SEAT - BLM

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					                       System Safety Assessment - Single Engine Airtankers (SEAT)
SEAT System - SEAT Aircraft
                                                                       Pre-Mitigation                                                                                Post-mitigation




                                                                                                                                                                      Likelihood




                                                                                                                                                                                                            Achieved?
                                                                                                                                                                                                            Mitigation

                                                                                                                                                                                                            Yes or No




                                                                                                                                                                                                                                                          Mitigation
                                                                       Likelihood




                                                                                                   Outcome




                                                                                                                                                                                                  Outcome
                                                                                    Severity




                                                                                                                                                                                   Severity




                                                                                                                                                                                                                                                            Value
                                                                                                                                                                                                                                                             Post
                                                                                                                                  Mitigation
   Sub-System                              Hazards                                                                                                                                                                       Additional Local Mitigation


                                                                                                             Assign appropriate SEAT aircraft for mission and




                                                                       Frequent
                                                                                                             typical DA. Conduct pre-mission performance




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote
                                                                                    Critical




                                                                                                                                                                                   Critical
                      High Density Altitude effects the aircraft




                                                                                                   High
                                                                                                             planning. Reinforce HHH Training. Acquire
                      quantity/performance
                                                                                                             incident altitude and route information when
    Capabilities                                                                                             available.

                                                                                                             Ensure SEAT is appropriate for temperatures,




                                                                       Occasional




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote
                                                                                                   Serious
                                                                                    Critical




                                                                                                                                                                                   Critical
                                                                                                             altitude terrain and mission. Receive feedback
                      Inappropriate Aircraft for Mission
                                                                                                             from pilots and Aerial Supervisor. Utilize electronic
                                                                                                             map technology when possible.




                                                                                    Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                       Occasional




                                                                                                                                                                      Remote




                                                                                                                                                                                                  Serious
                                                                                                             Pilot & SEMG monitor maintenance schedule. Pilot




                                                                                                   High
                      Mechanical Failure
                                                                                                             reviews & understands emergency procedures.



                                                                                                             Follow Contract requirements and Aircraft
   Maintenance                                                                                               Maintenance Manual. Aircraft inspectors check that
                                                                                    Catastrophic
                                                                       Occasional


                                                                                                             FAA maintenance requirements are met. Pilot




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote


                                                                                                                                                                                   Critical
                                                                                                   High
                      Aircraft Improperly Maintained                                                         performs/ensures that daily pre-flight inspections
                                                                                                             are complete and that all life/time limit maintenance
                                                                                                             items are within limits. SEMG ensure pre/post flight
                                                                                                             inspections completed.


                                                                                                             Maintain VMC. Practice See & Avoid. Establish
                                                                                                             Communications. Ensure sound mission planning
                                                                                    Catastrophic
                                                                       Frequent




                                                                                                             is performed and weather briefing is received.




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote


                                                                                                                                                                                   Critical
                      Smoke/Lighting/Inversion - Inclement Weather
                                                                                                   High




                                                                                                             Know and understand Fire Traffic Area (FTA).
                      conditions between Airbase & Incident
                                                                                                             Keep windscreen clean. Pilot and ground
                                                                                                             resources must maintain Situational Awareness.
                                                                                                             Pilot should exercise go/no-go option.
                                                                       Occasional




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote
                                                                                                   Serious
                                                                                    Critical




                                                                                                                                                                                   Critical
                      Un-used or inoperable High Visibility aircraft                                         Aircraft lighting systems need to be utilized and
Collision Avoidance
                      lighting systems                                                                       maintained.



                                                                                                             Comply with Interagency Aerial Supervision guide.
                                                                                    Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                                                             Ensure effective airspace coordination is
                                                                       Frequent




                                                                                                                                                                      Remote




                                                                                                                                                                                                  Serious
                      Congested Airspace, Military Airspace,                                                 conducted between Dispatch & FBOs & Military
                                                                                                   High




                      Uncontrolled Airports,                                                                 Units. Understand, review, and discuss the Fire
                                                                                                             Traffic Area (FTA) in briefings. Review known
                                                                                                             aerial hazards.




          1                                                                                                                                                                                                                                            Revised 2011
SEAT System - SEAT Aircraft (continued)
                                                                      Pre-Mitigation                                                                              Post-mitigation




                                                                                                                                                                   Likelihood




                                                                                                                                                                                                         Achieved?
                                                                                                                                                                                                         Mitigation




                                                                                                                                                                                                                                                        Mitigation
                                                                                                                                                                                                         Yes or No
                                                                      Likelihood




                                                                                                  Outcome




                                                                                                                                                                                               Outcome
                                                                                   Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                          Value
                                                                                                                                                                                                                                                           Post
                                                                                                                                 Mitigation
    Sub-System                            Hazards                                                                                                                                                                      Additional Local Mitigation




                                                                      Occasional

                                                                                   Marginal




                                                                                                                                                                                Marginal
Aircraft Carding and                                                                                        Ensure implementation of standardized SEAT




                                                                                                  Medium




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
  Pilot Inspection   Lack of Standardization                                                                aircraft and pilot inspection process. Train
      Process                                                                                               inspectors on new standards.




