Safety Enhancement in Helicopter Operations

IHST Latin American Regional Conference

Sao Paulo , Brazil

Somen ChowdhuryExecutive Committee Member, IHST

VP Internationl, AHS

Contents

• Why IHST : Background• Objectives, Goals & Implementation• Safety : in Design, manufacturing &

operations - Every Step of the Way• IHSS 2005 Montreal Conference • IHST Regional Cooperation• IHSS 2007• Conclusions

Background: Current State of Affairs

Too many Accidents ~ 565/year worldwide Lives lost Poor Public imageBusiness loss Injuries Too expensive

UNACCEPTABLE

PumaCrash.wmv

24,294 Worldwide Civil Helicopters

Worldwide distribution by country

India (140)0.53%

South Africa (563)2.14%

Germany (698)2.65%France (796)

3.03%England (1080)

4.11% Canada (1801)6.85%

Brazil (435)1.65%

Australia (1215)4.62%

Others (4386)16.67%

New Zealand (642)2.44%

Mexico (368)1.40%

Japan (799)3.04%

Italy (642)2.44%

United States (12743)48.44%

Six Years Data2000- 2005

• Civil & Military uses

– 3049 accidents– 2643 fatalities– 1027 serious injuries– 5439 minor/ no injuries

Worldwide Helicopter Accidents/ year

1980-2005 Worldwide Helicopter Accidents/Year

1980 - 2005

0

100

200

300

400

500

600

700

800

Ac

cid

en

ts/y

ea

r

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

Source : Roy Fox Bell Helicopter

Accidents rates per 100,000 hr

• As per AUA ( Mike Kriebel):– 2,225,000 total helicopter hours in USA in

2004– Accident rate per 100,000 flight hours : 8.09– Fatal rate 1.48– Turbine civil accident rate : 5.11– By contrast : U.S. Air carrier rate : 0.159

• US data shows no change in rate over 24 years

Need to bring down helicopter accident rates

Bell civil turbine accident causes worldwide (1994-2003)

Airworthiness14%

Non-AW (human, etc.)74%

Unknown12%

Source : Roy Fox, Bell Helicopter Textron

Causes of Accidents

• Bell Civil turbine accident causes world wide (Pie chart)

– Non Air worthiness ( Human) 74%– Unknown 12%– Airworthiness 14%

Accident status in SAM countries

• SAM: covers South, Central and Carribean countries

• Reference ICAO report 297- AN/171presented in ICAO conference RAAC/9 , Santiago Chile 2005

• Data primarily discusses large transport aircraft accidents

• Conclusions of report generally valid for helicopter operations

SAM countries ( contd)

• 1992 – 2001 ( 10 year period) Transport A/c accident dataAsia-Australia 26.8% of all accidents

Europe 21% of accdnts 29% of oprns

N.America 20.5% of accdnts 42% of opns

Central &S. America 16.8 % vs 9%

Africa 14.5%

ICAO Conclusion : accidents 3.8 times more likely in Latin American countries than in

USA & Canada

SAM countries (contd)

• ICAO statistics (297 AN/171 ADREP) mentions hull losses in the region is 2 to 3 times world average (from 1993 to 2002)

• Flight Safety Foundation suggests a risk multiplier of 5 be considered for CFIT for Central & S American airspace compared to Australia /N Zland /US & Canada

ICAO report conclusions

• Air cargo operations hull losses have tripled from 1993 to 2002 world wide : accidents 22 times more frequent than passenger operations

• Cause : Less attention paid; operational hours are different; older fleet

• Helicopter accidents are frequent ( do not have separate numbers)

• Main causes: Human Factors, maintenance, operational issues, situational awareness, training

• Helicopter accidents globally about 50 times more than passenger transport aircraft

Less attention and lack of enforcement of safety practices seem to be the primary cause of increased accidents

The Real Challenge Iceberg Theory

Hidden or Unseen Conditions are Below The Surface

The BIG Picture

1

300

1200

10

Heinrich Ratio

Serious Incidents

Accidents

Incidents

Near Misses

The ‘Swiss Cheese’ Model

Some holes dueto active failures(present in use)

Other holes due tolatent conditions

(present, not visible)

Successive layers of defenses, barriers, & safeguards

Hazards

ACCIDENT

Barriers areSafety Nets

When barriers fail

The Danger…

- is all around us!!!

Goals & ImplementationNeed to Act

• Can the industry do better ?

• How ?

