2009 Aviation

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					      2009 Aviation
Risk Management Workbook




           US Forest Service
     DOI Bureau of Land Management
Table of Contents

Introduction to Aviation Risk Management ...................................................................................... i

Risk Management Matrix................................................................................................................... iv

Operational Flowchart ....................................................................................................................... v



Assessments


Aerial Supervision Assessment .......................................................................................................... 1

Heavy Airtanker Program................................................................................................................... 8

Single Engine Airtankers .................................................................................................................... 12

Infrared Program ............................................................................................................................... 21

FHP Aerial Application ...................................................................................................................... 28

FHP Aerial Photography ..................................................................................................................... 44

FHP Aerial Detection Survey .............................................................................................................. 61

Helicopters ......................................................................................................................................... 82

Rope Assisted Deployment Systems (Type 1 and Type 2 Helicopters) .............................................. 103

WCF Maintenance.............................................................................................................................. 108

Blank Risk Assessment Forms ............................................................................................................ 122
                    INTRODUCTION TO AVIATION RISK MANAGEMENT
                                                                June 2009

Objective: The objective of a Safety Management System (SMS) is to provide structure to control risk in operations. A formal
system of hazard identification and safety risk management is essential in controlling risk to acceptable levels. System Safety is
centered on an organized approach to hazard identification and risk management with intent to minimize the effect on property,
financial, environmental, human and societal losses.

Significant attention to good practices in the aviation industry has evolved over many years. Continuous improvement in accident
rates are being experienced internationally. Participants in System Safety continually challenge the processes, the culture, and the
systems to identify weaknesses that can be mitigated toward the greater purpose of mishap prevention.

Description: The System Safety concept is a comprehensive process to analyze system characteristics and engineer solutions to
prevent mishaps from occurring. Aviation Safety Management System (SMS) is an approach to managing safety that includes the
necessary organizational structures, accountabilities, policies and procedures. The SMS process identifies hazards and control risks,
then provides assurance that risk controls are effective. Although we currently do a good job of identifying hazards and controlling
risks, we are not realizing the full benefit that a system wide approach provides.

The foundation of SMS consists of four “components,” they are Policy, Risk Management, Assurance and Safety Promotion.
When fully implemented SMS provides and promotes a Positive Safety Culture. The desired positive Safety Culture is informed,
flexible, learning, just and a reporting culture that captures the operational knowledge and experience of the employees. The end result
of this cultural shift is to achieve the status of a High Reliability Organization (HRO). **

Following your review of the stated Objective and Description of System Safety, you probably have questions on how to best utilize
the Guide, as well as how this fits into “the big picture”. First the big picture; the agencies started looking into System Safety in 2005.
The findings were positive and in 2006 the BLM and USFS partnered in their work on Aviation Safety Assessments. The first
assessments were completed by Interagency Subject Matter Experts (SME) in March of 2007 and were made available on line in May
of 2007. This third revision, completed in March of 2009, is posted online and has been distributed in hard copy as the Aviation Risk
Management Workbook. This workbook helps to establish an Interagency Safety Management System that incorporates all four of
the SMS components mentioned earlier. Adoption of SMS also brings the agencies into alignment with the minimum aviation safety
standards agreed to internationally within guidelines of the International Civil Aviation Organization. (ICAO 9859).

** Weick and Sutcliff, Managing the Unexpected



i
What are the four “components” that will achieve the SMS goal?
1. Safety Policy. We have existing policy in place that supports the foundation of SMS in our aviation safety programs. This policy
is reflected in the “Red Book”, Interagency Standards for Fire and Fire Aviation Operations.

2. Safety Risk Management. This workbook contains the completed program assessments on Helicopter Operations, Rappel/RADs,
External Loads, Aerial Supervision, SEATs, Heavy Airtankers, Infra-Red, EHELL, and Forest Health programs.

3. Safety Assurance. Accident Investigation, Program Reviews, Fire Aviation Safety Teams (FAST), Aviation Safety Technical
Assistance Teams (STAT), Aviation Safety Assistance Teams (ASAT), and numerous other tools monitor and report the health of our
prevention efforts. Currently we are working towards implementation of an Aviation Lessons Learned web site and work towards a
“Reporting Culture”.

4. Safety Promotion. We have the ability to implement very positive change in this area by creating a positive “Learning Culture”.
Communication is the key to success in this component. Training systems are being updated to reflect the principles and procedures
being implemented in SMS. Other tools include SAFECOMs, Safety Alerts, Technical Bulletins, Lessons Learned, SAFECOM
trending, safety memoranda, Aviation Safety Committees, tailgate sessions and video clips such as the Six Minutes for Safety series.

How should I use this workbook as a Risk Management tool?
Local action plans should incorporate some or all of the best practices that will effectively accomplish hazard mitigation. These
assessments can and should be used for briefing tools, tailgate safety sessions, Project Aviation Safety Plans (PASP), and especially
during periods of increased fire activity. Area Command, Aviation Safety Assistance Teams (ASAT), Incident Management Teams
(IMT), Contractor/Vender employees, as well as all aviation users can benefit from reviewing and utilizing this valuable information.
We encourage Interagency personnel to request pilots to participate in morning briefings and After Action Reviews (AAR) utilizing
the applicable mission assessments.




ii
HOW DO I USE THIS WORKBOOK ON MY LOCAL UNIT?
Risk Management Workbook: This workbook is intended for use in the management of flight operations. Each section is designed
to provide you with information regarding the hazards, risks, and suggested mitigations for most of the agencies aviation missions.

Program Risk Assessments. The tabbed sections contain individual Hazard Logs developed by an SME Team for each mission.
These sections depict mission sub-systems, hazards, risk assessments and suggested mitigations associated with each hazard. The
workbook is designed for local use to determine if the suggested mitigation is accomplished.
Follow these steps during your review:
    1. Review the description of each hazard, risk level and mitigation.
    2. Determine if your local unit complies with the suggested mitigation(s). Log your answer by checking the YES/NO column.
    3. If you checked NO; and if the associated risk level is Yellow or RED; you need to assure that the risk is mitigated to an
       acceptable level.
    4. Go to the reverse side of the page to the blank spreadsheet.
    5. Enter your list of Hazards that require mitigation.
    6. Enter new or additional hazards not identified, assess the level of risk, and enter the new mitigation to be completed.

Risk Assessment Matrix. This section contains the risk assessment matrix used by the SME teams. The matrix is accompanied by
the definitions of each of the levels of Severity and Probability that result a final risk level stated as Low, Medium, Serious, or High.

Flow Chart. The final tab contains a flow chart that provides a checklist of items to monitor when preparing a JHA, PASP, or during
the planning stage for any flight operation.




iii
                           Risk Assessment Matrix
                                             Severity
     Likelihood      Negligible        Marginal       Critical       Catastrophic
                        IV               III             II                I
      Frequent
         A
      Probable
         B
                                                                    High 4
     Occasional
         C
                                             Serious 3
       Remote
         D                           Medium 2
     Improbable
         E           Low 1

                             Severity Scale Definitions
      Catastrophic     Results in fatalities and/or loss of the system.
        Critical       Severe injury and/or major system damage.
       Marginal        Minor injury and/or minor system damage.
       Negligible      Less that minor injury and/or less than minor system damage.

                            Likelihood Scale Definitions
       Frequent         Individual    Likely to occur often.
                          Fleet       Continuously experienced.
       Probable         Individual    Will occur several times.
                          Fleet       Will occur often.
       Occasional       Individual    Likely to occur sometime.
                          Fleet       Will occur several times.
        Remote          Individual    Unlikely to occur, but possible.
                          Fleet       Unlikely but can reasonably be expected to occur.
      Improbable        Individual    So unlikely, it can be assumed it will not occur.
                          Fleet       Unlikely to occur, but possible.

iv
                                                                 Aviation project or
                                                               incident is in progress




    Hazards are confirmed and                Hazards identified.                New/unexpected                       Hazards are confirmed
     are discussed at briefings.             Risk remains high or               hazards develop that                 and remain unchanged.
    Assessments seem correct.                increases, and/or                  were not previously                  Mitigation effectiveness
    Mitigations have effectively             mitigations ineffective            identified/assessed.                  or level of risk changes
            reduced risk.                                                                                            with dynamic conditions.


                                                          Reconsider mission necessity,
                                                           or find alternative method to
                                                             to accomplish mission.

                                                                        OR


                                                            Conduct new assessments,
                                                            document changes in PASP
                                                           and system hazard outcomes,
                                                          communicate through briefings.


                                                                                                Establish and adhere to
                                                                                               well-defined, measurable
                                                                                               go-no-go decision points.
                                                                                               Review decision checklist
                                                                                                   in daily briefings.


                                                         Acquire approval for revised plan,
                                                         or request higher level approval.



                                    Monitor operations, be alert to new hazards. Modify Plans and procedures as
                                    needed. Document process, findings, and lessons learned into next Program
                                   Assessment. Utilize AAR amd SMS. Reward employees for safe performance.


v
                                                                                                                             08 Aerial Supervision
System - Aircraft
                                                                                                                             Assessment                                                                                                                              z
                                                                 Pre Mitigation                                                                                                     Post mitigation




                                                                                                                                                                                                                          Achieved?
                                                                 Likelihood




                                                                                                                                                                                    Likelihood




                                                                                                                                                                                                                                                                     Mitigation
                                                                                                                                                                                                                          Mitigation

                                                                                                                                                                                                                          Yes or No
                                                                                                                   Outcome




                                                                                                                                                                                                                Outcome
                                                                                                    Severity




                                                                                                                                                                                                 Severity




                                                                                                                                                                                                                                                                       Value
                                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                                        Post
  Sub-systems                      Hazards                                                                                                                                                                                             Additional Local Mitigation



                                                                                                                             Integrate into preflight checklist. Add to
                                                                                                                             phase/hourly inspections. Thorough post season




                                                                                                                                                                                    Improbable
                                                                 Occasional


                                                                                                    Marginal




                                                                                                                                                                                                 Marginal
                                                                                                                   Medium




                                                                                                                                                                                                                Medium
                Avionics failures: overheating, faulty wiring,                                                               inspection. Identify radio location to ensure
                etc.                                                                                                         adequate ventilation. Use extra radio sparingly.
                                                                                                                             Proactive maintenance schedule. When one wire
                                                                                                                             fails replace entire wiring harness.




                                                                                                                                                                                    Improbable
Avionics




                                                                 Occasional Occasional Occasional


                                                                                                    Negligible




                                                                                                                                                                                                 Negligible
                                                                                                                             Mount components in accessible areas. Change




                                                                                                                   Low




                                                                                                                                                                                                                Low
                Inaccessible avionics components                                                                             contract to reflect this? Standardize within AC
                                                                                                                             Models?




                                                                                                    Marginal




                                                                                                                                                                                                 Marginal
                                                                                                                   Medium




                                                                                                                                                                                                                Medium
                                                                                                                                                                                    Remote
                Flight crew unfamiliar with components.                                                                      Training, briefings, carding, pre-flight inspection.




                                                                                                                                                                                    Improbable
                                                                                                    Negligible




                                                                                                                                                                                                 Negligible
                                                                                                                             Avoid low wing for ATGS operations. High wing



                                                                                                                   Low




                                                                                                                                                                                                                Low
Configuration   Poor visibility                                                                                              provides substantially more visibility. Ensure
                                                                                                                             aircraft is appropriate for the mission.

                                                                                                                             Avoid high density altitudes. Download cargo/fuel
                                                                                                    Catastrophic




                                                                                                                                                                                                 Catastrophic
                                                                 Occasional




                                                                                                                             load. Relocate to favorable location. Alter the




                                                                                                                                                                                    Remote




                                                                                                                                                                                                                Serious
Performance     Poor engine performance (single/twin,
                                                                                                                   High

                                                                                                                             mission. Upgrade the aircraft. Ensure aircraft is
Standards       turbin/recip).
                                                                                                                             appropriate for the mission. Perform pre-flight
                                                                                                                             planning.




                                                                                                                                                                                    Improbable
                                                                 Occasional


                                                                                                    Negligible




                                                                                                                                                                                                 Negligible
                                                                                                                   Low




                                                                                                                                                                                                                Low
                Sub-standard avionics components.                                                                            Add TCAS/AFF to CWN contracts.


Contracting -                                                                                                                Conduct thorough briefings. Ride along with
CWN VS                                                                                                                       veteran fire pilot. Document performance via




                                                                                                                                                                                    Improbable
Exclusive Use   Low ATGS CWN pilot skill/fire experience                                                                     contract evaluation process. CWN/ARA
                                                                                                                   Medium




                                                                                                                                                                                                                Medium
                                                                 Remote


                                                                                                    Critical




                                                                                                                                                                                                 Critical
                leading to sub-standard performance during                                                                   Contractors need to receive better training,
                flight operations.                                                                                           possibly in the form of computer-based training.
                                                                                                                             Require Air Attack pilots to take a check ride every
                                                                                                                             three years.
                                                                 Occasional




                                                                                                                             Prior to re-fueling from an unknown source,




                                                                                                                                                                                                                Medium
                                                                                                                                                                                    Remote
                                                                                                                   Serious
                                                                                                    Critical




                                                                                                                                                                                                 Critical
Fuel            Bad fuel                                                                                                     ensure fuel is tested for type and quality. Monitor
                                                                                                                             quantity pumped.




       1
System - Flight Operations
                                                                   Pre Mitigation                                                                                Post mitigation




                                                                                                                                                                                                       Achieved?
                                                                   Likelihood




                                                                                                                                                                 Likelihood




                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                       Yes or No
                                                                                               Outcome




                                                                                                                                                                                             Outcome
                                                                                Severity




                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                    Value
                                                                                                                              Mitigation




                                                                                                                                                                                                                                                     Post
  Sub-systems                        Hazards                                                                                                                                                                        Additional Local Mitigation




                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                         Determine effectiveness of the operation (risk vs.




                                                                                                                                                                 Occasional
                                                                   Frequent
                                                                                                         benefit) and discontinue if warranted. Limit




                                                                                               High




                                                                                                                                                                                             High
                  Poor visibility (smoke)
                                                                                                         number of aircraft in operating area. Increase
                                                                                                         vertical/horizontal separation of aircraft.

                                                                                                         Use show me or chase profile. Use lead profile
                                                                                                         only when necessary. Performance maneuvers




                                                                                                                                                                 Occasional
                                                                   Frequent




                                                                                                                                                                                             Serious
                                                                                Critical




                                                                                                                                                                              Critical
                  Wake turbulence and speed differential                                                 (e.g.. Steep turns and pushovers) should be




                                                                                               High
                  (SEATs)                                                                                communicated to other aircraft. SEAT
                                                                                                         performance (speed) needs to be pre-determined
                                                                                                         in order to set the correct drop speed.
                                                                                                         Adjust tactics or shut down air ops. Increase
                                                                                                         vertical/horizontal separation of aircraft. Utilize




                                                                                                                                                                 Occasional
                                                                   Frequent




                                                                                                                                                                                             Serious
                                                                                Critical




                                                                                                                                                                              Critical
                                                                                                         human aided technology (weather radar, etc.).




                                                                                               High
                  Weather (turbulence/wind/thunderstorms)
                                                                                                         Encourage dispatch to obtain/communicate
                                                                                                         weather information. Utilize and share pilot reports
                                                                                                         of severe weather.
                                                                   Occasional
                                                                                                         Monitor fuel quantities. Follow fuel transfer




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                               Serious
                                                                                Critical




                                                                                                                                                                              Critical
                  Fuel management                                                                        procedures. Pre-flight the aircraft. Plan the flight;
                                                                                                         know refueling locations. Query other aircraft.
                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                   Frequent




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                                         Relocate aircraft. Consult performance charts.
                                                                                               High

                  Density altitude
                                                                                                         Download fuel.

Fire Operations                                                                                          Ensure high and mid-level recon is completed
                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                         prior to commencing low level flight. ASM - ATS
                                                                   Frequent




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                  Exposure to terrain in low level environment                                           assists ATP with aerial/ground hazard
                                                                                               High




                  (Lead/ASM).                                                                            identification and instrument monitoring (airspeed,
                                                                                                         altitude, hard deck, etc.). Perform only pertinent
                                                                                                         radio communication.
                                                                                                         Conduct only pertinent communication with the
                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                   Frequent




                                                                                                         ground (line clearance, etc). Maintain "eyes out"




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                  Operating in close proximity to other aircraft
                                                                                               High




                                                                                                         for hazards (terrain, vegetation, birds, other
                  (collision potential).
                                                                                                         aircraft, etc). ASM - ATS assists ATP with tracking
                                                                                                         other aircraft (spacing, location, closure, etc).
                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                   Probable




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                                         High level recon, hazard/sectional map, consult
                                                                                               High




                  Obstructions (towers, cables, wires, etc)
                                                                                                         ground personnel/other AC.

                                                                                                         Remember the eyes are the primary tool for
                  Reliance on technology: TCAS, WSI, GPS,                                                spotting traffic. Don't rely too much on TCAS.
                                                                                                                                                                 Occasional
                                                                   Frequent




                                                                                                                                                                                             Serious
                                                                                Critical




                  Laptops. Flight crew members spending too                                              Don't ignore TCAS traffic warnings with a tanker in                  Critical
                                                                                               High




                  much time looking at things inside the cockpit                                         tow (Lead). Prioritize tasks (i.e.: mapping vs.
                  instead of out.                                                                        looking for traffic/hazards while in low level ops).
                                                                                                         Utilize good CRM practices.
                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                   Remote




                                                                                                                                                                 Remote
                                                                                               Serious




                                                                                                                                                                                             Serious



                                                                                                          Crew should be trained and remain familiar with
                  Aircraft emergency
                                                                                                         a/c systems and emergency procedure checklists.




    2
System - Flight Operations (cont.)
                                                                 Pre Mitigation                                                                                  Post Mitigation




                                                                                                                                                                                                       Achieved?
                                                                 Likelihood




                                                                                                                                                                 Likelihood




                                                                                                                                                                                                       Mitigation




                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                       Yes or No
                                                                                             Outcome




                                                                                                                                                                                             Outcome
                                                                              Severity




                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                     Post
  Sub-systems                        Hazards                                                                                Mitigation                                                                              Additional Local Mitigation




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                       Proper rest, thorough briefing (incoming and




                                                                 Occasional




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                                       change out between aerial supervisors), use




                                                                                             High
                  Lack of situational awareness
                                                                                                       TCAS/TCAD, use appropriate tactics, maintain
                                                                                                       commo with other AC/ground/disp. Utilize CRM.




                                                                 Frequent




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                              Critical




                                                                                                                                                                              Critical
                                                                                                       Monitor radio traffic, remain calm, follow incident




                                                                                             High
                  Sense of urgency
                                                                                                       strategy/tactics.

                                                                                                       Ensure roles and responsibilities are assigned and




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                 Frequent
                                                                                                       understood within aerial supervision crew. Assign




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                             High
                  Exceeded span of control                                                             aircraft to common functions and tasks with a
                                                                                                       single point of contact. Hold aircraft at base to limit
                                                                                                       the number of assigned aircraft over the incident.
                                                                                                       Establish flight paths; avoid creating hazards to




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                       persons or property on the ground. Lead/ASM

                                                                 Remote




                                                                                                                                                                 Remote
                                                                                             Serious




                                                                                                                                                                                             Serious
                                                                                                       must be on order and ATGS must be on scene
                  Urban interface/congested areas
                                                                                                       prior to airtanker operations. Aerial supervision
                                                                                                       must have positive communication with the IC or
                                                                                                       designated ground contact.
                                                                                                       Use proper frequencies, maintain positive
                                                                                                       communication, ensure strategy and tactics are




                                                                                                                                                                 Occasional
                                                                 Frequent




                                                                                                       clear and understood, use only common




                                                                                                                                                                                             Serious
                                                                              Critical




                                                                                                                                                                              Critical
                                                                                             High
                  Lack of air to ground coordination                                                   terminology, ensure line clearance, solicit
                                                                                                       feedback. Move helicopters to Division or tactical
                                                                                                       frequencies as needed. Request more
                                                                                                       frequencies as needed.
                                                                                                       Strictly adhere to minimum drop heights (60 feet
                                                                 Occasional




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                             Serious




Fire Operations
                                                                              Critical




                                                                                                                                                                              Critical
                                                                                                       for SEATs and 150 feet for heavy tankers). Solicit
                  Improper drop heights
                                                                                                       and utilize feedback from ground. Improve and
                                                                                                       conduct training for tanker/SEAT pilots.
                                                                 Probable




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                              Critical




                                                                                                                                                                              Critical
                                                                                                       ASM should assist single pilot operations in
                                                                                             High




                  Target fixation
                                                                                                       maintaining situational awareness.

                                                                                                       Make sure Air to Air frequency is clear when lead
                                                                                                       and tankers are on final drop run. Ensure
                                                                 Frequent




                                                                                                                                                                 Probable
                                                                                                       frequency assignments are understood by air and
                                                                              Critical




                                                                                                                                                                              Critical
                  Missing radio calls/Poor communications (air
                                                                                             High




                                                                                                                                                                                             High
                                                                                                       ground personnel. Ensure volume knobs are
                  to air)
                                                                                                       adjusted properly. Prioritize radios during fire ops
                                                                                                       (i.e.: Air to Air vs. dispatch). Provide flight crew
                                                                                                       training.
                                                                                                       Make sure ground contact is available on the
                                                                                                       radio during tactical operations. A ground contact
                                                                 Frequent




                                                                                                                                                                 Probable
                                                                              Critical




                  Missing radio calls/Poor communications (air                                         with a non-scanning radio dedicated to the air to                      Critical
                                                                                             High




                                                                                                                                                                                             High
                  to ground)                                                                           ground frequency is helpful. Provide training to
                                                                                                       ground personnel. Debrief/conduct AAR after
                                                                                                       incidents.
                                                                                                       Maintain positive communications with ground
                                                                                                                                                                 Occasional
                                                                 Frequent




                                                                                                       resources. Ensure strategy and tactics are
                                                                                                                                                                                             Serious
                                                                              Critical




                                                                                                                                                                              Critical
                                                                                             High




                  Poor/unclear tactics                                                                 clear/understood. Use only common terminology,
                                                                                                       solicit/utilize feedback. Provide communication
                                                                                                       training for ground crews.
                                                                 Occasional




                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                             Serious
                                                                              Critical




                                                                                                                                                                              Critical




                                                                                                       Training/mentoring, qualifications/currency, CRM,
                  Low aircrew experience levels
                                                                                                       brief/debrief, honest feedback.



    3
System - Flight Operations (cont.)
                                                                        Pre Mitigation                                                                                                              Post Mitigation




                                                                                                                                                                                                                                          Achieved?
                                                                        Likelihood




                                                                                                                                                                                                    Likelihood




                                                                                                                                                                                                                                          Mitigation




                                                                                                                                                                                                                                                                                     Mitigation
                                                                                                                                                                                                                                          Yes or No
                                                                                                                                   Outcome




                                                                                                                                                                                                                                Outcome
                                                                                                                    Severity




                                                                                                                                                                                                                 Severity




                                                                                                                                                                                                                                                                                       Value
                                                                                                                                                                                                                                                                                        Post
  Sub-systems                         Hazards                                                                                                                      Mitigation                                                                          Additional Local Mitigation




                                                                        Probable Occasional Occasional Occasional




                                                                                                                                                                                                                                Medium
                                                                                                                                                                                                    Remote
                                                                                                                                   Serious
                                                                                                                    Critical




                                                                                                                                                                                                                 Critical
                                                                                                                                             Ensure flight crews understand/implement PPE
                  PPE not utilized
                                                                                                                                             policies and are held accountable.




                                                                                                                                                                                                                                Medium
                                                                                                                                                                                                    Remote
                                                                                                                                   Serious
                                                                                                                    Critical




                                                                                                                                                                                                                 Critical
                  Checklists not utilized                                                                                                    Ensure flight crews are using checklists.

Fire Operations




                                                                                                                                                                                                                                Medium
                                                                                                                                                                                                    Remote
                                                                                                                                   Serious
                                                                                                                    Critical




                                                                                                                                                                                                                 Critical
                  Shoulder restraints not utilized when
                                                                                                                                             Ensure flight crews are using restraints.
                  available.




                                                                                                                                                                                                                                Medium
                                                                                                                                                                                                    Remote
                                                                                                                    Critical




                                                                                                                                                                                                                 Critical
                                                                                                                                             SOPs for all tactical aircraft types. Right tool for




                                                                                                                                   High
                  Inefficient operational use of tactical aircraft
                                                                                                                                             job. Training, feedback, brief/debrief.




                                                                                                                    Catastrophic




                                                                                                                                                                                                                 Catastrophic
                                                                                                                                                                                                    Occasional
                                                                        Frequent                                                             Aerial supervision is trained and enforces FTA




                                                                                                                                   High




                                                                                                                                                                                                                                High
                  FTA: Aircraft not complying with procedures.                                                                               procedures. Utilize virtual fences, IP's, quadrants,
                                                                                                                                             etc.
                                                                        Probable




                                                                                                                                             Deconflict SUA. See and avoid. Know SUA areas.




                                                                                                                                                                                                                                Medium
                                                                                                                                                                                                    Remote
                                                                                                                    Critical




                                                                                                                                                                                                                 Critical
                  Special use airspace: Aircraft not complying                                                                     High
                                                                                                                                             Establish commo with controlling agency.
                  with procedures.
                                                                                                                                             Thorough briefings. Training for flight crews.
                                                                                                                    Catastrophic




                                                                                                                                                                                                                 Catastrophic
                                                                        Probable




                                                                                                                                             Dispatch in contact with media. Utilize airspace




                                                                                                                                                                                                    Remote




                                                                                                                                                                                                                                Serious
Airspace
                                                                                                                                   High




                  TFR: Aircraft not complying with procedures.                                                                               coordinator. Communicate intrusions.
                                                                                                                                             Monitor/assign TFR Frequency.

                                                                                                                                             Validate TFR as incident expands, Deconflict
                                                                                                                                             SUA, Establish commo with controlling agency,
                                                                                                                    Catastrophic




                                                                                                                                                                                                                 Catastrophic
                                                                        Probable




                  Incident location: Fires in proximity to                                                                                   notify other aircraft. Provide TFR transition




                                                                                                                                                                                                    Remote




                                                                                                                                                                                                                                Serious
                                                                                                                                   High




                  congested airspace (airport approaches/high                                                                                corridors for non-incident aircraft on large
                  GA traffic areas). Potential for mid-air collision.                                                                        incidents. Increase awareness of GA operators
                                                                                                                                             and other agency flight crews not assigned to
                                                                                                                                             incident.
                                                                                                                                             Prepare pre-season route planning to identify best




                                                                                                                                                                                                    Occasional
                                                                        occasional




                                                                                                                                                                                                                 Marginal
                  Flight routes need to be planned to account




                                                                                                                                                                                                                                Medium
                                                                                                                                   Serious
                                                                                                                    critical




                                                                                                                                             enroute cruise altitude, single engine glide
Planning          for average terrain height. Sufficient time in
                                                                                                                                             distance, and locations of safe landing areas or
                  emergency to glide to safe landing area.
                                                                                                                                             back country airports.




    4
System - Dispatch
                                                               Pre Mitigation                                                                                                                       Post mitigation




                                                                                                                                                                                                                                                                      Achieved?
                                                               Probable Frequent Probable Frequent Likelihood




                                                                                                                                                                                                    Likelihood




                                                                                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                                                                                      Mitigation

                                                                                                                                                                                                                                                                      Yes or No
                                                                                                                                     Outcome




                                                                                                                                                                                                                                        Outcome
                                                                                                                          Severity




                                                                                                                                                                                                                    Severity




                                                                                                                                                                                                                                                                                                                   Value
                                                                                                                                                                    Mitigation




                                                                                                                                                                                                                                                                                                                    Post
  Sub-systems                        Hazards                                                                                                                                                                                                                                       Additional Local Mitigation




                                                                                                                                                                                                                                        Medium Medium Medium Medium
                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                                                                                                                                               Make alternative frequencies readily available.




                                                                                                                                     High
                 Radio frequency congestion
                                                                                                                                               Publish secondary frequencies.




                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                                                                                                                                               Assign local flight following frequencies. Utilize




                                                                                                                                     High
                 Flight following on district frequencies
                                                                                                                                               AFF. Utilize National Flight Following.




                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                                                                                                                                               Obtain and publish more FM and AM frequencies




                                                                                                                                     High
                 Lack of available frequencies
                                                                                                                                               for fire operations.




                                                                                                                          Marginal




                                                                                                                                                                                                                    Marginal
                                                                                                                                                                                                    Remote
                                                                                                                                     Serious
                 Frequency management - lack of timely                                                                                         ROSS orders through NICC are too slow. Make
                 response to additional frequency orders.                                                                                      frequencies available at the GACC level.

Communications                                                                                                                                 Design a system which establishes compatibility


                                                                Probable




                                                                                                                                                                                                                                        Medium
                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                 State/County/Rural resources on different                                                                                     between Fed and State/County/Rural radios.




                                                                                                                                     High
                 bandwidth.                                                                                                                    Provide training to agency personnel addressing
                                                                Frequent Frequent Probable Probable Occasional Frequent                        the differences between radio systems.




                                                                                                                                                                                                                                        Medium Medium
                                                                                                                                                                                                    Remote Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical Critical
                 Non dedicated/published frequencies within                                                                                    Obtain and publish more FM and AM frequencies


                                                                                                                                     High
                 geographic areas.                                                                                                             for fire operations at the GACC/local level.
                                                                                                                                     Serious
                                                                                                                          Critical



                                                                                                                                               Ensure dispatchers are aware that most lead
                 Centers assigning Leadplanes as ATGS
                                                                                                                                               pilots are not ATGS qualified.
                                                                                                                          Marginal




                                                                                                                                                                                                                    Marginal
                                                                                                                                               Better oversight of frequency allocation/use at




                                                                                                                                                                                                                                        Medium
                                                                                                                                                                                                    Remote
                                                                                                                                     Serious




                 Duplicate frequency assignments within same
                                                                                                                                               local/GACC level during periods of high/large fire
                 geographic area.
                                                                                                                                               activity.




                                                                                                                                                                                                                                        Medium Medium Medium
                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                                                                                                                                               Allocate funding for equipment and personnel to
                                                                                                                                     High




                 Outdated radio equipment/poor reliability.
                                                                                                                                               repair/replace radio/commo systems.
Equipment




                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                 Lack of technical support for radio system                                                                                    Establish dedicated positions for radio techs.
                                                                                                                                     High




                 repair.                                                                                                                       Scrap outsourcing and centralizing. It's too slow.

                                                                                                                                               Funding for training and proficiency. Establish an




                                                                                                                                                                                                    Remote
                                                                                                                          Critical




                                                                                                                                                                                                                    Critical
                                                                                                                                     High




Training         Aircraft dispatcher experience/currency.                                                                                      aircraft dispatcher position with IADP as a
                                                                                                                                               requirement.




    5
System - Personnel
                                                               Pre Mitigation                                                                                                 Post Mitigation




                                                                                                                                                                                                                                        Achieved?
                                                               Likelihood




                                                                                                                                                                               Likelihood




                                                                                                                                                                                                                                        Mitigation




                                                                                                                                                                                                                                                                                   Mitigation
                                                                                                                                                                                                                                        Yes or No
                                                                                                             Outcome




                                                                                                                                                                                                                        Outcome
                                                                                     Severity




                                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                                                     Value
                                                                                                                                            Mitigation




                                                                                                                                                                                                                                                                                      Post
 Sub-systems                        Hazards                                                                                                                                                                                                          Additional Local Mitigation


                                                                                                                       Maintain a sensible diet and hydration. Limit




                                                                                                                                                                               Occasional
                                                                                                                       mission time and request relief to allow for




                                                               Probable




                                                                                                                                                                                                                        Serious
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                             High
                                                                                                                       adequate rest periods. Monitor fatigue levels of
                Aircrew fatigue/burnout
                                                                                                                       flight crews. Adjust flight schedules to incorporate
                                                                                                                       adequate rest that consider environmental factors
                                                                                                                       that contribute to fatigue.