                                                                      Occasional
                                                                                                            Train and utilize more Interagency Inspectors




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                                  Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                      Not Enough Inspectors to consistently detect
                                                                                                            (include all agencies) with past SEAT program
                      unsafe equipment, inadequate skills, etc.
                                                                                                            experience and knowledge.
    Equipment
                                                                                                            Agency and vendor should ensure adequate time




                                                                      Occasional




                                                                                                                                                                                Marginal

                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                                  Serious
                                                                                   Critical
                                                                                                            for Inspection. Encourage pilot to utilize time to
                      Inadequate Pre-Flight/Post-Flight Inspections
                                                                                                            complete Inspections. Document Pre/Post Flight
                                                                                                            Inspections daily.



                                                                      Probable
                                                                                                            Inspection & carding process ensure Contractors




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                   Critical




                                                                                                                                                                                Critical
                                                                                                  High
                      Changing Technology & Lack of Training                                                (Pilots) are skilled with equipment provided - GPS,
                                                                                                            VHF & UHF Radios, AFF, etc.

                                                                                                            Continue to work with State, City & County Fire                                                           Provide programming software
                                                                                                            Departments to meet future Federal Standards and
                                                                      Occasional




                      Lack of Radio Equipment Compatibility




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                                  Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                                                                                                            compatibility issues. Work with national
                      (Narrow Banding & Frequencies). Future
                                                                                                            agency/interagency radio program leaders ensure
                      considerations: Digital requirements.
                                                                                                            the policies they develop are compatible with
                                                                                                            aviation requirements.

                                                                                                            Conduct effective air base in-briefings. Develop
                                                                                                            specialized training-simulations. Conduct frequent
                                                                                   Catastrophic
                                                                      Frequent




                                                                                                            AARs and/or sand table exercises. Perform




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote


                                                                                                                                                                                Critical
                                                                                                  High




                      Inadequate Frequency Management                                                       periodic reviews of frequency lists and avionics
                                                                                                            equipment operations. Check radio systems
                                                                                                            following relief pilot duty. Ensure that positive
 Communications
                                                                                                            communications are established.
                                                                                   Catastrophic




                                                                                                                                                                                Catastrophic
                                                                      Occasional




                                                                                                                                                                   Occasional
                                                                                                            Follow appropriate checklists and procedures. If no




                                                                                                                                                                                               Medium
                      No Communications between SEAT pilot and
                                                                                                  High




                                                                                                            contact can be established on incident return to
                      ground/air ops.
                                                                                                            base.

                                                                                                            Make alternative frequencies readily available.
                                                                                                            Publish secondary frequencies. Utilize AFF when
                                                                      Frequent




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                   Critical




                                                                                                                                                                                Critical
                                                                                                            possible to reduce congestion. Maintain effective
                                                                                                  High




                      Radio Frequency Congestion
                                                                                                            working relations with frequency coordinators.
                                                                                                            During high fire activity consider ordering stand
                                                                                                            alone frequency coordinator.

                                                                                                            Assign discreet local flight following frequencies
                                                                      Probable




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                   Critical




                                                                                                                                                                                Critical

                                                                                                            whenever possible. Utilize standardized AFF
                                                                                                  High




                      Lack of flight following frequencies
                                                                                                            procedures. Utilize National Flight Following if
                                                                                                            necessary.




          2                                                                                                                                                                                                                                          Revised 2011
SEAT System - Maintenance
                                                                       Pre-Mitigation                                                                                      Post-mitigation




                                                                                                                                                                            Likelihood




                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation




                                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                                   Yes or No
                                                                       Likelihood




                                                                                                          Outcome




                                                                                                                                                                                                         Outcome
                                                                                               Severity




                                                                                                                                                                                         Severity




                                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                                    Post
                                                                                                                                         Mitigation
    Sub-System                           Hazards                                                                                                                                                                                Additional Local Mitigation



                                                                                                                    SEMG should be proactive during the pre-use
                                                                                                                    inspection. SEMG should proactively seek and




                                                                       Occasional




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                                          Serious
                                                                                               Critical




                                                                                                                                                                                              Critical
                                                                                                                    document maintenance information when the
  Documentation       Maintenance not tracked well
                                                                                                                    aircraft and pilot reports for assignment. Vendor
                                                                                                                    needs to share maintenance information as SEAT
                                                                                                                    moves between assignments.




                                                                       Occasional Occasional
                      Experience and/or knowledge level of                                                          Emphasis should be focused on verification of




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                                          Serious
                                                                                               Critical




                                                                                                                                                                                         Critical
                      contractor personnel assigned to perform                                                      credentials by Government Inspectors. SEMG/PI
                      maintenance duties is unknown.                                                                should coordinate with COTR.
  Responsibilities




                                                                                                                                                                                         Marginal
                                                                                                                    Avoid overloading support personnel with




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                                          Serious
                                                                                               Critical
                      Distractions created by Collateral Duties
                                                                                                                    responsibilities and workload. Utilize additional
                      (A&P/driver/mixer etc).
                                                                                                                    crew members as necessary.

