Focus: The Dirty Dozen

FOCUS
Mission Success Safety Always - Mission Success Safety Always - Mission Success Safety Always - Mission Success Safety Always - Mission Success
January 2012
FOCUS
Republic of Singapore Air Force Safety Magazine
Issue
70
The Dirty Dozen

Inside:
>> Stress >> Distraction >> Project Management and The Dirty Dozen >> Fokker-50 At Gulf of Aden
Mission Success Safety Always - Mission Success Safety Always - Mission Success Safety Always - Mission Success Safety Always - Mission Success
RSAF Safety Magazine Issue 70 | January 2012
CONTENTS
FOCUS Issue 70 - January 2012
Front Cover Image: A showcase of the

RSAFs 12 safety posters on The Dirty
Dozen.
EDITORIAL BOARD
Chairman
COL Aw Kwee Siong
Members
LTC Danny Koh

LTC Alex Cornelius
ME6 Lee Lip Kee
MAJ Peter Ho
MAJ Macus Woo
CPT Khoo Pak Syn
CPT (DR) Jocelyn Ong Siyu
Ms Audrey Siah
COPING WITH STRESS
Production Crew
Editor
20 Fokker-50
At the Gulf of Aden
MAJ Mike Chua Kim Sai
Assistant / Photographer
2WO Steven Goh
Graphic / Layout Design
10 Distraction
2WO Steven Goh
Printed By
99 Degree Communications LLP
Foreword
FOCUS is published by Air Force Inspectorate, HQ

RSAF, for accident prevention purpose. Use of information contained herein for purposes other
than accident prevention, requires prior authorisation from AFI. The content of FOCUS are of an
informative nature and should not be considered
as directive or regulatory unless so stated. The
opinions and views in this magazine are those expressed by the writers and do not reflect the official views of the RSAF. The contents should not be
discussed with the press or anyone outside armed
services establishment. Contributuons by way of
articles, cartoons, sketches and photographs are
welcome as are comments and criticisms.
The Dirty Dozen
FOCUS magazine is available on these sites:

http://webhosting.intranet.defence.gov.sg/web/
AirForce/AFI/index.htm (intranet)
http://www.mindef.gov.sg/rsaf (internet)
ISO 9001:2008
BS OHSAS 18001:2007
By COL Aw Kwee Siong
The beginning
14
Project Management
and The Dirty Dozen
18
Safety Activities
27
CAF Quarterly
Safety Forum
28
What Our People

Think?
30
Cross Word Puzzle
Workshops
$30 Popular Voucher to be won
FOCUS
FOREWORD
Foreword
This issue of FOCUS celebrates the 70th Platinum Edition of the magazine. We have come a long way
from the 1st edition's free hand drawings and type-written layouts 33 years ago, to the current high
resolution pictures and fanciful digital layouts. It is only apt that we launch this milestone FOCUS with a
new look and feel as the RSAF propels through its second spiral transformation. I would like to take this
opportunity to extend my deep appreciation to all the people who had contributed the great articles,
photos and illustrations; to all our readers for their many years of support and feedback; and to all past
and present editorial board members who have been instrumental in the magazine's success!
About three quarters of aviation accidents were caused by human errors. As such, this platinum issue
looks at the The Dirty Dozen. Since its first introduction in the RSAF in 1998, Dirty Dozen has played
and will continue to play a vital role in managing Human Factors in the RSAF. The articles discuss on the
various aspects of the Dirty Dozen that we are likely to encounter. They will provide some understanding of how these factors affect us and what are the measures that we as individuals and/or commanders can introduce to mitigate their effects. We have also included an article on the RSAF's successful
deployment of a F-50 Maritime Patrol Aircraft to the Gulf of Aden as part of the international anti-piracy
operations. Strong understanding of Human Factors and the Dirty Dozen have played an important
role in the implementation of numerous proactive measures that have directly contributed to the very
successfully deployment in a totally unfamiliar and harsh environment without any safety incidents.
My congratulations to all for achieving this milestone Platinum Edition!
COL Aw Kwee Siong
Head Air Force Inspectorate
THE DIRTY DOZEN
The Dirty Dozen

During the late 1980s and early 1990s, there
were a spate of maintenance related aviation
incidents in Canada. These incidents spurred
Transport Canada to launch an initiative that
would aid aviation companies in their fight to
prevent unnecessary accidents. Gordon Dupont, who was a Special Program Coordinator
at Transport Canada at the time, was credited
with the introduction of The Dirty Dozen
which was the identification of 12 human factor elements highly likely to degrade peoples
ability to perform effectively and safely, leading to maintenance errors. Today, the ubiquity
of this term, in both the flying and maintenance communities is testament to the success of the campaign. The RSAF adopted the
Dirty Dozen concept in 1998 to complement
the Human Error Accident Reduction Training (HEART) and Human Error Analysis Tool (HEAT) for our operations
and logistics communities respectively.
The Dirty Dozen consists of 12 identified human factors. They are:

Lack of Communication : A Lack of clear direct statements and good, active listening skills
Complacency
: Self-satisfaction accompanied by loss of awareness of the potential dangers
Lack of Knowledge
: Lack of experience or training in the task at hand
Distraction
: Drawing ones attention away from a task
Lack of teamwork
: Lack of working together to achieve a common goal
Fatigue

: Weariness from labor or exertion, nervous exhaustion or the temporary loss

of power to respond
Lack of Resources

: Failure to use or acquire the appropriate tools, equipment, information and

procedures for the task at hand
Pressure

: Pushing for something in spite of opposing odds, creating a sense of urgency or hassle
Lack of Assertiveness
: A lack of positive communication of ones ideas, wants and needs
Stress
: Mental, emotional or physical tension, strain or distress
Lack of Awareness
: Failure to be alert or vigilant in observing
Norms

3
: Commonly accepted practices where assumptions are made that the course
of action or procedure is correct based on history without re- validating
or verifying the current procedures
FOCUS
STRESS
Coping With
Stress
LTC (DR) Benjamin Tan Boon Chuan, ARMC
LTC (DR) Tan is currently Head, Crew Safety and Flight Environment in ARMC, overseeing the development of 3rd generation Aviation Physiology Training for pilots and aircrew amongst several other projects. He is concurrently a Researcher-Clinician at the Vision Performance Centre
and a Registrar in the Department of Ophthalmology, National University Hospital. His previous postings include staff positions in Certification
and Standards Branch, ARMC as well as Performance Maximization Branch, ARMC. His last appointment was Commanding Officer of 1 Medical
Squadron. He has a keen interest in vision performance, organizational safety and training matters.
In this article, we will focus on one of the Dirty Dozen factors, Stress. Stress is unique as a Human Factor in that
it directly affects the physical and mental well-being of the individual. While stress is an easily acknowledged
and often mentioned Human Factor (much more than, say, Norms), it is probably the most difficult to fully comprehend and manage. Interestingly, it is very often neglected when it comes to identification in open reporting
systems but appears as a prominent feature in accident investigations! And because stress is often not identified
early, it is not adequately managed by the individual and prone to oversight by the management. This article will
attempt to define what stress really is, identify the sources of it and explore how to better mitigate and manage
stress at the respective workplaces not only applicable to the aircraft maintenance community but the flying
community at large.
DEFINITION OF STRESS
From a physiological standpoint, stress

can be defined as any bodily response to a
stimulus that disturbs or interferes with the
normal physiological equilibrium of a person. From an operational standpoint, we
define stress as a reaction that is initiated
when a situation or event is evaluated as a
threat and requires actions beyond an individuals normal operational intensity level.
An interesting concept is expounded in this
definition in that stress is defined as a reaction mounted by an individual and not the
perceived threat itself; what this means is
that when caught in an identical situation,
2 different people can have 2 different reactions to it. One person may find the situation
stressful, while the other is able to take it
in his stride and manage the situation in a
Figure 1 - The transactional model of stress developed by Lazarus and Folk- calm manner. In this respect, personality and
man.
character as well as perceived ability in managing the threat have key roles to play in the
development of stress.
This definition of stress is derived from the transactional model of stress developed by Lazarus and Folkman (see
Fig 1). In this model, it is hypothesized that the first thing a person automatically does when encountering what
could be a stressful event is to appraise the situation (termed primary appraisal).
This is done to assess the level of danger, the potential loss or discomfort and the amount of effort that have to
be exerted to handle the situation. If no threat is perceived, then potentially no stress is felt. However, it is important to note that while this outcome appears ideal in most situations, it sets up a highly dangerous disposition
when the primary appraisal is not properly done, either through inexperience or disregard. The former is often
termed lack of knowledge/training while the latter is commonly known as complacency.
STRESS
Night flying using night vision devices can pose a different
level of stress to the flight crew.
However if a threat is perceived, the individual then undergoes a secondary appraisal whereby he or she will examine his or her own resources and ability to cope with
the threat. How a person copes with the perceived threat
is a function of many interacting elements, which include
his or her personality, confidence and perceived ability
to handle the situation as well as mental models of similar situations and outcomes based on past experiences.
Hence, an individuals level of stress is really an interaction
between the extent of the situation or threat and the individuals perceived ability to cope with it. It is important to
note that when an individual perceives he or she is able to
cope with the situation, it generates positive stress; when
he perceives an inability to do so or that the situation is
overwhelming, it invariably results in negative stress.
TYPES OF STRESS
We can classify stress based what has just been discussed eustress (positive stress) and distress (negative stress).
Eustress generally motivates an individual to handle the situation well and often leads to increased performance
while distress results in a degradation of performance. When the perceived inability to cope with the situation
escalates in a vicious cycle, many anticipatory emotions and negative behavior will start to set in, including fear,
worry, anxiety and panic. These will further degrade performance and jeopardize an individuals ability to handle
the situation.
Stress can also be classified based on its duration.
Acute stress is usually of a short duration which the
individual is able to resolve and return the physical
and mental states to normalcy. When such stress is
overcome, this generates positive stress. However,
when the acute situation overwhelms the coping
abilities of an individual, over-stimulation may occur, resulting in negative stress. And when the body
or mind is made to undergo repeatedly these overstimulations, chronic stress will develop slowly
but surely. Chronic stress hence is a result of exposure to a constant stream of demands, threats and
risks over a prolonged period. Very often, chronic
stress drains the mental and physical resources of
an individual, resulting in lower motivation and
confidence as well as chronic health problems. Due
to its prolonged nature and gradual decline in performance, it may go unnoticed by the individual or
colleagues for a period of time.
Mental preparation before flight can help to relief some level of

