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1JHSAT - January 2007

JHSAT StatusJanuary 2007

JHSIT Kickoff meetingAHS – Alexandria, VA

Mark Liptak FAA ANE-110


JHSAT Goal:

Provide intervention strategies to the IHST and Joint Helicopter Safety Implementation Team (JHSIT) that maximize the likelihood of reducing worldwide helicopter accident rates by 80 percent by 2016.


Basic CAST ProcessCAST (IHST)Charters Activity

JSAT (JHSAT)Analyzes DataProposes most

effective interventions

JSIT (JHSIT)Assesses feasibility of

interventions works implementation

Continued data analysis,measure intervention

effectiveness


JHSAT Team Membership:

Mark Liptak – FAA ANE co-chair Jack Drake – HAI co-chair

Joan Gregoire - Turbomeca Steve Gleason - Schweizer Helicopters

Roy Fox - Bell Helicopter Ron Luhmann - Silver State Helicopters

Tony Alfalla - Sikorsky Ray Wall & Tom Fleming – Bristow Group

Sandra Hart - NASA Barry Rohm - Rolls Royce

Laura Iseler AHS/NASA Clark Davenport & Matthew Rigsby – FAA ASW

Ed Stockhausen & Joe Lemma – Airmethods

Joe Syslo & Lindsay Cunningham – US Eurocopter


JHSAT Web Site

http://www.ihst.org/jhsat/jhsat_top.htmUser id – jhsat, password – helicoptersafe

Contents:

JHSAT charter and process docsDataset detailsMeeting minutes/agendaPresentationsInterim RecommendationsResource documents

Not open to the public, restrict access for JHSIT needs only

http://www.ihst.org/jhsat/jhsat_top.htm


JHSAT Status

Data Analysis

Engaging with the international community

Near term safety recommendations


Data Analysis


JHSAT currently working process areas highlighted in yellow

CharterDevelopment

EstablishTeam

Select Data Set

ReviewNTSB

Docket Data

DevelopEvent

Sequence

IdentifyProblems

(what/why)

Assign StdProblem

Statements

ScoreProblem

Validity &Importance

Identify InterventionStrategies

ScoreInterventionAbility/Usage

Categorize and Prioritize Data

TechnicalReview

&Expert

Validation

Conflicts? ReportResults

No

Yes

IHST

JHSITCurrent task


SPS No

Popping noise Engine power loss Exhaust valve failure - root cause not determined

24010 engine component failure

Mandate Textron Lycoming SB388B to reduce liklihood of exhaust valve failure

4 4 3 3

Overflew wires, then crashed onto street in nose low, left skid low attitude. Nosed downward and turned CCW

Improper autorotation or loss of control?

Lost of control when making emerg/auto to street

21074 pilot control/handling, inadequate autorotation

Autorotation training aids, simulators etc

3 4 3 2

Pilot had 3.2 hours in R22 last 90 days; marginal autorotations on Com-helicopter check 3.5 mos before acdt.

Lack of recent experience in M/M and with autorotations

13071 Transition to aircraft make/model

Develop company policy and training rqts for pilots transitioning between m/m

4 3 3 3

Pilot had 67 hours in helicopters.

Lack of total helicopter experience

13070 Pilot transition training model specific simulator training

4 3 2 3

Pilot intentions and actions unknown. Flight/systems information unkown.

Lack of information - flight and systems information

41020 information unavailable to investigators

cockpit recording devices

4 4 4 3

Event/Conditions Problem (what) Contributing Factor (why)

Standard Problem Statement

Intervention Recommendation UV I A

Sample of event processing


Data Analysis:The JHSAT team is currently processing 195 accidents from the NTSB year 2000 database

The accident data has been downloaded from the NTSB (~4000 files)

For each accident the JHSAT performs the following:reconstruct the sequence of eventsidentify what went wrong and why it went wrongassign an appropriate problem statementidentify appropriate corrective action(s)score findings based on validity, importance, ability

and usage


Data Analysis Status:To date the accidents analyzed have covered a wide spectrum of helicopter types and operations.