SEAT System - SEAT Base Facilities (Permanent & Temporary)
                                                                       Pre-mitigation                                                                                      Post-mitigation




                                                                                                                                                                            Likelihood


                                                                                                                                                                                         Severity

                                                                                                                                                                                                         Outcome


                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation

                                                                                                                                                                                                                   Yes or No




                                                                                                                                                                                                                                                                 Mitigation
                                                                       Likelihood




                                                                                                          Outcome
                                                                                               Severity




                                                                                                                                                                                                                                                                   Value
                                                                                                                                         Mitigation




                                                                                                                                                                                                                                                                    Post
    Sub-System                           Hazards                                                                                                                                                                                Additional Local Mitigation
                                                                       Occasional




                                                                                                                    Continue efforts to upgrade/improve




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                                          Serious
                                                                                               Critical




                                                                                                                                                                                         Critical
                      Lack of Adequate Radio Equipment,
  Communications                                                                                                    communications and IT equipment, and program
                      Computers & IT Support
                                                                                                                    support on an annual basis.

                                                                                                                    Comply with Contract requirements. Discuss and
                                                                       Frequent




                                                                                                                    exercise after-hours options to provide security.




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                               Critical




                                                                                                                                                                                         Critical
                      Unsecured Air Base Facilities increase risk of
                                                                                                          High




     Security                                                                                                       Address security concerns during initial briefings.
                      sabotage.
                                                                                                                    Ensure thorough pre-use inspections on all
                                                                                                                    equipment and facilities.

                                                                                                                    Verify that length, width and surface conditions,
                                                                       Frequent




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                               Critical




                                                                                                                                                                                         Critical
                                                                                                                    congested area and elevation for minimum
                                                                                                          High




                      Inadequate Runway Minimums.
                                                                                                                    operational use are adequate. (Make & Model of
                                                                                                                    aircraft).
SEAT Base Standards
                                                                                                                    Verify that length, width and surface conditions for
                                                                       Frequent




                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                               Critical




                                                                                                                                                                                         Critical
                                                                                                                    type and number of equipment and aircraft are
                                                                                                          High




                      Inadequate Ramp Space Minimums
                                                                                                                    adequate. Consider ordering qualified Ramp
                                                                                                                    Manager with communications.

                                                                                                                    Provide SEAT base operations (both
                                                                                                                    government/vendor) with approved Haz Mat
                                                                       Frequent

                                                                                               Marginal




                                                                                                                                                                                         Marginal

                                                                                                                                                                                                         Medium
                                                                                                                                                                            Remote
                                                                                                          Serious




     Haz Mat           Lack of adequate spill prevention/mitigation                                                 storage and containment facilities/equipment.
  concerns/spills     equipment on site and the knowledge to use it.                                                Solicit for National Contracts to provide portable
                                                                                                                    haz mat storage facilities for incidents. Provide
                                                                                                                    hands on training.




          3                                                                                                                                                                                                                                                   Revised 2011
SEAT System - SEAT Contracts
                                                                      Pre-mitigation                                                                           Post-mitigation




                                                                                                                                                                Likelihood




                                                                                                                                                                                        Outcome
                                                                                                                                                                             Severity




                                                                                                                                                                                                  Achieved?
                                                                                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                  Yes or No
                                                                      Likelihood




                                                                                              Outcome
                                                                                   Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                             Mitigation




                                                                                                                                                                                                                                                   Post
   Sub-System                             Hazards                                                                                                                                                              Additional Local Mitigation



                                                                                                        Utilizing more Variable Term contracts will increase
                                                                                                        continuity between contractor and local unit which




                                                                      Frequent
                       Lack of Continuity, Efficiency, Proficiency,




                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                   Critical




                                                                                                                                                                             Critical
On-Call vs. Variable                                                                                    produces better CRM and reduces exposure/safety




                                                                                              High
                       Training, Familiarization and CRM with
       Term                                                                                             issues for managers and ground personnel. Both
                       Contractor Personnel and Local Operations.
                                                                                                        Government and Vendor should secure adequate
                                                                                                        funding to provide training and simualtions.

SEAT System - Personnel (Government)
                                                                      Pre-mitigation                                                                           Post-mitigation




                                                                                                                                                                Likelihood


                                                                                                                                                                             Severity

                                                                                                                                                                                        Outcome


                                                                                                                                                                                                  Achieved?
                                                                                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                  Yes or No
                                                                      Likelihood




                                                                                              Outcome
                                                                                   Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                   Post
                                                                                                                             Mitigation
   Sub-System                             Hazards                                                                                                                                                              Additional Local Mitigation



                                                                                                        Ensure that base operations plans address




                                                                                                                                                                Occasional
                                                                      Frequent
                                                                                                        contingency to handle events where span-of-




                                                                                                                                                                                        Serious
                                                                                   Critical




                                                                                                                                                                             Critical
                                                                                              High
    Utilization        Span of Control                                                                  control may be exceeded. Home units need to
                                                                                                        mitigate this issue by pre-training and recruitment
                                                                                                        of supplemental personnel. Comply with ISOG.

                                                                                                        Agency personnel need to rely upon AMD
                                                                                                        Technical Service Maintenance Inspectors to
                                                                      Frequent

                                                                                   Marginal




                                                                                                                                                                             Marginal

                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                              Serious




                       SEAT Managers & ATB Managers are not fully                                       determine proper maintenance procedures and
   Management
                       aware of Aircraft Maintenance Issues.                                            authorization to return the aircraft to contract
                                                                                                        availability. SEMG notifies local UAO of any
                                                                                                        maintenance issues.