• Need a mitigation Strategy

Need to Act

• Helicopter operations are essential• There is a need to have a

comprehensive hard look as to how we operate and do business

• There is an absence of any concerted plan so far

• IHSS 2005 was held in Montreal to kick – off the accident reduction process

CAST (commercial aviation safety team) was considered a good model to follow

IHSS 2005 Montreal Conference

• Four day program– Training Sessions

• Management• Military• Maintenance

– Invited Speakers– Paper sessions

• Military & Civil missions• Human Performance &

Training• Design & Maintenance• Accidents & Regulation• Management & Economics

– Discussion panels – Plenary session

• Results–Attendance ~250–International

• 13 countries • 5 continents

–Industry wide• Government

•Regulatory•Accident Investigators

• OEMs• Mission groups• Operators•Pilots•Maintainers•Aviation PressIHST set up

IHSTMission

To provide government, industry and operator leadership to develop and focus implementation of an integrated, data-driven strategy to improve helicopter aviation safety worldwide, both military and civil.

VisionTo achieve the highest levels of safety in the international helicopter communities by focusing on appropriate initiatives prioritized to result in the greatest improvement in helicopter aviation safety. Goal

To reduce helicopter accidents by 80%By 2016

Executive Committee

IHSTIHST

JHSATJHSAT JHSITJHSIT

Subcommittees Subcommittees

Secretariat

IHSTOrganisation

JHSAT - Joint Helicopter Safety Advisory TeamJHSIT - Joint Helicopter Safety Implementation Team

Implementation:Process

Influence Safety Enhancements -

Worldwide

DataAnalysis

Set SafetyPriorities

Achieve consensus onpriorities

Integrate into existing work and distribute

Implement Safety Enhancements - U.S.

Agree onproblems and interventions

Charters Joint Helicopter Safety Analysis Team (JHSAT) Charter:

Conduct, review and analyse accident report and identify causal factors;

Investigate and recommend improvements and develop mitigation strategies to meet 80% goal ; periodic status measurements;

Draft action plans to determine intervention strategies and milestones for IHST approval.

Joint Helicopter Safety Implementation Team (JHSIT) Charter:

Develop and prioritize implementation plan;

Carry out rigorous cost-benefit analysis for implementation strategies to achieve IHST goals;

Develop action plans;

Coordinate implementation of IHST-approved strategies;

Develop and track performance; Determine progress in meeting major milestones and effectiveness of

interventions.

Buy-in Worldwide: Government, Military & Civil Groups, OEMs

• USA– AHS - American Helicopter Society

International– AAMS - Association of Air Medical Services– FAA - Federal Aviation Administration – FSF - Flight Safety Foundation Inc.– HAI - Helicopter Association International– NAVAIR - U.S. Navy - Naval Safety Center– NTSB - National Transportation Safety Board– U.S. Army Combat Readiness Center

• Europe– BEA - Bureau d'Enquêtes et d'Analyses pour

la Sécurité de l'Aviation Civile

– EHA - European Helicopter Association

• Canada– TCCA - Transport Canada Civil Aviation– TSB - Transportation Safety Board of

Canada

• India, Australia & now Brazil & Latin America (ABRAPHE, CENIPA)

USA

BellBoeingSikorskyRRPratt & WhitneyHoneywell

EuropeEurocopterAugusta-WestandTurbomeca

CanadaCHC Helicopters

Brazil : Petrobras,Lider

Need all operators to buy-in

D

(OEM) Original

Equipment Manufacturer

OEM

OEM

OEM

Approach

• How do we achieve the best decisions?

• Regulatory obligations

• Voluntary Actions

Regulation

Regulation = An enforced rule of conduct

• Tells industry: What to do / What not to do• Outlines legal Obligations & authorities• Assumes the industry will by default not comply• Directed towards meeting public expectations• Elements of posturing

• New Approach : sharing of responsibilities

Voluntary Compliance

In the interest of one’s business, lives and efficiency of operations

• Develop a voluntary code of conduct : reflects maturity of the industry

The Safety management system

• Need to Outline a plan• Will be a proactive system• Will be documented• Will have a safety oversight system• Training• Quality Assurance• Emergency preparedness• A closed loop corrective system

Product Life CycleDesign

Manufacture

Operations

Maintenance

Modifications & Repairs

ContinuingAirworthiness

Design FieldOperation

Airworthy

Product

S M S S M SS M S

3 years 20-30 years

SafetyFailure Prevention

technologies

Reliability-anti corrosion

-- reduce vibration

Survivabilitytechnology-ext. airbag

-Crash worthy seats& fuel tanks

-- floatation gear-- egress

Quality Assurance- No Flaw

Operational regulations Maintenance

Human Factors-Training of all parties

--Pilot aids-Mission comprehension

Manufacturing

Safety: Every Step of the Way

IHST StrategyContinuing Airworthiness

Short term

Action

Design• Failure Prevention Technologies

– Fail safe design vs safe life design/ CPR for evolutionary design– Composite structures : prevents catastrophic failures– HUMS : DPHM; embedded sensors

• Reliability– Corrosion control– No single point failure for critical components : 10-9

probability– FMEA

• Survivability– Energy absorbing seats– Crash worthy fuel tanks– Energy absorbing structures– egress

RETURN

DESIGN

ENGINEERING MAINTENANCE

SYSTEMS STRUCTURES SYSTEMS STRUCTURES

STRUCTURALMAINTENANCE

REQUIREMENTS- Damage Tolerance Insp.