                                                               Probable




                                                                                                                                                                                                                        Medium
                                                                                                                                                                                Remote
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                             High
                Lack of CRM                                                                                            Training, brief/debrief, maintain positive attitude.




                                                                                     Critical Catastrophic




                                                                                                                                                                                                Critical Catastrophic
                                                               Probable
                                                                                                                       Validate mission, solicit feedback from others,




                                                                                                                                                                                Remote




                                                                                                                                                                                                                        Serious
                                                                                                             High
                Acceptance of risk as normal.                                                                          reevaluate risk vs benefit, or remove the high risk
Human Factors                                                                                                          taking individual from the mission.




                                                               Frequent




                                                                                                                                                                              Occasio




                                                                                                                                                                                                                        Serious
                                                                                                                       Delegate duties, Employ CRM using span-of-




                                                                                                             High




                                                                                                                                                                                nal
                Task saturation
                                                                                                                       control guidelines. Adjust tactics as needed.

                                                                                                                       Remove the individual from the mission. Properly




                                                                                                                                                                                Occasional
                                                               Frequent
                Hazardous attitude: Anti authority, macho,




                                                                                                                                                                                                                        Serious
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                                       supervise employees. Adhere to work-rest


                                                                                                             High
                invulnerability, impulsiveness, and
                                                                                                                       guidelines, flight and duty limitations policy, etc.
                resignation.
                                                                                                                       Validate and stick to incident strategy and tactics.




                                                                                                                                                                                Occasional
                                                               Frequent




                                                                                                                                                                                                                        Serious
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                                       Brief/debrief, CRM, honest feedback, maintain
                                                                                                             High


                Conflicting personalities
                                                                                                                       positive attitude.
                                                               Occasional




                                                                                                                                                                                                                        Medium
                                                                                                                                                                                Remote
                                                                                                             Serious
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                                       Track mission/refresher experience annually as
                Lapsed qualifications (currency)
                                                                                                                       per the IASG.

Government




                                                                                                                                                                                Occasional
                                                               Probable




                                                                                                                                                                                                                        Serious
                                                                                     Critical




                                                                                                                                                                                                Critical
                                                                                                                       Track mission/refresher experience annually as
                                                                                                             High




                Lack of AD training/currency
                                                                                                                       per the IASG. Utilize GACC ATGS Reps.
                                                               Occasional Probable




                                                                                                                                                                                                                        Medium Medium
                                                                                                                                                                                Remote Remote
                                                                                     Critical




                                                                                                                                                                                                Critical
                Proficiency/currency: Non compliance with                                                              Plan/budget for annual, bi-weekly proficiency
                                                                                                             High




                established standards.                                                                                 simulations; include actual flight time.




                                                                                                                                                                                                Critical
                                                                                                             Serious
                                                                                     Critical




                                                                                                                       Establish tracking system through CO or COR.
                Lack of tracking work/rest for relief pilots
                                                                                                                       Modify contract to indicate relief pilot hours.




                                                                                                                                                                                                                        Medium
                                                                                                                                                                                                Marginal
                                                                                                                                                                                Occasional

                                                                                                                       Identify dedicated training platforms. Analyze
                                                               Frequent


                                                                                     Marginal




                                                                                                                       current ATGS qualification standards. Incorporate
                                                                                                             Serious




                Lack of qualified ATGS in the system (too
                                                                                                                       simulator training into taskbook completion.
                many trainees).
                                                                                                                       Develop a list of trainee priorities based on
                                                                                                                       state/unit level approval/support.




    6
System - Maintenance
                                                                Pre Mitigation                                                                        Post Mitigation




                                                                              Severity




                                                                                                                                                                   Severity
                                                                                         Outcome




                                                                                                                                                                              Outcome
                                                                Likelihood




                                                                                                                                                      Likelihood




                                                                                                                                                                                        Achieved?
                                                                                                                                                                                        Mitigation




                                                                                                                                                                                                                                   Mitigation
                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                     Value
                                                                                                                      Mitigation




                                                                                                                                                                                                                                      Post
  Sub-systems                       Hazards                                                                                                                                                          Additional Local Mitigation


                                                                                                   Vendor needs to share maintenance information
                                                                                                   as aircraft moves between assignments. ATGS




                                                                 Occasional




                                                                                                                                                                              Medium
                                                                                                                                                      Remote
                                                                                         Serious
                                                                              Critical




                                                                                                                                                                   Critical
                                                                                                   should be proactive during the initial briefing.
                   Maintenance not tracked well (CWN)
                                                                                                   COR/PI should proactively seek maintenance
General Aircraft
                                                                                                   information when the aircraft reports for it's
Maintenance
                                                                                                   assignment.




                                                                                                                                                                              Medium
                                                               Occasio




                                                                                                                                                      Remote
                                                                                         Serious
                                                                              Critical




                                                                                                                                                                   Critical
                   Unqualified maintenance personnel working                                       Ensure task specific qualified mechanics are




                                                                 nal
                   on the aircraft.                                                                performing repairs/maintenance.

                                                                                                   Accept the fact that maintenance problems will
                                                                                                   occur during high use periods. Allow maintenance




                                                                 Occasional




                                                                                                                                                                              Medium
                                                                                                                                                      Remote
                                                                                         Serious
                                                                              Critical




                                                                                                                                                                   Critical
                   Undue pressure on mechanics to keep the                                         crews to perform tasks in a stress free
                   aircraft available for assignment.                                              environment. COR/PI should encourage
                                                                                                   maintenance and show lattitude when enforcing
                                                                                                   contract maintenance/availability.




     7
                              System Safety Assessment - Heavy Airtanker Program
Heavy Airtanker Program System - Airworthiness
                                                                         Pre Mitigation                                                                                                                         Post mitigation




                                                                                                                                                                                                                                                                    Achieved?
                                                                                                                                                                                                                                                                    Mitigation

                                                                                                                                                                                                                                                                    Yes or No




                                                                                                                                                                                                                                                                                                               Mitigation
                                                                         Likelihood




                                                                                                                                                                                                                Likelihood
                                                                                                                                             Outcome




                                                                                                                                                                                                                                                    Outcome
                                                                                                        Severity




                                                                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                                                                                 Value
                                                                                                                                                                                                                                                                                                                  Post
                                                                                                                                                                            Mitigation
    Sub-systems                          Hazards                                                                                                                                                                                                                                 Additional Local Mitigation




                                                                                                        Catastrophic
                      Forest Service has not historically conducted                                                                                    Continue contractual requirements commensurate




                                                                                                                                                                                                                                Marginal

                                                                                                                                                                                                                                                    Medium
                                                                         Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious
                      airworthiness inspections; it has relied upon                                                                                    with industry standards required by FAR 25.571
                      the FAA for that expertise. The perceived role                                                                                   for aircraft continued airworthiness. Incorporate
Operational Service   was one of contract compliance.                                                                                                  the latest inspection technology.
Life




                                                                                                        Marginal Catastrophic Catastrophic




                                                                                                                                                                                                                                Marginal

                                                                                                                                                                                                                                                    Medium
                      Forest Service has not identified metrics that




                                                                         Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious
                                                                                                                                                       Employee additional workforce with the skills to
                      define the fire environment for the purpose of
                                                                                                                                                       determine airworthiness.
                      establishing effects on airworthiness.




                                                                                                                                                                                                                                Marginal

                                                                                                                                                                                                                                                    Medium
                                                                                                                                                       Encourage the design and procurement of




                                                                         Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious
                      Overloading Structure                                                                                                            purpose built aircraft. Incorporate the latest
Maintenance and                                                                                                                                        inspection technology.
Inspections

                                                                         Probable




                                                                                                                                                                                                                                Marginal

                                                                                                                                                                                                                                                    Medium
                                                                                                                                                                                                                Remote
                                                                                                                                             Serious
                      Engine Failures                                                                                                                  Changing to turbine engines.


                                                                                                        Catastrophic
                      The NTSB surmised that significant exposure                                                                                      Incorporate structural health monitors and




                                                                                                                                                                                                                                Marginal

                                                                                                                                                                                                                                                    Medium
                                                                         Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious
Airframe Fatigue      to airframe stresses in the firefighting mission                                                                                 technologies to detect structural fatigue damage
Damage                profile poses additional fatigue factors that                                                                                    resulting from aircraft operations in the firefighting
                      shorten airframe life expectancy.                                                                                                mission environment.

Heavy Airtanker Program System - Contract Process
                                                                                  Pre Mitigation                                                                                                                Post mitigation




                                                                                                                                                                                                                                                                    Achieved?
                                                                                                                                                                                                                                                                    Mitigation




                                                                                                                                                                                                                                                                                                               Mitigation
                                                                                                                                                                                                                                                                    Yes or No
                                                                         Frequent Frequent Likelihood




                                                                                                                                                                                                                Likelihood
                                                                                                                                             Outcome




                                                                                                                                                                                                                                                    Outcome
                                                                                                        Severity




                                                                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                                                                                 Value
                                                                                                                                                                                                                                                                                                                  Post
                                                                                                                                                                            Mitigation
    Sub-systems                          Hazards                                                                                                                                                                                                                                 Additional Local Mitigation




                                                                                                                                                                                                                                Marginal Marginal

                                                                                                                                                                                                                                                    Medium Medium
                      Current contracting fosters best value                                                                                           Incorporate addition contract incentives that give




                                                                                                                                                                                                                Remote Remote
                                                                                                        Critical


                                                                                                                                             High




                      process which guarantees only minimum                                                                                            credit in the competition process for going
                      standards.                                                                                                                       "beyond minimum programs."
Cost
                                                                                                                                                       Incorporate addition contract incentives that give
                                                                                                        Critical




                      Lack of contract incentive to develop a
                                                                                                                                             High




                                                                                                                                                       credit in the competition process for going
                      system safety driven program.
                                                                                                                                                       "beyond minimum programs."
                      Modernization of the airtanker fleet will take                                                                                   Implement airtanker modernization and evaluation
                                                                                                        Catastrophic




                                                                                                                                                                                                                                Catastrophic
                      significant funding. As new equipment is                                                                                         criteria in best value contracts including but not
                                                                         Occasional




                                                                                                                                                                                                                Remote




                                                                                                                                                                                                                                                    Serious
                      brought into the mix of aircraft, unplanned                                                                                      limited to: performance, sustainable airframes,
                                                                                                                                             High




                      events are inevitable. The agency does not                                                                                       ergonomics, additional contractor offered
                      have the skill mix to oversee flight testing and                                                                                 innovation and technology, damage tolerant
                      development in house.                                                                                                            design and technology.




       8
Heavy Airtanker Program System - Mission Environment
                                                                        Pre Mitigation                                                                                          Post mitigation




                                                                                                                                                                                                                  Achieved?
                                                                                                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                             Mitigation
                                                                                                                                                                                                                  Yes or No
                                                                     Likelihood




                                                                                                                                                                                Likelihood
                                                                                                              Outcome




                                                                                                                                                                                                        Outcome
                                                                                  Severity




                                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                               Value
                                                                                                                                             Mitigation




                                                                                                                                                                                                                                                                Post
     Sub-systems                       Hazards                                                                                                                                                                                 Additional Local Mitigation




                                                                                  Catastrophic
                   Quality of performance data and reference




                                                                     Probable




                                                                                                                                                                                                        Medium
                                                                                                                        Develop a contract requirement for airtanker pilots




                                                                                                                                                                                Remote

                                                                                                                                                                                             Critical
Performance        charts at typically high density altitudes is a




                                                                                                              High
                                                                                                                        to complete weight and balance calculations prior
Planning           concern for safe flight in the fire mission
                                                                                                                        to each mission.
                   environment.
                                                                                                                        Incorporate human aided technology to assist in




                                                                                  Catastrophic
                                                                                                                        decision making including tools to aid in time




                                                                     Probable




                                                                                                                                                                                                        Medium
                                                                                                                                                                                Remote

                                                                                                                                                                                             Critical
                                                                                                                        critical risk assessments. Adapt technology for in




                                                                                                              High
Flight Profile     Mission operations below 500' AGL.
                                                                                                                        flight decision making, post flight mission debriefs,
                                                                                                                        and accident investigation. Consider CVR and
                                                                                                                        cockpit c.




                                                                                  Catastrophic Catastrophic
                   Operations in the urban interface have led to                                                        Return to the initial attack mission doctrine as a




                                                                     Probable




                                                                                                                                                                                                        Medium
                                                                                                                                                                                Remote

                                                                                                                                                                                             Critical
                   an increase in expectations, exposure to                                                             driving force in aircraft selection and approval,




                                                                                                              High
                   hazards, and cumulative aircraft and pilot                                                           operations standards, and program/infrastructure
                   fatigue.                                                                                             design.
Mission Creep


                                                                     Probable




                                                                                                                                                                                                        Medium
                                                                                                                        Return to the initial attack mission doctrine as a




                                                                                                                                                                                Remote

                                                                                                                                                                                             Critical
                   Transfer of risk from ground firefighters to




                                                                                                              High
                                                                                                                        driving force in policies that govern the airtankers
                   airborne firefighters.
                                                                                                                        role in wildland fire suppression.

Heavy Airtanker Program System - Facilities
                                                                        Pre Mitigation                                                                                          Post mitigation




                                                                                                                                                                                                                  Achieved?
                                                                                                                                                                                                                  Mitigation




                                                                                                                                                                                                                                                             Mitigation
                                                                                                                                                                                                                  Yes or No
                                                                     Likelihood




                                                                                                                                                                                Likelihood
                                                                                                              Outcome




                                                                                                                                                                                                        Outcome
                                                                                  Severity




                                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                               Value
                                                                                                                                                                                                                                                                Post
                                                                                                                                             Mitigation
     Sub-systems                       Hazards                                                                                                                                                                                 Additional Local Mitigation
                                                                     Occasional




                                                                                                                                                                                             Marginal

                                                                                                                                                                                                        Medium
                                                                                                                        Ensure micro motion meters have been




                                                                                                                                                                                Remote
                                                                                                              Serious
                                                                                  Critical




Tanker Bases       Overloading and mixing errors                                                                        calibrated. Vendor and government personnel
                                                                                                                        review mixing procedures.


Heavy Airtanker Program System - Ground Fire Personnel
                                                                        Pre Mitigation                                                                                          Post mitigation




                                                                                                                                                                                                                  Achieved?
                                                                                                                                                                                                                  Mitigation

                                                                                                                                                                                                                  Yes or No




                                                                                                                                                                                                                                                             Mitigation
                                                                     Likelihood




                                                                                                                                                                                Likelihood
                                                                                                              Outcome




                                                                                                                                                                                                        Outcome
                                                                                  Severity




                                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                               Value
                                                                                                                                                                                                                                                                Post
                                                                                                                                             Mitigation
     Sub-systems                       Hazards                                                                                                                                                                                 Additional Local Mitigation



                                                                                                                        National leadership through regional/state
                   Use of tankers for escaped fire situations has
                                                                     Probable




                                                                                                                                                                                             Marginal

                                                                                                                                                                                                        Medium
                                                                                                                        organizations must promote safe and efficient use
                                                                                                                                                                                Remote
                                                                                  Critical




                   increased risk, exposure, and failure. This
                                                                                                              High




                                                                                                                        of aircraft. Incident Commanders at all levels need
                   issue rests outside of the control of the
                                                                                                                        to be persistent in working with team members to
                   aviation program.
                                                                                                                        keep efforts based on obtainable goals.




       9
Heavy Airtanker Program System - Human Factors
                                                                           Pre Mitigation                                                                                        Post mitigation




                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation

                                                                                                                                                                                                                   Yes or No




                                                                                                                                                                                                                                                              Mitigation
                                                                        Likelihood




                                                                                                                                                                                 Likelihood
                                                                                                                 Outcome




                                                                                                                                                                                                         Outcome
                                                                                     Severity




                                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                                Value
                                                                                                                                                                                                                                                                 Post
                                                                                                                                                Mitigation
    Sub-systems                            Hazards                                                                                                                                                                              Additional Local Mitigation


                                                                                                                           Vendors have instituted training programs such as




                                                                                     Catastrophic
                                                                                                                           CRM, risk management, and flight safety with the




                                                                                                                                                                                 Occasional
                                                                        Probable




                                                                                                                                                                                                         Serious
                                                                                                                                                                                              Critical
Pilot Proficiency and   Lack of fire mission training and Lack of                                                          intent to standardize cockpit procedures. Increase




                                                                                                                 High
Training                proficiency flight time.                                                                           the scope and complexity of the NAFA program,
                                                                                                                           develop the McClellan training center for fire
                                                                                                                           environment.




                                                                                     Catastrophic Catastrophic




                                                                                                                                                                                 Occasional
                                                                        Probable
                        Aircraft performance planning for successful                                                       Address airtanker pilot training and proficiency to




                                                                                                                                                                                                         Serious
                                                                                                                                                                                              Critical
                                                                                                                 High
                        outcome in a high rate of descent, level off,                                                      reduce frequency of accidents occurring from
                        and climb out profile.                                                                             CFIT.




                                                                                                                                                                                 Occasional
                                                                        Probable
                                                                                                                           Address human factors including target fixation,




                                                                                                                                                                                                         Serious
                                                                                                                                                                                              Critical
                        High number of target fixation and tactical




                                                                                                                 High
                                                                                                                           situational awareness, task overload,
                        maneuvering errors.
                                                                                                                           performance/tactical planning errors.

Heavy Airtanker Program System - Policy, Procedure, and Doctrine
                                                                           Pre Mitigation                                                                                        Post mitigation




                                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                                   Mitigation




                                                                                                                                                                                                                                                              Mitigation
                                                                                                                                                                                                                   Yes or No
                                                                        Likelihood




                                                                                                                                                                                 Likelihood
                                                                                                                 Outcome




                                                                                                                                                                                                         Outcome
                                                                                     Severity




                                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                                Value
                                                                                                                                                                                                                                                                 Post
                                                                                                                                                Mitigation
    Sub-systems                            Hazards                                                                                                                                                                              Additional Local Mitigation
                                                                                     Catastrophic


                                                                                                                           Establish a requirement to initiate a safety
                                                                        Probable




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                         Medium
                        No requirement to implement a system safety




                                                                                                                                                                                 Remote
Management                                                                                                                 management system between the contractor and
                                                                                                                 High

                        program that is common between the
Oversight                                                                                                                  the agency. Require the contractor to designate a
                        contractor and the agency.
                                                                                                                           safety officer.


                                                                                                                           The Blue Ribbon Panel stated: "significant funding
                                                                        Probable




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                         Medium
                                                                                                                                                                                 Remote
                                                                                     Critical




                        "Can do" philosophy has developed aviation                                                         will provide adequate knowledge of aircraft
                                                                                                                 High




                        programs with minimal budgets and staffing.                                                        conditions, training and maintenance, that will
                                                                                                                           serve to improve the safety record."
Agency Culture
                                                                                                                           Establish a higher expectation beyond minimum
                                                                        Probable




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                         Medium
                                                                                                                                                                                 Remote
                                                                                     Critical




                        A culture of acceptable loss has evolved in                                                        requirements for safety with a lower tolerance for
                                                                                                                 High




                        the agency regarding airtanker losses.                                                             accidents. This will encourage a cultural change
                                                                                                                           away from one of acceptable loss.

                                                                                                                           Develop a QA program for improved oversight of
                                                                        Probable




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                         Medium
                                                                                                                           the contracted fleet ranging from improved



                                                                                                                                                                                 Remote
                                                                                     Critical




Quality Assurance       Lack of an operative quality assurance and
                                                                                                                 High




                                                                                                                           checkrides, workforce efficiency, adequate staffing
and Inspections         inspection program.
                                                                                                                           of trained inspectors, and standardized
                                                                                                                           procedures.
                                                                        Probable


                                                                                     Marginal




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                         Medium
                                                                                                                                                                                 Remote
                                                                                                                 Serious




Public Perception       Influence on the agency                                                                            Establish doctrine




       10
Heavy Airtanker Program System - Technology
                                                       Pre Mitigation                                                                           Post mitigation




                                                                                                                                                                                  Achieved?
                                                                                                                                                                                  Mitigation




                                                                                                                                                                                                                             Mitigation
                                                                                                                                                                                  Yes or No
                                                    Likelihood




                                                                                                                                                Likelihood
                                                                            Outcome




                                                                                                                                                                        Outcome
                                                                 Severity




                                                                                                                                                             Severity




                                                                                                                                                                                                                               Value
                                                                                                                                                                                                                                Post
                                                                                                           Mitigation
    Sub-systems                       Hazards                                                                                                                                                  Additional Local Mitigation



                                                                                      Incorporate HAT with the intent to raise situational




                                                    Occasional




                                                                                                                                                Occasional

                                                                                                                                                             Marginal

                                                                                                                                                                        Medium
                                                                            Serious
                                                                 Critical
Human Aided                                                                           awareness, reduce cockpit workload, reduce
                  HAT underutilized
Technology                                                                            distractions, and assist with environmental
                                                                                      conditions of high density altitude and low visibility.

Heavy Airtanker Program System - Training
                                                       Pre Mitigation                                                                           Post mitigation




                                                                                                                                                                                  Achieved?
                                                                                                                                                                                  Mitigation

                                                                                                                                                                                  Yes or No




                                                                                                                                                                                                                             Mitigation
                                                    Likelihood




                                                                                                                                                Likelihood
                                                                            Outcome




                                                                                                                                                                        Outcome
                                                                 Severity




                                                                                                                                                             Severity




                                                                                                                                                                                                                               Value
                                                                                                                                                                                                                                Post
                                                                                                           Mitigation
    Sub-systems                       Hazards                                                                                                                                                  Additional Local Mitigation



                                                                                      Increase the scope and complexity of NAFA and




                                                    Occasional




                                                                                                                                                Occasional

                                                                                                                                                             Marginal

                                                                                                                                                                        Medium
                                                                                      require tanker crew attendance. Fund the




                                                                            Serious
                                                                 Critical
Internal          Pilot currency and proficiency.                                     development and implementation of fire simulation
                                                                                      training in the flight environment for contract and
                                                                                      agency personnel.


                                                                                      Increase the scope and complexity of NAFA and
                                                    Occasional




                                                                                                                                                Occasional

                                                                                                                                                             Marginal

                                                                                                                                                                        Medium
                                                                                      require tanker crew attendance. Fund the
                                                                            Serious
                                                                 Critical


External          Pilot currency and proficiency                                      development and implementation of fire simulation
                                                                                      training in the flight environment for contract and
                                                                                      agency personnel.




       11
                  2008- 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




                                                                                                                                                                                                  Medium
                                                                                                                 typical DA (Turbine vs. Radial Engine). Conduct




                                                                                                                                                                      Remote
                                                                                        Critical




                                                                                                                                                                                   Critical
                   High Density Altitude effects the aircraft




                                                                                                       High
                                                                                                                 pre-project performance planning. Reinforce HHH
                   quantity/performance
                                                                                                                 Training. Acquire incident altitude information
   Capabilities                                                                                                  when available.




                                                                Occasional Occasional




                                                                                                                                                                                                  Medium
                                                                                                                 Ensure SEAT is appropriate for temperatures,




                                                                                                                                                                      Remote
                                                                                                       Serious
                                                                                        Critical




                                                                                                                                                                                   Critical
                   Inappropriate Aircraft for Mission                                                            altitude terrain and mission. Receive feedback
                                                                                                                 from pilots and Aerial Supervisor.




                                                                                        Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                                                                 Pilot & SEMG monitor maintenance schedule.




                                                                                                                                                                      Remote




                                                                                                                                                                                                  Serious
                                                                                                       High
                   Mechanical Failure                                                                            Pilot reviews & understands emergency
                                                                                                                 procedures.

   Maintenance                                                                                                   Follow Contract requirements and Aircraft




                                                                                        Catastrophic
                                                                Occasional




                                                                                                                                                                                                  Medium
                                                                                                                 Maintenance Manual. Aircraft inspectors check




                                                                                                                                                                      Remote


                                                                                                                                                                                   Critical
                                                                                                       High
                   Aircraft Improperly Maintained                                                                that FAA maintenance requirements are met.
                                                                                                                 SEMG ensure pre/post flight inspections
                                                                                                                 completed.


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




                                                                                                                                                                                                  Medium
                                                                                                                 is performed and weather briefing is received.




                                                                                                                                                                      Remote


                                                                                                                                                                                   Critical
                   Smoke/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
                                                                                                                 Aircraft lighting systems need to be utilized and
                   High Visibility aircraft lighting systems
                                                                                                                 maintained.
    Visibility

                                                                                                                 Comply with Interagency Aerial Supervision guide.
                                                                                                                 Ensure effective airspace coordination is
                                                                                                                 conducted between Dispatch & FBOs & Military
                                                                                        Catastrophic




                                                                                                                                                                                   Catastrophic
                                                                                                                 Units. Understand, review, and discuss the Fire
                                                                Frequent




                   Congested Airspace, Military Airspace,



                                                                                                                                                                      Remote




                                                                                                                                                                                                  Serious
                                                                                                                 Traffic Area (FTA) in briefings. Review known
                                                                                                       High




                   Uncontrolled Airports, Ramp/Taxi
                                                                                                                 aerial hazards and acquire complete Dispatch
                   Communications.
                                                                                                                 forms prior to dispatching or diverting SEATs.
                                                                                                                 Comply with sterile cockpit procedures & policy .
                                                                                                                 Establish local ramp and taxi protocols in
                                                                                                                 cooperation with local airport operations.




    12
SEAT System - SEAT Aircraft
                                                                  Pre-Mitigation                                                                                            Post-mitigation




                                                                                                                                                                             Likelihood




                                                                                                                                                                                                               Achieved?
                                                                                                                                                                                                               Mitigation

                                                                                                                                                                                                               Yes or No




                                                                                                                                                                                                                                                          Mitigation
                                                                  Occasional Likelihood




                                                                                                         Outcome




                                                                                                                                                                                                     Outcome
                                                                                          Severity




                                                                                                                                                                                          Severity




                                                                                                                                                                                                                                                            Value
                                                                                                                                                                                                                                                             Post
                                                                                                                                        Mitigation
   Sub-System                         Hazards                                                                                                                                                                               Additional Local Mitigation




                                                                                          Marginal




                                                                                                                                                                                          Marginal
                                                                                                         Medium




                                                                                                                                                                                                     Medium
                                                                                                                   Ensure implementation of standardized SEAT




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

                                                                                                                   Equipment required in the contract should be




                                                                  Occasional




                                                                                                                                                                                                     Medium
                                                                                                                   monitored and evaluated. Determine if it is viable




                                                                                                                                                                             Remote
                                                                                                         Serious
                                                                                          Critical




                                                                                                                                                                                          Critical
                  Ineffective and out dated equipment                                                              to retain as a requirement in the contract. If it does
                                                                                                                   not work - replace it. If it is not needed - remove it
   Equipment                                                                                                       from the contract.

                                                                                                                   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.

SEAT System - SEAT Aircraft (Cont.)
                                                                  Pre-Mitigation                                                                                            Post-mitigation




                                                                                                                                                                             Likelihood




                                                                                                                                                                                                               Achieved?
                                                                  Likelihood




                                                                                                                                                                                                               Mitigation

                                                                                                                                                                                                               Yes or No




                                                                                                                                                                                                                                                          Mitigation
                                                                                                         Outcome




                                                                                                                                                                                                     Outcome
                                                                                          Severity




                                                                                                                                                                                          Severity




                                                                                                                                                                                                                                                            Value
                                                                                                                                                                                                                                                             Post
                                                                                                                                        Mitigation
   Sub-System                         Hazards                     Probable                                                                                                                                                  Additional Local Mitigation




                                                                                                                                                                                                     Medium
                                                                                                                   Inspection & carding process ensure Contractors




                                                                                                                                                                             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
                                                                                                                   Departments to meet future Federal Standards
                                                                  Occasional




                                                                                                                                                                                                     Medium
                  Lack of Radio Equipment Compatibility




                                                                                                                                                                             Remote
                                                                                                         Serious
                                                                                          Critical




                                                                                                                                                                                          Critical
                                                                                                                   and 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




                                                                                                                                                                                                     Medium
                                                                                                                   AARs and/or sand table exercises. Perform




                                                                                                                                                                             Remote


                                                                                                                                                                                          Critical
                                                                                                         High




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


                                                                                                                   Make alternative frequencies readily available.
                                                                  Frequent




                                                                                                                                                                                                     Medium
                                                                                                                                                                             Remote
                                                                                          Critical




                                                                                                                                                                                          Critical
                                                                                                                   Publish secondary frequencies. Utilize AFF when
                                                                                                         High




                  Radio Frequency Congestion
                                                                                                                   possible to reduce congestion. Maintain effective
                                                                                                                   working relations with frequency coordinators.

                                                                                                                   Assign discreet local flight following frequencies
                                                                  Probable




                                                                                                                                                                                                     Medium
                                                                                                                                                                             Remote
                                                                                          Critical




                                                                                                                                                                                          Critical


                                                                                                                   whenever possible. Utilize standardized AFF
                                                                                                         High




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




     13
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



                                                                                                                               Vendor needs to share maintenance information
                                                                                                                               as SEAT moves between assignments. SEMG




                                                                       Occasional




                                                                                                                                                                                                                    Medium
                                                                                                                                                                                       Remote
                                                                                                                     Serious
                                                                                                          Critical




                                                                                                                                                                                                         Critical
                                                                                                                               should be proactive during the pre-use inspection.
   Documentation      Maintenance not tracked well.
                                                                                                                               PI should proactively seek and document
                                                                                                                               maintenance information when the aircraft and
                                                                                                                               pilot reports for assignment.




                                                                       Occasional Occasional Occasional




                                                                                                                                                                                                                    Medium
                                                                                                                                                                                       Remote
                                                                                                                     Serious
                                                                                                          Critical




                                                                                                                                                                                                    Critical
Inspection/ Evaluation                                                                                                         Train and utilize more Interagency Inspectors with
                       Not Enough Inspectors
      Process                                                                                                                  past SEAT program experience and knowledge.




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




                                                                                                                                                                                       Remote
                                                                                                                     Serious
                                                                                                          Critical




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




                                                                                                                                                                                                    Marginal

                                                                                                                                                                                                                    Medium
                                                                                                                               Avoid overloading support personnel with




                                                                                                                                                                                       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




                                                                                                                                                                                                    Severity

                                                                                                                                                                                                                    Outcome
                                                                                                                                                                                       Likelihood




                                                                                                                                                                                                                              Achieved?
                                                                                                                                                                                                                              Mitigation

                                                                                                                                                                                                                              Yes or No




                                                                                                                                                                                                                                                                         Mitigation
                                                                       Likelihood




                                                                                                                     Outcome
                                                                                                          Severity




                                                                                                                                                                                                                                                                           Value
                                                                                                                                                    Mitigation




                                                                                                                                                                                                                                                                            Post
    Sub-System                           Hazards                                                                                                                                                                                           Additional Local Mitigation
                                                                       Occasional




                                                                                                                                                                                                                    Medium
                                                                                                                               Continue efforts to upgrade/improve




                                                                                                                                                                                       Remote
                                                                                                                     Serious
                                                                                                          Critical




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




                                                                                                                                                                                                                    Medium
                                                                                                                               Comply with Contract requirements. Discuss and




                                                                                                                                                                                       Remote
                                                                                                          Critical




                                                                                                                                                                                                    Critical
                      Unsecured Air Base Facilities increase risk of
                                                                                                                     High




      Security                                                                                                                 exercise after-hours options to provide security.
                      sabotage.
                                                                                                                               Address security concerns during initial briefings.