                                                                                                        Recommend SEAT Manager attend aviation
                                                                      Frequent

                                                                                   Marginal




                                                                                                                                                                             Marginal
                       Lack of knowledge and experience in Aviation
                                                                                              Medium




                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                                        contract administration course. Also highly
                       Contract Administration and Aviation Program
                                                                                                        recommend a season of wildland fire line
                       Management for SEAT Manager Trainees.
                                                                                                        experience.
     Training
                                                                      Frequent




                                                                                                                                                                             Marginal

                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                   Critical




                       Lack of knowledge and experience in ramp                                         Develop standardized ramp management training
                                                                                              High




                       operations                                                                       for SEAT managers.

                                                                                                        Adhere to established work-rest policy/guidelines
                                                                      Probable




                                                                                                        and promote additional off-time when possible.




                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                   Critical




                                                                                                                                                                             Critical
                                                                                              High




                       Fatigue                                                                          Request additional staffing and/or detailers during
                                                                                                        peaks of high fire activity. Ensure adequate
                                                                                                        facilities and supplies are available.

                                                                                                        Emphasize importance of "situational awareness"
                                                                                                        as a means to recognizing risk. Consider
                                                                      Probable




                                                                                                        utilization of the SEAT Coordinator, SEAT Program                               Medium
                                                                                                                                                                Remote
                                                                                   Critical




                                                                                                                                                                             Critical


  Human Factors
                                                                                              High




                       Acceptance of Risk as Normal                                                     Manager positions as a method of mitigating risk.
                                                                                                        Provide Risk Management Training for the SEMG.
                                                                                                        Ensure SEAT Manager reviews Risk Management
                                                                                                        Workbook with the vendor.
                                                                      Probable

                                                                                   Marginal




                                                                                                                                                                             Marginal




                                                                                                        Clarify & Confirm Program changes. Notify
                                                                                                                                                                                        Medium
                                                                                                                                                                Remote
                                                                                              Serious




                       Changes in standard operating procedures not
                                                                                                        appropriate personnel, in a timely manner. Accept
                       known
                                                                                                        questions and seek out responses.




          4                                                                                                                                                                                                                                  Revised 2011
SEAT System - Personnel (Government continued)
                                                                          Pre-mitigation                                                                             Post-mitigation




                                                                                                                                                                      Likelihood


                                                                                                                                                                                   Severity

                                                                                                                                                                                              Outcome


                                                                                                                                                                                                        Achieved?
                                                                                                                                                                                                        Mitigation




                                                                                                                                                                                                                                                      Mitigation
                                                                                                                                                                                                        Yes or No
                                                                          Likelihood




                                                                                                  Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                        Value
                                                                                                                                                                                                                                                         Post
                                                                                                                                 Mitigation
    Sub-System                            Hazards                                                                                                                                                                    Additional Local Mitigation



                                                                                                            If individuals cannot professionally resolve
                                                                                                            differences, managers and supervisors must




                                                                          Occasional




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                                  Serious
                                                                                       Critical




                                                                                                                                                                                   Critical
  Human Factors        Conflicting personalities resulting in hazardous                                     intervene immediately. Brief/debrief, employ CRM,
   (continued)         attitudes                                                                            provide honest and objective feedback, maintain
                                                                                                            positive attitude. Maintain professionalism and
                                                                                                            mission focus at all times.

                                                                                                            Provide program oversight (Local, State or Natl.,




                                                                          Frequent

                                                                                       Marginal




                                                                                                                                                                                   Marginal

                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                                  Serious
                                                                                                            IQCS) to ensure that SEMG meet currency
                       Variable Term vs. On-Call SEAT Manager.
                                                                                                            experience requirements and have completed tri-
                                                                                                            annual refresher as per ISOG.
    Experience
                                                                                                            Provide thorough pre-mission briefing, conduct




                                                                          Probable




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                       Critical




                                                                                                                                                                                   Critical
                       Aerial Supervision - Lack of SEAT specific                                           post-mission AARs and have an experienced




                                                                                                  High
                       knowledge and experience                                                             ATGS ride-along if available. Include specific SEAT
                                                                                                            section for ATGS.

                                                                                                            Re-enforce and emphasize to SEMGs to
                                                                          Occasional

                                                                                       Marginal




                                                                                                                                                                                   Marginal
                                                                                                  Medium




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                                            communicate with local UAO, SECOs, Contracting
                       Policy Deviation
                                                                                                            Officers, SAMs, etc. when questions and issues
                                                                                                            arise.
 Policy/ Procedure




                                                                                                                                                                      Occasional
                                                                          Frequent




                                                                                                            Recommend continued development &




                                                                                                                                                                                              Serious
                                                                                       Critical




                                                                                                                                                                                   Critical
                       Multiple Agencies - Differing Standards (State
                                                                                                  High


                                                                                                            implementation of Interagency standardized SEAT
                       vs Fed)
                                                                                                            program management and policy.
                                                                          Occasional

                                                                                       Marginal




                                                                                                                                                                                   Marginal
                                                                                                            Stronger emphasis by agency to contractor
                                                                                                  Medium




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                       Drivers not understanding/following DOT
     Utilization                                                                                            regarding their responsibility to comply with policies
                       Policy/Regulations
                                                                                                            and regulations (rest, driving and duty).
                                                                          Occasional




                                                                                                            Continue with further development of contractor




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                                  Serious
                                                                                       Critical




                                                                                                                                                                                   Critical
   Training - Pilot    Potential for Inadequate SEAT Pilot Training                                         SEAT Pilot training program opportunities and/or
                                                                                                            BLM/FS NAFA & SEAT Pilot Academy.