The team has currently completed 187 of 195 accidents

1200+ scored problem statements/intervention findings have been developed

JHSAT currently doing some “cleanup” work, will start categorization and prioritization work at our Feb meeting

Expect to offer recommendations for all major operational groups in the helicopter community


Validity - How valid do we think the Problem Statement is in this accident based on the available accident information?

Range:Guess = 0 Absolutely Sure = 4

Importance - How important is this particular Problem Statement in the causal chain in this accident?

Range:No importance = 0Cause of accident = 4

Ability - How well can this particular Intervention mitigate the cause or contributing factors of this accident scenario?

Range:No effect on Problem Statement = 0 Would Prevent Problem Statement = 4

Usage – Given this accident scenario, how confident are we that this Intervention will be utilized and will perform as expected in the real world?

Range:No Utilization = 0100% Utilization = 4

JHSAT Scoring Criteria


Primary Ops SecondaryAerial Application External Load Aerial Observation/patrol TrainingAir Tour Positioning/RTBSightseeing FerryBusiness - company owns a/c Air Taxi - Cargo (135)Corp/Exec - dedicated pilot Air Taxi - Passenger (135)EMS Cargo (91)ENG Public UseFirefighting Maintenance/Test flightInstructional/Training Evaluation flightLaw EnforcementLoggingCommercial OperatorExternal Load OffshoreOther Aerial Work Personal/PrivateUtilities - Patrol & Construction

JHSAT Operational Categories (as of 1/07, still being worked)


JHSAT Intervention Frequency

11

12

22

36

42

55

61

71

106

173

211

0 50 100 150 200 250

Enhanced CFI rqts

Disciplinary Action

Enhanced Reg Rqts/Guidance

Enhanced Maintenance Proceedures

Improved Data/Info to Pilots w x/lz/etc

New In Cockpit Systems/Warnings

Formal Risk Process & Oversight

Enhanced Data Recording

Improved Operational SOPs

Training

Better Crew Decision Making

Snapshot after analysis of 90 accidents

15JHSAT - January 2007 Snapshot after analysis of 90 accidents


Engaging with the international community


Worldwide Helicopter Accidents/Year

1980 - 2005

0

100

200

300

400

500

600

700

800A

ccid

ents

/yea

r

US Civil Registry Non-US Civil & Military US Military & USCG (ABC)


Engaging with the international communityThe preceding slide shows worldwide accident trends for the last 26 years. The criticality of working with the international community to reduce worldwide rates is readily apparent since the US accounts for only 35 to 40% of accidents on an annual basis.

On-going efforts to identify other partners from Asia, South America, Oceania, etc.

The JHSAT team is developing contacts and coordinating this activity. Matt Rigsby from FAA-ASW will be acting as the contact point for identifying overseas and military partners.

Any entity that possess large helicopter accident datasets that could be processed by the JHSAT method should be considered.

EASA and Canada moving toward partnering with us in this process.

mailto:[email protected]

mailto:[email protected]


Engaging with the international communityA structured approach will be used to manage the analytical and implementation work sponsored by the IHST.

Key attributes:

All recommendations will be data driven

Regional ownership - Data is owned and analyzed by those most familiar with it. Safety recommendations will be implemented by teams most familiar with local needs.

JHSAT and JHSIT lead teams will be responsible for training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness.


JHSAT/JHSIT

cross-talk

IHST Safety InitiativeAnalysis, Implementation and Metrics Management Structure

IHSTExecutive Committee

JHSATLead Group

JHSITLead Group

Canada JHSAT

EASA JHSAT

Canada JHSIT

EASA JHSIT

Region X, Y, Z JHSIT

US/CAN/EASA Consolidated

Recommendations

JHSAT sends recommendations to JHSIT

US/CAN/EASA/X,Y,Z Implementation

Results

Need to maintain a strongcommunication/feedback loopbetween IHST – JHSAT - JHSIT

Process development usingUS NTSB datarepresents 48% ofworldwide fleet

Measure Accident Reductions

Effectiveness

Measure Implementation

Effectiveness

Regions X, Y, Z defined as those pockets of operation not ableto staff a full JHSAT team and are willing to work implementation of US/CAN/EASA findings to benefit their fleets

Others?