                                                                                                                               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
                                                                       Frequent




                                                                                                                                                                                                                    Medium
                                                                                                                               Verify that length, width and surface conditions for
                                                                                                                                                                                       Remote
                                                                                                          Critical




                                                                                                                                                                                                    Critical
                                                                                                                     High




                      Inadequate Ramp Space Minimums                                                                           type and number of equipment and aircraft are
                                                                                                                               adequate.




      14
SEAT System - SEAT Contracts
                                                                      Pre-mitigation                                                                          Post-mitigation




                                                                                                                                                                            Severity

                                                                                                                                                                                       Outcome
                                                                                                                                                               Likelihood




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                            Mitigation
                                                                      Likelihood




                                                                                              Outcome
                                                                                   Severity




                                                                                                                                                                                                                                              Value
                                                                                                                            Mitigation




                                                                                                                                                                                                                                               Post
   Sub-System                            Hazards                                                                                                                                                              Additional Local Mitigation



                                                                                                        Utilizing more Variable Term contracts will




                                                                      Frequent




                                                                                                                                                                                       Medium
                       Lack of Continuity, Efficiency, Training,                                        increase continuity between contractor and local




                                                                                                                                                               Remote
                                                                                   Critical




                                                                                                                                                                            Critical
On-Call vs. Variable




                                                                                              High
                       Familiarization and CRM with Contractor                                          unit which produces better CRM and reduces
       Term
                       Personnel and Local Operations.                                                  exposure/safety issues for managers and ground
                                                                                                        personnel.

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




                                                                                                                                                                            Severity

                                                                                                                                                                                       Outcome
                                                                                                                                                               Likelihood




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                            Mitigation
                                                                      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.

                                                                                                        Agency personnel need to rely upon AMD
                                                                      Frequent

                                                                                   Marginal




                                                                                                                                                                            Marginal

                                                                                                                                                                                       Medium
                                                                                                        Technical Service Maintenance Inspectors to




                                                                                                                                                               Remote
   Management
                       SEAT Managers & ATB Managers are not                                   Serious   determine proper maintenance procedures and
                       fully aware of Aircraft Maintenance Issues.
                                                                                                        authorization to return the aircraft to contract
                                                                                                        availability.


                                                                                                        Recommend SEAT Manager at least attend ACE
                                                                      Occasional

                                                                                   Marginal




                                                                                                                                                                            Marginal
                                                                                              Medium




                                                                                                                                                                                       Medium
                       Lack of knowledge and experience in Aviation                                     or equivalent aviation contract administration




                                                                                                                                                               Remote
     Training          Contract Administration and Aviation Program                                     courses. Add new information in the next rewrite
                       Management for SEAT Manager Trainees.                                            of S-273. Also highly recommend a season of
                                                                                                        wildland fire line experience.


                                                                                                        Adhere to established work-rest policy/guidelines
                                                                      Probable




                                                                                                                                                                                       Medium
                                                                                                                                                               Remote
                                                                                   Critical




                                                                                                                                                                            Critical
                                                                                                        and promote additional off-time when possible.
                                                                                              High




                       Fatigue
                                                                                                        Request additional staffing and/or detailers during
                                                                                                        peaks of high fire activity.

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




                                                                                                                                                                                       Medium
                                                                                                                                                               Remote
  Human Factors
                                                                                   Critical




                                                                                                                                                                            Critical
                                                                                                        utilization of the SEAT Coordinator, SEAT
                                                                                              High




                       Acceptance of Risk as Normal
                                                                                                        Program Manager positions as a method of
                                                                                                        mitigating risk. Provide Risk Management Training
                                                                                                        for the SEMG.
                                                                      Probable

                                                                                   Marginal




                                                                                                                                                                            Marginal

                                                                                                                                                                                       Medium
                                                                                                        Clarify & Confirm Program changes. Notify
                                                                                                                                                               Remote
                                                                                              Serious




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




     15
SEAT System - Personnel (Government cont.)
                                                                        Pre-mitigation                                                                                             Post-mitigation




                                                                                                                                                                                                  Severity

                                                                                                                                                                                                             Outcome
                                                                                                                                                                                     Likelihood




                                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                                       Yes or No




                                                                                                                                                                                                                                                                  Mitigation
                                                                        Likelihood




                                                                                                                    Outcome
                                                                                                         Severity




                                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                                     Post
                                                                                                                                                   Mitigation
    Sub-System                            Hazards                                                                                                                                                                                   Additional Local Mitigation



                                                                                                                              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 training.




                                                                        Occasional Frequent Occasional

                                                                                                         Marginal




                                                                                                                                                                                                  Marginal
                                                                                                                    Medium




                                                                                                                                                                                                             Medium
                                                                                                                              Re-enforce and emphasize to SEGMs to




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




                                                                                                                                                                                   Occasion
                                                                                                                              Recommend continued development &




                                                                                                                                                                                                             Serious
                                                                                                         Critical




                                                                                                                                                                                                  Critical
                       Multiple Agencies - Differing Standards (State




                                                                                                                    High
                                                                                                                              implementation of Interagency standardized SEAT




                                                                                                                                                                                      al
                       vs Fed)
                                                                                                                              program management and policy.



                                                                                                         Marginal




                                                                                                                                                                                                  Marginal
                                                                                                                    Medium




                                                                                                                                                                                                             Medium
                                                                                                                              Stronger emphasis by agency to contractor




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




                                                                                                                                                                                                             Medium
                                                                                                                              Continue with further development of contractor




                                                                                                                                                                                     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 contractors provide adequate training
                                                                        Occasional




                                                                                                                                                                                                             Medium
                                                                                                                              to ground personnel prior to fire assignment.




                                                                                                                                                                                     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.




      16
SEAT System-Personnel (Contractor)
                                                                  Pre-mitigation                                                                              Post-mitigation




                                                                                                                                                                            Severity

                                                                                                                                                                                       Outcome
                                                                                                                                                               Likelihood




                                                                                                                                                                                                 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




                                                                  Probable




                                                                                                                                                                                       Medium
                                                                                                        limitations for ground support personnel so as not




                                                                                                                                                               Remote
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                              High
                  Ground support personnel fatigue                                                      to overextend. (Company and agencies are
                                                                                                        responsible to monitor closely). Utilize additional
                                                                                                        crew members as necessary.

                                                                                                        Ensure that these items are addressed in the




                                                                  Probable




                                                                                                                                                                                       Medium
                  Ground Personnel - poor decision making,




                                                                                                                                                               Remote
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                                        contract pre-work meeting and re-enforced in the




                                                                                              High
                  multi tasking, mission focus, sense of
                                                                                                        daily air base briefings, post mission briefings or
                  urgency, peer pressure
                                                                                                        whenever the need is identified.

                                                                                                        Ensure contractor compliance with rest and duty




                                                                  Probable




                                                                                                                                                                                       Medium
                                                                                                        limitations for Pilots so as not to overextend.




                                                                                                                                                               Remote
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                              High
                  Pilot fatigue                                                                         (Company and agencies responsibility to monitor
                                                                                                        closely). Allow additional time off if needed or
                                                                                                        requested. Request relief Pilot if available.

                                                                                                        Ensure that these items are addressed in the
                                                                  Frequent




                                                                                                                                                                                       Medium
                  Pilot - poor decision making: multi tasking,




                                                                                                                                                               Remote
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                                        contract pre-work meeting and re-enforced in the



                                                                                              High
                  mission focus, sense of urgency, peer
                                                                                                        daily air base briefings, post mission briefings or
                  pressure
                                                                                                        whenever the need is identified.
  Human Factors                                                                                         Emphasize importance of "situational awareness"
                                                                               Catastrophic




                                                                                                                                                               Occasional
                                                                  Probable




                                                                                                        as a means to recognizing risk. Consider




                                                                                                                                                                                       Serious
                                                                                                                                                                            Critical
                                                                                              High

                  Acceptance of Risk as Normal                                                          providing Risk Management Training for the Pilot.
                                                                                                        Re-address complacency and self discipline in
                                                                                                        daily air base briefings.

                                                                                                        Make effort to ensure that contractor relief




                                                                                                                                                               Occasional
                                                                  Probable




                  Poor CRM with crew rotations; Crew rotation




                                                                                                                                                                                       Serious
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                                        personnel arrive at base prior to relief cycle with
                                                                                              High




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

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




                                                                                                                                                               Occasional
                                                                  Frequent




                  be excessive based on demands that he/she




                                                                                                                                                                                       Serious
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                                        as AFF to minimize radio traffic. Conduct AARs,
                                                                                              High




                  be able to operate several cockpit equipment
                                                                                                        sand table exercises and on ground CRM
                  items during mission performance (i.e. Multi-
                                                                                                        Exercises. Incorporate Operations personnel in
                  Tasking Overload.).
                                                                                                        simulations and exercises.

                                                                                                        Conduct effective and objective briefings and

                                                                                                                                                               Occasional
                                                                  Probable




                                                                                                                                                                                       Serious
                                                                               Critical




                                                                                                                                                                            Critical
                                                                                                        debriefings. Encourage honest feedback.
                                                                                              High




                  Conflicting and/or Difficult Personalities
                                                                                                        Maintain positive and proffessional attitude.
                                                                                                        Document discussions and briefings.




     17
SEAT System-Personnel (Contractor cont.)
                                                                          Pre-mitigation                                                                          Post-mitigation




                                                                                                                                                                                Severity

                                                                                                                                                                                           Outcome
                                                                                                                                                                   Likelihood




                                                                                                                                                                                                     Achieved?
                                                                                                                                                                                                     Mitigation

                                                                                                                                                                                                     Yes or No




                                                                                                                                                                                                                                                Mitigation
                                                                          Likelihood




                                                                                                  Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                                Mitigation




                                                                                                                                                                                                                                                   Post
    Sub-System                            Hazards                                                                                                                                                                 Additional Local Mitigation



                                                                                                            Take a stronger approach with all personnel




                                                                          Occasional




                                                                                                                                                                                           Medium
                                                                                                            (Pilots, Dispatchers, Managers, etc.) to ensure




                                                                                                                                                                   Remote
                                                                                                  Serious
                                                                                       Critical




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

                                                                                                            Standardize equipment specifications through the




                                                                          Occasional




                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                                  Serious
                                                                                       Critical




                                                                                                                                                                                Critical
                      Lack of standardized aircraft, support                                                procurement process and mandate within the
  Standardization
                      equipment, and communications equipment.                                              contract solicitation. Work with contractors to
                                                                                                            emphasize the importance of standardization.

                                                                                                            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 to ensure aviation needs are
                                                                                                            addressed.




     18
SEAT System - SEAT Operations
                                                                 Pre-mitigation                                                                                            Post-mitigation




                                                                                                                                                                                           Severity

                                                                                                                                                                                                          Outcome
                                                                                                                                                                            Likelihood




                                                                                                                                                                                                                    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

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




                                                                                     Critical

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




                                                                Occasiona




                                                                                                                                                                                                          Medium
                                                                                                                   Agency and Contractor should provide training




                                                                                                                                                                            Remote
                                                                                                         Serious
                                                                                     Critical




                                                                                                                                                                                           Critical
                Jurisdiction & Border Issues                                                                       and orientation. Local unit to brief and initiate




                                                                    l
                                                                                                                   utilization of the local Airspace Boundary Plan.

                                                                                                                   Re-enforce local Interagency Lead Plane SOPs




                                                                  Probable




                                                                                                                                                                                                          Medium
                                                                                                                                                                            Remote
                                                                                     Critical




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




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




                                                                                     Catastrophic




                                                                                                                                                                                           Catastrophic
                                                                                                                   Perform high level reconnaissance prior to


                                                                  Frequent




                                                                                                                                                                            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
                                                                  Frequent                                         proper aircraft energy management techniques.

    Missions




                                                                                                                                                                                                          Medium
                                                                                                                   Agency & Contractors need to evaluate required




                                                                                                                                                                            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




                                                                                                                                                                                                          Medium
                A Sense of urgency may be placed on




                                                                                                                                                                            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.
                                                                                            Catastroph




                                                                                                                                                                                         Catastroph
                                                                  Frequent




                                                                                                                   Define 60 ft. obstacle clearance as the minimum




                                                                                                                                                                            Remote




                                                                                                                                                                                                          Serious
                                                                                                         High




                Drop Height Minimums                                                                               decent altitude for all fire operations except during
                                                                                                ic




                                                                                                                                                                                             ic
                                                                                                                   takeoff and landing.
                                                                               Catastrophic




                                                                                                                                                                                           Catastrophic
                                                                                                                   Monitor fuel quantities. Follow fuel transfer
                                                                  Remote




                                                                                                                                                                            Remote
                                                                                                         Serious




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




                                                                                                                                                                                                          Medium
                                                                                                                                                                            Remote
                                                                                                         Serious
                                                                                     Critical




                                                                                                                                                                                           Critical
                Wake Turbulence                                                                                    Exercise "CAUTION" when sharing local airspace.




    19
SEAT System - SEAT Operations
                                                                  Pre-mitigation                                                                         Post-mitigation




                                                                                                                                                                       Severity

                                                                                                                                                                                  Outcome
                                                                                                                                                          Likelihood




                                                                                                                                                                                            Achieved?
                                                                                                                                                                                            Mitigation

                                                                                                                                                                                            Yes or No




                                                                                                                                                                                                                                       Mitigation
                                                                  Likelihood




                                                                                          Outcome
                                                                               Severity




                                                                                                                                                                                                                                         Value
                                                                                                                                                                                                                                          Post
                                                                                                                        Mitigation
   Sub-System                       Hazards                                                                                                                                                              Additional Local Mitigation



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




                                                                  Occasional




                                                                                                                                                                                  Medium
                                                                                                                                                          Remote
                                                                                          Serious
                                                                               Critical




                                                                                                                                                                       Critical
                                                                                                    on Special Use Airspace, MTRs, TFRs etc.
                  Conflicting Airspace Environment
                                                                                                    Assure that Dispatch and aviation program
                                                                                                    personnel are trained in Dispatch procedures for
                                                                                                    SUA. Use aerial supervision when available.

                                                                                                    Confirm weather information flow is in place.
                                                                                                    Confirm that red-flag warnings are distributed.




                                                                  Frequent




                                                                                                                                                                                  Medium
                                                                                                                                                          Remote
                                                                               Critical




                                                                                                                                                                       Critical
                                                                                                    Ensure there are continual updates on changing




                                                                                          High
                  Hazardous and Extreme Weather Conditions.
  Environment                                                                                       weather conditions shared between pilots, air
                                                                                                    base mangers, dispatchers, etc. Go-No-Go is PIC
                                                                                                    decision.
                                                                                                    Get an adequate mission briefing and use



                                                                  Frequent




                                                                                                                                                                                  Medium
                                                                                                    performance planning to prevent CFIT events.




                                                                                                                                                          Remote
                                                                               Critical




                                                                                                                                                                       Critical
                                                                                          High
                  Hazards and Extreme Terrain                                                       Perform high level reconnaissance prior to
                                                                                                    descending to the low level environment. Use
                                                                                                    Aerial Supervision when available.
                                                                  Frequent




                                                                                                                                                                                  Medium
                                                                                                    Comply with congested area policies and ensure




                                                                                                                                                          Remote
                                                                               Critical




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

                                                                                                    Manage available frequencies as best as




                                                                                                                                                          Occasional
                                                                  Frequent




                                                                                                    possible. Request additional frequencies as




                                                                                                                                                                                  Serious
                                                                               Critical




                                                                                                                                                                       Critical
                                                                                          High




                  Lack of Available Frequencies                                                     needed and release frequencies in a timely
                                                                                                    manner when no longer needed. Train all users in
 Communications                                                                                     radio discipline.
                                                                  Occasional




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




                                                                                                                                                          Remote
                                                                                          Serious
                                                                               Critical




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


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




                                                                                                                                                                                  Medium
                                                                                                    and shared with base personnel. Utilize




                                                                                                                                                          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.


  Performance                                                                                       Specify length, width and surface conditions,
                                                                  Occasional




                                                                                                                                                                                  Medium
                                                                                                    congested areas and elevations for minimum
                                                                                                                                                          Remote
                                                                                          Serious
                                                                               Critical




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

                                                                                                    Utilize A/C dispatch form, obtain as much
                                                                                                    information as possible from other aerial and
                                                                  Occasional




                                                                                                                                                                                  Medium
                                                                                                                                                          Remote
                                                                                          Serious
                                                                               Critical




                                                                                                                                                                       Critical




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




    20
System: Flight Operations                                                                             2008 Infared Program Assessment
                                                                Pre Mitigation                                                                               Post Mitigation




                                                                                                                                                                                                              Achieved?
                                                                                                                                                                                                              Mitigation

                                                                                                                                                                                                              Yes or No




                                                                                                                                                                                                                                                         Mitigation
                                                                Likelihood




                                                                                                                                                             Likelihood
                                                                                            Outcome




                                                                                                                                                                                                    Outcome
                                                                             Severity




                                                                                                                                                                                     Severity




                                                                                                                                                                                                                                                           Value
                                                                                                                                                                                                                                                            Post
                                                                                                                            Mitigation
Sub-systems                         Hazards                                                                                                                                                                                Additional Local Mitigation



                                                                                                      Keep your cell phone handy (and charged up).




                                                                                            Medium




                                                                                                                                                                                                    Medium
                                                                Remote




                                                                                                                                                             Remote
                                                                             Critical




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




                                                                Occasional




                                                                                                                                                                                     Marginal


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




                                                                                                                                                             Occasional Improbable
                                                                Frequent




                                                                                                                                                                                     Marginal


                                                                                                                                                                                                    Medium
                                                                                                      Update the equipment/design for standardization,




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




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




                                                                             Negligible




                                                                                                                                                                                     Negligible
                                                                Frequent




                                                                                            Medium
                                                                                                      Coordinate with all staffs on modifications prior to




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




                                                                                                                                                             Occasional
                                                                Frequent




                                                                                                                                                                                                    Serious
                                                                             Critical




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

                                                                                            High
                                                                                                      Install and utilize satellite up-link capability
                 off immagery




                                                                                                                                                                                     Negligible
                                                                Frequent




                                                                                                                                                             Frequent
                                                                             Marginal




                                                                                                                                                                                                    Medium
                 Nitrogen servicing (Improper technique), not
                                                                                            Serious


                 wearing proper PPE and ultimately causing                                            Proper training/procedures
                 personal injury
                                                                             Catastrophic




                                                                                                                                                                                     Catastrophic
                                                                Occasional




                                                                                                                                                             Remote




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




                 technicians/repair stations)                                                         repair stations

Maintenance




                                                                                                                                                             Improbable
                                                                Occasional


                                                                             Marginal




                                                                                                                                                                                     Marginal
                                                                                            Medium




                                                                                                                                                                                                    Medium
                 Undocumented open discrepancies                                                      Follow SOPs
                                                                             Catastrophic




                                                                                                                                                             Improbable




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




                                                                                            Serious




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


                                                                                                                                                             Improbable
                                                                Frequent




                                                                                                                                                                                     Marginal


                                                                                                                                                                                                    Medium
                                                                                                      Update the equipment/design for standardization
                                                                             Critical


                                                                                            High




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




21
System: Flight Operations (cont.)
                                                                  Pre Mitigation                                                                                                      Post Mitigation




                                                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                                                       Yes or No




                                                                                                                                                                                                                                                                                  Mitigation
                                                                  Likelihood




                                                                                                                                                                                      Likelihood
                                                                                                                    Outcome




                                                                                                                                                                                                                             Outcome
                                                                                                     Severity




                                                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                                                     Post
                                                                                                                                                   Mitigation
Sub-systems                         Hazards                                                                                                                                                                                                         Additional Local Mitigation


                Effects of modifications that decrease aircraft




                                                                                                                                                                                                              Negligible
                                                                  Frequent


                                                                                                     Marginal




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




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




                                                                                                     Catastrophic




                                                                                                                                                                                      Improbable
                Increased exposure to mid-air collision due to




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




                                                                                                                    High




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




                                                                                                     Catastrophic




                                                                                                                                                                                                              Catastrophic
                                                                                                                                                                                      Improbable




                                                                                                                                                                                                                             Medium
                                                                  Remote




                                                                                                                    Serious
                Bad Fuel                                                                                                      Observe fueling; sump fuel as required.

Fuel




                                                                                                     Catastrophic




                                                                                                                                                                                                              Catastrophic
                                                                                                                                                                                      Improbable




                                                                                                                                                                                                                             Medium
                                                                  Remote




                                                                                                                    Serious
                Improper fuel loading                                                                                         Observe fueling; confirm loading.



System: Environmental
                                                                  Pre Mitigation                                                                                                      Post Mitigation




                                                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                                                       Yes or No




                                                                                                                                                                                                                                                                                  Mitigation
                                                                  Likelihood




                                                                                                                                                                                      Likelihood
                                                                                                                    Outcome




                                                                                                                                                                                                                             Outcome
                                                                                                     Severity




                                                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                                                     Post
                                                                                                                                                   Mitigation
Sub-systems     Hazards                                                                                                                                                                                                                             Additional Local Mitigation



                                                                                                                              Preflight planning;Just say NO (accept the fact




                                                                                                                                                                                      Occasional
                                                                  Probable




                                                                                                                              that the mission cannot be completed)! PIREPS,




                                                                                                                                                                                                                             Serious
                                                                                                     Critical




                                                                                                                                                                                                              Critical
                                                                                                                    High




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




                                                                                                                                                                                      Improbable Occasional
                                                                  Frequent




                                                                                                                              Just say NO! Education/Training of the ground




                                                                                                                                                                                                                             Serious
                                                                                                     Critical




                                                                                                                                                                                                              Critical
                Pressure to complete the mission regardless
                                                                                                                    High




                                                                                                                              personnel regarding go-no-go situations. Preflight
                of the Wx
                                                                                                                              planning. Give options.
Weather
                                                                                                     Marginal




                                                                                                                                                                                                              Marginal
                                                                                                                    Medium




                                                                                                                                                                                                                             Medium
                                                                  Remote




                                                                                                                              Preflight checks of icing equipment, proper
                Icing equipment (aircraft) failing
                                                                                                                              maintenance of icing equip.
                                                                  Occasional Improbable Occasional




                                                                                                                                                                                                                             Medium
                                                                                                                              IR Technician reports, PIREPS, Debrief other fire       Remote
                                                                                                                    Serious
                                                                                                     Critical




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




                                                                                                                                                                                      Improbable
                                                                                                                    Medium




                                                                                                                              Maintain Situational Awareness, File IFR, Train                                                Medium
                Contolled flight into terrain
                                                                                                                              and remain proficient
Topography
                                                                                                     Marginal




                                                                                                                                                                                                              Marginal


                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote
                                                                                                                    Serious




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




22
System: Airports
                                                               Pre Mitigation                                                                                                                      Post Mitigation




                                                                                                                                                                                                                                                                                                    Achieved?
                                                                                                                                                                                                                                                                                                    Mitigation

                                                                                                                                                                                                                                                                                                    Yes or No




                                                                                                                                                                                                                                                                                                                                               Mitigation
                                                               Likelihood




                                                                                                                                                                                                   Likelihood
                                                                                                                                Outcome




                                                                                                                                                                                                                                                                                          Outcome
                                                                                       Severity




                                                                                                                                                                                                                                                 Severity




                                                                                                                                                                                                                                                                                                                                                 Value
                                                                                                                                                                                                                                                                                                                                                  Post
                                                                                                                                                               Mitigation
Sub-systems   Hazards                                                                                                                                                                                                                                                                                            Additional Local Mitigation




                                                                                       Catastrophic
                                                               Occasional Occasional




                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                   Remote


                                                                                                                                                                                                                                                 Critical
              Mountainous Terrain-Unfamiliar, leading to                                                                                  Preflight planning, instrument approaches, refusal




                                                                                                                                High
              CFIT,                                                                                                                       of delivery point, landing during daylight hours
Location




                                                                                                                                                                                                   Improbable Improbable Improbable Improbable




                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                Serious
                                                                                       Critical




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




                                                                                                                                Medium




                                                                                                                                                                                                                                                                                          Medium
                                                               Remote


                                                                                       Critical




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




                                                               Occasional Occasional




                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                Serious
                                                                                       Critical




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




                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                Serious
                                                                                       Critical




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




                                                                                                                                                                                                                                                 Catastrophic Catastrophic Catastrophic
                                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                                                                                          Medium
                                                               Remote




                                                                                                                                Serious
              Lighting systems are inop/inadequate leading
                                                                                                                                          ATIS UNICOM, visual cues, preflight planning
              to a short landing/go-around, CFIT




                                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                                                                                          Medium
                                                               Remote




                                                                                                                                Serious




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




                                                                                                                                                                                                   Improbable
                                                                                                                                          Preflight planning. Performing approach briefings,
                                                               Occasional




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




              Not having an IAP leading to a CFIT
                                                                                                                                          land if conditions are such that it is unsafe to
                                                                                                                                          make a safe visual approach and landing
                                                                                       Catastrophic Catastrophic




                                                                                                                                                                                                                                                 Catastrophic Catastrophic
                                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                                                                                          Medium
                                                               Remote




                                                                                                                                Serious




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



                                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                                                                                          Medium
                                                               Remote




                                                                                                                                Serious




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




                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                   Remote
                                                                                                                                Serious
                                                                                       Critical




                                                                                                                                                                                                                                                 Critical

                                                                                                                                          SA, CRM, TCAS, Communications, A/C lighting,
              Incursions on the runway and parking areas
                                                                                                                                          training, parking tenders, familiar with the airport

              Unqualified Personnel (ground/ramp or
                                                                                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                   Remote
                                                                                                                                Serious
                                                                                       Critical




                                                                                                                                                                                                                                                 Critical




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




23
System: Personnel
                                                                   Pre Mitigation                                                                               Post Mitigation




                                                                                                                                                                                                                          Achieved?
                                                                                                                                                                                                                          Mitigation

                                                                                                                                                                                                                          Yes or No




                                                                                                                                                                                                                                                                     Mitigation
                                                                   Likelihood




                                                                                                                                                                Likelihood
                                                                                               Outcome




                                                                                                                                                                                                                Outcome
                                                                                Severity




                                                                                                                                                                                                   Severity




                                                                                                                                                                                                                                                                       Value
                                                                                                                                                                                                                                                                        Post
                                                                                                                             Mitigation
Sub-systems     Hazards                                                                                                                                                                                                                Additional Local Mitigation



                                                                                                         Scheduling management (reduce duty hrs and/or




                                                                   Frequent




                                                                                                                                                                                                   Marginal


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




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




                                                                                                                                                                                                   Negligible
                                                                   Frequent




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




                                                                                               High




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




                                                                   Occasional




                                                                                                                                                                                                                Medium
                Trans-cockpit authority gradient, junior




                                                                                                                                                                Remote
                                                                                               Serious
                                                                                Critical




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




                                                                                Catastrophic
                                                                   Frequent




                                                                                                                                                                                                   Marginal


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




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


                                                                                Catastrophic
                Mission pressure from other factions                                                     Education/training, attending the IMT/dispatch




                                                                                                                                                                Occasional
                                                                   Frequent




                                                                                                                                                                                                   Marginal
Human Factors




                                                                                                                                                                                                                Medium
                (dispatch/fire teams), leading to fatigue,                                               meetings, ensuring open communication between

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




                                                                                                                                                                                                   Negligible
                                                                   Frequent




                                                                                                         Staff and budget at appropiate levels, support the




                                                                                                                                                                Remote
                                                                                Critical




                Stress and fatigue from insufficient staffing
                                                                                               High




                                                                                                                                                                                                                Low
                                                                                                         crews decision to manage workloads that are
                levels leading to the can-do/will-do attitudes
                                                                                                         commencerate with the staffing levels
                Logisitical issues with non-co-located
                                                                                Catastrophic




                                                                                                                                                                Improbable


                                                                                                                                                                                                   Negligible
                                                                   Frequent




                personnel leading to additional exposure of
                                                                                                         Co-locate personnel at single base/unit, RON at
                                                                                               High




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

                Personnel dissention between factions of the                                             CRM & teambuilding training for all IR systems




                                                                                                                                                                Improbable


                                                                                                                                                                                                   Negligible
                                                                   Probable




                IR "System" leading to stress and anxiety,                                               staff; open communications; pre/post season
                                                                                Critical


                                                                                               High




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




                                                                                                                                                                Improbable Improbable Improbable
                                                                   Occasional




                                                                                                                                                                                                   Negligible
                Unqualified personnel flying the aircraft-
                                                                                               Serious
                                                                                Critical




                                                                                                         Qualified and mission profecient personnel flying




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

                                                                                                                                                                                                   Negligible
                                                                                               Medium
                                                                   Remote


                                                                                Critical




                Unqualified IR technicians leading to damage                                             Qualified and mission profecient personnel


                                                                                                                                                                                                                Low
                to aircraft and/or personnel                                                             operating/maintaining the equipment.
                                                                   Occasional




                                                                                                                                                                                                   Negligible



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




                                                                                                                                                                                                                Low

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




24
System: Personnel (continued)
                                                                   Pre Mitigation                                                                            Post Mitigation




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                            Mitigation
                                                                   Likelihood




                                                                                                                                                             Likelihood
                                                                                               Outcome




                                                                                                                                                                                       Outcome
                                                                                Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                              Value
                                                                                                                                                                                                                                               Post
                                                                                                                             Mitigation
Sub-systems      Hazards                                                                                                                                                                                      Additional Local Mitigation




                                                                   Occasional




                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                               Serious
                                                                                Critical




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

Night Ops




                                                                                Catastrophic




                                                                                                                                                             Occasional
                                                                   Frequent
                 Incidents or errors caused by physiological




                                                                                                                                                                                       Serious
                                                                                                                                                                          Critical
                                                                                                         Education and training; implement CRM; knowing




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


                 Lack of skilled leadership/managerial skills in




                                                                   Probable




                                                                                                                                                                          Marginal


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




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


System: Policy
                                                                   Pre Mitigation                                                                            Post Mitigation




                                                                                                                                                                                                 Achieved?
                                                                   Likelihood




                                                                                                                                                             Likelihood




                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                            Mitigation
                                                                                               Outcome




                                                                                                                                                                                       Outcome
                                                                                Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                              Value
                                                                                                                                                                                                                                               Post
                                                                                                                             Mitigation
Sub-systems      Hazards                                                                                                                                                                                      Additional Local Mitigation



                                                                                                         Scheduling management (reduce duty hrs and/or
                                                                   Frequent




                                                                                                                                                                          Marginal


                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                Critical




                                                                                                         flight time), sufficient staffing levels, sleep-
                                                                                               High




                 Fatigue-Cronic, errors due to fatigue (SA)
                                                                                                         power naps, training, CRM, support crew decision
                                                                                                         to decrease duty day
Duty Day




                                                                                                                                                                          Negligible
                                                                   Frequent




                                                                                                                                                             Remote
                                                                                Critical




                                                                                                         Training, CRM, sleep-power naps, support crew
                                                                                               High




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




                                                                                                                                                             Improbable
                                                                   Occasional




                                                                                                                                                                          Negligible
                 Unqualified personnel flying the aircraft-
                                                                                               Serious
                                                                                Critical




                                                                                                         Qualified and mission proficient personnel flying




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


                 Procedures that do not reflect the entire IR



                                                                                                                                                             Improbable
                 system leading to ambiguity in the decisions
                                                                   Occasional




                                                                                                                                                                          Negligible
Ill-defined                                                                                              Clearly defined policies, procedures, and roles
                                                                                               Serious
                                                                                Critical




                 that need to be made, adding stress and




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




25
System: Flight Operations
                                                                  Pre Mitigation                                                                               Post Mitigation




                                                                                                                                                                                                     Achieved?
                                                                  Likelihood




                                                                                                                                                               Likelihood




                                                                                                                                                                                                     Mitigation




                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                     Yes or No
                                                                                              Outcome




                                                                                                                                                                                           Outcome
                                                                               Severity




                                                                                                                                                                            Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                   Post
                                                                                                                            Mitigation
Sub-systems      Hazards                                                                                                                                                                                          Additional Local Mitigation



              Use of uncarded aircraft and crew. Failure to




                                                                                                                                                               Improbable
              follow policy/safety recommendations




                                                                  Occasional


                                                                               Negligible




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




                                                                                              Low




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




                                                                               Catastrophic




                                                                                                                                                               Occasional
                                                                  Frequent
                 Incidents or errors caused by physiological




                                                                                                                                                                                           Serious
                                                                                                                                                                            Critical
                                                                                                        Education and training; implement CRM;




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




                                                                               Negligible




                                                                                                                                                                            Negligible
                                                                  Remote




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




                                                                                              Low




                                                                                                                                                                                           Low
                 Losing radio communications
                                                                                                        cell phones available

Communication




                                                                                                                                                               Improbable
                                                                  Occasional




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



                                                                                              Serious
                                                                               Critical




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




                                                                                                                                                               Improbable
                                                                               Marginal




                                                                                                                                                                            Marginal
                                                                                              Medium




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




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




                                                                                                                                                                            Catastrophic
                                                                                                                                                               Improbable




                                                                                                                                                                                           Medium
                                                                  Remote




                                                                                              Serious




Instrument                                                                                              Maintain currency and proficiency; Do not allow
                 Lack of currency and proficiency
Flying                                                                                                  non-current crewmembers to fly missions
                                                                               Catastrophic




                                                                                                                                                                            Catastrophic
                                                                  Improbable




                                                                                                                                                               Improbable
                                                                                              Medium




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




26
System: Flight Operations (continued)
                                                                Pre Mitigation                                                                            Post Mitigation




                                                                                                                                                                                                Achieved?
                                                                Likelihood




                                                                                                                                                          Likelihood




                                                                                                                                                                                                Mitigation




                                                                                                                                                                                                                                           Mitigation
                                                                                                                                                                                                Yes or No
                                                                                            Outcome




                                                                                                                                                                                      Outcome
                                                                             Severity




                                                                                                                                                                       Severity




                                                                                                                                                                                                                                             Value
                                                                                                                                                                                                                                              Post
                                                                                                                         Mitigation
Sub-systems   Hazards                                                                                                                                                                                        Additional Local Mitigation




                                                                             Catastrophic




                                                                                                                                                                       Catastrophic
                                                                                                                                                          Improbable




                                                                                                                                                                                      Medium
                                                                Remote




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

Airspace




                                                                             Catastrophic




                                                                                                                                                                       Catastrophic
                                                                                                                                                          Improbable




                                                                                                                                                                                      Medium
                                                                Remote




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




                                                                             Catastrophic




                                                                                                                                                                       Catastrophic
                                                                                                                                                          Improbable




                                                                                                                                                                                      Medium
                                                                                                      Ensure crew is adequately trained. Maintain




                                                                Remote




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

                                                                                                      Ensure crew is adequately trained. Maintain

                                                                             Catastrophic




                                                                                                                                                                       Catastrophic
                                                                                                                                                          Improbable




                                                                                                                                                                                      Medium
                                                                                                      Situational Awareness. Be sure communications
                                                                Remote




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

                                                                                                      Training, Situational Awareness, CRM, clear and
                                                                             Catastrophic




                                                                                                                                                                       Catastrophic
                                                                Probable




                                                                                                      positive air to ground communications, IAPs, Use




                                                                                                                                                          Remote




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



                                                                                                      radio altimeter, Determine criteria for go-no go
              resulting CFIT
                                                                                                      situations/decisions. Drop only during clear VFR
                                                                                                      conditions.