stress.
SOURCES OF STRESS
Stress can come from many sources. Any activity, event or stimulus that causes stress is termed a stressor. Stressors can be classified as external or internal to the individual; the former include environmental stressors while
latter can either be cognitive or physical in nature.
In general, stressors come from 3 large sources namely physiological stress, work-related stress and personal
stress.
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FOCUS
Work-related stress is often derived from the amount of workload itself. Work underload or, more often, overload
may lead to increased stress levels. It is generally viewed that persistent high tempo work without adequate time
for rest can result in chronic stress and fatigue. Organizations which use pressure to ensure on-time performance
with little regard for the workers stress and fatigue levels can be caught in a situation whereby low morale and
motivation is prevalent. Low morale and motivation may lead to high numbers reporting sick or declaring poor
health, which adds further stress onto the reduced workforce sustaining on-going operations. All these can build
up toward the inevitable accident over time. In addition to workload, stress can arise in a workplace via poor
group dynamics and tense working relationships. Lack of communication and high levels of distrust are often
features in such workplaces. All these can lead to stress at individual and management levels, the former resulting
from negative emotions while the latter occurs when time and effort are consumed to manage it.
Personal stressors refer to events arising outside the workplace that can affect an individuals performance at
work. Examples of personal stressors include loss of a close relative, financial problems, family-related problems,
health and illness as well as injuries. Depending on the magnitude of the problem, personal stressors can cause
inadvertent pre-occupation of the problem with consumption of mental resources and energy. This invariably
leads to distraction at work, which often allows mistakes to creep in especially when performing routine tasks.
MANIFESTATIONS OF STRESS AND ITS EFFECTS OF PERFORMANCE

Stress can lead to a myriad of physiological and psychological effects (see Table 1). As mentioned earlier, stress is in
actual fact, a physiological phenomenon. What happens when a body is under stress is that stress hormones called
adrenaline are released into the blood circulation. One of the main effects of the increased adrenaline is that it excites the nervous system, resulting in a heightened alertness state. Other effects include stimulating the heart, increasing the blood pressure, increasing glucose in the body as well as increasing the metabolic rate. This prepares
the body for a fight or
Physiological
Psychological
flight response. Hence,
from a physiological Cardiovascular: increased pulse rate, high Emotional: anger, guilt, mood swings and
low self-esteem, depression
standpoint, stress is an blood pressure, chest pains
adaptive process in al- Respiratory: shortness of breath, hyperventi- Pessimism
lowing the body to cope lation, dizziness
with demanding situa- Gastrointestinal: loss of appetite, gas pains, Irritable temper
tions.
indigestion, diarrhea, nausea
Others: headaches, muscular tension, sleep Loss of interest
disturbances, general weakness
Loss of control
Table 1: Physiological and Psychological Effects of Stress
STRESS
Photo courtesy of CPT Khoo Pak Syn

Physiological stress can occur when the job at hand is encumbered with numerous physiological stressors, both physically and mentally and the epitome of this is when flying in
the cockpit of a fighter aircraft; this would invariably expose
the pilot to a myriad of physical stressors, which include G-acceleration forces, risk of hypoxia, positive pressure breathing,
motion sickness, loud radio communications, vibration, fatigue arising from use of night vision goggle (NVG) and many
others. These physical stressors are in addition to the all-important task of executing the mission safely and successfully,
which requires high cognitive functioning and psychomotor
skills. Hence, the impact of physiological stressors cannot be
underestimated; pilots and aircrew are routinely reminded of
these hazards during their Aviation Physiology Training (APT) Flying a fighter jet subjects the individual to numerous
physiological and cognitive stressors
refresher courses. In addition to the acute form of physiological stress, a chronic type can develop from fatigue, which may
be a result of sleep deprivation and/or circadian disruption due to crossing of time-zones. This usually results in
chronic stress when exposed over prolonged periods; ensuring proper sleep hygiene and pharmacological intervention are but some ways to counter such stressors.
STRESS
The body therefore needs to mount this cascade of stress reaction to be able to cope with it, and with that, performance improves with an increasing heightened state of alertness.
However, when the situation is perceived more demanding
than it is or when coping mechanisms are exceeded by demands of the situation, the resulting over-stimulation of the
body and mind can result in the body feeling overwhelmed.
At the height of this over-stimulation, panic and anxiety ensue.
Actions are very often haphazard in a panic situation and do
not translate to meaningful outcomes in handling the situation.
Hence, performance will start to drop once over-stimulation
sets in and degrades further with increasing stress, or arousal.
This phenomenon is clearly explained via the Yerkes Dodson
Law (see Figure 2).
Figure 2. The Yerkes Dodson Law, 1908
Hence, up to a certain point, with increasing amounts of stress, degradation of performance will follow. The
negative effects of stress on performance can be found in Table 2.

Difficulty concentrating and reduced vigilance - easily distracted
Errors, omissions, mistakes, incorrect actions, poor judgment and memory
Tendency to cut corners, skip items and look for the easiest way out
Either slowness (due to lack of interest) or hyperactivity (due to adrenaline)
Focusing on easily manageable details while ignoring serious threats
Tendency to pass responsibility on to others
Fixation on single issues or even a mental block
Unwillingness to make decisions - decisions are postponed or take longer to make
Fewer plans and backup plans are made
Increase in risk-taking leading to an increase in the number of violations, especially when frustrated with
failures
Excessively hurried actions - Due to adrenaline and alertness level, there is a tendency to act very quickly even
when there is no time pressure. Hurried actions increase the chance of errors.
Table 2 - Negative Effects of Stress on Performance
How Can We Manage Stress?

At the individual level
The first strategy in trying to cope with individual stress is to first identify it, and to identify it early. One should
be cognizant of the sources of stressors which may potentially arise, whether it is work-related or personal. Some
symptoms signal the onset of stress and these include the following:

Physical signs: cold, sweaty hands, headache, tension.

Behavioral changes: irritability, anger, hurriedness, fixation.
Speech patterns: fast, irregular, non-standard phrases, noise tone or loudness.
While the above symptoms may herald the onset of acute stress, the symptoms of chronic stress are often more
subtle and are closely linked with fatigue. These symptoms include slower mentation and speech, poor short
term memory, inattention, increasing error rates in routine tasks and even daytime somnolence (sleepiness).
FOCUS
In addition to the above 2 strategies, the management of chronic

stress entail the following components:

Ensuring optimal health and fitness. This includes getting

enough rest and sleep, eating regular meals and exercising regularly. Exercise, for example, is well-established in helping to reduce stress levels. It is important to incorporate some form of
exercise in ones weekly schedule.
Ensuring adequacy of knowledge and currency of training.