- Safe Life ComponentRetirements

SYSTEMS/POWERPLANTSMAINTENANCE

REQUIREMENTS- Maintenance Significant Items

(MSIs)

STRUCTURALMAINTENANCE

REQUIREMENTS- Structure Significant Items

(SSIs)

MANUFACTURER- Servicing

- Maintenance Tasks- Repair Instructions

- Components Manuals- Inspection Techniques

- Troubleshooting- Tooling

- Etc.

ICAs

MAINTENANCEREVIEW BOARD

REPORT

Functional HazardsAnalysis (FHA)

Systems Safety Analysis (SSA)

- Candidate CertificationMaintenance Requirements (CCMRs)

- Major Futur Consequences

Certification MaintenanceRequirements (CMRs)

AIRWORTHINESSLIMITATIONS

Probability and Severity Relationships

EF

FE

CT

ON

AIR

CR

AF

T A

ND

OC

CU

PA

NT

S

Normal Nuisance Operatinglimitations;emergencyprocedures

Significant reductionin safety margins;difficult for crew tocope with adverseconditions:passenger injuries

Large reductio insafety maragins; crewextended because ofwork load or environ-mental conditions,serious injury ordeath of small num-ber of occupants

Multipledeaths,usually withloss ofaircraft

FA

R 2

5P

RO

BA

BIL

ITY

(RE

F.

ON

LY)

PROBABLEEXTREMELY

IMPROBABLE

JAR

25

PR

OB

AB

ILIT

Y

PROBABLE

REASONABLYPROBABLE

EXTREMELY

IMPROBABLE

CA

TE

GO

RY

OF

EF

FE

CT

MINOR MAJOR HAZARDOUSCATA-

STROPHE

IMPROBABLE

IMPROBABLE

FREQUENT REMOTEEXTREMELY

REMOTE

100 10-1 10-2 10-3 10-4 10-5 10-6 10-7 10-8 10-9

Failure risk mitigation strategy

HAZARD SEVERITY  

HAZARDPROBABILITY

  Catastrophic

Level 1

 CriticalLevel 2

 Significant

Level 3

 Negligible

Level 4

Frequent – Level A 1A = EXTREMELY HIGH

2A = EXTREMELY HIGH

3A = HIGH 4A = MEDIUM

Probable – Level B 1B = EXTREMELY HIGH

2B = HIGH 3B = MEDIUM

4B = LOW

Occasional – Level C

1C = HIGH 2C = HIGH 3C = MEDIUM

4C = LOW

Remote/Seldom - Level D

1D = MEDIUM 2D = MEDIUM 3D = MEDIUM

4D = LOW

Improbable/Unlikely - Level E

1E = LOW 2E = LOW 3E = LOW 4E = LOW

Manufacturing

• Flawless manufacturing– Reduce MDRs– Improved inspection technologies– Reduced variability

RETURN

Monitoring of Fielded Systems

• Service Difficulty Reporting System (SDRS)

• Computerized Airworthiness Information System (CAIS)

• Civil Aviation Daily Occurrence Reporting Systems (CADORS)

Murphy’s Law No. 3If anything can possibly

go wrong, it will!

MAMA

MIA !

Murphy’s Law No. 8

By making something perfectly clear, someone will be totally confused!

???

Field & Flight OperationsHuman Factors

RETURN

The door opened in flight!

Human Factors is cause of 75% accidents

It is critical to enhanced safety

Need to integrate HF in maintenance

Provide smarter maintenance aids

Provide increased situational awareness inputs to pilots

IHST Regional CooperationInternational Cooperation is essential

– Regulators– Operators– OEMS

In all regions of the world.

We started with S Asia, Australia then BrazilGo to: S.Africa, Middle East, JapanRussia

We are all in it together

IHSS 2007• Montreal• Dates –September 19 to 21, 2007• Action Plan from JHSAT, JHSIT • Report on worldwide participation

Pictures from www.tourisme-montreal.org

Conclusions

• Need to act urgently in improving the safety of helicopter operations

• Important area of focus is human factors and situational awareness

• Get involved in the IHST process• Accidents can be avoided : need to set up

the right process• The present accident rates in the

helicopter industry are unacceptable

Questions?

Please check out the IHST website:

www.ihst.org

Thank you