27
System: FHP Aerial Application - Aircraft
                                                                       Pre Mitigation                                                                                              Post Mitigation
Sub-systems         Hazards




                                                                                                                                                                                                                                      Achieved?
                                                                       Likelihood




                                                                                                                                                                                   Likelihood




                                                                                                                                                                                                                                      Mitigation




                                                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                                                      Yes or No
                                                                                                                Outcome




                                                                                                                                                                                                                            Outcome
                                                                                    Severity




                                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                                                    Post
                                                                                                                                               Mitigation
                                                                                                                                                                                                                                                   Additional Local Mitigation


Avionics (for       Unplanned avionics failures (overheating,                                                             Have portable radio/handheld, users prepared to




                                                                       Occasional


                                                                                    Marginal




                                                                                                                                                                                                Marginal
                                                                                                                Medium




                                                                                                                                                                                                                            Medium
                                                                                                                                                                                   Remote
radios see          faulty wiring, etc.)                                                                                  use alternate frequencies (guard), land and repair
"Technology" tab)                                                                                                         or replace aircraft

                    Unavailable or disfunctional emergency locator                                                        Switch to 406 MHz digital ELT systems before




                                                                                                                                                                                   Improbable


                                                                                                                                                                                                Negligible
                                                                                    Marginal

                                                                                                                Medium
                                                                       Remote
                    (analog ELT systems will be discontinued                                                              February 1, 2009; require digital ELT in all




                                                                                                                                                                                                                            Low
                    affecting most aircraft; not required for P-137                                                       contracts; recommend ELTs with real time or
                    but may be equipped)                                                                                  satellite flight following functionality
Aircraft            Helicopter may be more difficult to land in                                                           Select appropriate aircraft based on project profile




                                                                                    Catastrophic




                                                                                                                                                                                                Catastrophic
                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                            Medium
                                                                       Remote




                                                                                                                Serious
Configuration       event of engine failure (flight below 500')                                                           weighing risk factors such as helicopter
                                                                                                                          manuverability compared to fixed wing glide
                                                                                                                          distance

                    Contract may not accurately specify                                                                   Specify in project design and in agency and state




                                                                       Improbable




                                                                                                                                                                                   Improbable
                    application equipment, pesticide formulation,                                                         contracts: nozzle type, rate of application, pesticide




                                                                                    Negligible




                                                                                                                                                                                                Negligible
                    and rates of application ( EPA, NEPA &                                                                formulation, dose, droplet size, swath width, and




                                                                                                                Low




                                                                                                                                                                                                                            Low
                    possibly state violations - env. Hazard, double                                                       environmental parameters during application.
                    applications increase exposure)

                    Reduced visibility if aircraft not purpose built                                                      Contracts use only aircraft designed and built for

                                                                                    Catastrophic




                                                                                                                                                                                   Improbable
                    for aerial application or if using bi-wing                                                            aerial application, conduct reconnaissance for




                                                                                                                                                                                                                            Medium
                                                                       Remote




                                                                                                                Serious




                                                                                                                                                                                                Critical
                                                                                                                          aerial hazards prior to project, recognize bi-wing
                                                                                                                          may not be the best choice for some applications

Performance      Insufficient planning considering project needs                                                          Contract to address minimum requirements:
Standards- Fixed and aircraft capabilities (mission profile,                                                              observation aircraft capable of transporting a
Wing             horsepower, etc.)                                                                                        minimum payload of 530 pounds on a standard day
                                                                                                                          at sea level and Power loading not greater than
                                                                                    Catastrophic
                                                                       Improbable




                                                                                                                                                                                   Improbable
                                                                                                                          13.5 pounds, (aircraft with a power loading greater
                                                                                                                Medium




                                                                                                                                                                                                                            Medium
                                                                                                                                                                                                Critical
                                                                                                                          than 13.5 pounds per horsepower (PPH) must be
                                                                                                                          turbo-charged), if multi-engine aircraft are used
                                                                                                                          they shall have 240-horsepower per engine, or
                                                                                                                          more, unless turbo-charged. Application aircraft
                                                                                                                          must be Turbine engine powered.

                    Overloading aircraft                                                                                  Perform load calculations based on weight of
                                                                                    Catastrophic Catastrophic




                                                                                                                                                                                                Catastrophic Catastrophic
                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                            Medium
                                                                       Remote




                                                                                                                Serious




                                                                                                                          pesticide formulation, weight of fuel and consider
                                                                                                                          distance to treatment area; download for pilots with
                                                                                                                          minimal experience

                    High density altitude operations                                                                      Match machine to task & environment, monitor



                                                                                                                                                                                   Improbable




                                                                                                                                                                                                                            Medium
                                                                       Remote




                                                                                                                Serious




                                                                                                                          weather, reduce load




 28
System: FHP Aerial Application - Aircraft (cont.)
                                                                      Pre Mitigation                                               Mitigation                         Post Mitigation




                                                                                                                                                                                                              Achieved?
Sub-systems        Hazards




                                                                                                                                                                                                              Mitigation

                                                                                                                                                                                                              Yes or No




                                                                                                                                                                                                                                                         Mitigation
                                                                        Likelihood




                                                                                                                                                                        Likelihood
                                                                                                    Outcome




                                                                                                                                                                                                    Outcome
                                                                                     Severity




                                                                                                                                                                                     Severity




                                                                                                                                                                                                                                                           Value
                                                                                                                                                                                                                                                            Post
                                                                                                                                                                                                                           Additional Local Mitigation


                   Possibility of fixed wing operating near stall                                             Brief on heavy load, wind direction &




                                                                                     Catastrophic




                                                                                                                                                                                     Catastrophic
                                                                                                                                                                        Occasional
                                                                        Frequent
                   speeds in downwind turns/operations in                                                     speed/downwind leg, avoid "high G" turns, pay




                                                                                                    High




                                                                                                                                                                                                    High
                   general                                                                                    attention to winds


Terrorist or       Remote, unsecure work areas and service                                                    Adhere to Project Aviation Safety and Security
malicious activity landings (risk to containment, aircraft,                                                   Plans. Contract to address security in remote




                                                                                     Catastrophic
                   personnel… theft or damage to                                                              locations, reference local Unit Aviation Plan (on all




                                                                                                                                                                                                    Medium
                                                                        Remote




                                                                                                                                                                        Remote
                                                                                                    Serious




                                                                                                                                                                                     Critical
                   aircraft/equipment… threat to public safety) 24                                            agency and state contracts, security plan required
                   hr security/agency-supplied at airport is not                                              for both insecticide & aircraft/support equipment…
                   required for all Agency and state contracts.                                               prop lock, fuel lock, chain of custody for
                                                                                                              insecticide)
Performance        Hover out of ground effect (HOGE), increased                                               Maintain forward airspeed, utilize higher




                                                                                     Catastrophic




                                                                                                                                                                                     Catastrophic
                                                                                                                                                                        Improbable
                   likelihood if using observation helicopter                                                 performance aircraft… OR to eliminate need for




                                                                                                                                                                                                    Medium
                                                                        Remote
Standards -




                                                                                                    Serious
helicopter                                                                                                    additional aircraft/personnel, consider other
                                                                                                              monitoring techniques in contract (e.g. real-time
                                                                                                              AFF subscription)
                   Propensity to operate within height-velocity                                               Maintain forward airspeed, utilize higher




                                                                                     Catastrophic




                                                                                                                                                                                     Catastrophic
                   curve, increased likelihood if using observation                                           performance aircraft, maintain adequate height




                                                                                                                                                                        Improbable




                                                                                                                                                                                                    Medium
                                                                        Remote




                                                                                                    Serious
                   helicopter                                                                                 above canopy… OR to eliminate need for
                                                                                                              additional aircraft/personnel, consider other
                                                                                                              monitoring techniques in contract (e.g.. realtime
                                                                                                              AFF subscription)




 29
System: FHP Aerial Application - Aircraft (cont.)
                                                                     Pre Mitigation                                               Mitigation                         Post Mitigation




                                                                                                                                                                                                             Achieved?
Sub-systems    Hazards




                                                                                                                                                                                                             Mitigation

                                                                                                                                                                                                             Yes or No




                                                                                                                                                                                                                                                        Mitigation
                                                                       Likelihood




                                                                                                                                                                       Likelihood
                                                                                                   Outcome




                                                                                                                                                                                                   Outcome
                                                                                    Severity




                                                                                                                                                                                    Severity




                                                                                                                                                                                                                                                          Value
                                                                                                                                                                                                                                                           Post
                                                                                                                                                                                                                          Additional Local Mitigation


Inspection &   Existence of corrosion/fracture in aircraft                                                   Partially mitigated by annual inspections per FAA




                                                                                    Catastrophic




                                                                                                                                                                                    Catastrophic
                                                                                                                                                                       Improbable
               components due to weights and chemical                                                        part 91, recommend increasing contractual




                                                                                                                                                                                                   Medium
                                                                       Remote
Maintenance




                                                                                                   Serious
               exposure (e.g.. Skids, landing gear, wing                                                     requirement to 100hr inspections (as in part 135),
               struts/attach fittings)                                                                       use only purpose built aircraft, utilize carding
                                                                                                             procedures
               Currently some states have no aircraft and                                                    Agency will assist in the development and suggest
               pilot inspection procedures.                                                                  use of an aircraft and pilot check list. The Agency




                                                                                    Catastrophic




                                                                                                                                                                                    Catastrophic
                                                                                                                                                                       Occasional
                                                                                                             will provide training to state program managers.




                                                                       Probable
                                                                                                             Even though aircraft will be inspected by state




                                                                                                   High




                                                                                                                                                                                                   High
                                                                                                             program managers, agency personnel will not be
                                                                                                             permitted to board application and observation
                                                                                                             aircraft unless carded per part 135.

               Aircraft not design/built for the specific mission                                            Require and implement a Structural Health




                                                                                    Catastrophic




                                                                                                                                                                                    Marginal
               profile (i.e. low-level, mountainous terrain, high                                            Monitoring Program approved by the aircraft’s




                                                                                                                                                                                                   Medium
                                                                       Remote




                                                                                                                                                                       Remote
                                                                                                   Serious
               cycle flight) on agency and state contracts.                                                  manufacturer. A copy of the program shall be
                                                                                                             provided to the CO and agency aviation inspectors.

               Aging aircraft and/or not identifying inspecting                                              Require and implement a Structural Health



                                                                                    Catastrophic




                                                                                                                                                                                    Marginal
               critical stress points (aerial application aircraft                                           Monitoring Program approved by the aircraft’s




                                                                                                                                                                                                   Medium
                                                                       Remote




                                                                                                                                                                       Remote
                                                                                                   Serious
               subject to multiple cycles and maximizing                                                     manufacturer. A copy of the program shall be
               payloads)                                                                                     provided to the CO and agency aviation inspectors.




                                                                                                                                                                                    Marginal
               Corrosion/fracture of spray tanks, delivery                                                   Develop monitoring program for spray operations,
                                                                                                   Medium




                                                                                                                                                                                                   Medium
                                                                       Remote




                                                                                                                                                                       Remote
                                                                                    Critical


               components leading to leakage, parts                                                          critical aircraft components and delivery system
               detaching
               Insufficient daily cleaning of aircraft to reduce                                             Agency and state contracts require that all
               corrosion (all aircraft)                                                                      equipment which comes in direct contact with the




                                                                                                                                                                       Improbable


                                                                                                                                                                                    Marginal
                                                                                                             pesticides must be kept thoroughly clean and free
                                                                                                   Medium




                                                                                                                                                                                                   Medium
                                                                       Remote


                                                                                    Critical




                                                                                                             of residues and foreign particulate matter, ensure
                                                                                                             adequate preflight/postflight inspection, provide for
                                                                                                             containment of residue in contract

               Insufficient cleaning of tanks and delivery                                                   Agency and state contracts require that all tanks




                                                                                                                                                                       Improbable
               components between projects, when changing                                                    and pesticide delivery systems must be thoroughly




                                                                                                                                                                                    Marginal
                                                                                                   Medium




                                                                                                                                                                                                   Medium
                                                                       Remote


                                                                                    Critical




               chemicals (env. hazard)                                                                       cleaned and free of rust, residues, and particulate
                                                                                                             matter, such as grit and sand and will inspect all
                                                                                                             tanks before they are filled with insecticide or
                                                                                                             water.
               Unapproved modifications to equipment or                                                      Both agency and state contracts require a
                                                                                    Catastrophic




                                                                                                                                                                                    Catastrophic
                                                                                                                                                                       Improbable




                                                                                                                                                                                                   Medium
                                                                       Remote




                                                                                                   Serious




               unapproved equipment                                                                          supplemental Type Certificate (STC) or FAA field
                                                                                                             approval for modified equipment (e.g. pheromone
                                                                                                             flake pods)




30
System: FHP Aerial Application - Aircraft (cont.)
                                                                        Pre Mitigation                                                            Mitigation                         Post Mitigation




                                                                                                                                                                                                                                                     Achieved?
Sub-systems         Hazards




                                                                                                                                                                                                                                                     Mitigation

                                                                                                                                                                                                                                                     Yes or No




                                                                                                                                                                                                                                                                                                Mitigation
                                                                          Likelihood




                                                                                                                                                                                       Likelihood
                                                                                                                   Outcome




                                                                                                                                                                                                                                           Outcome
                                                                                       Severity




                                                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                                                                   Post
                                                                                                                                                                                                                                                                  Additional Local Mitigation


Contract Aircraft Minimally skilled pilots                                                                                   Require in all agency and state contracts (1500 hrs




                                                                                       Catastrophic




                                                                                                                                                                                       Improbable


                                                                                                                                                                                                               Negligible
(common to both                                                                                                              minimum for application pilot, 25 hrs in




                                                                          Remote




                                                                                                                   Serious




                                                                                                                                                                                                                                           Low
State and Federal                                                                                                            make/model used, 100 hrs experience in aerial
operations = mix                                                                                                             application & 200 hrs experience in typical terrain)
of fixed and rotor
wing, CWN or Exc Using incorrect aircraft type for terrain (fixed                                                            Project planning shall determine the type of aircraft




                                                                                       Catastrophic




                                                                                                                                                                                                               Catastrophic
                                                                          Occasional
Use)               vs. rotor wing)                                                                                           required, contracts may specify when important to




                                                                                                                                                                                       Remote




                                                                                                                                                                                                                                           Serious
                                                                                                                   High
                                                                                                                             do so. Establish parameters for a/c type (e.g.
                                                                                                                             some mountainous terrain may be better suited for
                                                                                                                             helicopter)
                    Incentive to maximize flight time, regardless if                                                         Flight Managers & Project Supervisor need to be




                                                                                       Catastrophic




                                                                                                                                                                                       Improbable


                                                                                                                                                                                                               Negligible
                    paid by acre treated or hours flown                                                                      involved in flight hour/duty day monitoring, flight




                                                                          Remote




                                                                                                                   Serious




                                                                                                                                                                                                                                           Low
                                                                                                                             duty limitations, agency standards apply to agency
                                                                                                                             and state operations through contracts.

                    Operations in densely populated/high air traffic                                                         Contractors must file Congested Area Plans with




                                                                          Probable




                                                                                                                                                                                       Probable


                                                                                                                                                                                                               Marginal
                    areas                                                                                                    FAA. Contractors must adhere to FAA




                                                                                                                                                                                                                                           Serious
                                                                                       Critical

                                                                                                                   High
                                                                                                                             requirements (i.e. some FAA offices require rotor
                                                                                                                             only, others may allow fixed wing operations)

                    There are no maintenance requirements 'per                                                               Consider contract requirements to include 100 hr

                                                                                       Catastrophic




                                                                                                                                                                                                               Catastrophic
                                                                                                                                                                                       Occasional
                                                                          Probable

                    se' for aircraft operating under FAA part 137,                                                           inspection; establish TBO or TBO extension


                                                                                                                   High




                                                                                                                                                                                                                                           High
                    only the minimum requirements per FAA part                                                               program through FAA
                    91 (annual inspection)

                    Too many or too few aircraft for production                                                              Project planning shall determine and contracts
                    needs/project area, unsuitable spray platform                                                            specify quantity & type of aircraft needed to
                    for mission profile                                                                                      complete the project. For example number of a/c
                                                                                       Catastrophic




                                                                                                                             or production rates (ac/hr) may be specified in




                                                                                                                                                                                                                                           Medium
                                                                          Remote




                                                                                                                                                                                       Remote
                                                                                                                   Serious




                                                                                                                                                                                                               Critical
                                                                                                                             contracts. In cases where planning is unable to
                                                                                                                             determine (ie, county coordinators may not be
                                                                                                                             certain of needs), specify two choices in the
                                                                                                                             contract or utilize RFP and review procedures to
                                                                                                                             determine acceptability
                    No pre-application survey of area prior to                                                               Contract requirement that all application pilots are
                                                                                       Catastrophic




                                                                                                                                                                                                               Catastrophic
                                                                                                                                                                                       Improbable




                                                                                                                                                                                                                                           Medium
                                                                          Remote




                                                                                                                   Serious




                    project for aerial hazards                                                                               responsible for the reconnaissance of each area
                                                                                                                             before treatment.


Fuel                Starvation                                                                                               Monitor quantity pumped during fueling, monitor
                                                                          Occasional

                                                                                       Catastrophic




                                                                                                                                                                                                                                           Medium
                                                                                                                                                                                       Remote


                                                                                                                                                                                                               Critical
                                                                                                                             flight time and distance to services
                                                                                                                   High




                    Bad fuel (more likely in portable fuel systems)                                                          Ensure fuel is tested for type and quality prior to

                                                                                                                                                                                       Improbable Improbable
                                                                                                                   Medium




                                                                                                                                                                                                                                           Medium
                                                                          Remote


                                                                                       Critical




                                                                                                                                                                                                               Critical
                                                                                                                             fueling. Monitor quantity pumped. Ensure fuel
                                                                                                                             filters are changed as required by manufacturer.

Foreign Aircraft    Not carded/inspected for use in other country                                                            Use in foreign territory not authorized and illegal                               Marginal
                                                                                                                   Medium




                                                                                                                                                                                                                                           Medium
                                                                          Remote


                                                                                       Critical




                    (e.g., US in Canada, Canada in US)



Availability        Sense of urgency & pressure to perform (pilot,                                                           Involve Supervisor, Program Manager & flight
                                                                                       Catastrophic Catastrophic




                                                                                                                                                                                                               Catastrophic Catastrophic
                                                                          Occasional




                                                                                                                                                                                       Remote




                                                                                                                                                                                                                                           Serious



                    manager, organization)                                                                                   Manager in all stages of planning and risk
                                                                                                                   High




                                                                                                                             assessment.
                                                                                                                                                                                       Improbable




                    Tendency to over utilize single vendor/pilot &                                                           Flight Managers & Program Manager need to be
                                                                          Remote




                                                                                                                   Serious




                                                                                                                                                                                                                                           Serious




                    maximize flight hours due to limited availability                                                        involved in flight hour/duty day monitoring. Adhere
                    of other aircraft                                                                                        to contract specifications regarding flight hour/duty
                                                                                                                             limitations.


 31
System: FHP Aerial Application - Environmental
                                                               Pre Mitigation                                                                         Mitigation                        Post Mitigation




                                                                              Severity




                                                                                                                                                                                                                  Severity
                                                                 Likelihood




                                                                                                                                                                                          Occasional Likelihood
                                                                                                                       Outcome




                                                                                                                                                                                                                                                           Outcome


                                                                                                                                                                                                                                                                     Achieved?
Sub-systems      Hazards




                                                                                                                                                                                                                                                                     Mitigation

                                                                                                                                                                                                                                                                     Yes or No




                                                                                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                                                                                   Post
                                                                                                                                                                                                                                                                                  Additional Local Mitigation


Weather          High wind, high temperatures, low humidity                                                                      Contract specifies thresholds for allowable winds,




                                                                 Frequent

                                                                              Marginal




                                                                                                                                                                                                                  Marginal

                                                                                                                                                                                                                                                           Medium
                                                                                                                       Serious
                 (pesticide drift)                                                                                               temperature & relative humidity, cease operations
                                                                                                                                 when drift conditions exist


                                                                                                                                 Contract specifies performance requirements,




                                                                              Catastrophic Catastrophic Catastrophic




                                                                                                                                                                                                                  Catastrophic Catastrophic Catastrophic
                                                                 Frequent
                                                                                                                                 conduct load calculations/weight & balance; cease




                                                                                                                                                                                          Remote




                                                                                                                                                                                                                                                           Serious
                                                                                                                       High
                                                                                                                                 operations when conditions out of parameter
                 High wind, low humidity, high temperatures
                 (affect on aircraft performance)
                 Thunderstorms, lightening, hail, high winds                                                                     Suggest pilots utilize on-board, real time weather




                                                                 Occasional
                                                                                                                                 program (such as XM weather on Garmin-type




                                                                                                                                                                                          Remote




                                                                                                                                                                                                                                                           Serious
                                                                                                                       High
                                                                                                                                 GPS); program managers monitor weather stations
                                                                                                                                 provided at airport office, use observation aircraft
                                                                                                                                 to help monitor weather conditions
                 Typically morning operations & in                                                                               Preflight briefing to raise awareness




                                                                 Frequent




                                                                                                                                                                                          Probable
                 shadows/glare conditions




                                                                                                                       High




                                                                                                                                                                                                                                                           High
Topography/Hi    Turbulence                                                                                                      Time application based on anticipated prevailing
                                                                 Frequent




                                                                                                                                                                                                                                                           Medium
                                                                                                                                                                                          Remote
                                                                              Critical




                                                                                                                                                                                                                  Critical
                                                                                                                       High
Alt                                                                                                                              winds, cease operations if unsafe/out of parameter


                 Terrain - box canyons                                                                                           Plan project/treatment block such that application
                                                                              Catastrophic
                                                                 Occasional




                                                                                                                                 flight lines allow egress; brief pilot




                                                                                                                                                                                                                                                           Medium
                                                                                                                                                                                          Remote


                                                                                                                                                                                                                  Critical
                                                                                                                       High




                 High Altitude - density altitude                                                                                Perform load calculations for departure and
                                                                              Catastrophic
                                                                 Occasional




                                                                                                                                 destination




                                                                                                                                                                                                                                                           Medium
                                                                                                                                                                                          Remote


                                                                                                                                                                                                                  Critical
                                                                                                                       High




Remote Areas or Lack of communications                                                                                           Test radio communications prior to project
                                                                              Catastrophic Catastrophic Catastrophic




                                                                                                                                                                                                                  Catastrophic Catastrophic
                                                                 Probable




                                                                                                                                 implementation




                                                                                                                                                                                          Remote




                                                                                                                                                                                                                                                           Serious
Poor Road
                                                                                                                       High




Access


                 Long response time in event of search and                                                                       Mishap Response Plan to address search and
                                                                 Occasional




                                                                                                                                                                                          Remote




                                                                                                                                                                                                                                                           Serious
                 rescue                                                                                                          rescue procedures, observation aircraft may be
                                                                                                                       High




                                                                                                                                 used to assist guiding rescue vehicles/personnel to
                                                                                                                                 accident site

                 Fuel starvation, proper fuel unavailable                                                                        Monitor flight time/fuel consumption, utilize fuel
                                                                                                                                                                                          Improbable




                                                                                                                                                                                                                                                           Medium
                                                                                                                                 trucks or have optional fuel sources identified
                                                                 Remote




                                                                                                                       Serious




                                                                                                                                                                                                                  Critical




32
System: FHP Aerial Application - Environmental (cont.)
                                                                      Pre Mitigation                                               Mitigation                          Post Mitigation




                                                                                     Severity




                                                                                                                                                                                      Severity
                                                                        Likelihood




                                                                                                                                                                         Likelihood
                                                                                                    Outcome




                                                                                                                                                                                                     Outcome


                                                                                                                                                                                                               Achieved?
Sub-systems       Hazards




                                                                                                                                                                                                               Mitigation

                                                                                                                                                                                                               Yes or No




                                                                                                                                                                                                                                                          Mitigation
                                                                                                                                                                                                                                                            Value
                                                                                                                                                                                                                                                             Post
                                                                                                                                                                                                                            Additional Local Mitigation


Remote Areas or Unimproved landing strips or helipads with                                                    Contractor required to locate and inspect all
Poor Road       poor dust abatement and/or poor surface                                                       landing zones prior to project implementation,
Access (cont.)  condition                                                                                     secure written permission if on private property; for




                                                                                                                                                                         Improbable
                                                                                                              fixed-wing operations, contractor must obtain




                                                                                     Marginal




                                                                                                                                                                                      Marginal
                                                                                                    Medium




                                                                                                                                                                                                     Medium
                                                                        Remote
                                                                                                              permission from airport manager, airstrips must be
                                                                                                              accessible to vehicles, therefore mostly utilizing
                                                                                                              developed airports (may use unimproved landing
                                                                                                              strip only in event of emergency); for rotor wing
                                                                                                              operations water is available for dust abatement if
                                                                                                              needed
Biological        Prioritizing treatment based on pest phenology                                              Contract specifications include adequate number of




                                                                                     Catastrophic
                                                                        Occasional
Window            over safety (must treat within window)                                                      aircraft to accomplish mission within biological




                                                                                                                                                                                                     Medium
                                                                                                                                                                         Remote


                                                                                                                                                                                      Critical
                                                                                                    High
                                                                                                              window, brief daily emphasizing safety over
                                                                                                              production, adhere to flight and duty limitations


Airspace          Working within Military Operating Area,                                                     Contact flight service station or ATC to determine if




                                                                                     Catastrophic




                                                                                                                                                                                      Catastrophic
                                                                        Probable
                  potential mid air collision                                                                 active and, if so, may request traffic advisories




                                                                                                                                                                         Remote




                                                                                                                                                                                                     Serious
                                                                                                    High
                                                                                                              from the controlling agency prior to entry; address
                                                                                                              during premission planning and briefing


                  Working within or proximity to Military Training                                            Address during permission planning and briefing;
                  Route, potential mid air collision                                                          keep alert (application aircraft and observation
                                                                                                              aircraft); contact flight service station to determine
                                                                                                              if active and, if so, request times of scheduled
                                                                                                              activity, altitudes in use, actual route width (route
                                                                                     Catastrophic




                                                                                                                                                                                      Catastrophic
                                                                        Probable




                                                                                                              may extend several miles beyond shown center




                                                                                                                                                                         Remote




                                                                                                                                                                                                     Serious
                                                                                                    High



                                                                                                              line); not all MTRs are published on sectionals...
                                                                                                              obtain copy of AP1B for phone numbers to military
                                                                                                              installations and contact schedulers to deconflict
                                                                                                              MTR; project manager post NOTAM for military to
                                                                                                              review during their daily briefing



                  Unable to establish TFR for applications                                                    Post applications projects as NOTAM, remain
                                                                                     Catastrophic




                                                                                                                                                                                      Catastrophic
                                                                        Probable




                  projects                                                                                    aware of potential for other aircraft to enter project




                                                                                                                                                                         Remote




                                                                                                                                                                                                     Serious
                                                                                                    High




                                                                                                              area



                  Military training operations distracting                                                    COR/Project Manager & National Airspace
                                                                                     Catastrophic




                                                                                                                                                                                      Catastrophic
                                                                        Occasional




                  application aircraft                                                                        Coordinator to communicate "training" problem to


                                                                                                                                                                         Remote




                                                                                                                                                                                                     Serious
                                                                                                              military, describe distraction to application
                                                                                                    High




                                                                                                              operations and risk (Air Force & Navy have contact
                                                                                                              points, also a primary single contact "Airspace
                                                                                                              Manager" for all branches)
                  Inability to post NOTAMs due to FAA office                                                  Go to FAA.gov to identify contact and follow
                                                                                     Catastrophic




                                                                                                                                                                                      Catastrophic
                                                                        Occasional




                  closures and difficulty identifying contact point                                           procedures for filing NOTAMs... post aerial
                                                                                                                                                                         Remote




                                                                                                                                                                                                     Serious
                                                                                                    High




                                                                                                              application NOTAM within 3 days of project




33
System: FHP Aerial Application - Environmental (cont.)
                                                                     Pre Mitigation                                                                                         Mitigation                        Post Mitigation




                                                                                                    Severity




                                                                                                                                                                                                                             Severity
                                                                       Likelihood




                                                                                                                                                                                                                Likelihood
                                                                                                                                             Outcome




                                                                                                                                                                                                                                                              Outcome


                                                                                                                                                                                                                                                                        Achieved?
Sub-systems        Hazards




                                                                                                                                                                                                                                                                        Mitigation

                                                                                                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                                                                                                   Mitigation
                                                                                                                                                                                                                                                                                                                     Value
                                                                                                                                                                                                                                                                                                                      Post
                                                                                                                                                                                                                                                                                     Additional Local Mitigation


Airspace (cont.)   Working in proximity to/or within FTA or TFR                                                                                        Typically avoid, however, Project Manager may
                                                                                                                                                       request permission to work within FTA or TFR if




                                                                                                    Catastrophic
                                                                                                                                                       possible and absolutely necessary, coordination




                                                                                                                                                                                                                                                              Medium
                                                                       Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious




                                                                                                                                                                                                                             Critical
                                                                                                                                                       between dispatch, application pilot, and aerial
                                                                                                                                                       supervision is required; ability to "XM download" to
                                                                                                                                                       on board GPS will help with TFRs.