Having a lack of knowledge but being put on a job not only
Having an exercise regime and family bondcreates undue stress at the outset, but grows into a bigger probing are some of the ways to reduce stress
lem in which acts are repeatedly performed without validation,
termed norms. Having adequate knowledge and up-to-date
training is therefore important in imbibing competence and confidence at ones job, reducing the day to day
negative stress which may accumulate over time.
Knowing ones ability in undertaking more tasks. For some of us who cannot say no, it is important to not
take on too many tasks and responsibilities to the extent that it causes work overload. This problem of work
overload may be amplified when personal stressors come into play. Watch out for symptoms of chronic stress
and alarm bells should ring when these symptoms start to occur. A time-out may be necessary to recharge
the body and mind.
Social interaction and communication. It is vital not to keep all problems to oneself and communication
can often vent off some of the stress that is accumulating. Maintaining a healthy social life is also important
in keeping a good work-life balance.
At the management level

At the management level, it is important to adequately manage the stress levels of ones subordinates. Some
individuals get more stressed than others while some might have personal stressors at home which might be erroneously judged as poor work performance. The management of stress at a management level hence is a highly
complex art from which requires a multitude of skills, honed by experience. This can range from being able to
utilize available resources optimally, to prioritizing work for subordinates adequately, to thinking of innovative
ways to further create capacity.
Training is another important area which the management must emphasize on. How to teach, what to teach, how
to motivate, how to bring out the best in the individual. In general, good training will result in a knowledgeable
and competent workforce and this will go a long way in reducing the day to day stress at work as well as in managing contingencies. Other than training, the process of mentoring and coaching must be pursued this means
imparting knowledge and experience as well as inspiring the younger ones to reach their full potential.
STRESS
The second strategy to managing stress is to understand that both preventive and reactive approaches are required to tackle stress. A simple way to reduce stress levels in actual operations is in fact through adequate preparation and practice the preventive approach. This means shifting more unexpected events into the realm of the
expected, by both building up a broad knowledge base as well as to rehearse important bold-face actions in the
event of emergency. A pre-flight brief consisting of a thorough risk analysis of the upcoming sortie and detailed
contingency planning is a good example of adopting a good preventive approach to tackling stress. The reactive
approach comes in when individuals learn how to manage the negative emotions that come with unexpected
events. In such situations, it is vital to maintain composure, execute the necessary tasks or bold-face actions as rehearsed (for time-critical situations) and to continuously maintain a heightened state of alertness and situational
awareness in managing the follow-on outcomes. It is therefore important to learn how to control all negative
emotions that usually come with stress, which includes irritation, nervousness and anxiety. These emotions have
the potential to cut off access to a rational mind. Hence, as long as the emotive component can be controlled,
most difficult situations and threats are by and large manageable with a sound mind and nimble body; actions
would be rational and logical based on the good training received and experience garnered over the years.
STRESS
While the above mentioned are the more recognizable

ways of managing stress at the management level, it is often forgotten that social interaction and bonding is also an
important piece to the jigsaw puzzle, and this may require
dedicated time and effort. The impact of social cohesion on
strengthening ties and bonds, improving communications
and fostering teamwork as well as allowing the chance to
know your subordinates at a personal level cannot be underestimated. Sometimes, it is only through informal events that
one gets to peek into the personal stressors affecting ones
subordinates and that may change entirely the approach and
management of many issues at hand.
Engaging people in an environment of positive stress to
produce a highly motivated and capable workforce is an
art of a great leader
It is also crucial to always keep active ones sensors in trying

to assess the amount of stress that is shouldered by subordinates, both at an individual and group level. While this ability
to sense and perceive the latent negative stress in the workforce will require some level of experience, the need
to constantly measure and titrate stress levels should not be entirely neglected in the sole pursuit of targets and
achievements. Hence, there is a need to routinely feel the pulse to see if the demands placed on the team are
overwhelming and whether morale and performance standards are starting to dwindle with small errors peppering throughout the team. These may indicate that a potential accident is brewing ahead! A time-check will need
to be objectively assessed based on the true capability and capacity of the workforce and not judged based on
ones ability or desire. Once that is done, it is then important to identify the source of stressors and to tackle the
issue at its source where possible.
In summary, it is well established that the best leaders inspire and motivate their men to constantly perform at
their peak under an environment of positive stress; how to always engage the entire team in an environment
of positive stress and not tipping over to the territory of negative stress or chronic stress is truly a fine art which
distinguishes a great leader from a mere task master. Hence, it may be timely to re-think about existing strategies
of managing stress so as to bring out the best in the team both in achieving mission success and enhancing
operational safety.
CONCLUSION
Stress is part and parcel of everyday living whether at work or at home and is something that everyone needs
to learn how to cope with. With a better understanding of what it really is and how it can affect the mind and
body, better stress management techniques can be employed in combating it. With continued efforts to manage
it at the individual and management levels, I am sure the dividends it pays back to morale, mission success and
safety will exceed expectation. As it is, we have managed to touch on almost all the Dirty Dozen Human Factors in
this single article on Stress (see all words in bold) highlighting its unassuming importance in the world of safety.
In short, below are the take home points on the Human Factor Stress:
Stress is a physiological and cognitive response to a stressor which generates alertness.
In excess, stress results in numerous physical and mental side effects.
Positive stress results in increased performance while negative stress degrades performance. The aim is to maintain a level
of positive stress so that performance improves over time, bearing in mind not to generate negative stress.
Stress can be acute or chronic. Chronic stress may go unnoticed and it important to look out for its signs and symptoms.
Strategies to reduce individual stress entail first being able to recognize it and secondly adopting the preventive and
reactive approaches to handling it. The preventive approach includes having a good training programme and ensuring
adequate preparation for all tasks while the latter deals with managing ones emotions. Keeping a fit and healthy body and
mind as well as maintaining good social interaction also help to reduce stress at an individual level.
At the management level, it is important to note that stress management is not merely an individual responsibility. It has
roles to play in the areas of resource management, quality of training and capacity creation. In addition, the importance of
social interaction and team dynamics should not be neglected. Sensors should be sent out to feel the pulse of the team,
and workload titrated accordingly.
FOCUS
508 SQN, CAB (W) and Flight Test Centre
ME5 Phua Kian Sean is currently Officer Commanding and Unit Safety Officer in 508 SQN, CAB(W). He holds a Diploma in Civil Engineering from
Singapore Polytechnic.
MAJ Andrew Keong is currently a Trial Pilot in the RSAF Flight Test Centre. He is a graduate of the United States Naval Test Pilot School and has a
Bachelor of Mechanical Engineering from Nanyang Technological University.
DISTRACTION
Distraction - it has earned the ignominy of belonging to the Dirty Dozen. The Oxford Dictionary defines it as a
thing that prevents someone from concentrating on something else. In the field of work within the RSAF, we find
that distraction is ubiquitous, affecting virtually everyone. Depending on circumstances, it may affect us to different degrees. How much do we understand distraction? Is it all bad as it is?
DISTRACTION - IN PERSPECTIVE
Let us first take a look at the all too familiar Dirty Dozen. The Dirty Dozen concept is well understood in the RSAF.
As part of safety education, safety posters were distributed in the RSAF to provide information in identifying each
of the Dirty Dozen factors and preventing accidents that may be caused by them. The caption to the Dirty Dozen
poster on Distraction reads, Hey, your wife is on the phone. It depicts how matters such as a call from ones
spouse can draw ones focus away from his work, and potentially lead to errors.
Distractions can come in different forms and can affect anyone, especially in the RSAF's work setting. From crewmen on the ground to pilots in the air, distractions cause us to omit work tasks, when our attention is
diverted to other things. This may in turn lead to minor accidents, or in the worse case, catastrophic accidents.
Closer to home, on 31 Dec 2009, a landrover was
damaged during a routine detail transporting
troops. En route, a loud metallic banging noise
was heard from the vehicles rear compartment.
The loud noise distracted both the driver and the
vehicle commander, and the former accidentally steered the vehicle off road and into a fence.
Thankfully, no injury was sustained. However,
there were damages to the vehicle and to the
fence.
In the same year, another Ground Accident/Incident report (GAIR) was filed on an incident
that occurred during an aircraft towing task. An
Apache helicopter was being towed to another A seemingly harmless call can draw ones focus away from his work,
and potentially lead to errors.
location for maintenance when it veered off the
taxiway. One of its wheels sank into a muddy grass
patch. The personnel were required to follow a specific route on the taxiway that was marked out by designated
points. As it was their first time on that particular towing route, they were overly cautious and too focused on
locating the new checkpoints. This distracted them.
Thankfully, both these incidents did not result in any injuries.
However, we were not that fortunate on 19 Aug 2009 when a routine morning brief was interrupted by a false
fire alarm in a RSAF facility. Besides the alarm, the buildings fire protection system was activated, and the fire
retardant chemical, FM 200, was discharged in the briefing room. All the personnel were immediately evacuated.
However, in the process of evacuation, a servicewoman tripped and fell, sustaining a stress fracture in one of her
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DISTRACTION
Distraction
Jointly Contributed by:
DISTRACTION
knees. The contractor had accidentally triggered the fire alarm and FM200 fire protection system when he was
attempting to disable them before proceeding on some maintenance works.
According to the investigation, the contractor who triggered the alarm was distracted by his thoughts on his upcoming daily work schedule. As he was distracted, he failed to perform a vital step in the disabling process, and
hence triggered the alarm as well as the fire protection system.
The cases mentioned were only a few of the many incidents and accidents involving distractions; some of which
were much more dire. They are, nonetheless, sufficient to show how costly and detrimental the effects of distraction can be. Equipment and facilities were damaged, and resources such as time and manpower have to be
expended to restore and repair the damages. Even worse, accidents resulting from distraction could potentially
cause harm and injury to personnel - a costly price that must be avoided by all means.
DISTRACTION - A CLOSER LOOK

