficient staffing levels

High

Low
crews decision to manage workloads that are
leading to the can-do/will-do attitudes
commencerate with the staffing levels

Logisitical issues with non-co-located personnel

Catastrophic

Improbable

Negligible
Frequent

leading to additional exposure of

Co-locate personnel at single base/unit, RON at
High

Low
flight/landings/take-offs ultimately leading to
single location
fatigue/stress/damage/injury to the aircraft and
or personnel

CRM & teambuilding training for all IR systems

Improbable
Personnel dissention between factions of the IR

Negligible
Probable

staff; open communications; pre/post season

Critical

"System" leading to stress and anxiety, resulting

High

Low
meeting to include all factions of IR systems staff;
in degraded decision making and ultimately
AARs; clearly defined policies, procedures & roles
possible damage/injury to aircraft or personnel
(Infrared Operations Guide).

Improbable
Occasional

Negligible
Unqualified personnel flying the aircraft-
Serious
Critical

Qualified and mission profecient personnel flying

Low
Resulting in: CFIT, emergency procedures,
the aircraft, adequate staffing levels.
incidents, accidents
Training
Improbable

Negligible
Medium
Remote

Critical

Unqualified IR technicians leading to damage to Qualified and mission profecient personnel

Low

aircraft and/or personnel operating/maintaining the equipment.

Improbable
Occasional

Negligible

Flying with known physiological conditions CRM, communications, training and education,
Serious
Critical

Low

Medical leading to degraded decisions, and hazardous take additional time off to recover, see the Doctor,
mistakes support from other factions

6 Completed 2008
System: Personnel (continued)
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Occasional

Medium
Remote
Serious
Critical

Critical
Accidents while driving to lodging after mission
Use of shuttles, most alert crewmember drives
completion late at night.

Night Ops

Catastrophic

Occasional
Frequent
Incidents or errors caused by physiological

Serious
Critical
Education and training; implement CRM; knowing

High
challenges (circadian rhythem deviations, vision,
and employing personnal limitations
fatigue)

Lack of skilled leadership/managerial skills in

Probable

Marginal

Medium
Remote
Critical
supervisors and upper management leading to Leadership training, participation in pre/post

High
Management
stress/anxiety of crews resulting in errors and/or meetings of IR system staff.
degraded decision-making skills.

System: Policy
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Scheduling management (reduce duty hrs and/or

Frequent

Marginal

Medium
Remote
Critical

flight time), sufficient staffing levels, sleep-

High

Fatigue-Cronic, errors due to fatigue (SA)

power naps, training, CRM, support crew decision
to decrease duty day
Duty Day

Negligible
Frequent

Remote
Critical

Training, CRM, sleep-power naps, support crew

High

Low
Fatigue-Acute, errors due to fatigue (SA)
decision to decrease duty day

Improbable
Occasional

Negligible
Unqualified personnel flying the aircraft-
Serious
Critical

Qualified and mission proficient personnel flying

Low
Qualifications Resulting in: CFIT, emergency procedures,
the aircraft, adequate staffing levels.
incidents, accidents

Procedures that do not reflect the entire IR Improbable

system leading to ambiguity in the decisions that
Occasional

Negligible
Clearly defined policies, procedures, and roles
Serious
Critical

Ill-defined policy need to be made, adding stress and anxiety to

Low
(Infrared Operations Guide); Have IR Ops Guide
and procedures the crew's workload ultimately leading to
approved by line officer authority.
hazardous decision making with possible
damage/injury to aircraft or crew

7 Completed 2008
System: Flight Operations
Pre Mitigation Post Mitigation

Achieved? Yes
Likelihood

Likelihood

Mitigation

Mitigation
Outcome

Outcome
Severity

Severity
Mitigation

or No

Value
Post
Sub-systems Hazards Additional Local Mitigation

Use of uncarded aircraft and crew. Failure to

Improbable
follow policy/safety recommendations resulting

Occasional

Negligible

Negligible
in use of pilots who are not proficient or current Check aircraft data cards and pilot qualification

Low

Low
CWN/Other A/C
for the mission. Using aircraft that may have cards
exceeded inspection and or component
replacement deadlines.

Catastrophic

Occasional
Frequent
Incidents or errors caused by physiological

Serious
Critical
Education and training; implement CRM;

High
Night Ops challenges (circadian rhythm deviations,
Recognize and operate within personal limitations.
impaired vision, fatigue)

Negligible

Negligible
Remote

Remote
Carry back up hand-held radio in the survival kit;

Low

Low
Losing radio communications
cell phones available

Communication

Improbable
Occasional

Negligible
Chance of striking person or property with drop Serious Ensure clear communications prior to drop--no
Critical

Low
tube because of a lack of clear communications drop if no communications; follow established drop
during air drop procedures

Improbable
Marginal

Marginal
Filing IFR; preflight planning; if you encounter IMC
Medium

Medium
Remote

Inadvertant flight into IMC Conditions inadvertantly fly instruments and exit IMC
conditions
Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious

Instrument Maintain currency and proficiency; Do not allow

Lack of currency and proficiency
Flying non-current crewmembers to fly missions
Catastrophic

Catastrophic
Improbable

Improbable
Medium

Medium
Controlled flight into terrain (CFIT) Maintain situational awareness; training; file IFR

8 Completed 2008
System: Flight Operations (continued)
Pre Mitigation Post Mitigation

Achieved?
Likelihood

Likelihood

Mitigation

Mitigation
Yes or No
Outcome

Outcome
Severity

Severity
Mitigation

Value
Post
Sub-systems Hazards Additional Local Mitigation

Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious
File IFR, TCAS, Situational awareness, visual
Congestion, mid-air collision potential
scanning

Airspace

Catastrophic

Catastrophic
Improbable

Medium
Remote

Serious
Non-radar/uncontrolled airspace-unknown
See and avoid, Use TCAS
aircraft, possible mid-air collision

Catastrophic

Catastrophic
Improbable
Ensure crew is adequately trained. Maintain

Medium
Remote

Serious
Hot hand-offs resulting serious injury or death Situational Awareness. Be sure communications
are clear between air-ground personnel.

Ensure crew is adequately trained. Maintain

Catastrophic

Catastrophic
Improbable
Situational Awareness. Be sure communications

Medium
Remote

Delivery of Air drop tubes striking an object or person Serious are clear between air-ground personnel. employ
Imagery causing damage or personnal injury
data transfer via satellite, No communications-NO
drop

Training, Situational Awareness, CRM, clear and

Catastrophic

Catastrophic
Probable

positive air to ground communications, IAPs, Use

Remote

Serious
Low/slow flight profile in delivery of air drop
High

radio altimeter, Determine criteria for go-no go

resulting CFIT
situations/decisions. Drop only during clear VFR
conditions.

9 Completed 2008