                   Restricted Areas (artillery firing, guided                                                                                          Typically avoid, however, if necessary permission




                                                                                                    Catastrophic
                   missiles or aerial gunnery)                                                                                                         to enter may be coordinated through ATC; know




                                                                                                                                                                                                                                                              Medium
                                                                       Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious




                                                                                                                                                                                                                             Critical
                                                                                                                                                       intercept procedures, reference in
                                                                                                                                                       contracts/prework and include in daily briefings.


                   Prohibited Areas (e.g.. lack of coordination                                                                                        For all intents and purposes "permanently off
                   prior to entering Camp David, White House,                                                                                          limits", typically avoid, however, applications
                   Presidential Ranch…)                                                                                                                projects are sometimes prescribed within PAs; if
                                                                                                                                                       necessary permission to enter may be coordinated
                                                                                                                                                       through ATC, DOD, Secrete Service... Example:




                                                                                                    Catastrophic
                                                                                                                                                       procedure for P-40 (Camp David) Project Manager




                                                                                                                                                                                                                                                              Medium
                                                                       Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious




                                                                                                                                                                                                                             Critical
                                                                                                                                                       contacts Park Service, Park Service contacts
                                                                                                                                                       Secrete Service; at minimum prebrief by Project
                                                                                                                                                       Manager includes Secrete Service to establish
                                                                                                                                                       agreed flight plan/flight lines, pilot must strictly
                                                                                                                                                       adhere to plan; know intercept procedures,
                                                                                                                                                       reference in contracts/prework and include in daily
                                                                                                                                                       briefings


                   Mid Air collision while working within or                                                                                           Observation and application aircraft remain aware
                                                                                                    Catastrophic Catastrophic Catastrophic




                                                                                                                                                                                                                             Catastrophic Catastrophic
                   crossing Class B, C, D Airspace                                                                                                     of other traffic, pilot request clearance, maintain
                                                                       Remote




                                                                                                                                                                                                                Remote
                                                                                                                                             Serious




                                                                                                                                                                                                                                                              Serious
                                                                                                                                                       communication with ATC or tower as required



                   Airspace in general - near miss/collision in                                                                                        Communicate with & utilize observation aircraft,
                                                                       Occasional




                   congested areas                                                                                                                     ATC, etc... see and avoid, consider TCAS to warn




                                                                                                                                                                                                                Remote




                                                                                                                                                                                                                                                              Serious
                                                                                                                                             High




                                                                                                                                                       of transponding aircraft in proximity to application
                                                                                                                                                       aircraft

Airstrip           No alternative or suitable landing location for                                                                                     Identify emergency landing zones in advance
                                                                       Probable




                                                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                                Remote
Availability,      emergency situations                                                                                                                (fields, open areas, meadows)




                                                                                                                                                                                                                             Critical
                                                                                                                                             High




Condition and
Services

                   No alternative fuel source                                                                                                          Call FBO/airport ahead of time to determine fuel
                                                                       Occasional

                                                                                                    Marginal

                                                                                                                                             Medium




                                                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                                Remote


                                                                                                                                                                                                                             Critical
                                                                                                                                                       availability, use alternate airport or fuel tender



                   One-way landing/departure                                                                                                           Be aware that preferred approach/departure based
                                                                                                                                                                                                                             Negligible Marginal Negligible
                                                                       Frequent Frequent Probable




                                                                                                                                                                                                                Probable
                                                                                                    Marginal

                                                                                                                                             Serious




                                                                                                                                                       on wind may not be an option, be aware of the
                                                                                                                                                                                                                                                              Low
                                                                                                                                                       potential for oncoming air traffic

                   No windsock at landing zones                                                                                                        Use vegetation (grass, tree tops) as reference; if
                                                                                                    Marginal




                                                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                                Remote
                                                                                                                                             Serious




                                                                                                                                                       available, ground support can call pilot with
                                                                                                                                                       conditions prior to landing, hang flagging

                   Effects of prevailing wind                                                                                                          Know local conditions, retrieve automated weather
                                                                                                                                                                                                                Frequent
                                                                                                    Marginal




                                                                                                                                                                                                                                                              Medium
                                                                                                                                             Serious




 34
System: FHP Aerial Application - Environmental (cont.)
                                                                       Pre Mitigation                                               Mitigation                          Post Mitigation




                                                                                      Severity




                                                                                                                                                                                       Severity
                                                                         Likelihood




                                                                                                                                                                          Likelihood
                                                                                                     Outcome




                                                                                                                                                                                                    Outcome


                                                                                                                                                                                                              Achieved?
Sub-systems         Hazards




                                                                                                                                                                                                              Mitigation

                                                                                                                                                                                                              Yes or No




                                                                                                                                                                                                                                                         Mitigation
                                                                                                                                                                                                                                                           Value
                                                                                                                                                                                                                                                            Post
                                                                                                                                                                                                                           Additional Local Mitigation


Terrain/Obstructi Operations below 500' in either helicopter or                                                Contract specifications require FAA part 137-




                                                                                      Catastrophic
ons               fixed-wing, potential to impact terrain or                                                   qualified pilots. Maintain situational awareness,




                                                                         Frequent




                                                                                                                                                                                                    Medium
                                                                                                                                                                          Remote


                                                                                                                                                                                       Critical
                                                                                                     High
                  obstruction - aerial application typically 50-200                                            identify emergency landing zones (fields, open
                  feet above tree tops                                                                         areas, meadows); preflight briefing, review aerial
                                                                                                               hazard map, contract specifies reconnaissance of
                                                                                                               area prior to treatment
Animal activity     Potential for serious injury/aircraft damage                                               Know flyways, observation aircraft and ground




                                                                         Occasional




                                                                                                                                                                                                    Medium
                                                                                                                                                                          Remote
                                                                                                     Serious
                    from birds                                                                                 support to communicate avian activity if present in




                                                                                      Critical




                                                                                                                                                                                       Critical
                                                                                                               area


                    Potential for serious injury/aircraft damage                                               Ground support to clear runway, communicate




                                                                         Occasional




                                                                                                                                                                                       Marginal
                    from wildlife on runway (common at remote                                                  activity to pilot; keep deer away by scattering "Irish




                                                                                                                                                                                                    Medium
                                                                                                                                                                          Remote
                                                                                                     Serious
                                                                                      Critical
                    and county airports)                                                                       Spring" soap around runway perimeter



Containment &                                                                                                  Contractor is required to have spill plan, agency




                                                                                                                                                                          Improbable


                                                                                                                                                                                       Negligible
                                                                                      Marginal

                                                                                                     Medium
                                                                         Remote
Handling                                                                                                       and state contracts require safety plan (includes




                                                                                                                                                                                                    Low
                                                                                                               spill plan) follow pesticide label regarding PPE
                    No spill plan for fuel & chemicals, no label and
                    MSDS for pesticide, no PPE
                                                                                                               Treatment areas are posted on public lands only




                                                                                                                                                                          Improbable


                                                                                                                                                                                       Negligible
                                                                                      Marginal                 (not necessary for private landowners requesting

                                                                                                     Medium
                                                                         Remote




                                                                                                                                                                                                    Low
                                                                                                               treatment), roads may be closed on public lands at
                    Human exposure due to treatment areas not                                                  discretion of site manager
                    posted




 35
System: FHP Aerial Application - Personnel
                                                                Pre Mitigation                                               Mitigation                          Post Mitigation




                                                                                                                                                                                                         Achieved?
Sub-systems    Hazards




                                                                                                                                                                                                         Mitigation

                                                                                                                                                                                                         Yes or No




                                                                                                                                                                                                                                                    Mitigation
                                                                  Likelihood




                                                                                                                                                                   Likelihood
                                                                                              Outcome




                                                                                                                                                                                               Outcome
                                                                               Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                      Value
                                                                                                                                                                                                                                                       Post
                                                                                                                                                                                                                      Additional Local Mitigation


Pilot and/or   Minimal local experience/unfamiliar with area                                            Preflight briefing, review aerial hazard maps,




                                                                               Catastrophic
                                                                  Frequent




                                                                                                                                                                   Frequent


                                                                                                                                                                                Marginal


                                                                                                                                                                                               Serious
vendor                                                                                                  conduct reconnaissance flights




                                                                                              High
               No current State Applicator License                                                      Agency and state contracts require contractor to




                                                                                                                                                                   Improbable


                                                                                                                                                                                Negligible
                                                                               Marginal
                                                                                                        obtain current State Applicator License… obtain




                                                                                              Medium
                                                                  Remote




                                                                                                                                                                                               Low
                                                                                                        certification within all states where project is
                                                                                                        planned, be aware that project may cross state
                                                                                                        lines
               State contracts are not required to meet                                                 Maintain/improve working relationship with state




                                                                  Probable




                                                                                                                                                                                Marginal


                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                               Critical

                                                                                              High
               agency standards for aerial application                                                  agencies (most states voluntarily adopt agency
                                                                                                        standards), involve states in risk management
               Minimal flight hours/mission hours                                                       Contract specifies number of hours by mission type




                                                                               Catastrophic
                                                                  Occasional




                                                                                                                                                                                Marginal
                                                                                                        (number of hours in typical terrain, number of hours




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                              High
                                                                                                        in make/model), check flight log files & be aware
                                                                                                        possibility exists for these to be falsified/unable to
                                                                                                        verify
               Inordinate attention to application, impacting                                           Agency and state contracts provide aerial hazard
               aerial hazards (new hazards installed often,                                             maps of known hazards on aerial photo or topo,


                                                                               Catastrophic




                                                                                                                                                                                Catastrophic
                                                                  Occasional
               e.g. cell towers)                                                                        some states will GPS hazards prior to project




                                                                                                                                                                   Remote




                                                                                                                                                                                               Serious
                                                                                              High
                                                                                                        implementation, agency and state contract require
                                                                                                        "all application pilots are responsible and required
                                                                                                        for the reconnaissance of each area before
                                                                                                        treatment"
               Coerced into uncomfortable situation                                                     Not all pilots equally skilled, do not pressure into
                                                                               Catastrophic




                                                                                                                                                                                Catastrophic
                                                                  Occasional




                                                                                                                                                                   Remote
                                                                                                        uncomfortable situations (encourage all to speak




                                                                                                                                                                                               Serious
                                                                                              High



                                                                                                        up)


               Inadequate briefings from Project Manager                                                Make contract requirement to hold preseason,
                                                                  Occasional




                                                                                                                                                                                Marginal


                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                              Serious
                                                                               Critical




                                                                                                        premission/daily, postmission briefings



               lack of awareness leading to fuel starvation                                             Proper preflight planning, Project Manager & pilot
                                                                               Catastrophic




                                                                                                                                                                                Catastrophic
                                                                  Occasional




                                                                                                        monitor flight time




                                                                                                                                                                   Remote




                                                                                                                                                                                               Serious
                                                                                              High




               Self-medication                                                                          All project personnel to be aware of illness (may be
                                                                               Catastrophic
                                                                  Occasional




                                                                                                        colds to serious health issue), ask if medicated,




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote


                                                                                                                                                                                Critical
                                                                                              High




                                                                                                        know FAA regs for use of over-the-counter and
                                                                                                        prescription drugs while operating equipment




 36
System: FHP Aerial Application - Personnel (cont.)
                                                                       Pre Mitigation                                                                         Mitigation                          Post Mitigation




                                                                                                                                                                                                                                                   Achieved?
Sub-systems       Hazards




                                                                                                                                                                                                                                                   Mitigation

                                                                                                                                                                                                                                                   Yes or No




                                                                                                                                                                                                                                                                                              Mitigation
                                                                         Likelihood




                                                                                                                                                                                                    Likelihood
                                                                                                                               Outcome




                                                                                                                                                                                                                                         Outcome
                                                                                      Severity




                                                                                                                                                                                                                            Severity




                                                                                                                                                                                                                                                                                                Value
                                                                                                                                                                                                                                                                                                 Post
                                                                                                                                                                                                                                                                Additional Local Mitigation


                  Incomplete preflight inspection                                                                                        Pilot to utilize preflight check list, FAA requirement




                                                                                      Catastrophic Catastrophic Catastrophic
                                                                         Occasional




                                                                                                                                                                                                                                         Medium
                                                                                                                                                                                                    Remote


                                                                                                                                                                                                                            Critical
                                                                                                                               High
                  Accepting unreasonable risk, "barnstormer"                                                                             Preflight briefing to establish tone for the day,




                                                                         Occasional




                                                                                                                                                                                                                                         Medium
                                                                                                                                                                                                    Remote
                  attitude                                                                                                               "aviation program first, pest management second"




                                                                                                                                                                                                                            Critical
                                                                                                                               High
                  Pilot incapacitated                                                                                                    Contracts specify that pilot may be relieved of




                                                                                                                                                                                                    Improbable


                                                                                                                                                                                                                            Negligible
                                                                         Remote




                                                                                                                               Serious
                                                                                                                                         duties (in event of sickness, under influence of




                                                                                                                                                                                                                                         Low
                                                                                                                                         alcohol or drugs, insufficient rest/time off)


                  Fatigue                                                                                                                Contract specifies duty limitations and rest periods;




                                                                                      Catastrophic
                                                                                                                                         contract specifies contractor not allowed to do



                                                                         Occasional




                                                                                                                                                                                                                            Marginal


                                                                                                                                                                                                                                         Medium
                                                                                                                                                                                                    Remote
                                                                                                                                         other projects until completing current agency or




                                                                                                                               High
                                                                                                                                         state project; assure enough personnel to support
                                                                                                                                         aircraft and project schedule

                  Complacency                                                                                                            Be aware that experienced pilots may tend toward
                                                                                      Catastrophic
                                                                         Occasional




                                                                                                                                                                                                                                         Medium
                                                                                                                                                                                                    Remote


                                                                                                                                                                                                                            Critical
                                                                                                                                         complacency… conduct morning safety briefings,


                                                                                                                               High
                                                                                                                                         retain situational awareness throughout day


Agency or State   Exposure to increased risk by boarding                                                                                 Most fixed-wing application aircraft seat pilot only,




                                                                                                                                                                                                    Occasional Improbable


                                                                                                                                                                                                                            Marginal
                                                                                                                               Medium




                                                                                                                                                                                                                                         Medium
                                                                         Remote


                                                                                      Critical




Personnel         unauthorized aircraft (FAA part 137 not carded                                                                         federal and state personnel may not fly in restricted
                  for personnel transport)                                                                                               category (FAA part 137) aircraft

                  Minimal experience with mission type                                                                                   Include expert aviation and pest management
                                                                         Probable




                                                                                                                                                                                                                                         Serious
                                                                                      Critical




                                                                                                                                                                                                                            Critical
                                                                                                                                         personnel in project planning, briefing and
                                                                                                                               High




                                                                                                                                         implementation; train and mentor new employees
                                                                                                                                         (subordinates and supervisors)
                  Undue pressure upon employees or contractor                                                                            Utilize crew resource management, all are
                                                                                      Catastrophic
                                                                         Occasional




                                                                                                                                                                                                                                         Medium
                                                                                                                                                                                                    Remote


                                                                                                                                                                                                                            Critical
                  to perform by Program Manager/Supervisor                                                                               empowered to stop an unsafe act
                                                                                                                               High




                  Exposure to risk for personnel if participating in                                                                     State and federal employees never ride in
                  observation flight                                                                                                     application aircraft under FAA part 137 but may in




                                                                                                                                                                                                                            Negligible
                                                                         Frequent




                                                                                                                                                                                                    Frequent
                                                                                                                                         observation aircraft (federal requirements: pilot
                                                                                      Marginal




                                                                                                                                                                                                                                         Medium
                                                                                                                               Serious




                                                                                                                                         carding per FAA part 135, monitoring personnel on
                                                                                                                                         board must be qualified Fixed-wing Flight Manager
                                                                                                                                         or Helicopter Manager); consider utilizing AFF to
                                                                                                                                         monitor operation




37
System: FHP Aerial Application - Personnel (cont.)
                                                                 Pre Mitigation                                                                                     Mitigation                         Post Mitigation




                                                                                                                                                                                                                                           Achieved?
Sub-systems   Hazards




                                                                                                                                                                                                                                           Mitigation

                                                                                                                                                                                                                                           Yes or No




                                                                                                                                                                                                                                                                                      Mitigation
                                                                   Likelihood




                                                                                                                                                                                                         Likelihood
                                                                                                                                      Outcome




                                                                                                                                                                                                                                 Outcome
                                                                                Severity




                                                                                                                                                                                                                      Severity




                                                                                                                                                                                                                                                                                        Value
                                                                                                                                                                                                                                                                                         Post
                                                                                                                                                                                                                                                        Additional Local Mitigation


              Fatigue (air or ground personnel)                                                                                                 Outline project schedule within the RFP, proposals
                                                                                                                                                to address how intended to meet production
                                                                                                                                                requirements/assure adequte rest, recommend




                                                                                Catastrophic
                                                                                                                                                RFP provide vendor weekly opportunity to specify




                                                                   Probable




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
                                                                                                                                                                                                         Remote
                                                                                                                                                changes to state or ageny for review; Positive




                                                                                                                                      High
                                                                                                                                                safety culture will encourage adequate rest for all,
                                                                                                                                                appropriate number of aircraft assigned to project;
                                                                                                                                                Responsibility of Project Manager to ensure
                                                                                                                                                adequate rest for all personnel (crew resource
                                                                                                                                                management);
              Complacency (air or ground personnel)                                                                                             Be aware that experienced project personnel may




                                                                   Occasional
                                                                                                                                                tend toward complacency… conduct morning




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
                                                                                                                                                                                                         Remote
                                                                                                                                      Serious
                                                                                Critical
                                                                                                                                                safety briefings, retain situational awareness
                                                                                                                                                throughout day (crew resource management)

              Condoning unreasonable risk                                                                                                       Complete Risk Assessment for each project;




                                                                                Catastrophic Catastrophic Catastrophic Catastrophic
                                                                   Occasional




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
                                                                                                                                                                                                         Remote
                                                                                                                                                preflight briefing to establish tone for the day,




                                                                                                                                      High
                                                                                                                                                "aviation program first, pest management second"


Training      Lack of educational opportunities for pilots and                                                                                  Consider including in contract specs that all




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
                                                                   Remote




                                                                                                                                                                                                         Remote
                                                                                                                                      Serious
              pilot operators that help reduce aircraft and                                                                                     application pilots must attend Professional Aerial
              drift accidents                                                                                                                   Applicator Support System (PAASS) certification
                                                                                                                                                course
              Minimal experience in areas with sporadic                                                                                         Agency to support and fund aerial application and




                                                                                                                                                                                                         Occasional
                                                                   Frequent




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
              application programs (particularly in west,                                                                                       safety training for all agency and state personnel,
                                                                                                                                      High



              occasionally in east)                                                                                                             implement mentoring program, share expertise
                                                                                                                                                across regions
              Lack of aviation awareness training and risk                                                                                      Consistent with the goals of the Aerial Application




                                                                                                                                                                                                         Occasional
                                                                   Frequent




                                                                                                                                                                                                                      Marginal


                                                                                                                                                                                                                                 Medium
              management in general                                                                                                             Safety Council, develop and provide aerial
                                                                                                                                      High




                                                                                                                                                application training program (e.g., ACE training for
                                                                                                                                                agency & state personnel)




38
System: FHP Aerial Application - Personnel (cont.)
                                                                         Pre Mitigation                                               Mitigation                         Post Mitigation




                                                                                                                                                                                                                                        Achieved?
Sub-systems           Hazards




                                                                                                                                                                                                                                        Mitigation

                                                                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                                                                   Mitigation
                                                                           Likelihood




                                                                                                                                                                           Remote Likelihood
                                                                                                       Outcome




                                                                                                                                                                                                                       Medium Outcome
                                                                                        Severity




                                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                                                     Value
                                                                                                                                                                                                                                                                                      Post
                                                                                                                                                                                                                                                     Additional Local Mitigation




                                                                                                                                                                                               Marginal
Flight Following      Lack of mission understanding and scheduled                                                Notify dispatch of planned activities and provide
Personnel             activities                                                                                 Project Aviation Management Plan for Agency




                                                                                                       Medium
                                                                           Remote

                                                                                        Critical
(typically dispatch                                                                                              contracts and any state contracts in proximity to
on FS contracts,                                                                                                 National Forest
FS land)




                                                                                                                                                                                               Negligible
                                                                                                                                                                           Improbable




                                                                                                                                                                                                                       Low
                      Inconsistent flight following procedures -                                                 Agency follow established protocol… address flight




                                                                           Occasional




                                                                                                       Serious
                      federal                                                                                    following procedures in communications plan




                                                                                        Critical




                                                                                                                                                                                               Critical Catastrophic

                                                                                                                                                                                                                       Serious
                                                                                                                                                                           Remote
                      No dispatch available/inability to communicate                                             Establish flight following in the field using ground




                                                                                        Catastrophic
                                                                           Probable
                      to center                                                                                  personnel in treatment area - specify in




                                                                                                       High
                                                                                                                 communication plan and utilize a combination of
                                                                                                                 communication methods (e.g., ground to ground,
                                                                                                                 air to ground, cell phone)




                                                                                                                                                                           Occasional




                                                                                                                                                                                                                       Serious
                      Inconsistent flight following procedures - state                                           Recommend states utilize protocol similar to




                                                                                        Catastrophic
                                                                           Occasional
                                                                                                                 federal... State projects often conducted with no




                                                                                                       High
                                                                                                                 dispatch but with flight following performed by state
                                                                                                                 employees positioned at airport… adhere to
                                                                                                                 procedures in communications plan




                                                                                                                                                                                               Marginal

                                                                                                                                                                                                                       Medium
                                                                                                                                                                           Remote
                      Flight following personnel fatigued or                                                     Ensure adequate rest; follow agency protocol for
                                                                           Occasional

                                                                                        Marginal

                                                                                                       Medium
                      complacent                                                                                 duty limitations, recommend similar for state
                                                                                                                 contracts




                                                                                                                                                                                               Marginal

                                                                                                                                                                                                                       Medium
                                                                                                                                                                           Remote
                      Poor frequency management/frequency                                                        Coordinate with dispatch or communication
                                                                           Occasional

                                                                                        Marginal

                                                                                                       Medium



                      congestion                                                                                 technicians to obtain additional frequencies and set
                                                                                                                 up portable repeaters if necessary




                                                                                                                                                                                               Marginal

                                                                                                                                                                                                                       Medium
                                                                                                                                                                           Remote
                      Lack of staffing on weekends or outside of                                                 Brief dispatch on operational periods, ensure
                                                                                        Catastrophic
                                                                           Occasional




                      flight hours                                                                               dispatcher staffing or flight following personnel
                                                                                                       High




                                                                                                                                                                                               Marginal

                                                                                                                                                                                                                       Medium
                                                                                                                                                                           Remote
                      Jurisdictional/boundary awareness and inability                                            Circulate flight plan to all dispatch centers in
                                                                           Occasional




                                                                                                       Serious




                      to maintain flight following                                                               project area, communication plan includes all
                                                                                        Critical




                                                                                                                 necessary frequencies/brief pilot, assure handoff
                                                                                                                 from one center to next




 39
System: FHP Aerial Application - Personnel (cont.)
                                                                       Pre Mitigation                                                                        Mitigation                         Post Mitigation




                                                                                                                                                                                                                                    Achieved?
Sub-systems        Hazards




                                                                                                                                                                                                                                    Mitigation

                                                                                                                                                                                                                                    Yes or No




                                                                                                                                                                                                                                                                               Mitigation
                                                                         Likelihood




                                                                                                                                                                                                  Likelihood
                                                                                                                               Outcome




                                                                                                                                                                                                                          Outcome
                                                                                      Severity




                                                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                                                 Value
                                                                                                                                                                                                                                                                                  Post
                                                                                                                                                                                                                                                 Additional Local Mitigation


Maintenance         Not current on maintenance issues for specific                                                                       Regularly check for new Airworthiness Directives,




                                                                                      Catastrophic Catastrophic Catastrophic
                                                                         Occasional




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
Inspector (aircraft aircraft that could lead to accidents                                                                                stay current on required training




                                                                                                                               High
& support
vehicles)
                   Insufficient number of inspectors may lead to                                                                         Ensure adequate staffing, Project Managers attend




                                                                         Occasional




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
                   fatigue, complacency, accepting or transferring                                                                       aircraft inspections




                                                                                                                               High
                   unreasonable risk


Oversight &        Lack of mission understanding among                                                                                   Project Managers participate in annual Forest




                                                                         Probable




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
Coordination in    RAOs/RASMs, FAOs, state directors, etc…                                                                               Aviation Officer meetings, RAOs/RASMs




                                                                                                                               High
General                                                                                                                                  review/approve aviation management plan


                   Lack of trend information helpful in preventing                                                                       Expand knowledge & how to use SAFECOM




                                                                         Probable
                   incidents/accidents                                                                                                   system, should include all agency funded aerial




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote
                                                                                      Critical




                                                                                                                                                                                                               Critical
                                                                                                                               High
                                                                                                                                         application projects (e.g., gypsy moth cooperative
                                                                                                                                         suppression projects); periodically query, review
                                                                                                                                         and report any trends
                   Lack of safety awareness and need to further                                                                          Encourage initiatives through the Aerial Application


                                                                                      Catastrophic
                   develop safety culture within state and federal                                                                       Safety Council that foster interagency safety
                                                                         Probable




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
                   agencies                                                                                                              awareness (e.g., through training, presentations at


                                                                                                                               High
                                                                                                                                         annual meetings, close coordination with other
                                                                                                                                         state and federal aviation staffs)

                   Lack of (or minimal) interagency coordination                                                                         Host annual interagency coordination meetings
                                                                                      Catastrophic Catastrophic Catastrophic
                                                                         Occasional




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
                   on aerial application projects that span private,                                                                     (e.g., Gypsy Moth Program Managers Meeting
                                                                                                                               High


                   state, and federal lands                                                                                              includes all state and federal agencies involved
                                                                                                                                         with gypsy moth)

Contracting                                                                                                                              Include expert aviation and pest management
                                                                         Occasional




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
                                                                                                                                         personnel as COTRs during contract development
                                                                                                                               High




                   CO, COR/COTR turnover leading to lack of
                                                                                                                                         and administration; train and mentor new
                   mission understanding and shortage of
                                                                                                                                         employees (future CORs, COTRs)
                   personnel performing oversight
                   Short time frame from contract advertising to                                                                         Begin drafting contract early enough to ensure that
                                                                         Occasional




                                                                                                                                                                                                                          Medium
                                                                                                                                                                                                  Remote


                                                                                                                                                                                                               Critical
                   implementation (impacts operating season,                                                                             a quality contract has been developed, draw
                                                                                                                               High




                   quality of contract, limits desirable/qualified                                                                       highest number of qualified bidders possible
                   bidders and awarded contractor readiness)




 40
System: FHP Aerial Application - Technology (Hardware/Software)
                                                                  Pre Mitigation                                                                 Mitigation                         Post Mitigation




                                                                                                                                                                                                                                       Achieved?
Sub-systems    Hazards




                                                                                                                                                                                                                                       Mitigation




                                                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                                                       Yes or No
                                                                    Likelihood




                                                                                                                                                                                      Likelihood
                                                                                                                  Outcome




                                                                                                                                                                                                                             Outcome
                                                                                          Severity




                                                                                                                                                                                                   Severity




                                                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                                                     Post
                                                                                                                                                                                                                                                    Additional Local Mitigation


AFF            Typically not used in application projects,                                                                  Utilize observation aircraft to monitor operations




                                                                                          Catastrophic




                                                                                                                                                                                                   Negligible Catastrophic
                                                                    Frequent




                                                                                                                                                                                      Remote




                                                                                                                                                                                                                             Serious
               dispatch centers do not have visual display of                                                               and alert other aircraft that may approach project




                                                                                                                  High
               application aircraft relative to other aviation                                                              area, consider including AFF requirement in state
               operations                                                                                                   and agency contracts
               Possible AFF antenna conflicts with other                                                                    Maintain separation between antenna per




                                                                                                                                                                                      Improbable
                                                                                                                  Medium
                                                                    Remote


                                                                                          Critical
               antenna on aircraft                                                                                          manufacturer, check that AFF is working prior to




                                                                                                                                                                                                                             Low
                                                                                                                            take off

               When in use AFF may lead to a false sense of                                                                 Be aware that all aircraft are not visible to flight




                                                                                          Catastrophic
                                                                    Occasional
               security if user thinks dispatch always knows                                                                following personnel (not everyone uses AFF) and




                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote


                                                                                                                                                                                                   Critical
                                                                                                                  High
               location OR if dispatch thinks all aircraft are                                                              that AFF is not "air traffic control" (intended to
               visible                                                                                                      augment radio communication); maintain positive
                                                                                                                            radio communication at all times
               AFF system failure in aircraft or on ground at                                                               Always maintain positive radio communication,




                                                                                                   Catastrophic
                                                                             Occasional
               computer                                                                                                     radio checks/position reports are still required (may




                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote


                                                                                                                                                                                                   Critical
                                                                                                                  High
                                                                                                                            be at greater time interval, 30 minute checks
                                                                                                                            instead of 15 minute) per communications plan

Aircraft GPS   Application aircraft flying in wrong area and/or                                                             State and agency contracts require all application
               misapplication of pesticide                          Occasional
                                                                                                                            aircraft have panel-mounted aerial application GPS
                                                                                                                            (limitations are called out in the contract: able to




                                                                                                                                                                                                   Marginal


                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote
                                                                                                                  Serious
                                                                                          Critical                          update location 5 times per second, upload
                                                                                                                            shapefile of treatment blocks, download flight files,
                                                                                                                            etc...); contract requires application aircraft to
                                                                                                                            return to base if GPS malfunction
               Observation aircraft unable accurately                                                                       State and agency contracts require all observation
                                                                    Occasional




                                                                                                                                                                                                   Marginal


                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote
                                                                                                                  Serious
                                                                                          Critical




               navigate to specific treatment area(s)                                                                       aircraft have at a minimum handheld GPS and
                                                                                                                            "...conveniently located for the pilot"


               Inexperienced users pay too much attention to                                                                Contract requires that application pilots must
                                                                                          Catastrophic