                                                                                                            Ensure that those bases using agency personnel
                                                                                                            for loading operations provide adequate training to
                                                                          Occasional




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                                  Serious
                                                                                       Critical




                                                                                                                                                                                   Critical
 Training - Mixers &   Not all Mixers & Loaders are adequately                                              ground personnel prior to fire assignment. Provide
       Loaders         trained and qualified.                                                               training documentation to agency aviation
                                                                                                            managers on the mixing and loading of fire
                                                                                                            chemical retardant products.

SEAT System-Personnel (Contractor)
                                                                          Pre-mitigation                                                                             Post-mitigation
                                                                                                                                                                      Likelihood


                                                                                                                                                                                   Severity

                                                                                                                                                                                              Outcome


                                                                                                                                                                                                        Achieved?
                                                                                                                                                                                                        Mitigation

                                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                                      Mitigation
                                                                          Likelihood




                                                                                                  Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                        Value
                                                                                                                                 Mitigation




                                                                                                                                                                                                                                                         Post
    Sub-System                            Hazards                                                                                                                                                                    Additional Local Mitigation



                                                                                                            Ensure contractor compliance with rest and duty
                                                                                                            limitations for ground support personnel so as not
                                                                          Probable




                                                                                                                                                                                              Medium
                                                                                                                                                                      Remote
                                                                                       Critical




                                                                                                                                                                                   Critical




                       Ground support personnel fatigue and                                                 to overextend. (Company and agencies are
                                                                                                  High




  Human Factors
                       workload                                                                             responsible to monitor closely). Utilize additional
                                                                                                            crew members as necessary. Monitor number of
                                                                                                            aircraft being loaded and additional workload.




           5                                                                                                                                                                                                                                       Revised 2011
SEAT System-Personnel (Contractor)
                                                                       Pre-mitigation                                                                                Post-mitigation




                                                                                                                                                                      Likelihood


                                                                                                                                                                                   Severity

                                                                                                                                                                                                  Outcome


                                                                                                                                                                                                            Achieved?
                                                                                                                                                                                                            Mitigation

                                                                                                                                                                                                            Yes or No




                                                                                                                                                                                                                                                          Mitigation
                                                                       Likelihood




                                                                                                   Outcome
                                                                                    Severity




                                                                                                                                                                                                                                                            Value
                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                             Post
    Sub-System                             Hazards                                                                                                                                                                       Additional Local Mitigation



                                                                                                             Ensure that these items are addressed in the
                                                                                                             contract pre-work meeting and re-enforced in the




                                                                       Frequent
                       Pilot - poor decision making: multi tasking,                                          daily air base briefings, post mission briefings or




                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote
                                                                                    Critical




                                                                                                                                                                                   Critical
                                                                                                   High
                       mission focus, sense of urgency, peer                                                 whenever the need is identified. All personnel
                       pressure                                                                              involved in operations should recognize hazardous
                                                                                                             situations or behavior. Communicate issues or
                                                                                                             concerns.

                                                                                                             Emphasize importance of "situational awareness"
                                                                                                             as a means to recognizing risk. Consider providing




                                                                                    Catastrophic




                                                                                                                                                                      Occasional
                                                                       Probable
                                                                                                             Risk Management Training for the Pilot. Re-




                                                                                                                                                                                                  Serious
                                                                                                                                                                                   Critical
                                                                                                   High
                       Acceptance of Risk as Normal                                                          address complacency and self discipline in daily air
                                                                                                             base briefings. Review Risk Management
                                                                                                             Workbook and/or Vendor SMS Manual on a regular
                                                                                                             basis.

  Human Factors                                                                                              Make effort to ensure that contractor relief




                                                                                                                                                                      Occasional
                       Poor CRM with crew rotations; Crew rotation     Probable




                                                                                                                                                                                                  Serious
                                                                                    Critical




                                                                                                                                                                                   Critical
   (continued)                                                                                               personnel arrive at base prior to relief cycle with



                                                                                                   High
                       may affect aircraft/equipment knowledge
                                                                                                             sufficient overlap time to receive good in-brief from
                       transfer.
                                                                                                             primary personnel.

                                                                                                             Utilize Aerial Supervision if available to reduce
                       Single Pilot workload may be considered to be
                                                                                                             cockpit workload. Utilize newer technology such as




                                                                                                                                                                      Occasional
                                                                       Frequent




                       excessive based on demands that he/she be




                                                                                                                                                                                                  Serious
                                                                                    Critical




                                                                                                                                                                                   Critical
                                                                                                             AFF to minimize radio traffic. Conduct AAR's, sand
                                                                                                   High


                       able to operate several cockpit equipment
                                                                                                             table exercises and on ground CRM Exercises.
                       items during mission performance (i.e. Multi-
                                                                                                             Incorporate Operations personnel in simulations
                       Tasking Overload.).
                                                                                                             and exercises, as well as AAR's.