ALEA groupEMS group


JHSAT Lead Group Analysis of

International DataMatt Rigsby is JHSAT POC Seeking data rich partners Preliminary discussions with: Canada EASA (CAA-UK, France BEA) Brazil (contacted, no reply) NZ (contacted, no reply) Australia Chile Canadian Military USN Near-term: bring Canada on-line as a test case Consider EASA next Interim Goal: have Canada/EASA present status at the 2007 IHSS Symposium in Montreal Demonstrate that this is an international effort, and it has momentum

JHSIT will also have international partnermanagement responsibilities: custom tailored regional solutions coordinated with JHSAT coordinated with IHST

IHSTOutreach/Marketing

Emerging FleetsSomen is the IHST POCIdentify emerging/high growth marketsDevelop strategy to: Foster participation Benefit from IHST knowledge baseCandidates: China India CIS?

Engaging with the International Community

JHSIT Lead Group Implementing

Regional Solutions


US CivilDataset

Selection (1/2 of

helicoptersWorldwide)

JSAT ProcessUnderstanding

RefiningJHSAT

Analysis

IdentifyFCAA &MilitaryPartners

Train FCAA &

Military Partners in JHSATProcess

FCAA & Military Partners conductJHSAT

analyses on their

accident data

Expert Review/

Validation

MitigationRecs - Global

MitigationRecs

FCAA & Mil

Coordinating JHSAT US and International Efforts

First SetUS Mitigation

RecsMar/Apr 06

May/June 06May-Jan 07 Apr 07

2Q 07

1Q 08

TBD 08TBD 07/08TBD 06/07

Sept 06

TechReview

Feb 07

IHST

JHSAT is now working to bring EASA and Canada into the process

Current task

Current task


Potential Barriers:

JHSAT:Variation in dataset quality, definitions, etc, around the world may make use of a standardized JHSAT approach more difficult.

Military data may not be available.

Lack of fleet hours will complicate ability to measure results.

Regional teams may be difficult to staff with sufficient level of expertise representing manufacturers, operators and regulatory interests.

JHSIT:Regional operations and regulations may make some implementation actions difficult.


Offering near term safety recommendations


Interim recommendationsReports reviewed by the JHSAT:NASA - U.S. Civil Rotorcraft Accidents, 1963 Through 1997NASA - Analysis of US Civil Rotorcraft Accidents from 1990 to 1996 and Implications for a Safety Program NASA - ASRS Rotorcraft Incident Study - Draft Data Summary Aviation Safety Reporting SystemNASA - Helicopter Accident Analysis TeamAMPA - A Safety Review and Risk Assessment in Air Medical TransportCRS - Report for Congress - Military Aviation SafetyOGP - Safety Performance of Helicopter Operations in the Oil and Gas Industry - 2000 DataTSB Canada - Lessons Learned from TSB Investigation of Helicopter Accidents (1994 - 2003)Bell Textron - History of Helicopter SafetyOther NTSB and international reports may be considered.

The JHSAT has identified important recommendations from a series of existing helicopter safety reports. (listed on the next slide)

These recommendations were submitted to the IHST in November so that the JHSIT would have several well founded general recommendations to work with.

The JHSAT plan to issue its full set of analytical results by 2Q07.


JHSAT interim recommendations:

1. – Promote the adoption of Safety Management Systems in the helicopter community.

2. – More consistent and comprehensive NTSB involvement and investigation needed in helicopter accidents.

3. – Reestablish the collection of worldwide helicopter fleet hour data as previously performed by the FAA.

4. – Establish a helicopter safety website to disseminate important information

5. – Use proximity detection equipment in helicopters.

6. – Use flight recording devices and cockpit image recording systems in helicopters.

7. – Develop a strategy to improve pilot Aeronautical Decision Making.

(NB: this listing is not intended to indicate prioritization)


Questions?

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