                                                                                                                                                                                                   Catastrophic
                                                                    Frequent




                                                                                                                                                                                      Remote




                                                                                                                                                                                                                             Serious
               GPS (head in cockpit) rather than flying the                                                                 demonstrate GPS proficiency (examples of flight
                                                                                                                  High




               mission                                                                                                      files working in similar operations)


               Cockpit clutter/loose equipment in observation                                                               Properly mount antenna, stow handheld GPS and
                                                                    Occasional




               aircraft (handheld GPS with wires for power                                                                  cables so as not to interfere with flight or utilize
                                                                                          Marginal




                                                                                                                                                                                                   Marginal
                                                                                                                  Medium




                                                                                                                                                                                                                             Medium
                                                                                                                                                                                      Remote
               and external antenna)                                                                                        yoke-mounted GPS (if fitted for yoke-mounted
                                                                                                                            GPS and unit is not in use, remove any protruding
                                                                                                                            brackets that may cause injury)




41
System: FHP Aerial Application - Technology (Hardware/Software - cont.)
                                                                   Pre Mitigation                                                                             Mitigation                          Post Mitigation




                                                                                                                                                                                                                                                                                                                       Achieved?
Sub-systems   Hazards




                                                                                                                                                                                                                                                                                                                       Mitigation

                                                                                                                                                                                                                                                                                                                       Yes or No




                                                                                                                                                                                                                                                                                                                                                                  Mitigation
                                                                     Likelihood




                                                                                                                                                                                                     Likelihood
                                                                                                                          Outcome




                                                                                                                                                                                                                                                                                                       Outcome
                                                                                                  Severity




                                                                                                                                                                                                                                                                    Severity




                                                                                                                                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                                                                                                                                     Post
                                                                                                                                                                                                                                                                                                                                    Additional Local Mitigation


Radios        No repeater available in project area                                                                                      Test frequencies and set up portable repeaters if




                                                                                                  Catastrophic




                                                                                                                                                                                                                                                                     Catastrophic
                                                                     Occasional
                                                                                                                                         necessary; communication plan requires backup




                                                                                                                                                                                                     Remote




                                                                                                                                                                                                                                                                                                       Serious
                                                                                                                          High
                                                                                                                                         communication by cell phone or satellite phone if
                                                                                                                                         necessary; in federal plans/suggest requiring in
                                                                                                                                         state plans
              No communications (in general) air-to-ground,                                                                              FAA requires ability to communicate with general




                                                                                                  Marginal




                                                                                                                                                                                                                                                                     Marginal
                                                                                                                          Medium




                                                                                                                                                                                                                                                                                                       Medium
                                                                     Remote




                                                                                                                                                                                                     Remote
              with other aircraft or dispatch centers                                                                                    aviation aircraft; contracts include necessary radio
                                                                                                                                         specifications; communications plan lists
                                                                                                                                         frequencies
              Inaccessible radios/controls, difficult to operate                                                                         Break from flight pattern to access radio and make




                                                                     Improbable




                                                                                                                                                                                                    Improbable Remote Improbable Occasional Occasional Improbable


                                                                                                                                                                                                                                                                     Negligible
                                                                                                  Marginal
                                                                                                                                         adjustments




                                                                                                                          Low




                                                                                                                                                                                                                                                                                                       Low
              P-25 Digital, Analog & Narrow Banding                                                                                      Identify issues prior to contract and operation, radio




                                                                     Probable


                                                                                                  Marginal




                                                                                                                                                                                                                                                                     Marginal


                                                                                                                                                                                                                                                                                                       Medium
                                                                                                                          Serious
              compatibility issues                                                                                                       check prior to project implementation - address in
                                                                                                                                         communication plan; provide time and training on
                                                                                                                                         new equipment
              Portable radios - not secure, controls easily                                                                              Secure and properly place portables so as not to




                                                                                                  Marginal




                                                                                                                                                                                                                                                                     Marginal
                                                                                                                          Medium




                                                                                                                                                                                                                                                                                                       Medium
                                                                     Remote
              bumped                                                                                                                     interfere with aircraft operations, use
                                                                                                                                         keypad/control locks

              Panel mounted radios - bump controls                                                                                       Use keypad/control locks
                                                                     Remote Probable Improbable




                                                                                                                                                                                                                                                                    Catastrophic Marginal Negligible
                                                                                                  Marginal

                                                                                                                          Medium




                                                                                                                                                                                                                                                                                                       Low
              Flight crew unfamiliar with components                                                                                     Preflight to include familiarization & programming
                                                                                                  Catastrophic Marginal




                                                                                                                                                                                                                                                                                                       Medium Medium
                                                                                                                          High Serious


                                                                                                                                         radios


TCAS          If not using TCAS: potential for midair collision                                                                          Use TCAS, continue practice of "see and avoid",
                                                                                                                                         apply CRM
                                                                     Occasional

                                                                                                  Catastrophic




                                                                                                                                                                                                                                                                    Catastrophic

                                                                                                                                                                                                                                                                                                       Serious
                                                                                                                          High




                                                                                                                                                                                                    Remote
              If using TCAS: false sense of security that all                                                                            Recognize that all other aircraft may not have
              other aircraft have functioning transponders                                                                               functioning transponders, continue practice of "see
                                                                                                                                         and avoid", apply CRM
                                                                     Occasional

                                                                                                  Catastrophic




                                                                                                                                                                                                                                                                    Catastrophic

                                                                                                                                                                                                                                                                                                       Serious
                                                                                                                          High




                                                                                                                                                                                                    Remote
              If using TCAS: Signal interference, antenna                                                                                Follow manufacturer's installation requirements
              positioned too close to other antennas




42
System: FHP Aerial Application - Technology (Hardware/Software - cont.)
                                                                Pre Mitigation                                                         Mitigation                         Post Mitigation




                                                                                                                                                                                                                  Achieved?
Sub-systems       Hazards




                                                                                                                                                                                                                  Mitigation

                                                                                                                                                                                                                  Yes or No




                                                                                                                                                                                                                                                             Mitigation
                                                                  Likelihood




                                                                                                                                                                            Likelihood
                                                                                                         Outcome




                                                                                                                                                                                                        Outcome
                                                                                          Severity




                                                                                                                                                                                         Severity




                                                                                                                                                                                                                                                               Value
                                                                                                                                                                                                                                                                Post
                                                                                                                                                                                                                               Additional Local Mitigation


Pesticide        Atomizer blades detaching and impacting                                                           Contract requires that rotary atomizer must be




                                                                                          Catastrophic




                                                                                                                                                                                         Catastrophic
Delivery Systems fuselage, rotor, or ground                                                                        installed in strict accordance to manufacturers




                                                                  Occasional




                                                                                                                                                                            Remote




                                                                                                                                                                                                        Serious
                                                                                                                   recommendations. All atomizers must be serviced




                                                                                                         High
                                                                                                                   and in good working condition. Agency and state
                                                                                                                   program managers inspect nozzles prior to project
                                                                                                                   implementation
                  Emergency dump valve malfunction causing                                                         Inspect and assure functioning dump valves for




                                                                  Occasional Occasional


                                                                                          Marginal




                                                                                                                                                                                         Marginal
                                                                                                         Medium




                                                                                                                                                                                                        Medium
                                                                                                                                                                            Remote
                  load to dump (misapplication of pesticide)                                                       helicopter & fixed-wing


                  Hose to nozzle detaching, pesticide                                                              Preflight inspection to include examining pesticide




                                                                                          Marginal




                                                                                                                                                                                         Marginal
                                                                                                         Medium




                                                                                                                                                                                                        Medium
                                                                                                                                                                            Remote
                  misapplication (not aviation hazard)                                                             delivery components


                  Inability to jettison in event of emergency                                                      Inspect and assure functioning dump valves for




                                                                                          Catastrophic




                                                                                                                                                                                         Catastrophic
                                                                  Remote




                                                                                                                                                                            Remote
                                                                                                         Serious




                                                                                                                                                                                                        Serious
                                                                                                                   helicopter & fixed-wing



                  Improper pesticide application rate                                                              Agency and state contracts specify all aircraft must
                                                                  Occasional


                                                                                          Marginal




                                                                                                                                                                                         Marginal
                                                                                                         Medium




                                                                                                                                                                                                        Medium
                                                                                                                                                                            Remote
                                                                                                                   be equipped with an electronic flow metering
                                                                                                                   system and delivery system must be calibrated
                                                                                                                   prior to project implementation




43
System: FHP Aerial Photography - Aircraft
                                                                      Pre Mitigation                                                                           Post Mitigation
Sub-systems         Hazards




                                                                                                                                                                                                    Achieved?
                                                                                                                                                                                                    Mitigation

                                                                                                                                                                                                    Yes or No




                                                                                                                                                                                                                                               Mitigation
                                                                     Likelihood




                                                                                                                                                                Likelihood
                                                                                                 Outcome




                                                                                                                                                                                          Outcome
                                                                                  Severity




                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                 Value
                                                                                                                                 Mitigation




                                                                                                                                                                                                                                                  Post
                                                                                                                                                                                                                 Additional Local Mitigation


Avionics (for       Unplanned avionics failures (overheating,                                              Have portable radio/handheld as back up, users




                                                                     Occasional
radios see          faulty wiring, etc.)                                                                   prepared to use alternate frequencies (guard),




                                                                                  Marginal




                                                                                                                                                                             Marginal
                                                                                                 Medium




                                                                                                                                                                                          Medium
                                                                                                                                                                Remote
"Technology"                                                                                               land and repair or use alternate aircraft
tab)

                    Loss of emergency locator ability (analog ELT                                          Switch to 406 MHz digital ELT systems before




                                                                                                                                                                Improbable

                                                                                                                                                                             Negligible
                                                                                  Marginal

                                                                                                 Medium
                                                                     Remote
                    systems will be discontinued)                                                          February 1, 2009




                                                                                                                                                                                          Low
Configuration       Window configuration - poor visibility of                                              Consider aircraft with better visibility




                                                                     Occasional




                                                                                                                                                                Occasional

                                                                                                                                                                             Negligible
                                                                                  Marginal

                                                                                                 Medium
                    hazards in certain models




                                                                                                                                                                                          Low
                    If non-pressurized aircraft operating at high                                          Use pressurized aircraft



                                                                     Occasional


                                                                                  Negligible




                                                                                                                                                                             Negligible
                    altitude, encumbrance caused by




                                                                                                                                                                Remote
                                                                                                 Low




                                                                                                                                                                                          Low
                    canulas/mask/hose


                    Insufficient work space, inability to use                                              None


                                                                                                 Medium




                                                                                                                                                                                          Medium
                                                                     Remote




                                                                                                                                                                Remote
                                                                                  Critical




                                                                                                                                                                             Critical
                    seatbelts during photo mission


                    Open camera port in belly - cold, fatigue                                              Wear warm clothes, fly fewer hours to avoid
                                                                     Occasional




                                                                                                                                                                             Negligible
                                                                                  Marginal




                                                                                                           fatigue or use aircraft with sealed port (such as
                                                                                                 Medium




                                                                                                                                                                Remote




                                                                                                                                                                                          Low
                                                                                                           King Air)


                    Open camera port in belly - loosing items                                              Secure items, keep from port or use aircraft with
                                                                     Occasional


                                                                                  Marginal




                                                                                                                                                                             Marginal
                                                                                                           sealed port (such as King Air)
                                                                                                 Medium




                                                                                                                                                                                          Medium
                                                                                                                                                                Remote
Terrorist or       Theft or damage to aircraft or gear &                                                   Adhere to Project Aviation Safety and Security
                                                                                  Catastrophic




malicious activity equipment (remote , unsecured overnight                                                 Plans; remove valuable equipment if overnight




                                                                                                                                                                                          Medium
                                                                     Remote




                                                                                                                                                                Remote
                                                                                                 Serious




                                                                                                                                                                             Critical
                   parking, risk to aircraft, personnel … theft or                                         parking, use prop lock and fuel lock
                   damage to aircraft and equipment… threat to
                   public safety.)




  44
System: FHP Aerial Photography - Aircraft (cont.)
                                                                       Pre Mitigation                                                                            Post Mitigation
Sub-systems         Hazards




                                                                                                                                                                                                        Achieved?
                                                                                                                                                                                                        Mitigation




                                                                                                                                                                                                                                                   Mitigation
                                                                                                                                                                                                        Yes or No
                                                                      Likelihood




                                                                                                                                                                  Likelihood
                                                                                                  Outcome




                                                                                                                                                                                              Outcome
                                                                                   Severity




                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                     Value
                                                                                                                                                                                                                                                      Post
                                                                                                                                Mitigation
                                                                                                                                                                                                                     Additional Local Mitigation


Performance         High density altitude operations                                                        Project Aviation Safety Plan and contract to




                                                                                   Catastrophic




                                                                                                                                                                  Improbable
Standards -                                                                                                 address minimum requirements, reference




                                                                                                                                                                                              Medium
                                                                      Remote




                                                                                                  Serious




                                                                                                                                                                               Critical
mountainous                                                                                                 Airman's Information Manual (AIM) for
terrain                                                                                                     mountainous terrain.

                    Insufficient Horsepower                                                                 Project Aviation safety plan & contract to address




                                                                                   Catastrophic
                                                                      Occasional
                                                                                                            minimum requirements, reference local unit




                                                                                                                                                                                              Medium
                                                                                                                                                                  Remote

                                                                                                                                                                               Critical
                                                                                                  High
                                                                                                            Aviation Plan if operating out of area


                    Insufficient payload capabilities - camera type                                         Match machine to task, perform weight and




                                                                                                                                                                  Improbable
                                                                      Probable




                                                                                                                                                                                              Medium
                    mismatch to platform, overnight gear                                                    balance calculation, reduce load




                                                                                   Critical




                                                                                                                                                                               Critical
                                                                                                  High
Contract Aircraft                                                                                           Conduct thorough market analysis and solicitation,




                                                                                                                                                                  Occasional
                                                                      Probable




                                                                                                                                                                               Marginal
                                                                                                            request performance history, require Part 135




                                                                                                                                                                                              Medium
                                                                                   Critical

                                                                                                  High
                    Many contract aircraft not configured for
                    equipment or experienced with mission type (if
                    turn-key, very expensive)
                    Aging aircraft                                                                          Consider aircraft health monitoring program to




                                                                                                                                                                  Occasional
                                                                                                            include strain gauge, oil analysis, special
                                                                      Probable


                                                                                   Marginal




                                                                                                                                                                               Marginal

                                                                                                                                                                                              Medium
                                                                                                  Serious
                                                                                                            inspection program



WCF (fleet)         Identifiable as agency aircraft may encourage                                           Utilize secure overnight parking if available
                                                                                   Catastrophic




                                                                                                                                                                               Catastrophic
Aircraft            vandalism
                                                                      Remote




                                                                                                                                                                  Remote
                                                                                                  Serious




                                                                                                                                                                                              Serious
                    Most agency pilots have tendency to lack                                                Establish mentoring program for photo pilots,




                                                                                                                                                                  Occasional
                                                                      Probable


                                                                                   Marginal




                                                                                                                                                                               Marginal
                    experience with mission type, not dedicated to                                          performance plan addresses support to other




                                                                                                                                                                                              Medium
                                                                                                  Serious




                    photography work                                                                        aviation functions (e.g., fire & photo)


                    Very few photo-capable aircraft in agency                                               Conduct thorough market research and consider




                                                                                                                                                                  Occasional
                                                                      Probable


                                                                                   Marginal




                                                                                                                                                                               Marginal
                    fleet, increases likelihood of contracting                                              best value for contracting if no agency available




                                                                                                                                                                                              Medium
                                                                                                  Serious




                    minimally skilled pilots/poor performing
                    aircraft through contracting

                    Aging aircraft                                                                          Consider aircraft health monitoring program to


                                                                                                                                                                  Occasional
                                                                                                            include strain gauge, oil analysis, special
                                                                      Probable


                                                                                   Marginal




                                                                                                                                                                               Marginal

                                                                                                                                                                                              Medium
                                                                                                  Serious




                                                                                                            inspection program (FHTET King Air '74, SPO
                                                                                                            Beavers '59-'64, DFO C206 newer)




 45
System: FHP Aerial Photography - Aircraft (cont.)
                                                                  Pre Mitigation                                                                             Post Mitigation
Sub-systems    Hazards




                                                                                                                                                                                                          Achieved?
                                                                                                                                                                                                          Mitigation

                                                                                                                                                                                                          Yes or No




                                                                                                                                                                                                                                                     Mitigation
                                                                 Likelihood




                                                                                                                                                              Likelihood
                                                                                             Outcome




                                                                                                                                                                                              Outcome
                                                                              Severity




                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                       Value
                                                                                                                            Mitigation




                                                                                                                                                                                                                                                        Post
                                                                                                                                                                                                                       Additional Local Mitigation


Fuel           Bad fuel                                                                                Ensure fuel is tested for type and quality prior to




                                                                 Occasional




                                                                                                                                                                                                 Medium
                                                                                                                                                                     Remote
                                                                                             Serious
                                                                                                       fueling




                                                                              Critical




                                                                                                                                                                                   Critical
               Starvation                                                                              Monitor quantity pumped during fueling, monitor




                                                                              Catastrophic
                                                                 Occasional
                                                                                                       flight time and distance to services




                                                                                                                                                                                                 Medium
                                                                                                                                                                     Remote

                                                                                                                                                                                   Critical
                                                                                             High
Availability   Lack of back up aircraft in event preferred                                             R8 has two configured King Airs for back up




                                                                              Negligible




                                                                                                                                                                              Negligible
                                                                 Remote




                                                                                                                                                              Remote
               aircraft unavailable (scrambling to find




                                                                                             Low




                                                                                                                                                                                              Low
               suitable substitute or settling for less than
               optimum)
               Minimal availability of photo platforms leading                                         Adhere to flight duty limitations




                                                                              Negligible




                                                                                                                                                                              Negligible
                                                                 Remote




                                                                                                                                                              Remote
               to maximizing flight hours with those




                                                                                             Low




                                                                                                                                                                                              Low
               aircraft/pilots that are available


               Sharing aviation assets (non-local pilot                                                R8 has two configured King Airs for back up

                                                                              Negligible




                                                                                                                                                                              Negligible
                                                                 Remote




                                                                                                                                                              Remote
               unfamiliar with area, photographer unfamiliar


                                                                                             Low




                                                                                                                                                                                              Low
               with pilot and aircraft)


               Not sharing aviation assets (overworking a
                                                                              Negligible




                                                                                                                                                                              Negligible
                                                                 Remote




                                                                                                                                                              Remote
               single asset)
                                                                                                       Utilize other aircraft equipped with camera hole
                                                                                             Low




                                                                                                                                                                                              Low
                                                                                                       (however, others are prioritized for fire... fire
                                                                                                       season and photo season overlap)




 46
System: FHP Aerial Photography - Environmental
                                                                Pre Mitigation                                                                              Post Mitigation
Sub-systems   Hazards




                                                                                                                                                                                                   Achieved?
                                                                                                                                                                                                   Mitigation




                                                                                                                                                                                                                                              Mitigation
                                                                                                                                                                                                   Yes or No
                                                               Likelihood




                                                                                                                                                             Likelihood
                                                                                           Outcome




                                                                                                                                                                                         Outcome
                                                                            Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                                Value
                                                                                                                                                                                                                                                 Post
                                                                                                                         Mitigation
                                                                                                                                                                                                                Additional Local Mitigation


Weather       Working in less-than-optimum conditions in                                             Preflight briefing to include unacceptable




                                                               Occasional




                                                                                                                                                                                         Medium
                                                                                                                                                             Remote
                                                                                           Serious
              order to take advantage of preferred sun                                               conditions for safe photography




                                                                            Critical




                                                                                                                                                                          Critical
              angles


              Lack of visibility - smoke, haze                                                       Maintain VFR, establish good communication




                                                                            Catastrophic




                                                                                                                                                                          Catastrophic
                                                                                                     w/air attack, remain outside of FTA/TFR w/out




                                                               Probable




                                                                                                                                                             Remote




                                                                                                                                                                                         Serious
                                                                                           High
                                                                                                     permission, practice see & avoid



              High winds                                                                             Abort mission until more favorable wind conditions




                                                               Frequent




                                                                                                                                                                          Marginal

                                                                                                                                                                                         Medium
                                                                                                                                                             Remote
                                                                            Critical

                                                                                           High
              IFR conditions take off/landing, ferry                                                 Stay on ground or use twin engine/IFR qualified




                                                                                                                                                                          Catastrophic
                                                                            Negligible
                                                               Probable




                                                                                           Medium




                                                                                                                                                             Remote




                                                                                                                                                                                         Serious
              Sudden changes in weather, unexpected                         Negligible
                                                                                                     Preflight weather briefing, maintain VFR




                                                                                                                                                                          Negligible
                                                               Remote




                                                                                                                                                             Remote
              extreme conditions
                                                                                           Low




                                                                                                                                                                                         Low
              Lack of visibility - fog                                                               Maintain VFR, continuously monitor conditions,




                                                                                                                                                                          Catastrophic
                                                                                                     have contingency plans for alternate
                                                               Probable




                                                                                                                                                             Remote




                                                                                                                                                                                         Serious
                                                                            Critical

                                                                                           High




                                                                                                     airports/survey areas, consider utilizing twin
                                                                                                     engine aircraft in project areas w/strong likelihood
                                                                                                     of fog during take-off/landings.
              Lack of visibility during IFR take off/landing                                         Pilot maintain IFR currency, abort mission until
                                                                            Catastrophic




              (OK for twin engine only)                                                              conditions improve.




                                                                                                                                                                                         Medium
                                                               Remote




                                                                                                                                                             Remote
                                                                                           Serious




                                                                                                                                                                          Critical
              Marginal VFR (having to avoid scud runners)                                            Preflight weather briefing, maintain VFR, see and
                                                                            Catastrophic




                                                                                                     avoid scud runners




                                                                                                                                                                          Negligible
                                                               Remote




                                                                                                                                                             Remote
                                                                                           Serious




                                                                                                                                                                                         Low




 47
System: FHP Aerial Photography - Environmental
                                                                     Pre Mitigation                                                                               Post Mitigation
Sub-systems       Hazards




                                                                                                                                                                                                         Achieved?
                                                                                                                                                                                                         Mitigation




                                                                                                                                                                                                                                                    Mitigation
                                                                                                                                                                                                         Yes or No
                                                                    Likelihood




                                                                                                                                                                   Likelihood
                                                                                                Outcome




                                                                                                                                                                                               Outcome
                                                                                 Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                      Value
                                                                                                                                                                                                                                                       Post
                                                                                                                               Mitigation
                                                                                                                                                                                                                      Additional Local Mitigation


Topography/Hi     Turbulence                                                                              Obtain weather briefings, move to alternate




                                                                    Frequent




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                 Critical




                                                                                                                                                                                Critical
                                                                                                          location or abort mission until more favorable




                                                                                                High
Alt
                                                                                                          weather.

                  Terrain - operating in box canyons (rare, photo                                         Maintain awareness of altitude above terrain, fly




                                                                                                Medium




                                                                                                                                                                                               Medium
                                                                    Remote




                                                                                                                                                                   Remote
                                                                                 Critical




                                                                                                                                                                                Critical
                  mission altitude fixed high above terrain)                                              ridges rather than drainage bottoms


                  High Altitude - density altitude                                                        Obtain weather briefings, review aircraft




                                                                    Frequent




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                 Critical




                                                                                                                                                                                Critical
                                                                                                          performance charts and data or abort mission until




                                                                                                High
                                                                                                          more favorable weather.

                  High Altitude above 18 thousand                                                         Mission planning, IFR clearance, working with IFR




                                                                    Frequent




                                                                                                                                                                   Frequent
                                                                                 Marginal




                                                                                                                                                                                Marginal
                                                                                                Serious




                                                                                                                                                                                               Serious
                                                                                                          traffic


                  Large scale photography/closer to terrain                                               change lens or camera


                                                                    Frequent




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                 Critical




                                                                                                                                                                                Critical
                                                                                                High
Minimal        Increased probability of encountering aerial                                               Address in safety briefing, consider TCAS,
                                                                                 Catastrophic




                                                                                                                                                                                Catastrophic
                                                                                                                                                                   Occasional
                                                                    Probable

Topography/Low hazards in areas with minimal topography                                                   practice see and avoid

                                                                                                High




                                                                                                                                                                                               High
Alt


Remote areas      lack of communications                                                                  Utilize AFF, know and use local repeaters (guard
                                                                                 Catastrophic




                                                                                                                                                                                Catastrophic
                                                                    Probable




                                                                                                          in emergency), possibly carry satellite phone




                                                                                                                                                                   Remote




                                                                                                                                                                                               Serious
                                                                                                High




                  Search and Rescue - delayed response within                                             UtilizeAFF, carry aircraft and personal survival
                                                                                 Catastrophic




                                                                                                                                                                   Occasional
                  critical period                                                                         gear, handheld radio/know frequencies, satellite
                                                                    Probable




                                                                                                                                                                                               Serious
                                                                                                                                                                                Critical
                                                                                                          phone
                                                                                                High




                  Fuel availability                                                                       Ensure mission planning includes fuel resources
                                                                    Occasional


                                                                                 Marginal




                                                                                                                                                                                Marginal
                                                                                                Medium




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                                          (call ahead), considers ferry distance/time, monitor
                                                                                                          flight time & distance to fuel location during flight


                  Oxygen availability to aircraft (if using non                                           Ensure mission planning includes oxygen
                                                                    Occasional


                                                                                 Marginal




                                                                                                                                                                                Marginal
                                                                                                Medium




                                                                                                                                                                                               Medium
                  pressurized aircraft)                                                                   resources (call ahead) & ferry distance/time,

                                                                                                                                                                   Remote
                                                                                                          monitor flight time & distance to location or if not
                                                                                                          available, spend less time at high elevations




 48
System: FHP Aerial Photography - Environmental (cont.)
                                                                     Pre Mitigation                                                                               Post Mitigation
Sub-systems        Hazards




                                                                                                                                                                                                         Achieved?
                                                                                                                                                                                                         Mitigation




                                                                                                                                                                                                                                                    Mitigation
                                                                                                                                                                                                         Yes or No
                                                                    Likelihood




                                                                                                                                                                   Likelihood
                                                                                                Outcome




                                                                                                                                                                                               Outcome
                                                                                 Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                      Value
                                                                                                                                                                                                                                                       Post
                                                                                                                                Mitigation
                                                                                                                                                                                                                      Additional Local Mitigation


Urgent             Forcing timing of flights to meet photo needs                                          Utilize additional assets to complete survey or




                                                                                 Catastrophic
Photography        rather than safety                                                                     prioritize high interest areas & complete first, it's




                                                                    Probable




                                                                                                                                                                                Marginal

                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
(Pest Signature,                                                                                          okay not to finish




                                                                                                High
Fall Colors,
Fire/Other
Damage)
Water              Amphibious aircraft landing on water with gear                                         Use pilot check list, confirm gear up… (typically




                                                                                 Catastrophic




                                                                                                                                                                                Catastrophic
                                                                                                                                                                   Improbable
                                                                    Occasional
                   down                                                                                   not using amphibious aircraft for photo missions)




                                                                                                                                                                                               Medium
                                                                                                High
                   Amphibious aircraft landing on land with gear                                          Use pilot checklist, confirm gear down… (typically




                                                                                                                                                                                Catastrophic
                                                                                                                                                                   Improbable
                                                                    Occasional
                   up                                                                                     not using amphibious aircraft for photo missions)




                                                                                                                                                                                               Medium
                                                                                                Serious
                                                                                 Critical
                   Poor depth perception to surface of water                                              Be aware during hazy conditions or dead-calm,

                                                                    Occasional




                                                                                                                                                                                Marginal
                   during landing                                                                         more difficult to see water surface; Use




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote
                                                                                                Serious
                                                                                 Critical
                                                                                                          experienced pilots, scan for water surface
                                                                                                          irregularities (wind, wake, fish, etc

                   Ill-equipped with survival gear and beyond                                             Carry survival/mustang suits cold water, PFDs
                                                                                 Catastrophic
                                                                    Occasional




                   glide distance to shore




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote

                                                                                                                                                                                Critical
                                                                                                High




                   Difficulty exiting aircraft after ditching or                                          Attending water ditching course, consider adding
                                                                                 Catastrophic




                   crashing in water                                                                      area-specific currency requirement in task book
                                                                    Probable




                                                                                                                                                                                               Medium
                                                                                                                                                                   Remote

                                                                                                                                                                                Critical
                                                                                                High




                                                                                                          (alternatively, other companies and universities
                                                                                                          offer)


                   Other watercraft & recreational users                                                  Pilot/crew increase SA (watch for fishermen,
                                                                                                          swimmers, jet skis, canoes, etc. speed boats can
                                                                                 Catastrophic




                                                                                                                                                                                Catastrophic
                                                                    Occasional




                                                                                                                                                                   Remote




                                                                                                                                                                                               Serious
                                                                                                          become a hazard quickly...), no radio
                                                                                                High




                                                                                                          communication with these hazards; make
                                                                                                          reconnaissance pass prior to landing and search
                                                                                                          for watercraft/other users
                   Turbidity - subsurface obstructions obscured                                           Utilize pilots experienced with local waters;
                                                                                 Catastrophic




                                                                                                                                                                                Catastrophic
                                                                                                          acquire local knowledge if operating away from
                                                                    Probable




                                                                                                                                                                   Remote




                                                                                                                                                                                               Serious
                                                                                                High




                                                                                                          familiar areas, check with dispatch; emergency
                                                                                                          landing only in unfamiliar waters


                   River current                                                                          Landing typically into wind and may be up or down
                                                                    Occasional




                                                                                                                                                                   Occasional

                                                                                                                                                                                Marginal

                                                                                                                                                                                               Medium
                                                                                                          stream, dock upstream
                                                                                                Serious
                                                                                 Critical




                   Floating debris                                                                        Be aware not all floating debris may be visible on
                                                                                 Catastrophic




                                                                                                                                                                   Occasional




                                                                                                          surface; Increase situational awareness… make
                                                                    Probable




                                                                                                                                                                                Marginal

                                                                                                                                                                                               Medium
                                                                                                High




                                                                                                          reconnaissance pass prior to landing, all flight
                                                                                                          crew search for hazards




 49
System: FHP Aerial Photography - Environmental (cont.)
                                                                  Pre Mitigation                                                                                Post Mitigation
Sub-systems   Hazards




                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                       Mitigation




                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                       Yes or No
                                                                 Likelihood




                                                                                                                                                                 Likelihood
                                                                                             Outcome




                                                                                                                                                                                             Outcome
                                                                              Severity




                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                     Post
                                                                                                                            Mitigation
                                                                                                                                                                                                                    Additional Local Mitigation


Airspace      Working within active MTR, MOA, warning                                                  Call ATC/military agency (possibly flight service




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
              areas                                                                                    station, less reliable) to determine "hot" or not, see




                                                                 Probable




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                             High
                                                                                                       and avoid, request deconfliction through dispatch



              Working in proximity to or within FTA/TFR                                                Maintain VFR, establish good communication




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                       w/air attack, remain outside of FTA/TFR w/out




                                                                 Probable




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                             High
                                                                                                       permission, practice see & avoid



              Working within restricted (military,                                                     Check TFRs daily, know intercept procedures,




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
              presidential, nuclear, etc.)                                                             Call ATC/ military agency to gain permission,




                                                                 Remote




                                                                                                                                                                 Remote
                                                                                             Serious




                                                                                                                                                                                             Serious
                                                                                                       determine if any other activity



              Grid & altitude is fixed and within high traffic                                         Comm. w/ATC… pilot & photographer to be extra




                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
              or controlled airspace                                                                   vigilant in scanning for other aircraft & hazards
                                                                 Occasional




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                                       while flying in a fixed patter (maintain SA, pilot to




                                                                                             High
                                                                                                       avoid inordinate focus on following
                                                                                                       GPS/photographer on operating camera)

              All B, C, D Class                                                                        Mission planning, requesting prior permission from
                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                                                       controlling tower & conducting mission during
                                                                 Frequent




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                             High
                                                                                                       minimal traffic times



              Risk of mid-air IFR altitudes (>18,000')                                                 Mission planning, IFR flight plan, comm. w/ATC
                                                                              Catastrophic




                                                                                                                                                                              Catastrophic
                                                                 Occasional




                                                                                                                                                                 Remote
                                                                                             Serious




                                                                                                                                                                                             Serious




 50
System: FHP Aerial Photography - Environmental (cont.)
                                                                    Pre Mitigation                                                                            Post Mitigation
Sub-systems       Hazards




                                                                                                                                                                                                     Achieved?
                                                                                                                                                                                                     Mitigation




                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                     Yes or No
                                                                   Likelihood




                                                                                                                                                               Likelihood
                                                                                               Outcome




                                                                                                                                                                                           Outcome
                                                                                Severity




                                                                                                                                                                            Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                   Post
                                                                                                                              Mitigation
                                                                                                                                                                                                                  Additional Local Mitigation


Airstrip          No alternative or suitable landing location                                            Premission planning to maintain options, call




                                                                                                                                                               Occasional

                                                                                                                                                                            Negligible
Availability,     (surface condition, environmental limitations)                                         ahead to check on runway condition, check




                                                                                               Medium
                                                                   Remote


                                                                                Critical




                                                                                                                                                                                           Low
Condition and                                                                                            NOTAM
Services

                  No fuel source                                                                         Call ahead to check availability of fuel




                                                                   Occasional


                                                                                Negligible




                                                                                                                                                                            Negligible
                                                                                                                                                               Remote
                                                                                               Low




                                                                                                                                                                                           Low
                  One-way landing - wind, terrain                                                        Premission planning for terrain/fixed approach,




                                                                                Catastrophic




                                                                                                                                                                            Catastrophic
                                                                                                         plan for alternative airports




                                                                   Probable




                                                                                                                                                               Remote




                                                                                                                                                                                           Serious
                                                                                               High
                  One-way departure - wind, terrain                                                      Premission planning for terrain/fixed departure,




                                                                                Catastrophic




                                                                                                                                                                            Catastrophic
                                                                                                                                                               Improbable
                                                                                                         stay on the ground & wait for favorable conditions

                                                                   Probable




                                                                                                                                                                                           Medium
                                                                                               High
                  No windsock                                                                            Observe ground/water conditions (tree lean, dust,
                                                                   Occasional



                                                                                                         water ripples, etc.)