                                                                                                             If individuals cannot professionally resolve
                                                                                                             differences, managers and supervisors must




                                                                                                                                                                      Occasional
                                                                       Probable




                                                                                                                                                                                                  Serious
                                                                                    Critical




                                                                                                                                                                                   Critical
                                                                                                             intervene immediately. Brief/debrief, employ CRM,
                                                                                                   High




                       Conflicting and/or Difficult Personalities
                                                                                                             provide honest and objective feedback, maintain
                                                                                                             positive attitude. Maintain professionalism and
                                                                                                             mission focus at all times.

                                                                                                             Vendors have instituted training programs such as
                                                                                    Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                                                             CRM, risk management, and flight safety with the




                                                                                                                                                                      Occasional
                                                                       Probable




                                                                                                                                                                                                  Serious
                       Lack of fire mission training and lack of                                             intent to standardize cockpit procedures. Develop
                                                                                                   High




                       proficiency flight time.                                                              the McCllelan training center for fire environment
                                                                                                             and make available for vendor use. Other training
                                                                                                             includes aircraft performance and limitations.
                                                                                    Catastrophic




 Pilot Training and                                                                                          Company training plans should address human              Occasional
                                                                       Probable




                                                                                                                                                                                                  Serious
                                                                                                                                                                                   Critical
                       High number of target fixation and tactical                                           factors including target fixation, situational
                                                                                                   High




     Experience
                       maneuvering errors.                                                                   awareness, task overload, and
                                                                                                             performance/tactical planning errors.
                                                                                    Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                       Occasional




                                                                                                             Adhere to existing contract requirements requiring
                                                                                                                                                                      Remote




                                                                                                                                                                                                  Serious
                                                                                                   High




                       Inadequate flight experience                                                          contractors to validate pilots' experience and
                                                                                                             training.

                                                                                                             Ensure that contractors provide adequate training
                                                                       Occasional




                                                                                                             to ground personnel prior to fire assignment.
                                                                                                                                                                                                  Medium
                                                                                                                                                                      Remote
                                                                                                   Serious
                                                                                    Critical




                                                                                                                                                                                   Critical




 Training - Mixers &   Not all Mixers & Loaders are adequately
                                                                                                             Provide training documentation to agency aviation
       Loaders         trained and qualified.
                                                                                                             managers on the mixing and loading of fire
                                                                                                             chemical retardant products.




          6                                                                                                                                                                                                                                            Revised 2011
SEAT System-Personnel (Contractor continued)
                                                                          Pre-mitigation                                                                                    Post-mitigation




                                                                                                                                                                             Likelihood


                                                                                                                                                                                          Severity

                                                                                                                                                                                                         Outcome


                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation




                                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                                   Yes or No
                                                                          Likelihood




                                                                                                      Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                                   Value
                                                                                                                                      Mitigation




                                                                                                                                                                                                                                                                    Post
    Sub-System                            Hazards                                                                                                                                                                               Additional Local Mitigation



                                                                                                                Take a stronger approach with all Vendor




                                                                          Occasional




                                                                                                                                                                                                         Medium
                                                                                                                                                                             Remote
                                                                                                      Serious
                                                                                       Critical




                                                                                                                                                                                          Critical
                      Lack of familiarity with technology, inability to                                         personnel to ensure that they are trained in the
  New Technology
                      utilize and operate equipment.                                                            function and operation of newer tech-equipment
                                                                                                                and systems prior to implementation and utilization.




                                                                          Occasional
                                                                                                                Standardize equipment specifications through the




                                                                                                                                                                                                         Medium
                                                                                                                                                                             Remote
                                                                                                      Serious
                                                                                       Critical




                                                                                                                                                                                          Critical
                      Lack of standardized aircraft, support
  Standardization                                                                                               procurement process and mandate within the
                      equipment, and communications equipment.
                                                                                                                contract solicitation.

                                                                                                                Agency radio system needs to be replaced, re-
                                                                                                                designed and upgraded to accommodate current
                                                                                                                demand and volume of use for current Fire &




                                                                                                                                                                             Occasional
                                                                          Frequent




                                                                                                                                                                                                         Serious
                                                                                       Critical




                                                                                                                                                                                          Critical
                      Lack of technical support/inadequate support                                              Aviation programs, as well as those of the future.




                                                                                                      High
Agency Radio System
                      system.                                                                                   (Standardize and buy user friendly equipment.)
                                                                                                                Maintain close working relations with agency radio
                                                                                                                program leaders and manufacturers to ensure
                                                                                                                aviation needs are addressed.