The cases discussed earlier provide
insights into some of the detrimental
consequences of distraction. However,
it is difficult for us to fully quantify distraction and understand it succinctly.
Distraction manifests itself both internally and externally with respect to the
individual. External stimuli are things in
our surroundings that are able to draw
our attention. These include innocuous things such as a phone call from
a loved one or a favourite song being
played on the radio. Other more potent
forms of distraction exist, such as the
loud noise from an aircraft engine or
unexpected thunder.
On the other hand, internal stimuli are very often linked to an individuals emotions, feeling and thoughts. Everyday personal issues from interpersonal relationships, problems in the workplace, to financial woes, would bring
certain amount of distraction. When these preoccupy a person's attention, they may interfere with his focus on
his work. He is unable to devote his focus on the task at hand.
DEALING WITH DISTRACTION

Distraction is a Human Factor, and that means no one is immune to it. Hence, everyone must take active measures to overcome the problems that distraction may cause.
When it comes to dealing with the problem of distraction, we
can tackle it with a 2-pronged approach Mitigation and Prevention.
The first prong is mitigation. This involves employing measures
to correct the situation such that it does not lead to further
complications. The second is to prevent distraction from occurring in the first place.
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There are various methods to mitigate the effects of distraction. An example is the '3-steps-back approach. Technician A is tasked to service a mobile generator, and part of his task involves securing conductive cables to the
generator set. As he is tightening a bolt in place, Technician A is momentarily distracted by a vehicle cruising by.
Complications can arise as result of his attention being drawn away from his work. Technician A can momentarily
forget that he is in the midst of fully tightening the particular bolt in place, and hence fails to complete his required task. To mitigate the situation, Technician A should refer to his checklist or Standard Operating Procedure
(SOP), to retrace 3 steps prior to the one in which he was interrupted. In so doing, he ensures that the 3 prior steps
have been completed, before continuing to complete the task.
Prevention
It is often said that prevention is better than a cure. If one should think about it, curing distraction is an incredulous, even impossible task. It is however, more feasible to prevent it instead. Let us consider some means in which
distraction can be prevented.
Sterile Flight Deck Periods of Restricted Communications (Qantas Flight Safety, Issue 4,
Summer 2002)
Distraction has not only been a bane to the RSAF, but also to the commercial aviation industry. As such, commercial airlines have implemented measures such as the Sterile Cockpit Rule. The Sterile Cockpit Rule implemented
by the American Federal Aviation Authority specifically prohibits crew member performance of any duties during a critical phase of flight except those duties required for the safe operations of the aircraft... (nor) any activity... which could distract any flight crew member from the performance of his or her duties below 10,000 feet.
One notorious form of distraction is the extraneous conversation between cockpit crew members, which may
arise from poor pre-flight co-ordination of in-flight responsibilities during critical phases of flight. This leads to an
unnecessary and distracting increase in verbal interaction between pilot and co-pilot. Extraneous conversation,
however benign as it may sound, has led to flight crews committing considerable errors of omission such as failure to complete checklists in their entirety or even landing without an air traffic control clearance.
In the RSAF, operators of dual cockpit fighter aircraft such as the F-16D+ aircraft, attest to the need for a sterile
cockpit during critical phases of flight. It is therefore an ingrained practice for the pilot and weapon system officer to establish crew responsibilities via the use of a tactical crew co-ordination checklist. The tactical crew
co-ordination checklist assigns specific crew responsibilities during all pertinent phases of flight, ranging from
administrative aspects such as departure and recovery, to tactical portions of the flight such as during air-to-air
intercepts and air-to-ground attacks. The specific, unambiguous assignment of intra-cockpit tasks and responsibilities significantly eliminates the impetus for extraneous intra-cockpit chatter, thereby reducing the potential
for distraction.
12
DISTRACTION
Mitigation
DISTRACTION
The field of medical healthcare has also started to deal with the
problems of distraction as well. In hospitals, patients who are
warded in hospital receive the medication they need from the
nursing staff. However, research has shown that distraction is a
prominent cause of nurses distributing the wrong medicine to
their patients by mistake. One contributing factor is the interruption of the nursing staff while they are in the midst of their rounds.
To combat such a problem, the medical staff in NHS Lanarkshire
have introduced the practice of donning special red tabards, with
the words Drug round in progress, please do not disturb emblazoned on them. These tabards help nurses to warn colleagues not
to interrupt them when they are on a medication round in a hospital. Nurses wearing these tabards are not to be interrupted from
their rounds, except when there are medical emergencies that require their attention. This practice has significantly reduced errors
in medicine distribution by nursing staff.
We have examined the measures that some organizations have
implemented in their fight against the problems that distraction
can cause. Now, how can a serviceman in the RSAF play a part in
dealing with distraction?
Besides diligently adhering to the policies promulgated by the organization, it is important for servicemen to micro-manage distractions. This would mean that servicemen should exercise their own individual responsibility in overcoming the problems of distraction. This would require taking measures to create a
distraction free work environment.
A good way to achieve such an environment is to be organized when it comes to work. This could include organizing ones workspace (e.g. office, workshop, hangar, etc.) and setting it up in a way which is convenient and conducive for one to work in. In a messy workspace, an individual has to spend time constantly rummaging through
piles of disorganized document or equipment in order to obtain the one that is needed. This can be avoided
when one is organized, such that all the document or equipment are packed and arranged in some order.
One could also organize the tools that one needs to go about his work. Organization of ones workspace and tools
ensures that the working environment is optimized for its purpose. When a workspace has all that is required for
ones work prepared beforehand, it reduces interruptions at work. Distractions are therefore minimized.
CONCLUSION
It is irrevocably important to manage distraction. This is critical to achieve zero accidents and optimise operational capability. We have discussed about the detrimental effects of distraction, and how it is important for us to
manage distraction to prevent costly accidents from occurring.
Reference:
- Aviation Knowledge. The "Dirty Dozen" in Aviation Maintenance. http://aviationknowledge.wikidot.com/aviation:dirty-dozen
- SKYbrary. Sterile Flight Deck (OGHFA BN): Operators Guide to Factors in Aviation Sterile Flight Deck. http://www.skybrary.aero/
index.php/Sterile_Flight_Deck_%28OGHFA_BN%29
- Do not disturb! The Pulse. News for NHS Lanarkshire Staff. May/June 2009. http://www. nhslanarkshire.org.uk/publications/
Documents/The%20Pulse%20May%20june%202009_wrap.pdf
- Personal Development Training with Sid Savara. 13 Ways to Improve Your Concentration With a Distraction Free Work Environment. http://sidsavara.com/personal-development/ improve-concentration-distraction-free-work-environment
13
FOCUS
Mr Ang Yin Zhong, DSTA Engineer, ALS ADOC

Mr Ang Yin Zhong is currently Dy OC in ALS ADOC, and is also the Unit Welfare Officer. He graduated from the National University of Singapore
with B.Eng (Electrical), and Masters of Science in Management of Technology. He was an Equipment Engineer and Project Engineer in the SemiConductor Industry, before joining DSTA. He is currently seconded to ALS ADOC.
Therefore, the General who knows the advantages of the nine changes knows how to
use the troops. If the General does not know the advantages of the nine changes, even
if he knows the way of the land, he will not be able to take advantage of the ground. He
who commands an army but does not know the principles of the nine changes, even if
he is familiar with the five advantages, will not be able to best use his troops.
SunZi's Art of War
Introduction
Harnessing advanced technologies and renewal of weapon
systems are key change areas in developing and forging
ahead towards a 3rd Generation RSAF. In Air Defence and
Operations Command (ADOC), we are currently in the process of phasing in new air defence systems to enhance the
RSAF's capabilities to deal with a wider spectrum of aerial
threats. The matured RAPIER surface-to-air missile system
and 35mm Guns system are being replaced by new systems
like the Surface-to-air PYthon-5 and DERby-Short-Range
(SPYDER-SR) ground based air defence system. The SPYDERSR will form part of the 3rd Generation RSAF Networked Air
Defence capability that builds upon the existing multi-layered air defence system to further strengthen Singapore's
air defences.1
As the RSAF goes about phasing in new air defence systems,

there will be interactions and work involved between project
teams and the new systems' Original Equipment Manufacturers (OEMs). Before the project teams start interacting and
working with the OEMs, the project teams have to be conscious of potential Dirty Dozen (human causal factors that
can set a serviceman up to make an error) and tackle them.
These potential Dirty Dozen can either be from within the
project teams or from the OEMs who have different cultures
and working systems. In this article, two of the potential Dirty
Dozen of project teams and two of the potential Dirty Dozen
of OEMs will be discussed and shared, for greater awareness.
RAPIER Surface-to-Air Missile System
The 35mm Oerlikon Gun
Fact sheet SPYDER-SR found in MINDEF Website

14
PROJECT MANAGEMENT
Project Management and

The Dirty Dozen
PROJECT MANAGEMENT
Dirty Dozen of Project Teams and OEMs

Knowing the potential Dirty Dozen of our project teams and potential Dirty Dozen of OEMs will help prevent errors, especially
safety errors, from occurring when the project teams and OEMs
come together. Four of the Dirty Dozen, namely Lack of Knowledge, Lack of Assertiveness, Lack of Communications and Norms,
are common in the working dynamics between project teams
and OEMs. These four potential human causal factors and possible mitigating measures will be discussed in this article.
If you know your enemies

and know yourself, you will
not be imperiled in a hundred
battles.
SunZi's Art of War
Two of the potential Dirty Dozen which are common in our project teams are Lack of Knowledge and Lack of Assertiveness.