                                                                                                                                                                                           Medium
                                                                                                                                                               Remote
                                                                                               Serious
                                                                                Critical




                                                                                                                                                                            Critical
                  Prevailing wind may not be favorable to                                                Know prevailing wind premission, use alternate




                                                                                                                                                               Occasional
                                                                   Probable




                  landing/departure                                                                      airport




                                                                                                                                                                                           Serious
                                                                                Critical




                                                                                                                                                                            Critical
                                                                                               High




Animal activity   Areas of high bird activity (flyways, nesting                                          Some areas are marked on sectional charts, local
                                                                   Occasional




                                                                                                                                                                                           Medium
                                                                                                                                                               Remote
                                                                                               Serious
                                                                                Critical




                                                                                                                                                                            Critical
                  areas, etc.)                                                                           knowledge of flyways - incorporate in premission
                                                                                                         planning; see and avoid

                  Survival in hostile wildlife habitat                                                   Stay with the plane, carry appropriate survival
                                                                                Catastrophic




                                                                                                                                                                            Catastrophic
                                                                                                                                                               Improbable
                                                                                                         equipment for survey area/time of year (pepper




                                                                                                                                                                                           Medium
                                                                   Remote




                                                                                               Serious




                                                                                                         spray, fire arm & mitigate carrying such items)



                  Potential for serious injury/aircraft damage                                           Contact ground to clear runway, communicate any
                                                                   Occasional




                                                                                                                                                                            Marginal
                  from wildlife on runway (common at remote                                              observed activity to pilot




                                                                                                                                                                                           Medium
                                                                                                                                                               Remote
                                                                                               Serious
                                                                                Critical




                  and county airports)




 51
System: FHP Aerial Photography - Personnel
                                                                Pre Mitigation                                                                             Post Mitigation
Sub-systems   Hazards




                                                                                                                                                                                                Achieved?
                                                                                                                                                                                                Mitigation




                                                                                                                                                                                                                                           Mitigation
                                                                                                                                                                                                Yes or No
                                                               Likelihood




                                                                                                                                                            Likelihood
                                                                                           Outcome




                                                                                                                                                                                      Outcome
                                                                            Severity




                                                                                                                                                                         Severity




                                                                                                                                                                                                                                             Value
                                                                                                                                                                                                                                              Post
                                                                                                                          Mitigation
                                                                                                                                                                                                             Additional Local Mitigation


Pilot         Minimal local experience                                                               Manager to brief pilot on project and area to be




                                                               Occasional
                                                                                                     photographed, frequencies, hazards, refueling




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                                           Serious
                                                                            Critical




                                                                                                                                                                         Critical
                                                                                                     sites, etc.


              LackJurisdictional/boundry awareness                                                   Premission planning/briefing, utilize digital




                                                               Occasional


                                                                            Negligible




                                                                                                                                                                         Negligible
                                                                                                                                                            Remote
                                                                                                     mapping system information, load backgrounds on




                                                                                           Low




                                                                                                                                                                                      Low
                                                                                                     portable GPS


              Unfamiliar with mission type - carded for                                              Conduct mission-specific flight review/training and




                                                               Frequent




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                            Critical




                                                                                                                                                                         Critical
              reconnaissance/photo but no FHP mission-                                               utilize FHP flight review checklist as required




                                                                                           High
              specific flight review                                                                 (applicable to agency-contracted pilots)

              Unaware of hypoxia effects in event of loss of                                         Recommend hyperbaric chamber training for pilots




                                                               Probable




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                            Critical




                                                                                                                                                                         Critical
              cabin pressure (whether nonpressurized or                                              and crew members/flight managers if program




                                                                                           High
              pressurized aircraft)                                                                  includes high altitude photography

              Minimal flight hours or experience with                                                Thorough preflight briefing to new pilots, utilize




                                                                                                                                                            Occasional
                                                               Probable




                                                                                                                                                                                      Serious
              mission type (varies annually)

                                                                            Critical
                                                                                                     FHP flight review checklist as required




                                                                                                                                                                         Critical
              Inordinate attention to photo mission rather                                 High      Thorough preflight briefing to new pilots,
                                                               Occasional




              than flying                                                                            observer/flight manager let pilot know if becoming




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                                           Serious
                                                                            Critical




                                                                                                                                                                         Critical
                                                                                                     a problem


              Pilots may not have dedication, skills to                                              CRM, discuss comfort level and environmental
                                                               Probable




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                            Critical




                                                                                                                                                                         Critical
              perform mission or may be "pushed" into                                                conditions, adjust flight profile accordingly
                                                                                           High




              uncomfortable situations

              No preflight mission briefing from flight                                              Pilot request thorough briefing, manager provides
                                                               Occasional




                                                                                                                                                                         Marginal
              manager (photo area, profile, objectives,




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                                           Serious
                                                                            Critical




              aerial hazards)


              lack of awareness leading to fuel starvation                                           Proper preflight planning, monitor consumption,
                                                               Occasional




                                                                                                                                                                                      Medium
                                                                                                                                                            Remote
                                                                                                     CRM to include crew observe flight time and fuel
                                                                                           Serious
                                                                            Critical




                                                                                                                                                                         Critical
                                                                                                     gauge; consider fuel totalizer for monitoring
                                                                                                     consumption & reset when fueling

              Has not checked for current NOTAM                                                      Proper preflight planning to include checking
                                                                            Catastrophic




                                                                                                     NOTAMs, CRM to include crew.


                                                                                                                                                                         Negligible
                                                               Remote




                                                                                                                                                            Remote
                                                                                           Serious




                                                                                                                                                                                      Low




  52
     Hazards




                                                                                                                                                                                         Achieved?
                                                                                                                                                                                         Mitigation




                                                                                                                                                                                                                                    Mitigation
                                                                                                                                                                                         Yes or No
                                                      Likelihood




                                                                                                                                                   Likelihood
                                                                                  Outcome




                                                                                                                                                                               Outcome
                                                                   Severity




                                                                                                                                                                Severity




                                                                                                                                                                                                                                      Value
                                                                                                                                                                                                                                       Post
                                                                                                                                                                                                      Additional Local Mitigation


     Incomplete preflight/post flight inspection                                            Take the time necessary to evaluate aircraft




                                                      Occasional




                                                                                                                                                                Marginal

                                                                                                                                                                               Medium
                                                                                                                                                   Remote
                                                                                  Serious
                                                                   Critical
                                                                                            thoroughly, CRM to include crew in inspection &
                                                                                            feel comfortable reporting anomalies


     Self-medicated (could range from a simple                                              All crew to crosscheck how each other is doing,




                                                      Occasional




                                                                                                                                                                               Medium
                                                                                                                                                   Remote
                                                                                  Serious
     cold to serious health issue)                                                          ask if medicated, know FAA regulations pertaining




                                                                   Critical




                                                                                                                                                                Critical
                                                                                            to prescription & over-the-counter medication


     Check list not utilized                                                                Utilize appropriate check lists, CRM to encourage




                                                                                                                                                                Negligible
                                                                                  Medium
                                                      Remote




                                                                                                                                                   Remote
                                                                   Critical
                                                                                            crew ask for check list.




                                                                                                                                                                               Low
     Accepting unreasonable risk (e.g., fixed photo                                         Conduct project-specific risk assessment, job




                                                                   Catastrophic
     transect and proximity to rising terrain)                                              hazard analysis and incorporate into premission




                                                                                                                                                                               Medium
                                                      Remote




                                                                                                                                                   Remote
                                                                                  Serious




                                                                                                                                                                Critical
                                                                                            briefing


     Incapacitated                                                                          Crew/Manager attend pinch hitter




                                                                   Catastrophic




                                                                                                                                                                               Medium
                                                      Remote




                                                                                                                                                   Remote
                                                                                  Serious




                                                                                                                                                                Critical
     Under the influence or hung over                                                       CRM to include awareness of regulations for 8
                                                                   Catastrophic




                                                                                                                                                                Catastrophic
                                                                                                                                                   Improbable
                                                                                            hours no alcohol, BA < .04 - crew to cancel




                                                                                                                                                                               Medium
                                                      Remote




                                                                                  High
                                                                                            mission if in question



     Fatigue, complacency                                                                   10 hours off duty, limit flight day to 8 hrs or less
                                                                   Catastrophic




                                                                                            depending on conditions (usually not prudent to
                                                      Probable




                                                                                                                                                                               Medium
                                                                                                                                                   Remote

                                                                                                                                                                Critical
                                                                                  High




                                                                                            push for full 8-hour flight days)



     Shortage of qualified, skilled pilots                                                  Implement mentoring program
                                                      Probable


                                                                   Marginal




                                                                                                                                                                Marginal

                                                                                                                                                                               Medium
                                                                                                                                                   Remote
                                                                                  Serious




     Gear up landing                                                                        Pilot training including simulation training twice a
                                                                                  Medium




                                                                                                                                                                               Medium
                                                      Remote




                                                                                                                                                   Remote
                                                                   Critical




                                                                                                                                                                Critical
                                                                                            year and aircraft check ride, utilize checklist &
                                                                                            CRM




53
System: FHP Aerial Photography - Personnel (cont.)
                                                                    Pre Mitigation                                                                                Post Mitigation
Sub-systems       Hazards




                                                                                                                                                                                                       Achieved?
                                                                                                                                                                                                       Mitigation




                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                       Yes or No
                                                                   Likelihood




                                                                                                                                                                   Likelihood
                                                                                               Outcome




                                                                                                                                                                                             Outcome
                                                                                Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                     Post
                                                                                                                              Mitigation
                                                                                                                                                                                                                    Additional Local Mitigation


Photographer (or Minimal experience with aircraft                                                        Obtain pilot safety briefing, don't board or egress




                                                                                Catastrophic
                                                                   Occasional
flight manager)                                                                                          w/engine(s) running




                                                                                                                                                                                Marginal

                                                                                                                                                                                             Medium
                                                                                                                                                                   Remote
                                                                                               High
                  Minimal experience with mission type                                                   Utilize Fixed-wing Flight Manager Special-Use




                                                                                                                                                                                Negligible
                                                                   Probable


                                                                                Marginal




                                                                                                                                                                   Remote
                                                                                               Serious
                                                                                                         Task Books (sections relevant to aerial




                                                                                                                                                                                             Low
                                                                                                         photography)

                  Fatigue, complacency                                                                   Consider flying less than 8 hour/ day, CRM




                                                                   Probable


                                                                                Marginal




                                                                                                                                                                                Marginal

                                                                                                                                                                                             Medium
                                                                                                                                                                   Remote
                                                                                               Serious
                  Self-medicated (colds to serious health issue)                                         All crew to crosscheck how each other is doing,




                                                                   Occasional




                                                                                                                                                                                Marginal
                                                                                               Medium




                                                                                                                                                                                             Medium
                                                                                                                                                                   Remote
                                                                                                         ask if medicated, know FAA regulations pertaining




                                                                                Critical
                                                                                                         to prescription & over-the-counter medication


                  Not ensuring pilot checklist used                                                      Practice CRM, assure checks complete
                                                                   Occasional




                                                                                                                                                                                Marginal
                                                                                               Medium




                                                                                                                                                                                             Medium
                                                                                                                                                                   Remote
                                                                                Critical

                  Accepting unreasonable risk in general (refers                                         Participate in project-specific risk assessment, job
                                                                   Occasional




                                                                                                                                                                                Negligible
                                                                                                                                                                   Remote
                  to individual's character and state of mind)                                           hazard analysis and incorporate into permission
                                                                                               Serious
                                                                                Critical




                                                                                                                                                                                             Low
                                                                                                         briefing


                  Lack of mentoring                                                                      Use experienced photographers, keep them




                                                                                                                                                                                Negligible
                                                                                Marginal

                                                                                               Medium
                                                                   Remote




                                                                                                                                                                   Remote
                                                                                                         current; train new people that have interest




                                                                                                                                                                                             Low
                  Not obtaining safety briefing                                                          Photographer/Flight Manager refer to 5 steps to
                                                                                Negligible




                                                                                                                                                                                Negligible
                                                                   Probable




                                                                                               Medium




                                                                                                                                                                   Remote
                                                                                                         safe flight & request safety briefing from pilot




                                                                                                                                                                                             Low
                  Not using CRM                                                                          Involve pilot or crew (as appropriate) during
                                                                                Catastrophic




                                                                                                         project-specific risk assessment, job hazard




                                                                                                                                                                                Marginal

                                                                                                                                                                                             Medium
                                                                   Remote




                                                                                                                                                                   Remote
                                                                                               High




                                                                                                         analysis and incorporate into permission briefing



                  Pressure employees to complete project                                                 Photographer/Flight Manager refer to "5 steps to
                                                                                Catastrophic




                                                                                                                                                                                Negligible
                                                                                                         safe flight" card & request safety briefing from pilot
                                                                   Remote




                                                                                                                                                                   Remote
                                                                                               Serious




                                                                                                                                                                                             Low
                  Lack of qualified photographer/flight manager                                          Cancel mission until rectified
                                                                                Catastrophic




                                                                                                                                                                   Improbable
                                                                   Occasional




                                                                                                                                                                                Negligible
                                                                                               High




                                                                                                                                                                                             Low




 54
System: FHP Aerial Photography - Personnel (cont.)
                                                                    Pre Mitigation                                                                          Post Mitigation
Sub-systems      Hazards




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation




                                                                                                                                                                                                                                            Mitigation
                                                                                                                                                                                                 Yes or No
                                                                   Likelihood




                                                                                                                                                             Likelihood
                                                                                           Outcome




                                                                                                                                                                                       Outcome
                                                                                Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                              Value
                                                                                                                                                                                                                                               Post
                                                                                                                         Mitigation
                                                                                                                                                                                                              Additional Local Mitigation


Supervisor/Progr Fatigue, complacency                                                                Communicate w/FWFMSU, consider requiring




                                                                   Probable


                                                                                Marginal




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                           Serious
am Manager                                                                                           employees to fly less than 8-hrs/day, practice
                                                                                                     CRM to include all aviation personnel

                 Accepting/promoting unreasonable risk                                               Supervise and set tone "aviation program first" -
                                                                                                     participate in programmatic and project-specific




                                                                   Probable


                                                                                Marginal




                                                                                                                                                                          Marginal
                                                                                                     risk assessments, do job hazard analysis and




                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                           Serious
                                                                                                     ensure incorporated into permission briefing;
                                                                                                     FWFMSU communicate with supervisor, FHP
                                                                                                     supervisors to attend required aviation safety
                                                                                                     training
                 Lack of project level knowledge & involvement                                       Supervisor briefed during mission planning




                                                                   Occasional




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                           Serious
                                                                                Critical
                 Not ensuring subordinates adequately trained                                        Supervisor monitor employees training


                                                                   Probable




                                                                                                                                                                          Marginal
                 on aviation safety/mission tasks                                                    requirements, have training identified on individual




                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                Critical

                                                                                           High
                                                                                                     training plan (assures subordinates stay current as
                                                                                                     Flight Manager or other positions as appropriate in
                                                                                                     FHP IAT Matrix)
                 Not completing required Supervisor training                                         Complete appropriate modules per FHP IAT
                                                                   Probable


                                                                                Marginal




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                           Serious
                                                                                                     Matrix and stay current



                 ABS issues - contributing to long duty day &                                        Supervisor, program manager/UAO to remain alert
                 vendors/pilots not being paid (contract                                             for flight managers having trouble using ABS




                                                                                                                                                                          Negligible
                                                                                Marginal




                 aviation services only)                                                             and/or vendors not getting paid; if occurring,
                                                                                           Medium
                                                                   Remote




                                                                                                                                                             Remote




                                                                                                                                                                                       Low
                                                                                                     potential to affect daily operations and safety...
                                                                                                     Respond to needs for additional ABS training
                                                                                                     (contact CO, other FHP COR's or F&AM staff for
                                                                                                     assistance)
                 Personality conflicts up/down leading to stress                                     Brief/debrief, CRM, maintain positive attitude,




                                                                                                                                                                          Negligible
                                                                                Marginal

                                                                                           Medium
                                                                   Remote




                                                                                                                                                             Remote
                 and poor communication                                                              promote honest/open communication




                                                                                                                                                                                       Low
                 General lack of mission understanding (within                                       Ensure agency personnel complete appropriate
                 flight crew, also includes aviation support                                         level of training/task books for position,
                                                                   Frequent




                                                                                                                                                                          Marginal
                 functions)                                                                          recommend for states. Have regional program




                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                Critical

                                                                                           High




                                                                                                     managers interact w/FAO, RAO, RASM,
                                                                                                     dispatchers, State Foresters, etc to increase
                                                                                                     understanding of photo operations and awareness




 55
System: FHP Aerial Photography - Personnel (cont.)
                                                                Pre Mitigation                                                                              Post Mitigation
Sub-systems   Hazards




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation




                                                                                                                                                                                                                                            Mitigation
                                                                                                                                                                                                 Yes or No
                                                               Likelihood




                                                                                                                                                             Likelihood
                                                                                           Outcome




                                                                                                                                                                                       Outcome
                                                                            Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                              Value
                                                                                                                                                                                                                                               Post
                                                                                                                         Mitigation
                                                                                                                                                                                                              Additional Local Mitigation


Dispatch      Uninformed or misinformed of Flight Plan                                               FHP UAO disseminate PASP and annual schedule




                                                               Occasional
                                                                                                     to dispatch centers and FAOs as early as




                                                                                                                                                             Occasional

                                                                                                                                                                          Negligible
                                                                            Marginal

                                                                                           Medium
                                                                                                     possible; FWFMSU to submit Flight Plan, call




                                                                                                                                                                                       Low
                                                                                                     dispatch in each area prior to mission, ensure
                                                                                                     good communication in all areas to be flown

              Limited FM capability in photo projects due to                                         Have and utilize a plan for using phone and AFF




                                                               Occasional




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                                           Serious
              distance to centers                                                                    systems.




                                                                            Critical
              Work load, fatigue, or complacency resulting                                           FWFMSU coordinate with dispatch centers,




                                                                            Catastrophic
              in missed flight following                                                             consider moving flight following services or project




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                               Remote




                                                                                                                                                             Remote
                                                                                           Serious
                                                                                                     to alternate area if dispatch workload too high



              Inconsistent flight following procedures                                               FHP UAO clearly identify radio/AFF procedures in




                                                                                                                                                                          Negligible
                                                               Probable




                                                                                                                                                             Remote
                                                                            Critical
                                                                                                     PASP, communicate to dispatch, FWFMSU call




                                                                                           High




                                                                                                                                                                                       Low
                                                                                                     dispatch daily


              Frequency congestion                                                                   Consider utilizing local repeater frequencies to
                                                               Frequent




                                                                                                                                                                          Marginal

                                                                                                                                                                                       Medium
                                                                                                                                                             Remote
                                                                            Critical
                                                                                                     ease congestion, provide alternative frequencies;
                                                                                           High
                                                                                                     augment radio use with AFF; or, file FAA flight
                                                                                                     plan
              Inoperability of National Flight Following                                             Have and utilize forest net frequencies, submit




                                                                                                                                                             Occasional
                                                               Probable




                                                                                                     safecom for outages or areas that should have




                                                                                                                                                                                       Serious
                                                                            Critical




                                                                                                                                                                          Critical
                                                                                           High



                                                                                                     NFF coverage


              Lack of staffing on weekends or outside of                                             Use alternate methods of flight following, request
                                                               Occasional


                                                                            Negligible




                                                                                                                                                                          Negligible
                                                                                                                                                             Remote
              flight hours                                                                           additional staffing, adjust flight hours to
                                                                                           Low




                                                                                                                                                                                       Low
                                                                                                     accommodate dispatch hours


              Jurisdictional/boundary awareness and                                                  Ensure positive radio communication and
                                                               Occasional




                                                                                                                                                                          Negligible
                                                                                                                                                             Remote
                                                                                           Serious




              inability to maintain flight following                                                 successful hand-off to neighboring dispatch, close
                                                                            Critical




                                                                                                                                                                                       Low
                                                                                                     out flight following with previous dispatch area.




 56
              Hazards




                                                                                                                                                                                                                     Achieved?
                                                                                                                                                                                                                     Mitigation




                                                                                                                                                                                                                                                                Mitigation
                                                                                                                                                                                                                     Yes or No
                                                               Likelihood




                                                                                                                                                                                 Likelihood
                                                                                                                   Outcome




                                                                                                                                                                                                           Outcome
                                                                                       Severity




                                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                                  Value
                                                                                                                                                                                                                                                                   Post
                                                                                                                                                                                                                                  Additional Local Mitigation


              Frequency guides unavailable or not current                                                                    GACC's to publish current frequency guides on the




                                                               Occasional




                                                                                                                                                                                              Negligible
                                                                                                                                                                                 Remote
                                                                                                                   Serious
                                                                                       Critical
                                                                                                                             internet & have links to neighboring GACC




                                                                                                                                                                                                           Low
                                                                                                                             frequency guides

              Not filing flight plan or initiating flight                                                                    FWFMSU or pilot shall initiate and close flight




                                                                                       Catastrophic
                                                               Occasional




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
              following/closing flight plan                                                                                  following w/dispatch for each leg of flight.




                                                                                                                   High
              Poor communication between local dispatch,                                                                     When utilizing dispatch flight following, FWFMSU
              GACC, NICC regarding flight plan                                                                               to assure mission specifics are communicated;




                                                               Occasional
                                                                                                                             communicate not only with unit through which




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
                                                                                                                   Serious
                                                                                       Critical
                                                                                                                             order is placed but with local centers where
                                                                                                                             project is planned, USFS and other other agencies
                                                                                                                             as needed - assure appropriate distribution of
                                                                                                                             flight plan; FAA flight following required at a
                                                                                                                             minimum
              Unable to adequately communicate aerial                                                                        Review hazard maps prior to flight (more of a




                                                                                       Catastrophic
                                                               Occasional




                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
              hazards                                                                                                        factor for lower altitude photography, King Air




                                                                                                                                                                                              Critical
                                                                                                                   High
                                                                                                                             frequently operates out of range from aerial
                                                                                                                             hazards)

              Minimally qualified/new dispatchers                                                                            Develop mentoring program for growing centers or
                                                               Occasional Occasional




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
                                                                                                                   Serious
                                                                                       Critical
                                                                                                                             for areas where turn over is anticipated (be
                                                                                                                             proactive, provide OJT to potential recruits)

Maintenance   Insufficient number of inspectors                                                                              Managers to assure enough inspectors to fulfill




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
                                                                                                                   Serious
                                                                                       Critical




Inspector                                                                                                                    area needs; hire additional and/or share
                                                                                                                             inspectors across regional boundaries

              Not current on AD's                                                                                            Use FAA website for new AD's, get subscription
                                                                                       Catastrophic Catastrophic




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                               Remote




                                                                                                                                                                                 Remote
                                                                                                                   Serious




                                                                                                                             (CD is available with 28-day updates)



              Fatigue, complacency                                                                                           Utilize other region's/agency inspectors to help




                                                                                                                                                                                              Marginal
                                                                                                                   Serious




                                                                                                                                                                                                           Medium
                                                               Remote




                                                                                                                                                                                 Remote
                                                                                                                             workload, provide second set of eyes



              Accepting & transferring unreasonable risk to                                                                  UAO's to participate in inspections for the




                                                                                                                                                                                 Improbable

                                                                                                                                                                                              Marginal
              aviation users                                                                                                 purposes of 1) gaining knowledge about
                                                                                                                   Medium




                                                                                                                                                                                                           Medium
                                                               Remote


                                                                                       Critical




                                                                                                                             inspections and 2) for raising general awareness
                                                                                                                             to new issues/ideas on aircraft health

Contracting   CO/COR turnover and/or lack of experience
                                                               Frequent




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
                                                                                       Critical




                                                                                                                             Aviation CO developmental positions, mentoring
                                                                                                                   High




                                                                                                                             programs, UAOs coordinate with Cos to assure
                                                                                                                             best value
              Very short timeframe from advertising to                                                                       Determine budget, funds available, and start
                                                               Frequent




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote
                                                                                       Critical




              award of aircraft contracts (affects operating                                                                 preparing contracts as early as possible
                                                                                                                   High




              season, potentially limits pool of most
              desirable/most qualified bidders)
              Stress in planning and completing missions                                                                     Aviation CO developmental positions, mentoring
                                                                                                                             programs, aviation specific training, create
                                                               Frequent




                                                                                                                                                                                              Marginal

                                                                                                                                                                                                           Medium
                                                                                                                                                                                 Remote




              while coordinating product delivery to
                                                                                       Critical

                                                                                                                   High




              customers (added complexity due to                                                                             contract template, FHP UAO's participate in
              contracted services - film acquisition,                                                                        contract development
              processing, delivery)



 57
System: FHP Aerial Photography - Personnel (cont.)
                                                                     Pre Mitigation                                                                              Post Mitigation
Sub-systems        Hazards




                                                                                                                                                                                                      Achieved?
                                                                                                                                                                                                      Mitigation




                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                      Yes or No
                                                                    Likelihood




                                                                                                                                                                  Likelihood
                                                                                                Outcome




                                                                                                                                                                                            Outcome
                                                                                 Severity




                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                    Post
                                                                                                                              Mitigation
                                                                                                                                                                                                                   Additional Local Mitigation


Oversight &        Lack of mission understanding among some                                               FHP to be proactive, educate and interact with




                                                                                                                                                                  Improbable

                                                                                                                                                                               Negligible
                                                                                                Medium
                                                                    Remote
                   RAOs/RASMs, FAOs, other aviation functions                                             other aviation staff during annual meetings




                                                                                 Critical
Coordination in




                                                                                                                                                                                            Low
General                                                                                                   (national and regional)


                   Lack of knowledge, use or misuse of                                                    Encourage FHP personnel to use system, provide




                                                                                                                                                                  Improbable
                                                                    Occasional
                   SAFECOM system                                                                         constructive quarterly summaries to field




                                                                                                                                                                               Marginal

                                                                                                                                                                                            Medium
                                                                                                Serious
                                                                                 Critical
                   Lack of mission understanding among aviation                                           Ensure agency personnel complete appropriate
                   users                                                                                  level of training/task books for position,




                                                                    Frequent




                                                                                                                                                                               Marginal

                                                                                                                                                                                            Medium
                                                                                                                                                                  Remote
                                                                                 Critical
                                                                                                          recommend for states. Have regional program




                                                                                                High
                                                                                                          managers interact w/FAO, RAO, RASM,
                                                                                                          dispatchers, State Foresters, etc to increase
                                                                                                          awareness.
                   Aviation Management Plan, PASP not current                                             FHP UAOs and Safety Manager (as appropriate)




                                                                                 Catastrophic




                                                                                                                                                                  Improbable

                                                                                                                                                                               Negligible
                   or non existent (required for agency)                                                  to assure plans are completed and distributed
                                                                    Remote




                                                                                                Serious




                                                                                                                                                                                            Low
                                                                                                          within project areas



System: FHP Aerial Photography - Technology (Hardware/Software)
                                                                   Pre Mitigation                                                                                Post Mitigation
Sub-systems        Hazards




                                                                                                                                                                                                      Achieved?
                                                                                                                                                                                                      Mitigation




                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                      Yes or No
                                                                    Likelihood




                                                                                                                                                                  Likelihood
                                                                                                Outcome




                                                                                                                                                                                            Outcome
                                                                                 Severity




                                                                                                                                                                               Severity




                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                    Post
                                                                                                                              Mitigation
                                                                                                                                                                                                                   Additional Local Mitigation


ABS (if contract   Difficulty inputting flight time for payment                                           Utilize ABS Helpdesk; acquire additional ABS
                                                                    Occasional




                                                                                                                                                                  Occasional

                                                                                                                                                                               Negligible
aircraft)          processing through ABS can cause frustration                                           training if necessary; report software problems to
                                                                                                Serious
                                                                                 Critical




                                                                                                                                                                                            Low
                   and long duty days                                                                     be addressed in future ABS versions


                   Disgruntled pilots/vendors due to process or                                           FWFMSU work with Pilot and/or CO as necessary




                                                                                                                                                                  Occasional
                                                                    Probable




                                                                                                                                                                               Marginal

                                                                                                                                                                                            Medium
                   not being paid (rippling effect on attitudes                                           to assure prompt payment for services
                                                                                 Critical

                                                                                                High




                   throught operation)


AFF                False sense of security (not a method for air                                          Better communication between pilot and dispatch
                                                                    Occasional




                                                                                                                                                                               Negligible
                   traffic control)                                                                       centers, train dispatchers and flight crew on proper




                                                                                                                                                                  Remote
                                                                                                Serious
                                                                                 Critical




                                                                                                                                                                                            Low
                                                                                                          use & limitations of AFF, dispatch must time and
                                                                                                          monitor display at required intervals

                   Flight manager trusting AFF absolutely with                                            Maintain positive radio communication, safety plan
                                                                    Occasional




                                                                                                                                                                               Marginal
                   minimal voice communication                                                            & flight plan include protocol for flight following



                                                                                                                                                                                            Medium
                                                                                                                                                                  Remote
                                                                                                Serious
                                                                                 Critical