SEAT System - SEAT Operations
                                                                          Pre-mitigation                                                                                    Post-mitigation




                                                                                                                                                                             Likelihood


                                                                                                                                                                                          Severity

                                                                                                                                                                                                         Outcome


                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation

                                                                                                                                                                                                                   Yes or No




                                                                                                                                                                                                                                                                 Mitigation
                                                                          Likelihood




                                                                                                      Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                                    Post
                                                                                                                                      Mitigation
    Sub-System                            Hazards                                                                                                                                                                               Additional Local Mitigation



                                                                                                                SEAT Pilot, Fire Managers, Dispatchers, line




                                                                                                                                                                             Occasional
                                                                          Frequent




                                                                                                                                                                                          Marginal
                      Inefficient use of SEATs may result in                                                    personnel, and aerial supervisors need proper




                                                                                                                                                                                                         Medium
                                                                                       Critical

                                                                                                      High




                      unnecessary risk exposure to SEAT Pilot and                                               education on use of SEATs. Use AAR as mitigation
                      ground personnel. (Risk vs. Reward)                                                       tool to prevent re-occurrence. Conduct pre and
                                                                                                                post -mission briefings.
                                                                          Occasional




                                                                                                                Agency and Contractor should provide training and




                                                                                                                                                                                                         Medium
                                                                                                                                                                             Remote
                                                                                                      Serious
                                                                                       Critical




                                                                                                                                                                                          Critical
                      Jurisdiction & Border Issues                                                              orientation. Local unit to brief and initiate utilization
                                                                                                                of the local Airspace Boundary Plan.

                                                                                                                Re-enforce local Interagency Lead Plane SOP's for
                                                                          Probable




                                                                                                                                                                                                         Medium
                                                                                                                                                                             Remote
                                                                                       Critical




                                                                                                                                                                                          Critical
                      Defined standard Lead Plane profiles for                                                  SEAT aircraft tactical operations. Contractors need
                                                                                                      High




                      SEATs                                                                                     to also address SEAT/Lead Plane SOPs during
                                                                                                                annual training.
                                                                                       Catastrophic




                                                                                                                                                                                          Catastrophic
                                                                                                                Perform high level reconnaissance prior to
                                                                          Frequent




     Missions                                                                                                                                                                Remote




                                                                                                                                                                                                         Serious
                      Flying low level at operational weights and                                               descending to work in the low-level environment.
                                                                                                      High




                      airspeeds in areas with hazards.                                                          Utilize aerial supervision when available. Utilize
                                                                                                                proper aircraft energy management techniques.
                                                                          Frequent




                                                                                                                Agency & Contractors need to evaluate required                                           Medium
                                                                                                                                                                             Remote
                                                                                       Critical




                                                                                                                                                                                          Critical



                      Inexperienced Personnel-Government &
                                                                                                      High




                                                                                                                training to determine if personnel are staying
                      Contractors
                                                                                                                current with program needs.
                                                                                                                Address the SAFETY vs. URGENCY issue as a
                                                                          Occasional




                      A Sense of urgency may be placed on
                                                                                                                                                                                                         Medium
                                                                                                                                                                             Remote
                                                                                                      Serious
                                                                                       Critical




                                                                                                                                                                                          Critical




                                                                                                                special-emphasis item during in-briefing with
                      Contractor personnel at various points in the
                                                                                                                contractor and agency employees. Reinforce this
                      mission.
                                                                                                                throughout the entire operational period.
                                                                                       Catastrophic




                                                                                                                                                                                          Catastrophic
                                                                          Frequent




                                                                                                                Maintain 60 ft. obstacle clearance as the minimum
                                                                                                                                                                             Remote




                                                                                                                                                                                                         Serious
                                                                                                      High




                      Drop Height Minimums                                                                      decent altitude for all fire operations except during
                                                                                                                takeoff and landing.




         7                                                                                                                                                                                                                                                    Revised 2011
SEAT System - SEAT Operations (continued)
                                                                  Pre-mitigation                                                                                Post-mitigation




                                                                                                                                                                 Likelihood


                                                                                                                                                                              Severity

                                                                                                                                                                                             Outcome


                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                       Yes or No




                                                                                                                                                                                                                                                     Mitigation
                                                                  Likelihood




                                                                                              Outcome
                                                                               Severity




                                                                                                                                                                                                                                                       Value
                                                                                                                                                                                                                                                        Post
                                                                                                                             Mitigation
   Sub-System                            Hazards                                                                                                                                                                    Additional Local Mitigation



                                                                                                        Monitor fuel quantities. Monitor fuel flow vs time.




                                                                               Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                        Follow fuel transfer procedures. Pre-flight the




                                                                  Remote




                                                                                                                                                                 Remote
                                                                                              Serious




                                                                                                                                                                                             Serious
                      Poor fuel management                                                              aircraft and plan the flight. Know refueling
                                                                                                        locations. Query other aircraft - fuel status and
                                                                                                        availability.




                                                                               Catastrophic
                                                                  Occasional




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                              Serious




                                                                                                                                                                              Critical
                                                                                                        Maintain sterile cockpit policy, minimize in-flight
                      Single Pilot cockpit workload
                                                                                                        diversions and frequency changes.




                                                                  Occasional




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                              Serious
                                                                               Critical




                                                                                                                                                                              Critical
Mission (continued)                                                                                     Exercise "CAUTION" when in congested airspace
                      Wake Turbulence
                                                                                                        or in trail.




