Safety Enhancement in Helicopter Operations

IHST Regional Conference

Delhi, IndiaHosted by DGCA, COSCAP SA & RWSI

Somen ChowdhuryExecutive Committee Member, IHST

VP Internationl, AHS

Contents

• Why IHST : Background• Objectives, Goals &

Implementation• Montreal Conference IHSS 2005• IHST Regional Cooperation• Safety : Every Step of the Way• IHSS 2007• Conclusions

Background: Current State of AffairsToo many

Accidents 2005- 565/year worldwide Lives lost Poor Public imageBusiness loss Injuries Too expensive

UNACCEPTABLE

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%

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

Accident rates in India

Source: RWSI : AVM Sridharan

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

• Data shows no change in rate over 24 years

• India rate: distributed average @ 400 hrs/yr– 8.9 per 100,000 hrs for 2004

Need to bring down helicopter accident rates

Aircraft issues14%

Non-AW (human, etc.)74%

Unknown12%

Unknown5%

Aircraft issues

32%

Non-AW (human,

etc.)63%

Civil Helicopter Accident, IndiaSource: AVM Sridharan, RWSI

Bell Civil turbine WorldwideSource: Roy Fox, Bell Helicopter Textron

Comparative Accidents Data

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 Danger…

- is all around us!!!

Need to Act

• Can the industry do better ?

• How ?

• Need a mitigation Strategy

IHSS 2005 was held in Montreal to kick- off the process

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

IHST Organisation

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

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

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

IHST Regional CooperationInternational Cooperation is essential

– Regulators

– Operators

– OEMS

In all regions of the world.

We start with S Asia

We are all in it together

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

Survivabilitytechnologies-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 Continuing

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– Pilot situational awareness technolgies for operational risks

• 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 capability

RETURN

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

RETURN

Field OperationsMaintenance

Definition:

A periodic maintenancetask established during the certification of the aircraft as an operating limitation of the type design certificate.

RETURN

Continuing Airworthiness Function

Airworthy:

In respect of an aeronautical product, in a fit and safe state of flight and in conformity with the type design

Field Operations• Continuing Airworthiness :

– fielded aircraft must meet regulatory compliance to retain certificate of AW : specified through ICAS

– Compliance with service bulletins and directives – Develop a SDR system : electronic data base (ICAO

Annex 8 Part II chapter 4, paras 4.3.5 & 4.3.6)– Develop common data base; FAA, TCCA, Australia

are already engaged in the process– Reliable data base is key to mitigation strategies– Country of registry needs to develop a strong

engineering group overseeing CAW activities – coordinate with OEM and certificating state– Must share incident data and failed components with

OEM immediately

Develop trust: Safety is everyone’s responsibility ; OEMs know their aircraft best

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

Need to Provide increased situational awareness aids to pilots

IHSS 2007• Montreal• Dates –September 17 to 20, 2007• Action Plans from JHSAT, JHSIT will be discussed• Report on worldwide participation

Conclusions• Safety is a way of life : Safety is to be

practised at every step: all the time• Need to develop safety management systems• We need to reduce helicopter accidents : meet

the 80% reduction goal• Short term focus : operations and human

factors• Continuing airworthiness is critical to the

process• Need reliable data; accident investigations

must be done by an independent body• Support the IHST initiative

Recommendations

• Create independent safety boards in each country; reporting to parliament. Need to ensure accident findings are unbiased

• Develop continuing AW organisation with strong understanding of the engineering of the product.

• Develop a worldwide common SDR data base• Increased training in maintenance and flight operations• Implement SMS • Achieve ownership by increased delegation of regulatory

responsibility : essential to develop a matured process• Gradually move away from “authorising” and “mandating” to

consensus. : Replace “control” to “manage” • Manage compliance via strong audit process • Share failed components and accident investigations easily

with OEMs

Build on trust; we are in it all together

Questions?

Please check out the IHST website:

www.ihst.org

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

Safety Management Systems - Transport Canada, FAA A systematic, explicit and comprehensive process for the management of safety risks

that integrates operations and technical systems with financial and human resource management for all activities

Benefits - a) Financial Benefit b) Legal Compliance & Protection c) Improved Business Management

d) Ethical Obligation

• Policy must address compliance, non- punitive reporting, continuous improvement and prevention

• SMS will not be effective in the absence of senior management commitment • Roles and responsibilities within the organization must be clearly understood • Communication and employee involvement are both crucial. • Require safety objectives and goals • Measures must be set up to track performance • A formal review is conducted to assure that the SMS is working

SMS will be implemented in all regulated Canadian civil aviation orgs by 2007

Training Sessions

Key Components1) Safety management plan 2) Document management 3) Safety oversight 4) Training 5) Quality Assurance 6) Emergency Preparedness

Military • Navy

Leadership, Training, Equipment, Culture

Kaki Risk Management (KRM)

Human Factors Analysis & Classification System Skill based errors & Decision errors

Crew Resource Management (CRM) Hard (letter of the law) & soft (spirit of the law) processes Human factors - understanding people!