Lack of Knowledge:
More often than not, project teams do not have prior experiences and deep
knowledge of the new systems, especially for developmental projects. There will also be new technology
which are unfamiliar to the project teams. Due to a lack of knowledge, project teams are inclined to wholly
accept information given by the OEMs who are deemed experts of the new systems. Project teams have the
tendency to accept information and technical manuals given by the OEMs as the gospel truth. However, the
OEMs may not be right all the time.
For example, years ago, an intermittent defect failure was found on the upgraded Improved Homing-All-theWay-Killer (I-HAWK) missile system. The OEM attributed the failure to a non-upgraded portion of the equipment. The I-HAWK team accepted the OEMs judegment wholly, and proceeded with regression testing on
the non-upgraded portion, which unfortunately led to further technical complications on the equipment. It
was only after 3 years of detailed investigation that the project team found that the defect was actually the
result of a design deficiency in a newly-introduced component, contrary to the OEMs claim. The OEM finally
acknowledged the design deficiency of the upgraded system2.
Therefore, project teams must always remind themselves not to accept all the information given by the OEMs
at face value. Project teams should always critically review information obtained from the OEMs. Technical
manuals given by the OEMs should be scrutinized by the project team too. Also, prior to interacting and working with the OEMs, project teams should carry out research and studies on the new systems which the RSAF
will be phasing in. Reading up on the new systems from the OEMs website, and gathering information from
open sources are just some ways to raise the initial knowledge level of the project teams on the new systems.

Photo Source from Internet: I-Hawk system conducting a live

firing exercise.
2
15
Lack of Assertiveness:
Project teams have
the tendency of following the OEMs' instructions
with little doubt on the reliability or factuality
of the information and technical instructions.
Project teams, hoping to build good rapport
with the OEMs, may feel that questioning the
OEMs might affect the working relationship.
Such mentality prevents the project teams to be
assertive.
When there is any doubt on instructions or procedures, project teams should be assertive and
post questions to the OEMs, especially when
safety may be compromised. As the saying goes,
the customer is always right, project teams always reserve the right to be assertive and demand for clarifications and improvements whenever and wherever necessary. This is especially
important for new system projects, where there
Safety Transformation: Personal Perspective by ME3 Lim Koon Bin in Safety Focus Issue 60.
FOCUS
We will now discuss two of the potential Dirty Dozen common

in the OEMs. They are Lack of Communications and Norms.

Lack of Communication:
OEMs are normally
from other countries and their main language for communication may not be English. Language can be a barrier to
communication and it may prevent crucial safety-related
information from being communicated to the project
team. This lack of communication can be in verbal form
and in written form such as the technical manuals. Important safety procedures and technical information may not
be adequately translated when the teams work with the
OEMs. Communication styles of the OEMs also vary. Some
OEMs prefer to communicate verbally while others prefer
to communicate via written means. Whether it is verbal or
written, there will always be the issue of misinterpretation,
and the possibility that the OEMs may have missed out
steps or indicated wrong steps.
For example, the OEM for a recently acquired system was
trying to explain a technical procedure to the project team,
but the project team was having difficulty understanding
the actual intended information due to the OEM's poor
command of English. They had to observe the OEM carry
out the actual intended steps before they realised that there were missing and wrong steps stated in the
technical manuals. The sequence of the procedural steps in the manuals was also different from the sequence
of steps actually carried out by the OEM. Initially the project team misinterpreted the intended information
of the technical procedure, and only after clarifying and re-clarifying several times did the project team fully
understood the intended steps of the procedure.
Therefore, to counter the lack of communication from the OEMs, either in verbal or written forms, whatever information and instructions from the OEMs should be clarified and re-clarified by the project teams to
eliminate any misinterpretations of the contents. When necessary, project teams must insist that the OEMs
demonstrate the written instructions, so as to verify that the written instructions are correct. The OEM should
be requested to assign instructors with better command of the English language, for pairing with engineers
from the project teams who have strong technical knowledge. This will ensure that crucial information, especially safety-related technical information, will be communicated effectively to the project teams.

Norms:
OEMs have worked on the new
systems for years and are considered the
experts on the systems. However, norms
may have been formed based on the different working culture and different priorities
of the OEMs.
The Surface-to-air PYthon-5 and DERby-Short-Range

(SPYDER-SR) Ground Based Air Defence System
16
PROJECT MANAGEMENT
are even more questions and doubts on reliability or factuality of information from the OEMs. Project teams
have to be inquisitive and pursue answers from the OEMs for any questions they have on the new systems.
All doubts have to be cleared to prevent errors from occurring.
PROJECT MANAGEMENT
For example, OEMs are profit-driven companies, and they may not emphasize on personnel safety as much
as the RSAF does. Their priority is to deliver functional effective equipment systems for customers, but their
culture may not produce equipment that are reliable or designed with sufficient safety emphasis. The design
of the equipment may be suitable for foreigners body-build and size, but not suitable for Singaporeans. Their
written procedures may not be concise and clear enough for our servicemen to follow. As long as the systems
are effective and functionable for operations, the OEMs will feel that they have delivered their products.
Therefore, we have to be aware of the OEM's norms and be careful not to take their norms applied on the new
systems as acceptable. We have to leverage on our RSAF's strong Safety Culture to review the practices of the
OEMs to prevent their unsafe norms from affecting us. Be ready to insist that the OEMs change and modify
their equipment and procedures to meet our operational and safety standards.
Also, to better deal with the different cultures and norms of the OEMs, the project teams could get people
who have previously worked with the OEMs to be part of the team. Alternatively, project teams could talk to
people who have worked with the same OEMs on other systems to better understand the OEMs' norms and
cultures.
Let me illustrate the above-mentioned points by sharing a recent encounter between a RSAF project team and
the OEM.
The RSAF project core team was having hands-on training on a new system under the guidance and supervision
of the OEM instructors. The core team found that the OEM instructors were having difficulty using English to explain and answer questions raised by the core team. This is a case of lack of communication and poor communication from the OEM. As the team was going through the battery replacement task listed in the technical manuals,
they realized that the safety instructions were too generic and not task-specific. In the task list, steps like ensuring
that the battery switch is OFF and that de-energizing of the system is done were not included in the technical
manuals. These steps were also not mentioned by the OEM during the hands-on training. Furthermore, the core
team also observed that the OEM instructors had a norm of going straight into maintenance tasks without prior
proper safety checks. When the project team raised their safety concerns, the OEM engineering instructors simply told them that it was safe without much explanation and assurance. The core team was still in a dilemma on
whether to carry on and follow the technical manuals steps or stop. Fortunately, the core team was assertive and
called for a safety time-out. After several rounds of clarifying the procedures with the OEM instructors, the team
confirmed that the safety procedures were inadequate. If the core team had carried out the battery replacement
task as per the OEM's instructions and technical manual, someone could have suffered an electric shock, because
the system has not been de-energized for the battery replacement task. The team went on to further insist that
the OEM revise all the tasks in the technical manuals. The OEM eventually acknowledged that the original procedures and task steps did pose some safety concerns, and agreed to revise all the instructions in their technical
manuals to incorporate the necessary safety precautionary steps and to make them more task-specific.
Conclusion
Through this article, two Dirty Dozen of project teams and
another two of the OEMs have been discussed and shared.
They are the Lack of Knowledge, Lack of Assertiveness,
Lack of Communications and Norm. As we develop and
forge ahead towards a 3rd Generation RSAF by harnessing
advanced technologies and phasing in new weapon systems, our project teams must emphasize our strong RSAF
Safety Culture to the OEMs, do their best to learn as much
as possible about the new system, improve communications with the OEMs and be assertive at all times to prevent norms and unsafe practices from forming.
17
FOCUS
At A Glance
3rd CAF Quarterly Safety Forum