                                                                  Probable




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                               Critical




                                                                                                                                                                              Critical
                                                                                                        Implement utilization of National standard Aircraft




                                                                                              High
                      Lack of standardized dispatch form          Frequent
                                                                                                        Dispatch Form.



                                                                                                        Establish local ramp/taxi protocols in cooperation




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                              Serious
                                                                               Critical




                                                                                                                                                                              Critical
                      Ramp/Taxi operations and communications                                           with local airport operations. Ensure thorough in-
                                                                                                        briefing and monitor assigned ramp frequency.

                                                                                                        Local agency must provide orientation and
                                                                                                        "situational awareness" overview to SEAT pilots on
                                                                  Occasional




                                                                                                        Special Use Airspace, MTRs, TFRs etc. Utilize




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                              Serious
                                                                               Critical




                                                                                                                                                                              Critical
                      Conflicting Airspace Environment                                                  updated electronic equipment if possible. Assure
                                                                                                        that Dispatch and aviation program personnel are
                                                                                                        trained in Dispatch procedures for SUA. Use aerial
                                                                                                        supervision when available.

                                                                                                        Confirm weather information resources are
                                                                                                        available. Utilize updated electronic equipment if
                                                                  Frequent




                                                                                                        possible. Confirm that red-flag warnings are




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                               Critical




                                                                                                                                                                              Critical
                                                                                              High




                      Hazardous and Extreme Weather Conditions.                                         distributed. Ensure there are continual updates on
                                                                                                        changing weather conditions shared between
   Environment
                                                                                                        pilots, air base mangers, dispatchers, etc. Go-No-
                                                                                                        Go is PIC decision.

                                                                                                        Get an adequate mission briefing and use
                                                                                                        performance planning to prevent CFIT events.
                                                                  Frequent




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                               Critical




                                                                                                                                                                              Critical
                                                                                                        Perform high level reconnaissance prior to
                                                                                              High




                      Hazards and Extreme Terrain
                                                                                                        descending to the low level environment. Use
                                                                                                        Aerial Supervision when available. Utilize electronic
                                                                                                        map technology if possible.
                                                                  Frequent




                                                                                                        Comply with congested area policies and ensure
                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                               Critical




                                                                                                                                                                              Critical
                                                                                              High




                      Congested areas and Urban Interface.                                              that aerial supervision is in place or has been
                                                                                                        requested.




         8                                                                                                                                                                                                                                        Revised 2011
SEAT System - SEAT Operations (continued)
                                                                      Pre-mitigation                                                                              Post-mitigation




                                                                                                                                                                   Likelihood


                                                                                                                                                                                Severity

                                                                                                                                                                                           Outcome


                                                                                                                                                                                                     Achieved?
                                                                                                                                                                                                     Mitigation

                                                                                                                                                                                                     Yes or No




                                                                                                                                                                                                                                                   Mitigation
                                                                      Likelihood




                                                                                              Outcome
                                                                                   Severity




                                                                                                                                                                                                                                                     Value
                                                                                                                                                                                                                                                      Post
                                                                                                                             Mitigation
    Sub-System                           Hazards                                                                                                                                                                  Additional Local Mitigation



                                                                                                        Manage available frequencies as best as possible.




                                                                                                                                                                   Occasional
                                                                      Frequent
                                                                                                        Request additional frequencies as needed and




                                                                                                                                                                                           Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                                                                                              High
                      Lack of Available Frequencies                                                     release frequencies in a timely manner when no
                                                                                                        longer needed. Train all users in radio discipline.
  Communications                                                                                        Utilize AFF when possible.




                                                                      Occasional
                                                                                                        Validate tactical (A-G & A-A) contacts identied on




                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                              Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                      Inadequate clarification of Chain of Command-
                                                                                                        the Aircraft Dispatch form. Ensure the pilot has a
                      Who is in charge.
                                                                                                        copy and validate frequencies.

                                                                                                        Pilots need to ensure that proper weight and
                                                                                                        balance and performance planning is completed




                                                                      Occasional
                                                                                                        and shared with base personnel. Utilize




                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                              Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                      Lack of Planning - incorrect calculation of
                                                                                                        appropriate aircraft performance charts for the
                      allowable retardant load; weight & balance
                                                                                                        designated base and area of operations. Base
                                                                                                        personnel should be aware of trigger points for
                                                                                                        downloading retardant, water, etc.

                                                                                                        Specify length, width and surface conditions,
                                                                      Occasional


                                                                                                        congested areas and elevations for minimum




                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                              Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                     Inadequate runway lengths and/or surface
Performance Planning                                                                                    operational use for each make and model of
                     conditions
                                                                                                        aircraft. This information must be validated by
                                                                                                        performance planning.

                                                                                                        Utilize (National standard) A/C dispatch form,
                                                                                                        obtain as much information as possible from other
                                                                      Occasional




                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                              Serious
                                                                                   Critical




                                                                                                                                                                                Critical
                                                                                                        aerial and ground resources. Obtain information
                      Lack of information on incident conditions
                                                                                                        from Pilot after initial load on additional downloads .
                                                                                                        Use Aerial Supervision when available. PIC has
                                                                                                        final authority on go/no go. Monitor AFF if possible.




           9                                                                                                                                                                                                                                    Revised 2011

				
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