                                                                                                          (reference MOB Guide, chapter 20)


                   Signal interruption due to antenna conflicts                                           Install and inspect per manufactures
                                                                                                                                                                               Negligible
                                                                                                Medium
                                                                    Remote




                                                                                                                                                                  Remote
                                                                                 Critical




                   with other aircraft antenna                                                            recommendation (maintain separation from other
                                                                                                                                                                                            Low


                                                                                                          antenna)


                   Portable units not secured, could become                                               securely mount portable components in tail section
                                                                                 Catastrophic




                                                                                                                                                                               Negligible




                   projectile in event of emergency landing                                               or strap down to floor
                                                                    Remote




                                                                                                                                                                  Remote
                                                                                                Serious




                                                                                                                                                                                            Low




 58
System: FHP Aerial Photography - Technology (Hardware/Software - cont.)
                                                                  Pre Mitigation                                                                                Post Mitigation




                                                                                                                                                                                                       Achieved?
Sub-systems    Hazards




                                                                                                                                                                                                       Mitigation




                                                                                                                                                                                                                                                  Mitigation
                                                                                                                                                                                                       Yes or No
                                                                   Likelihood




                                                                                                                                                                 Likelihood
                                                                                               Outcome




                                                                                                                                                                                             Outcome
                                                                                Severity




                                                                                                                                                                              Severity




                                                                                                                                                                                                                                                    Value
                                                                                                                                                                                                                                                     Post
                                                                                                                             Mitigation
                                                                                                                                                                                                                    Additional Local Mitigation


Aircraft GPS   Not having latest software or map updates                                                 Contract to include GPS specifications and




                                                                   Occasional




                                                                                                                                                                 Occasional

                                                                                                                                                                              Marginal

                                                                                                                                                                                             Medium
                                                                                               Serious
                                                                                Critical
                                                                                                         requirement for updates



               Waypoint input errors                                                                     Train pilots on GPS operation, double check




                                                                                                                                                                              Negligible
                                                                                Marginal

                                                                                               Medium
                                                                   Remote




                                                                                                                                                                 Remote
                                                                                                         waypoints prior to mission




                                                                                                                                                                                             Low
               Hand-held units not secured, could become                                                 securely mount portable components in tail section




                                                                                                                                                                              Negligible
                                                                   Probable


                                                                                Marginal




                                                                                                                                                                 Remote
                                                                                               Serious
               projectile in event of emergency landing                                                  or strap down to floor




                                                                                                                                                                                             Low
Radios         No frequency or repeater available in project                                             Test frequencies and set up portable repeaters if




                                                                                Catastrophic




                                                                                                                                                                              Catastrophic
                                                                   Occasional
               area                                                                                      necessary; communication plan requires backup




                                                                                                                                                                 Remote




                                                                                                                                                                                             Serious
                                                                                               High
                                                                                                         communication by cell phone or satellite phone if
                                                                                                         necessary; in federal plans/suggest requiring in
                                                                                                         state plans

               No communications (in general) air-to-ground,                                             FAA requires ability to communicate with general


                                                                                Marginal




                                                                                                                                                                              Marginal
                                                                                               Medium




                                                                                                                                                                                             Medium
                                                                   Remote




                                                                                                                                                                 Remote
               with other aircraft or dispatch centers                                                   aviation aircraft; contracts include necessary radio
                                                                                                         specifications; communications plan lists
                                                                                                         frequencies
               Inaccessible radios/controls, difficult to                                                Break from flight pattern to access radio and make
                                                                   Improbable




                                                                                                                                                                 Improbable

                                                                                                                                                                              Negligible
                                                                                Marginal

               operate                                                                         Low       adjustments




                                                                                                                                                                                             Low
               P-25 Digital, Analog & Narrow Banding                                                     Identify issues prior to contract and operation,




                                                                                                                                                                 Occasional
                                                                   Probable




               compatibility issues                                                                      radio check prior to project implementation -
                                                                                Marginal




                                                                                                                                                                              Marginal

                                                                                                                                                                                             Medium
                                                                                               Serious




                                                                                                         address in communication plan; provide time and
                                                                                                         training on new equipment

               Portable radios - not secure, controls easily                                             Secure and properly place portables so as not to




                                                                                                                                                                 Occasional
                                                                                Marginal




                                                                                                                                                                              Marginal
                                                                                               Medium




                                                                                                                                                                                             Medium
                                                                   Remote




               bumped                                                                                    interfere with aircraft operations, use
                                                                                                         keypad/control locks


               Panel mounted radios - bump controls                                                      Use keypad/control locks
                                                                   Improbable




                                                                                                                                                                 Improbable

                                                                                                                                                                              Negligible
                                                                                Marginal

                                                                                               Medium




                                                                                                                                                                                             Low
               Flight crew unfamiliar with components                                                    Preflight to include familiarization & programming
                                                                   Probable


                                                                                Marginal




                                                                                                                                                                              Marginal

                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                               Serious




                                                                                                         radios


               Frequency congestion                                                                      alternate frequency planning
                                                                                Catastrophic
                                                                   Occasional




                                                                                                                                                                              Marginal

                                                                                                                                                                                             Medium
                                                                                                                                                                 Remote
                                                                                               High




               Faulty wiring leading to intermittent operations                                          Have portable radio/handheld, users prepared to
                                                                                Marginal




                                                                                                                                                                              Marginal
                                                                                               Medium




                                                                                                                                                                                             Medium
                                                                   Remote




                                                                                                                                                                 Remote




                                                                                                         use alternate frequencies (guard), land and repair
                                                                                                         or replace aircraft

               Inoperability of National Flight Following                                                Identify and rectify NFF system failures (computer,
                                                                   Occasional


                                                                                Negligible




                                                                                                                                                                              Negligible
                                                                                                                                                                 Remote




                                                                                                         satellite and aircraft equipment)
                                                                                               Low




                                                                                                                                                                                             Low




 59
System: FHP Aerial Photography - Technology (Hardware/Software - cont.)
                                                                  Pre Mitigation                                                                               Post Mitigation




                                                                                                                                                                                                      Achieved?
Sub-systems   Hazards




                                                                                                                                                                                                      Mitigation




                                                                                                                                                                                                                                                 Mitigation
                                                                                                                                                                                                      Yes or No
                                                                   Likelihood




                                                                                                                                                                Likelihood
                                                                                               Outcome




                                                                                                                                                                                            Outcome
                                                                                Severity




                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                   Value
                                                                                                                                                                                                                                                    Post
                                                                                                                             Mitigation
                                                                                                                                                                                                                   Additional Local Mitigation


TCAS          If not using TCAS: potential for midair collision                                          Use TCAS, continue practice of "see and avoid",




                                                                                Catastrophic




                                                                                                                                                                             Catastrophic
                                                                                                                                                                Improbable
                                                                                                         apply CRM




                                                                                                                                                                                            Medium
                                                                   Remote




                                                                                               High
              If using TCAS: false sense of security that all                                            Recognize that all other aircraft may not have




                                                                                Catastrophic




                                                                                                                                                                             Catastrophic
                                                                   Occasional
              other aircraft have functioning transponders                                               functioning transponders, continue practice of "see




                                                                                                                                                                Remote




                                                                                                                                                                                            Serious
                                                                                               High
                                                                                                         and avoid", apply CRM



              If using TCAS: Signal interference, antenna                                                Follow manufacturer's installation requirements




                                                                                Catastrophic




                                                                                                                                                                             Catastrophic
                                                                   Occasional
              positioned too close to other antennas




                                                                                                                                                                Remote




                                                                                                                                                                                            Serious
                                                                                               High
Camera &      Loose Items                                                                                properly secure loose equipment, brief on hazards


                                                                   Occasional




                                                                                                                                                                Occasional

                                                                                                                                                                             Marginal
Associated




                                                                                                                                                                                            Medium
                                                                                               Serious
                                                                                Critical
Equipment


              Electronic failures & diagnosis cause                                                      Make equipment checks before flight in the lab
                                                                   Occasional


                                                                                Marginal




                                                                                                                                                                             Marginal
              confusion, mission interruption, deviation from                                            and on the ground
                                                                                               Medium




                                                                                                                                                                                            Medium
                                                                                                                                                                Remote
              flight plan




 60
System: FHP Aerial Detection Surveys - Aircraft
                                                                     Pre Mitigation                                                                                                        Post Mitigation
Sub-systems        Hazards




                                                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                                                            Mitigation
                                                                     Likelihood




                                                                                                                                                                                           Likelihood
                                                                                                                           Outcome




                                                                                                                                                                                                                       Outcome
                                                                                  Severity




                                                                                                                                                                                                        Severity




                                                                                                                                                                                                                                                                              Value
                                                                                                                                                          Mitigation




                                                                                                                                                                                                                                                                               Post
                                                                                                                                                                                                                                              Additional Local Mitigation


Avionics (for      Unplanned avionics failures (overheating,                                                                         Have portable radio/handheld as back up, users




                                                                     Occasional

                                                                                  Marginal




                                                                                                                                                                                                        Marginal
                                                                                                                           Medium




                                                                                                                                                                                                                       Medium
                                                                                                                                                                                           Remote
radios see         faulty wiring, etc.)                                                                                              prepared to use alternate frequencies (guard),
"Technology"                                                                                                                         land and repair or use alternate aircraft
tab)
                   Loss of emergency locator ability (analog ELT                                                                     Switch to 406 MHz digital ELT systems before




                                                                                                                                                                                           Improbable


                                                                                                                                                                                                        Negligible
                                                                                  Marginal

                                                                                                                           Medium
                                                                     Remote
                   systems will be discontinued)                                                                                     February 1, 2009




                                                                                                                                                                                                                       Low
Configuration      Reliability of non-turboprop-powered fixed                                                                        Check into availability of other better performing




                                                                     Occasional




                                                                                                                                                                                                                       Medium
                                                                                                                                                                                           Remote
                                                                                                                           Serious
                                                                                  Critical




                                                                                                                                                                                                        Critical
                   wing (if used)                                                                                                    a/c. Include language in MOU, grant, cooperative
                                                                                                                                     agreement for state operations.

                   Selection of inappropriate platform for terrain                                                                   Utilize technical specialists in project design and




                                                                                                                                                                                                        Negligible
                                                                                                                           Medium
                                                                     Remote




                                                                                                                                                                                           Remote
                                                                                  Critical
                   & objectives - windows, low wing, seating                                                                         contract preparation




                                                                                                                                                                                                                       Low
                   (certain models)

Terrorist or       Theft or damage to aircraft or gear &                                                                             Project Aviation Safety Plan & contract to address



                                                                                  Catastrophic
malicious activity equipment (remote, unsecure overnight                                                                             security in remote locations, reference local Unit




                                                                                                                                                                                                                       Medium
                                                                     Remote




                                                                                                                                                                                           Remote
                                                                                                                           Serious




                                                                                                                                                                                                        Critical
                   parking (risk to aircraft, personnel… theft or                                                                    Aviation Plan, use aircraft locking devices
                   damage to aircraft/equipment… threat to
                   public safety)
Performance        Insufficient Performance (including                                                                               Project Aviation Safety Plan & contract to address
Standards -        horsepower, turbo vs. normally aspirated, etc.)                                                                   minimum requirements, reference Airman's
                                                                                  Catastrophic
                                                                     Occasional




mountainous                                                                                                                          Information Manual (AIM) for "mountainous




                                                                                                                                                                                                                       Medium
                                                                                                                                                                                           Remote


                                                                                                                                                                                                        Critical
                                                                                                                                     terrain"… carding process doesn't necessarily
                                                                                                                           High


terrain (AIM)
                                                                                                                                     address FHP performance needs… FHP UAOs
                                                                                                                                     remain involved in a/c selection; if concerns,
                                                                                                                                     consult regional mtc inspector or subject matter
                                                                                                                                     expert
                   High density altitude operations                                                                                  Match machine to task & environment, monitor
                                                                                  Catastrophic Catastrophic Catastrophic
                                                                     Probable




                                                                                                                                                                                                                       Medium
                                                                                                                                                                                           Remote
                                                                                                                           Serious




                                                                                                                                                                                                        Critical
                                                                                                                                     weather, reduce load



                   Insufficient payload capabilities                                                                                 Perform weight & balance/load calculations,




                                                                                                                                                                                           Improbable
                                                                     Probable




                                                                                                                                                                                                                       Medium
                                                                                                                                                                                                        Critical
                                                                                                                                     consider multiple observer and overnight gear
                                                                                                                           High




Performance -      Increased probability of encountering aerial                                                                      Review current Aeronautical Sectional Charts,




                                                                                                                                                                                                        Catastrophic
                                                                     Probable




                                                                                                                                                                                           Remote




                                                                                                                                                                                                                       Serious
low elevation      hazards in areas with minimal topography                                                                          aerial hazard maps
                                                                                                                           High




  61
System: FHP Aerial Detection Surveys - Aircraft (cont.)
                                                                  Pre Mitigation                                                                                                                      Post Mitigation
Sub-systems     Hazards




                                                                                                                                                                                                                                        Achieved?
                                                                                                                                                                                                                                        Mitigation

                                                                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                                                                   Mitigation
                                                                  Likelihood




                                                                                                                                                                                                      Likelihood
                                                                                                                                     Outcome




                                                                                                                                                                                                                              Outcome
                                                                                Severity




                                                                                                                                                                                                                   Severity




                                                                                                                                                                                                                                                                                     Value
                                                                                                                                                                   Mitigation




                                                                                                                                                                                                                                                                                      Post
                                                                                                                                                                                                                                                     Additional Local Mitigation


Performance -   Hover out of ground effect (HOGE)                                                                                              Maintain forward airspeed, utilize higher




                                                                               Catastrophic




                                                                                                                                                                                                                              Medium
                                                                  Remote




                                                                                                                                                                                                      Remote
                                                                                                                                     Serious




                                                                                                                                                                                                                   Critical
helicopter                                                                                                                                     performance aircraft, maintain adequate height
                                                                                                                                               above canopy


                Reduced lift due to surface conditions (tall                                                                                   Flight manager/observer discuss flight plan and




                                                                                                                                                                                                      Improbable


                                                                                                                                                                                                                   Marginal
                                                                                                                                     Medium




                                                                                                                                                                                                                              Medium
                                                                  Remote

                                                                               Critical
                grass, native soil/gravel vs. hard surface like                                                                                potential landing zones with helicopter manager
                helipad)

                Loss of power                                                                                                                  Perform regular power checks




                                                                               Catastrophic Catastrophic Catastrophic Catastrophic




                                                                                                                                                                                                                              Medium
                                                                  Remote




                                                                                                                                                                                                      Remote
                                                                                                                                     Serious




                                                                                                                                                                                                                   Critical
                Propensity to operate within height-velocity                                                                                   Maintain forward airspeed, utilize higher




                                                                                                                                                                                                                              Medium
                                                                  Remote




                                                                                                                                                                                                      Remote
                                                                                                                                     Serious




                                                                                                                                                                                                                   Critical
                curve (if survey is low and slow)                                                                                              performance aircraft, maintain adequate height
                                                                                                                                               above canopy


CWN (agency)    Minimally skilled pilots                          Occasional                                                                   Address in Contract requirements and with flight




                                                                                                                                                                                                                   Marginal


                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                      Remote
                                                                                                                                               reviews.



                Incentive to fly for hourly rate, accept more                                                                        High      Flight Managers & Project Supervisor need to be




                                                                                                                                                                                                                   Marginal


                                                                                                                                                                                                                              Medium
                                                                  Remote




                                                                                                                                                                                                      Remote
                                                                                                                                     Serious
                risk                                                                                                                           involved in flight hour/duty day monitoring.



                Aging aircraft (has been a real concern for                                                                                    (Status: FAA currently defining "aging aircraft", 16
                F&AM's heavy airtankers/heli - likelihood may                                                                                  years being considered, more specific mitigations
                be more remote for lighter recon. aircraft)                                                                                    may evolve). Establish more thorough structural
                                                                                                                                               inspection program; damage tolerance,
                                                                                                                                               maintenance and overhaul standards to address
                                                                               Catastrophic
                                                                  Occasional




                                                                                                                                               older aircraft operating within FHP mission profile




                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                      Remote


                                                                                                                                                                                                                   Critical
                                                                                                                                     High




                                                                                                                                               as needed; adhere to original type certificate &
                                                                                                                                               maintain manufacturer support (e.g., Rockwell,
                                                                                                                                               Aerocommander... original manufacturer Pratt &
                                                                                                                                               Whitney not supporting, new manufacturer
                                                                                                                                               supporting Beaver); if in doubt about condition,
                                                                                                                                               defer use & contact maintenance inspector

                Tendency to have less crew continuity and                                                                                      Conduct thorough premission briefing, document
                                                                  Occasional

                                                                               Marginal




                                                                                                                                                                                                                   Marginal
                                                                                                                                     Medium




                                                                                                                                                                                                                              Medium
                                                                                                                                                                                                      Remote
                familiarity with all involved in mission and                                                                                   performance issues, select another CWN or
                mission objectives                                                                                                             agency aircraft; consider exclusive use contracts




  62
System: FHP Aerial Detection Surveys - Aircraft (cont.)
                                                                Pre Mitigation                                                                               Post Mitigation
Sub-systems     Hazards




                                                                                                                                                                                                 Achieved?
                                                                                                                                                                                                 Mitigation

                                                                                                                                                                                                 Yes or No




                                                                                                                                                                                                                                            Mitigation
                                                                Likelihood




                                                                                                                                                             Likelihood
                                                                                            Outcome




                                                                                                                                                                                       Outcome
                                                                             Severity




                                                                                                                                                                          Severity




                                                                                                                                                                                                                                              Value
                                                                                                                          Mitigation




                                                                                                                                                                                                                                               Post
                                                                                                                                                                                                              Additional Local Mitigation


Exclusive Use   Incentive to fly for hourly rate, accept more                                         Flight Managers & Project Supervisor need to be




                                                                             Catastrophic
(agency)        risk                                                                                  involved in flight hour/duty day monitoring.




                                                                                                                                                                          Marginal


                                                                                                                                                                                       Medium
                                                                Remote




                                                                                                                                                             Remote
                                                                                            Serious
                Aging aircraft (has been a real concern for                                           (Status: FAA currently defining "aging aircraft", 16
                F&AM's heavy airtankers/heli - likelihood may                                         years being considered, more specific mitigations
                be more remote for lighter recon. aircraft)                                           may evolve). Establish more thorough structural
                                                                                                      inspection program; damage tolerance,
                                                                                                      maintenance and overhaul standards to address




                                                                             Catastrophic
                                                                                                      older aircraft operating within FHP mission profile




                                                                                                                                                                                       Medium
                                                                Remote




                                                                                                                                                             Remote
                                                                                            Serious




                                                                                                                                                                          Critical
                                                                                                      as needed; adhere to original type certificate &
                                                                                                      maintain manufacturer support (e.g., Rockwell,
                                                                                                      Aerocommander... original manufacturer Pratt &
                                                                                                      Whitney not supporting, new manufacturer
                                                                                                      supporting Beaver); if in doubt about condition,
                                                                                                      defer use & contact maintenance inspector

                Committed to unsatisfactory vendor and                                                Specify project objectives in solicitation and




                                                                                                                                                                          Negligible
                                                                                            Medium
                                                                Remote




                                                                                                                                                             Remote
                                                                             Critical
                platform                                                                              contract, conduct thorough premission briefing,




                                                                                                                                                                                       Low
                                                                                                      document performance issues, terminate for
                                                                                                      performance and use a different aircraft/vendor




  63
System: FHP Aerial Detection Surveys - Aircraft (cont.)
                                                                      Pre Mitigation                                                                               Post Mitigation
Sub-systems          Hazards




                                                                                                                                                                                                     Achieved?
                                                                                                                                                                                                     Mitigation

                                                                                                                                                                                                     Yes or No




                                                                                                                                                                                                                                                Mitigation
                                                                      Likelihood




                                                                                                                                                                   Likelihood
                                                                                                  Outcome




                                                                                                                                                                                           Outcome
                                                                                   Severity




                                                                                                                                                                                Severity




                                                                                                                                                                                                                                                  Value
                                                                                                                                 Mitigation




                                                                                                                                                                                                                                                   Post
                                                                                                                                                                                                                  Additional Local Mitigation


Cooperating          Minimally skilled for mission                                                          Recommend states complete Aviation Safety




                                                                                   Catastrophic




                                                                                                                                                                   Occasional
Aircraft                                                                                                    Plans & describe minimum skill level... Also




                                                                      Probable




                                                                                                                                                                                           Serious
                                                                                                                                                                                Critical
                                                                                                  High
particularly state                                                                                          address within MOU, grant or cooperative
operations not                                                                                              agreement
under MOU with
FS (could be
private, guard,      State possibility to utilize inappropriate                                             Recommend states complete Aviation Safety




                                                                                   Catastrophic




                                                                                                                                                                   Occasional
                     platform                                                                               Plans & include preferred make(s)/model(s)... Also




                                                                      Probable




                                                                                                                                                                                           Serious
other… may not




                                                                                                                                                                                Critical
                                                                                                  High
be P135, and                                                                                                address within MOU, grant or cooperative
usually not                                                                                                 agreement
carded)
                     Uncertain if meeting federal safety standards,                                         Check for pilot and aircraft carding, federal




                                                                                   Catastrophic
                     no carding or letter of authorization                                                  employees will not fly in uncarded aircraft




                                                                      Probable




                                                                                                                                                                                Marginal


                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                                  High
                     Relaxed maintenance standards if Part 91                                               Federal employees will not fly uncarded,


                                                                                   Catastrophic




                                                                                                                                                                   Occasional
                     operator                                                                               encourage states adopt Part 135 maintenance
                                                                      Probable




                                                                                                                                                                                           Serious
                                                                                                                                                                                Critical
                                                                                                  High
                                                                                                            standards



                     Aging aircraft (has been a real concern for                                            (Status: FAA currently defining "aging aircraft", 16
                     F&AM's heavy airtankers/heli - likelihood may                                          years being considered, more specific mitigations
                     be more remote for lighter recon. aircraft)                                            may evolve). Recommend states use pilots and
                                                                                                            aircraft meeting Part 135 experience and
                                                                                                            maintenance standards. Establish more
                                                                                                            thorough structural inspection program; damage
                                                                                   Catastrophic




                                                                                                                                                                   Occasional
                                                                                                            tolerance, maintenance and overhaul standards to
                                                                      Probable




                                                                                                                                                                                           Serious
                                                                                                                                                                                Critical
                                                                                                  High




                                                                                                            address older aircraft operating within FHP
                                                                                                            mission profile as needed; adhere to original type
                                                                                                            certificate & maintain manufacturer support (e.g.,
                                                                                                            Rockwell, Aerocommander... original manufacturer
                                                                                                            Pratt & Whitney not supporting, new manufacturer
                                                                                                            supporting Beaver); if in doubt about condition
                                                                                                            defer use; consider agency maintenance
                                                                                                            inspection in cooperative agreements?

                     No flight hour/duty day limitation if pilot                                            Recommend states establish limitations similar to
                                                                                   Catastrophic




                     operating under Part 91                                                                agency - state Project Supervisors/observers
                                                                      Probable




                                                                                                                                                                                Marginal


                                                                                                                                                                                           Medium
                                                                                                                                                                   Remote
                                                                                                  High




                                                                                                            monitor pilot & crew fatigue, flight hour/duty day




   64
System: FHP Aerial Detection Surveys - Aircraft (cont.)
                                                                   Pre Mitigation                                                                                   Post Mitigation
Sub-systems      Hazards




                                                                                                                                                                                                             Achieved?
                                                                                                                                                                                                             Mitigation

                                                                                                                                                                                                             Yes or No




                                                                                                                                                                                                                                                        Mitigation
                                                                   Likelihood




                                                                                                                                                                    Likelihood
                                                                                               Outcome




                                                                                                                                                                                                Outcome
                                                                                Severity




                                                                                                                                                                                 Severity




                                                                                                                                                                                                                                                          Value
                                                                                                                                Mitigation




                                                                                                                                                                                                                                                           Post
                                                                                                                                                                                                                          Additional Local Mitigation


WCF Aircraft     Aging aircraft (has been a real concern for                                               (Status: FAA currently defining "aging aircraft", 16
                 F&AM's heavy airtankers/heli - likelihood may                                             years being considered, more specific mitigations
                 be more remote for lighter recon. aircraft)                                               may evolve). Establish more thorough structural
                                                                                                           inspection program; damage tolerance,
                                                                                                           maintenance and overhaul standards to address




                                                                                Catastrophic
                                                                                                           older aircraft operating within FHP mission profile




                                                                                                                                                                                                Medium
                                                                   Remote




                                                                                                                                                                    Remote
                                                                                               Serious




                                                                                                                                                                                 Critical
                                                                                                           as needed; adhere to original type certificate &
                                                                                                           maintain manufacturer support (e.g., Rockwell,
                                                                                                           Aerocommander... original manufacturer Pratt &
                                                                                                           Whitney not supporting, new manufacturer
                                                                                                           supporting Beaver); if in doubt about condition,
                                                                                                           defer use & contact maintenance inspector

                 Agency pilots have tendency to lack                                                       Use experienced agency pilots dedicated to FHP




                                                                   Probable




                                                                                                                                                                                 Marginal


                                                                                                                                                                                                Medium
                                                                                                                                                                    Remote
                                                                                Critical

                                                                                               High
                 experience with mission type, not dedicated to                                            program
                 FHP
                 Minimal availability, necessitating looking to                                            Hire dedicated pilots and purchase aircraft for



                                                                                Catastrophic
                 minimally skilled pilots/poor performing          Frequent
                                                                                                           FHP and/or carefully address skills/performance




                                                                                                                                                                                 Marginal


                                                                                                                                                                                                Medium
                                                                                                                                                                    Remote
                                                                                               High
                 aircraft through contracting (increased                                                   through contracts
                 probability)


                 Identifiable as agency aircraft may encourage                                             Use secure airport/tanker base facilities or hanger
                                                                                Catastrophic




                                                                                                                                                                                 Negligible
                 vandalism                                                                                 aircraft, use locking devices.
                                                                   Remote




                                                                                                                                                                    Remote
                                                                                                 Serious




                                                                                                                                                                                                   Low
Foreign Agency   Minimal or no standards for pilot, aircraft, or                                           Look for a/c that meet specifications.
                                                                                Catastrophic




                                                                                                                                                                                 Catastrophic
                                                                   Occasional




Aircraft         operations                                                                                Familiarization with aircraft, do thorough pre-flight,




                                                                                                                                                                    Remote




                                                                                                                                                                                                   Serious
                                                                                               High




                                                                                                           set up communication/dispatch plan.




  65
System: FHP Aerial Detection Surveys - Aircraft (cont.)
                                                                     Pre Mitigation                                                                                           Post Mitigation
Sub-systems        Hazards




                                                                                                                                                                                                                        Achieved?
                                                                                                                                                                                                                        Mitigation

                                                                                                                                                                                                                        Yes or No




                                                                                                                                                                                                                                                                   Mitigation
                                                                     Likelihood




                                                                                                                                                                              Likelihood
                                                                                                            Outcome




                                                                                                                                                                                                            Outcome
                                                                                             Severity




                                                                                                                                                                                             Severity




                                                                                                                                                                                                                                                                     Value
                                                                                                                                             Mitigation




                                                                                                                                                                                                                                                                      Post
                                                                                                                                                                                                                                     Additional Local Mitigation


Fuel               Bad fuel                                                                                             Ensure fuel is tested for type and quality prior to




                                                                     Occasional




                                                                                                                                                                                                               Medium
                                                                                                                                                                                    Remote
                                                                                                            Serious
                                                                                             Critical




                                                                                                                                                                                             Critical
                                                                                                                        fueling


                   Starvation                                                                                           Monitor quantity pumped during fueling, monitor




                                                                                             Catastrophic
                                                                     Occasional
                                                                                                                        flight time and distance to services




                                                                                                                                                                                                               Medium
                                                                                                                                                                                    Remote

                                                                                                                                                                                             Critical
                                                                                                            High
Availability of    Tendency to settle for less-than optimal                                                             Delay project until adequate a/c and or pilot is




                                                                                Occasional




                                                                                                                                                                                             Negligible
                                                                                                                                                                              Remote
                                                                                                              Serious
                                                                                             Critical
Aircraft (in       platform/pilot                                                                                       available




                                                                                                                                                                                                               Low
general)

                   Less than enough acceptable aircraft                                                                 Involve Supervisor, Project Manager & flight
                   available to project, may be coupled with                                                            Manager in all stages of planning and risk


                                                                     Probable
                   pressure to perform/sense of urgency to                                                              assessment… identify and assign sufficient




                                                                                                                                                                                                            Medium
                                                                                                                                                                              Remote
                                                                                             Critical




                                                                                                                                                                                             Critical
                                                                                                            High
                   complete (from pilot, flight manager/crew, or                                                        number of appropriate resources to complete
                   upper management), slow progress or aircraft                                                         project, schedule conservatively with room for
                   becoming unavailable further threatens                                                               unexpected delays
                   completion
                   Sharing assets from other regions/areas (pilot                                                       Conduct thorough premission briefing identifying
                                                                     Probable

                                                                                             Marginal




                                                                                                                                                                                             Marginal


                                                                                                                                                                                                            Medium
                                                                                                                                                                              Remote
                                                                                                              Serious
                   unfamiliar w/area, observer unfamiliar w/pilot,                                                      expectation and local hazards, practice CRM
                   aircraft)

                   Not sharing assets across regional/area
                                                                     Probable Occasional




                                                                                                                                                                                             Marginal


                                                                                                                                                                                                            Medium
                                                                                                                                                                              Remote
                                                                                                              Serious
                                                                                             Critical




                   boundaries (adds burden & pressure on the                                                            COR's & FWFMSU monitor flight hours, educate
                   few assets that are available)                                                                       Program Managers and Supervisors of inter-
                                                                                                                        regional needs, FHP coordinate more with RAO's.
                   Tendency to maximize flight hours ("make hay                                                         Operational risk assessment to address fatigue,




                                                                                                                                                                                             Marginal


                                                                                                                                                                                                            Medium
                                                                                                                                                                              Remote
                                                                                             Critical

                                                                                                            High




                   while the sun is shinning")                                                                          consider flying less than 8 hours per day (6 hours
                                                                                                                        is a prudent recommendation)
Damaged Aircraft Utilizing aircraft with any perceived mtc. issue                                                       Mtc Inspect to return to service, FWFMSU and/or
                                                                                             Catastrophic




                                                                                                                                                                                             Catastrophic
                                                                     Occasional




                 or physical damage                                                                                     Crew to speak up if uncomfortable with the




                                                                                                                                                                              Remote




                                                                                                                                                                                                            Serious
                                                                                                            High




                                                                                                                        condition of aircraft, components or instruments




   66
System: FHP Aerial Detection Surveys - Environmental
                                                                 Pre Mitigation                                                                               Post Mitigation
Sub-systems     Hazards




                                                                                                                                                                                                    Achieved?
                                                                                                                                                                                                    Mitigation




                                                                                                                                                                                                                                               Mitigation
                                                                                                                                                                                                    Yes or No
                                                                 Likelihood




                                                                                                                                                              Likelihood
                                                                                             Outcome




                                                                                                                                                                                          Outcome
                                                                              Severity




                                                                                                                                                                           Severity




                                                                                                                                                                                                                                                 Value
                                                                                                                                                                                                                                                  Post
                                                                                                                           Mitigation
                                                                                                                                                                                                                 Additional Local Mitigation


Weather         Inappropriate clothing for "field operation"                                           Clothing to improve survivability and footware




                                                                 Occasional




                                                                                                                                                                           Marginal