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What did he say?

It was a cold, clear, dark night in the dead of a January winter off the Virginia Capes. The fleet replacement squadrons (FRS) from Oceana and Norfolk were flying carrier quals on USS George Washington (CVN-73). That night, I witnessed an event which proved that bad communication can cause a mishap, while crew resource management (CRM) can prevent once.

I am a JAG officer, not an aviator. While I have worked with aviators throughout my career and have a bit of flight time in F-14s and other aircraft, I freely admit when I am on bean a CVN, I am a pure JAFO (just another freaking officer). That being said, I am a trained observer, and I try, every chance I get. to learn about naval-aviation operations.

On this night, I was standing behind the Air Boss, watching the launches and recoveries. He and the Mini were trying to educate me about what was happening on the deck, in pri-fly, and in the air. Over the course of a few hours, I had begun m understand the intricate actions around me. Just as we started a new cycle, a curious thing happened.

While listening m the radio calls, I noticed the E-2s were going by the call sign Greyhawk." There were four Hawkeyes in the pattern, along with several Hornets and Tomcats. I also saw a lone COD in the pattern, getting ready to make his traps along with everyone else.

The ship was having trouble with squadron maintainers fouling the LA (landing area), which really got the Boss worked up. I soon beard background conversations in the tower about how many foulers we had. When the deck fouled with a Tomcat close in, the Boss exploded. but had calmed down. by the time the next aircraft called the ball. I heard, "Greyhawk 611, ball. 4.3."

I looked over the shoulder of the young petty officer second class at the arresting-gear monitoring panel and watched all the arresting engines move to the setting I just had learned was for an E-2. Several seconds passed, with more small talk about people fouling the deck, when suddenly the woman at the panel bolted upright.

"Wave off!" she screamed, scaring every, one.

The Mini-Boss was so startled he hit his noggin on the overhead. To everyone's credit, there was no hesitation: The Boss instantly called for the wave off. About three seconds later, the COD flew slowly and gracefully by the rower windows, with everyone stunned by the sight.

When the Boss turned around, the petty officer explained what had happened. She had realized, after thinking about the situation for a few seconds, that the previous radio call actually had been, "Greyhound 611, ball, 4.3." Greyhound or Greyhawk, it made all the difference. They sound almost identical on the radio, plus the COD had a 600-series number, not a zero series.

The Boss quickly realized we just had avoided a mishap. Maybe not a Class-A mishap, but, as they explained to the ignorant bystander (me), hitting the gear on the wrong setting would have created a mess and fouled the CQ for the night.

I realize aloe of things went wrong that night, but one thing went right. To be honest, there was a distraction in the tower: me. While I tried to stay out of the way, a lot of people were taking time from their regular jobs to teach me.

Another hole in the Swiss cheese [see editor's note at end of article] came with the maintainers who were fouling the deck. After about the third incident, the Boss started to pay a lot of attention to them--instead of flight ops. I know they had no idea what the implications of their actions were, but they were contributing to a mishap-in-the-making.

My next observation lies with the squadron. They had a 600-series number on a COD. From one point of view, it makes sense: The E-2 and C-2 communities share an FRS. So why shouldn't all the squadron's aircraft have the same number? Consider, though, since the GW only recently had returned from a combat cruise to the Gulf, maybe the Boss was thinking about the air wing he had flown with for the last six months: the air wing where CODs had zero numbers, not 600s.

The last hole in the cheese that lined up was the fault of the pilots in the pattern. All the E-2s were using a call sign they didn't realize (I'm sure) was similar to the one the COD was using. The call signs were virtually indistinguishable over the radio. It's the same reason the Hornet drivers don't like to use "Super Hornet"; one radio squelch, and you have a problem.

As it turned out, the piece that didn't line up belonged to the team in pri-fly. Let's give credit to this young petty officer who was assertive and had the courage to call for a waveoff. She knew her job and made the call without hesitation. Something wasn't right, and she made a gutsy--and the right--call. Add a little CRM to the scenario with the Boss not questioning her call. A member of his team in a better position to see the problem had made the call, and he backed her 100 percent.

We say all the holes in the Swiss cheese have to line up for a mishap to occur. Everyone in naval aviation on the deck, in the tower, or in the cockpit, has a chance to block a hole. Situational awareness by any one of them can do the trick.

I'm still a JAFO, and I thank that young second class, whose name I don't even know, for teaching me a little about how naval aviation really works.

Lt. George is with the Naval Safety Center.

To learn more about the Human Factors Analysis and Classification System (HFACS), which describes the "Swiss cheese" model mentioned in this article, read the Approach "Work Zone" entry in the July-August 2004 issue. View it at: www.safetycenter.navy.mil/media/approach/issues/julaug04--Ed.
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Title Annotation:United States; military naval-aviation operations; Lieutenant Taylor George
Author:George, Taylor
Publication:Approach
Geographic Code:1USA
Date:Jan 1, 2006
Words:1011
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