The 3rd CAF Quarterly Safety Forum was held at Changi Air
Base (West) on 10 Oct 2011. The forum aims to promote safety
awareness in the RSAF with the highest command emphasis. The theme for the forum was Strong Fundamentals and
Teamwork for Mission Success.
The forum began with Head AFI, COL Aw Kwee Siong, updating
on the RSAFs safety trends and statistics for the past quarter.
MAJ Teo Mun Tiong, an instructor from 124 SQN then shared
his experience from his recent EC-120B engine-off landing incident. This was followed by a caf style discussion on several
case studies to draw the relevant safety lessons.
CAF, MG Ng Chee Meng, presented the CAF Safety Awards to
MAJ Teo Mun Tiong and LTA Nathaniel Goh Wen Keng for their
professional handling of the EC-120B engine failure emergency.
CAF then closed the forum by commending all the participants
for a job well done in the past quarter and reminded all to be
on guard against complacency.
18
SAFETY ACTIVITIES
Safety Activities
SAFETY ACTIVITIES
Safety Activities
At A Glance
2nd WHIP Workshop

AFIs Accident Prevention Branch (APB) conducted the
2nd Wildlife Hazards Intervention Programme (WHIP)
Workshop on 18th November 2011 at the Inno Room,
AFTC. The workshop gathered the WHIP Officers and
Squadron Unit Safety Officers from various commands
to promote awareness on wildlife hazards through
education, dissemination and interaction. A bird control specialist company, MasterMark Pte Ltd was also
invited to share on her experience in the control of
aerodrome wildlife hazards. APB shared on the latest development in wildlife hazard control measures
in the RSAF. A case study on bird strikes in Elmendorf
Air Force Base, Alaska was also conducted. Overall, the
workshop refreshed the 20 participants' knowledge of
bird hazards and enhanced their understanding and
awareness of the various WHIP programmes.
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19
FOCUS
Fokker 50 MPA in the Gulf of Aden
MAJ Clement Wee, OC, 121 SQN

MAJ Clement is a Fokker-50 pilot who is currently undergoing the command and staff course in Goh Keng Swee Command Staff College. He
held the appointment as an Officer Commanding in 121 SQN during the MPA deployment to the Gulf of Aden in 2011.
A RSAF Fokker 50 Maritime Patrol Aircraft
As part of Singapore's contribution

to the international counter piracy
efforts in the Gulf of Aden (GoA), a
Fokker 50 Maritime Patrol Aircraft (F50 MPA) detachment was deployed
to Djibouti in the Horn of Africa from
April to July 2011 to conduct maritime air counter piracy operations.
The Detachment comprised mission
crew from 121 SQN, logistics personnel from the Singapore Technologies
Aerospace (STAe) F-50 Programme,
ground security troopers from various Field Defence Squadrons and
ground support staff. This was the
RSAF's very first maritime air counter
piracy mission to the GoA and the
first deployment for many detachment personnel to the African continent.
During this three month deployment, the detachment contributed in niche areas and played a significant part
in the multinational effort to counter piracy in the GoA. The F-50 MPA successfully flew 58 maritime air counterpiracy missions in support of the Combined Maritime Force (CMF) and CTF 151. We investigated 3642 vessels
ranging from small fishing and cargo vessels such as skiffs and dhows to large merchant vessels (MVs) including MVs on the Vulnerable Shipping List and MVs that did not conform to the promulgated counter-piracy Best
Management Practices (BMPs). On 13 separate occasions, the F-50 MPA was also dynamically tasked in-flight to
investigate distress calls by merchant vessels and to perform coordinated search with coalition surface forces.
Besides marking our presence through a high mission rate of close to 20 missions a month, the Detachment
also established its standing as a credible, competent and dependable partner in multinational counter piracy
operations. This was testified by regular commendations by the CMF on the quality of the Detachment's post
mission products as well as accolades offered by visiting senior coalition officials. In this deployment, the F-50
MPA detachment achieved mission success, showcased the RSAF's professionalism.
These achievements were not without its accompanying set of challenges and uncertainties. Our key challenges
were in dealing with the harsh semi-desert environment and the unfamiliar operating environment as well as
executing an unprecedented1 extended range operational deployment of the F-50 MPA over 4000nm and across
continents. Uncertainties were also abound in-theatre with real time developments in our operating conditions
including the eruption of Volcano Nabro 140km away in neighbouring Erithrea and ground security developments. These challenges and uncertainties potentially threatened our mission success and compromised safety.
The last deployment of the RSAF F-50 aircraft over such extended distances was during the ferry of the aircraft
from Holland to Singapore in 1993.
20
DEPLOYMENT TO GULF OF ADEN
Counter Piracy Operations -
SIZING UP THE CHALLENGES & UNCERTAINTIES

High Temperatures, Sandy Environment and Strong Winds. The harsh semi-desert environment was characterised by high temperatures, a sandy environment and strong seasonal winds marked by the Khamsin2 wind
phenomenon. The Apr to Jul deployment window coincided with summer in Djibouti with temperatures soaring
into the mid-40oc range. Many detachment personnel were exposed for the first time to operations under high
temperature. The need to sustain operations had to be balanced against the physiological limitations of our
personnel particularly the logistics crew and ground security troopers who spent a higher proportion of their
working hours in the exposed aircraft dispersal. The high temperature also affected operations in the area of aircraft performance. The harshness of the semi-desert environment was compounded by sandy conditions which
presented challenges in regard to aircraft maintenance and reduced flight visibility. Strong winds were also forecasted as part of the annual Khamsin phenomenon in the Jun to Jul period. This raised concerns over the safety
of the parked aircraft particularly after similar strong winds had reportedly tipped aircraft and damaged hangars
at Djibouti Ambouli Airport around the same time a year ago.
Unfamiliar Operating Airfield and Environment. In addition to these elements of nature, the other major
set of challenges revolved around the unfamiliar operating environment. Operating for the first time in Djibouti
and the Gulf of Aden, the Detachment was relatively unfamiliar with the air traffic environment over Djibouti
and the characteristics of our area of operations in the GoA. While the SAF had previously operated in the GoA
and transited Djibouti through the deployment of the RSN's Landing Ship Tank (LST) and the RSAF's Super Puma
helicopters, the operating context for our Detachment was different. Based out of Djibouti Ambouli International
Airport, the non-radar controlled terminal area was of a particular concern due to the complexity of operations
aggravated by high air traffic density and military-civilian mixed operations. Proximity to international airways
and unfamiliar Danger NOTAM areas were the other watch areas. The ground operating environment also posed
its own set of challenges in terms of ground security and movement safety.
Logistics Supportability.
The extended deployment of

the F-50 MPA from Singapore
to Djibouti entailed a significant amount of coordination.
It was a logistical and administrative challenge deploying
the aircraft over the vast Indian Ocean and Arabian Sea,
across the intricate Indian airspace and through multiple
stops. It was critical that the
Detachment harmonised the
many moving parts to ensure
the smooth and safe execution of the deployment for a
timely arrival of the F-50 MPA
in Djibouti.
A Fokker 50 prepares for an early morning

flight operation.
The aforementioned challenges represented known unknowns for the Detachment. However, there remained a set of unknown unknowns
which presented a level of uncertainty. These unknowns were elements which were not pre-empted in spite of
our best effort in preparing for the mission. The eruption of Volcano Nabro was a good example of such unknown
unknowns which the Detachment had to address while in theatre. Such developments, if not handled competently, could pose a significant safety hazard and compromise mission success.
2

21
Khamsin refers to a dry, hot and dusty local wind blowing in North Africa and the Arabian Peninsula. These dry,
dust-filled windstorms often blow sporadically over fifty days.
FOCUS
ROBUST PREPARATION PROCESS

Comprehensive PDSS. A robust preparation process was executed by the Detachment in collaboration with
HQ RSAF and Campaign HQ. The pre-deployment site survey (PDSS) conducted by key stakeholders prior to
the deployment provided the Detachment with an appreciation of the in-theatre operating environment and
details regarding potential challenges. Besides walking the ground for administrative and logistics coordination,
the PDSS team visited the various coalition force detachments based in Djibouti for a first hand account of their
operations. The PDSS team also spoke at length with the coalition forces and local Djiboutian officials about the
challenges posed by the harsh semi-desert environment and the operating environment. This helped to bridge
the Detachment's knowledge gap and addressed the challenge of AO unfamiliarity.
Robust Pre-Departure Preparations. Armed
with better knowledge and awareness of our challenges, the Detachment set out to finalise its preparation for the deployment. In addressing the harsh
semi-desert environment, a heat management matrix for aircraft maintenance crew and ground security troopers was promulgated. Cooling vests were
also acquired to complement this matrix. With regard to the sandy environment, a launch and recovery matrix was promulgated to address minimum
visibility conditions. In addition, the STAe F-50 program actively solicited inputs from the KC-135 programme and Fokker Services and worked with ALD
to promulgate in-theatre desert maintenance proA Fokker 50 departs from the airfield to the area of operations. cedures. Protective covers were designed and fabricated to protect critical aircraft components such
as the engine-intake, propellers, landing gears and cockpit window against sand ingestion, sand-pitting and
material degradation.
Innovation for Enhanced Effectiveness and Safety. The Detachment identified ways to modify the aircraft
and to improve its piracy surveillance and photo-imageries. This led to the installation of camera windows and
the acquisition of a Maritime Automatic Identification System (MAIS). These enhancements significantly levelled
up the F-50 MPA's ability to conduct close-in surveillance and produce high quality imagery of vessels from safe
distances. These changes improved the mission effectiveness of the F-50 MPA in counter piracy surveillance and,
more importantly, enhanced the safety of the aircraft.
Detailed Contingency Plans. Taking the preparation process one level higher,
the Detachment worked closely with HQ RSAF and Campaign HQ to promulgate
drawer plans for various contingency scenarios. This process helped sharpened
the Detachment's planning and decision making mechanism against potentially
disruptive contingencies. Squaring away these known unknowns with higher
HQ raised our preparedness and bolstered our confidence for the deployment.
The rigour of the Detachment's preparations facilitated the commencement of
counter piracy operations just 3 days after arriving in Djibouti. This was an achievement and a measure of the Detachment's operational readiness.
22
Notwithstanding the challenges and uncertainties, the Detachment successfully and safely accomplished its mission. This was made possible by a robust preparation process, deep competencies of our people and a strong
safety culture.
DEEP COMPETENCIES OF OUR PEOPLE

The key to the Detachment's mission success laid in the deep competencies of our people. No amount of preparation would be meaningful without having competent people drive the detachment. The
high standards that the RSAF had enforced in the professional and
personal development of her people had translated into deep competencies which came to play during the Detachment. This was underpinned by a firm grounding in core values particularly in the areas
of professionalism, discipline and fighting spirit.
Building on this strong baseline of deep competencies and core values, the detachment customised its training for counter piracy operations and successfully integrated the F-50 MPA enhancements into its
concept of operations. This enabled the Detachment to level up the
competency of the mission crew to further localise tripwires and piracy indicators such as ropes, ladders and weapons to positively prosecute pirates.
It was also the deep competencies of our people that ensured effective and safe operations in the face of uncertainties. When Volcano
NABRO erupted, the Detachment, in consultation with higher HQ,
A Loadmaster conducting surveillance over
promptly assessed the situation and promulgated a Volcanic Ash
suspicious vessels
Matrix. This matrix considered factors ranging from flight operations
to aircraft maintenance. The matrix served as an important decision
making tool in achieving mission success without compromising safety. The expedient response to the volcano
eruption bears testimony to the deep competencies of our people and the difference it made to the management of challenges and uncertainties.
STRONG SAFETY CULTURE

A strong safety culture underpinned the Detachment's robust preparation process and the deep competencies
of her people. This safety culture steered the Detachment in the management of operations in-theatre. Safety
management tools were used in the conduct of daily operations. The Dirty Dozen Human Factors method was
one useful framework which the Detachment used, focusing on Teamwork, Knowledge, Resources, Communication, Fatigue, Pressure and Stress.
Teamwork, Knowledge, Resources

The Detachment consolidated on the linkages that were established with coalition partners during the PDSS
and opened the door to a wealth of knowledge and resources. This teamwork levelled up the Detachment on the
peculiarity of the local area of operations and enhanced our operational knowledge as well as safety awareness.
When Volcano NABRO erupted, the Detachment worked closely with coalition partners to better understand
their operational and safety considerations. This facilitated the promulgation of the Detachment's Volcanic Ash
matrix which ensured sound decision making for the safe and effective conduct of our missions.
Teamwork with coalition partners was also instrumental in the conduct of counter piracy operations. Having
established a good understanding on the mission capabilities of other coalition maritime patrol operators, the
Detachment worked closely with these operators to optimise the surveillance coverage over the vast expanse
of the Gulf of Aden. This prevented a duplication of surveillance effort and maximised the efforts of the coalition
force. This teamwork created capacity and generated extra resource for the Detachment.
With detachment personnel hailing from different segments of the SAF and defence industry, teamwork also
played an important part in harmonising the roles of the mission crew, logistics crew, ground security troopers
and ground support staff. This facilitated a unity of effort towards the common goal of mission success and the
safe conduct of operations.
23
FOCUS
Communication was critical to

the safe conduct of operations
particularly in a see-and-beseen environment. During the
conduct of surveillance operations in the Gulf of Aden, the F-50
MPA communicated with various
platforms ranging from warships,
ship-based helicopters to other
maritime patrol aircraft. This
helped to enhance the air and sea
situational awareness and played
an important role in airspace deconfliction in the non-radar conCommunication also included collaboration with other foreign forces and platforms
trolled environment. While there
were some initial challenges in
adapting to the various foreign
accents, this was overcome through adherence to communications discipline and procedures.
Communication could not have been more emphasised in the terminal area over Djibouti Ambouli International
Airport. In this non-radar controlled terminal area, ATC controllers relied on the reporting of aircraft position
to ensure separation. This reliance on voice communications had a tendency to result in cluttered comms. To
enhance our flight safety in the terminal area, the Detachment listened out closely on the ATC frequencies, maintained good lookout and leveraged on the F-50 MPA onboard systems to provide a recognised air situation picture. This was augmented by the Squadrons Executive Officer who helped to monitor the ATC frequencies from
the detachments Ops Room for timely CRM.
Communication featured prominently in the Detachment's daily operations. Daily detachment briefs served
as useful platforms for detachment personnel to share lessons and information on their respective areas of responsibilities. These briefs also enabled the detachment leadership to regularly communicate the commanders
intent and to solicit ground feedback. Key lessons learnt were diligently captured by personnel and communicated to their counterparts in Singapore, thereby facilitating a seamless transition during personnel change over.
This communication between in-theatre personnel and across the two frames enriched the learning experience
of the Detachment. This served to enhance our operational effectiveness and the safe conduct of operations.
24
Communication
Fatigue, Pressure & Stress

Fatigue was a key watch area, particularly after the take-off timing for our counter piracy
patrols was brought forward to coincide with
the early morning high piracy threat window
in the GoA. Logistics personnel and mission
crew had to wake up at wee hours of the
morning to support this arrangement. Proper
crew scheduling helped guard detachment
personnel against fatigue and ensured sufficient rest for all. Heat fatigue was another area
of concern. With the mounting temperatures
in summer, the Detachment ensured that heat
management measures which were earlier
identified were diligently followed through.
Flight line crew turning round the aircraft after flight.
The pressure and stress of an extended deployment

o
n
personnel were not discounted. The Detachment regularly organised social interactions and professional exchanges with coalition partners to take the load off work pressure and to de-stress. This helped to upkeep the
morale and psychological well-being of detachment personnel.
CONCLUSION
The F-50 MPA detachment achieved a 100% mission launch rate with zero safety incidents and maintenance deviations. This helped to showcase the RSAF's professionalism. The successful conduct of operations in the Gulf of
Aden, in spite of challenges and uncertainties, testifies to the importance of having a robust preparation process,
deep competencies of our people and a strong safety culture.
The GoA deployment crew posing for a group photo with senior MINDEF and
SAF personnel during the OSM Presentation Ceremony
25
FOCUS
Defence Aviation and Air Force Safety Conference and the Safeskies 2011 Aviation
Safety Conference
The Royal Australian Air Force (RAAF) conducted its Defence Aviation and
Air Force Safety Conference in Canberra, Australia from 24 to 25 Oct 2011.
The theme for the conference was Leadership in Safety and served as
an avenue to strengthen the information sharing and exchange between
the RAAF and other Air Forces. The highlights of the conference included
information on the 2012 Workplace Health and Safety Legislation and
case studies on leadership in safety and topics related to aviation and
ground safety.
Following the Defence Aviation and Air Force Safety Conference, was the Safeskies 2011 Aviation Safety Conference from 26 to 27 Oct 2011 at the same location. This was a biennial international event with the primary objective of promoting and facilitating the exchange of information and opinions between agencies and organisations
involved in aviation safety. The theme for this years conference was Future Growth: Future Challenges. The conference brought together operational personnel from the airlines, defence, government, training organisations,
charter operators, air traffic managers as well as experts from aviation-related fields to facilitate sharing of knowledge and experience in aviation safety.
LTC Alex Cornelius, Head Accident Prevention Branch, in Air Force Inspectorate, represented the RSAF at both the
conferences.
2011 SAFE Symposium

The 2011 SAFE Symposium was held at Reno, NV, USA from 24 to 26 Oct 11. This was an annual international
event with the primary objective of promoting research and development and the exchange of information in
the fields of flight safety, survival and life-support. Participants were kept abreast with the latest developments
and innovations in aircrew protection, personal worn safety and life support survival equipment.
The discussions held during the conference allowed the participants to better understand the issues pertaining
to current aircrew life support and survival equipment issues.
LTC (DR) Benjamin Tan, Head Crew Safety and Flight Environment (CSAFE) Branch in Aeromedical Centre, CPT
Khoo Pak Syn, Staff Officer from Accident Prevention Branch in Air Force Inspectorate, and Mr Chan Beow Koon,
Staff Officer from Life Support Safety Section in Air Logistics Department, represented the RSAF in the symposium.
They were updated on the latest performance and safety issues pertaining to the RSAF in-service life support
equipment. They also learnt about new life support technologies and equipment applicable to the RSAF which
may be procured in the future.
26
SAFETY CONFERENCES
Safety Conferences
WHAT OUR PEOPLE THINK
What Our People Think?

Editors Note:
Commencing from this issue, servicemen and women on the ground will be asked about their thoughts on
the theme and the articles in the FOCUS Magazine. Some of their thoughts and feedback are edited and
published here for sharing. Some of them have chosen to remain anonymous.
To me, the dirty dozen serves as an analysis tool to identify, investigate and internalise (the 3Is) HF related
causal factors or issues. It allows my SQN safety office to better analyse the HF causal factors in line with AFIs
HFAM model.
The Dirty Dozen can also be used as a safety mechanism for the prevention of HF errors. Personnel can use
the Dirty Dozen during their daily work cycles to look out and prevent themselves or others from being
victims of HF Errors.
Some examples are follows: Am I equipped to carry out the mission? Do I have the sufficient resources and
knowledge? (Using Lack of Knowledge and Lack of Resources) Am I felling tired today? Am I in the right
frame of mind to fly? (Using Fatigue or Stress or Pressure)
CPT Ashley Jude Peterson

USO, 112 SQN
Coming from a unit where 70% are full-time National Servicemen, the concept of Dirty Dozen is applica-
ble in every part of our work. It was observed that most of the discussions and presentation topics we had on
the units safety day were surrounding the Dirty Dozen. Since most of our incidents/accidents occured during Motor Transport (MT) vehicular movements, especially during administrative phases, the Dirty Dozen is
often highlighted, especially on the Lack of Situational Awareness, Complacency and Lack of Communication.
The Dirty Dozen is a list of factors/reasons related to human factors which lead to incidents or accidents.
Lacking situational awareness for drivers and vehicle commanders often lead to MT incidents/accidents. Our
unit recently had one due to both the driver and vehicle commander not having the situational awareness.
Communication is also emphasied to all when the crew is carrying heavy equipment for deployment training. This is because the lack of communication will lead to injuries to personnel.
As most of the case studies from outside the unit were related to aircraft maintenance, extra effort is often
needed to link the lessons learnt back to our day-to-day taskings. Hence, I find the Dirty Dozen to be easier
and more useful.
CPT XXX XXX XXX

18 DA Bn
27
FOCUS
WHAT OUR PEOPLE THINK
Dirty Dozen is one of the tools the RSAF uses to identify, investigate and analyse HF related incidents/accidents. We have incorporated the Dirty Dozen in our Continuous Trade Learning to help us identify the lessons learnt from the past incidents/accidents so as not to repeat the same mistake. Always learn from others
mistake and not your own mistake.
ME2 XXX XXX XXX

HQ APGC
Dirty Dozen is one of the first few safety tools or phrases introducted to me when I signed on a decade ago.
Everyone, including me, in the aviation line know and is familiar with it but how many people actually remember or apply it? Personally, I feel that if our people remind themselves subconsciously every time when they
are doing their job it will definitely reduce Human Factor related errors. It may seem to be a simple slogan/tool
but it certainly helps us even in our daily life in reminding us that we are always subjected to one if not many
of the Dirty Dozen. It is just like driving on an expressway without cars, we tend to speed and forget about
the speed limit as it is a norm.
ME2 Ken Ong Ti Ching
CSS, PC
As we know, the Dirty Dozen is about the 12 common human factors that contribute to most of the accidents in the aviation world. Most of us will assume that we will not fall prey to the Dirty Dozen. If we turn
the pages of aviation accident history, we will be surprised to learn that, in fact, the most experienced and
most qualified personnel have committed simple mistakes that had led to devastating accidents. Therefore,
these human factors have to be dealt with seriously. Proper training emphasizing these effects of the human
factors has to be conducted to prevent accidents. Although the RSAF has a strong safety culture, with numerous safety nets in our system that is complete with established processes and procedures, we should not be
complacent.
ME2 Ramesh Kumar

Safety Spec, 201 SQN
Frankly, remembering or memorising the dirty dozen is not easy as there are 12 of them. However, it helps to
know that the word dirty reminds us that these things can creep in without us knowing and eventually, the
consequences hit us really hard. The monthly case studies on the dirty dozen provide good food for thought
and also remind us that we cannot be nonchalant when going about our daily duties even though weve done
it umpteen times.
Ive never applied the Dirty Dozen in my daily course of work but rather more of the RSAF Core Value SAFETY. Safety must be internalised in everyone as we need to work safely for ourselves and our comrades.
Imbuing SAFETY will eventually lead us to not fall into the DIRTY hole of the DOZEN.
2WO Subramaniam S/O Thaburan Rangasamy

Ops Warrant, HQ DAG
28
CROSSWORD PUZZLE
* Answers can be found in this issue of FOCUS
Email your answers with your Rank/Name, NRIC,

Unit and Contact details to 2WO Steven Goh before 02 March 2012.
All correct entries will be balloted and 3 winners
will receive a $30 Popular Voucher each.
The crossword puzzle is open to all RSAF personnel except personnel from AFI and the FOCUS Editorial Board.
29
FOCUS #69 Quiz Winners

1. PTE Teoh Yi Chao
ATD
2. ME3 Loh Lan Mee
203 SQN
3. CPL Michael Alexander Chee
AMD
FOCUS
OUR HISTORY
FOCUS
.... Changes Over The Years
1978 - 1986
Our first edition of FOCUS magazine was printed in 1978 by the then
Accident Prevention Office. At that time, FOCUS was published on an
adhoc basis only.
1986 - 1990
First change in our front cover design. The magazine was published
regularly on a quarterly basis. However, its cover and contents took
on differnt and various styles and layouts.
1990 - 1994
Second change in our front cover design. The magazine began to
adopt a consistent layout and style. A running issue number was also
used to keep track of the magazine.
1994 - 2002
Third change in our front cover design. The overall design of the
magazine also moved from the newsletter format to a more magazine format and style.
2003 - 2011
Fourth change in our front cover design. The layout of the magazine
has also became more colourful and vibrant. Specific safety theme
was also adopted for each issue.
30

Focus: The Dirty Dozen

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FOCUS

Republic of Singapore Air Force Safety Magazine

The Dirty Dozen

FOCUS Issue 70 - January 2012

Front Cover Image: A showcase of the

COL Aw Kwee Siong

LTC Danny Koh

COPING WITH STRESS

MAJ Mike Chua Kim Sai

Graphic / Layout Design

2WO Steven Goh

FOCUS is published by Air Force Inspectorate, HQ

The Dirty Dozen

FOCUS magazine is available on these sites:

RSAF Safety Magazine Issue 70 | January 2012

By COL Aw Kwee Siong

What Our People

Cross Word Puzzle

$30 Popular Voucher to be won

THE DIRTY DOZEN

The Dirty Dozen

: Self-satisfaction accompanied by loss of awareness of the potential dangers

: Lack of experience or training in the task at hand

: Drawing ones attention away from a task

: Lack of working together to achieve a common goal

: Weariness from labor or exertion, nervous exhaustion or the temporary loss

: Failure to use or acquire the appropriate tools, equipment, information and

: A lack of positive communication of ones ideas, wants and needs

: Mental, emotional or physical tension, strain or distress

: Failure to be alert or vigilant in observing

RSAF Safety Magazine Issue 70 | January 2012

From a physiological standpoint, stress

Mental preparation before flight can help to relief some level of

RSAF Safety Magazine Issue 70 | January 2012

MANIFESTATIONS OF STRESS AND ITS EFFECTS OF PERFORMANCE

RSAF Safety Magazine Issue 70 | January 2012

Photo courtesy of CPT Khoo Pak Syn

Figure 2. The Yerkes Dodson Law, 1908

Difficulty concentrating and reduced vigilance - easily distracted

Errors, omissions, mistakes, incorrect actions, poor judgment and memory

Either slowness (due to lack of interest) or hyperactivity (due to adrenaline)

Focusing on easily manageable details while ignoring serious threats

Tendency to pass responsibility on to others

Fixation on single issues or even a mental block

Unwillingness to make decisions - decisions are postponed or take longer to make

Fewer plans and backup plans are made

How Can We Manage Stress?

Physical signs: cold, sweaty hands, headache, tension.

RSAF Safety Magazine Issue 70 | January 2012

In addition to the above 2 strategies, the management of chronic

Ensuring optimal health and fitness. This includes getting

Ensuring adequacy of knowledge and currency of training.

At the management level

While the above mentioned are the more recognizable

It is also crucial to always keep active ones sensors in trying

Stress is a physiological and cognitive response to a stressor which generates alertness.

In excess, stress results in numerous physical and mental side effects.

RSAF Safety Magazine Issue 70 | January 2012

508 SQN, CAB (W) and Flight Test Centre

Jointly Contributed by:

DISTRACTION - A CLOSER LOOK

DEALING WITH DISTRACTION

RSAF Safety Magazine Issue 70 | January 2012