• ArmyCumulative Risk Model

Risk Management Process - hazard identification, - severity & probabilityMilitary Flight Operations Quality Assurance (MFOQA)

Proactive and systematic collection and analysis of operational data from aircraft for use in the continuous improvement of flight operations and readiness, specifically in the areas of Operations, Training, Maintenance and Safety

Aviation Safety Investment Strategy Team Risk management - identify hazards & determine prevention & mitigation strategies Shift focus from blame to prevention, from individual to system

Hazard Tracking Data Base Web-based, provide customizable or standard briefing charts

Training Sessions

Maintenance - Grey Owl & HAI

Human Factors!!!The Dirty Dozen

1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms

Training Sessions

Maintenance Resource Management (MRM)

–improving communication skills–decision making–effectiveness and safety in aircraft maintenance operations–Non-technical training

Operational IntegritySituational AwarenessError Chain RecognitionCommunication SkillsBriefingsSynergy / Team ConceptsLeadershipConflict ResolutionDecision MakingStress Management

• Dr. Forster - HAIReflecting on the ICAO and its success, we determined that the issue of rotorcraft safety requires the

initiation of a similar community-wide and international, military and civil collaborative effort to reduce

the accident rate in the vertical flight community – both military and civil. • Mr. Resavage - President, HAIThere have been many safety initiatives but few of them have been coordinated and that identifying

safety interventions, alone, is not enough, “they must be implemented.” “there is more than one path to safety. We must explore the potential for improvement through R&D and technological improvements but recognize that these are long term approaches and must be accompanied with interventions that can improve safety immediately through leadership, cultural change, improved

internal systems and behavioral approaches for short term gains.” • Marinus Heijl, Deputy Director, Air Navigation Bureau, ICAO

– xxx

• BG Joseph Smith, US Army, Director of Army Safety/ Commanding General, U.S. Army Combat Readiness Center – xxx

Invited Speakers

• Paul Arslanian, Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile (BEA)– xxx

• Steve Finger, President, Sikorsky Aircraft Corp. – xxx

• Mike Blake, Executive Vice President and Chief Operating Officer, Commercial Products, Bell Helicopter Textron, Inc. – xxx

• Richard Healing, Former Member of the National Transportation Safety Board (NTSB) – xxx

Invited Speakers

• Bob Sheffield, Managing Director, Shell Aircraft International – xxx

• Sylvain Allard, President and CEO, CHC Helicopter Corp.– xxx

• Tom Judge, President, AAMS - USA – different issues than rest of helicopter industry - business model, medical & aviation

issues, reviewed Flight Operations database for AMS

• Werner Marty, Flight Safety Officer and Pilot, Swiss Air Ambulance (REGA)

– large operator (Safety program - management driven, reporting system, anti-collision, remove

unused cables, review & revise SOPs, training, regulations, design,

Invited Speakers

IHST Executive Committee

Government Co-Chair Dave Downey, FAA

Industry/Operator Co-Chair Matt Zucarro, HAI

Secretariat Rhett Flater, AHS

Member Bob Sheffield, Shell Aircraft

Member Somen Chowdhury, IHSS Chair

Member Don Sherritt, Transport Canada

The way forward…

JHSATAnalyze accidents to determine whatsolutions can prevent &

mitigatethe problems

JHSITDetermine how to

best implement the

solutions

recommended by

the JHSAT.

Measure success via the diminishing accident rate!

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

Buy-in worldwide

• Australia• Brazil• Canada• Columbia• France• Germany• India

• Italy• Japan

• Netherlands• Switzerland

• United Kingdom• United States

• Who’s Next??

Training Panel SummaryTraining Objectives:•Review present flight review requirement standards/minimum requirements

•Review international regulations (JAA, TC, ICAO) •Review inadvertent IFR training requirements

•Develop/explore distance learning instruction (HAI, Diamond endorsements) for Mx, Pilot, management • Increase use of synthetic (simulator-based) training

•Synthetic auto-rotation training • Emphasis on IFR training• Review long term training objective

•Current certification criteria for pilots and mechanics•CRM, MRM, safety culture

Training Panel Summary (cont.)• OEM develop training standards that should be

verified by audit process– Training Recurrent and Initial schedules

• Training for new technology – FITS training model as guideline

• Better accident/incident statistics are necessary– Self disclosure program

• HOW DO WE PROVIDE INCENTIVES FOR OPERATORS TO ADOPT SAFETY GUIDELINES ?!

Training Panel Summary (cont.)OEM :•OEM develop training standards that should be verified by audit process

Training Recurrent and Initial schedules

• Survey by OEMs on training issues for HeliExpo, other conventions and mailing• Heliprops-type program for maintainers

Review Medallion program or similar programs (HAI platinum) for roadmap Encourage membership in similar programs

Last Six Years Data2000- 2005

• Civil & Military uses

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

PRINCIPAL MAINTENANCEINSPECTOR

ICAs

OPERATOR

OPERATORMAINTENANCE

PROGRAM

Operator ReliabilityProgram

Feedback to Manufacturer

In-ServiceMonitoring

Monitoring

RegulatoryApproval

Bell civil turbine accident causes worldwide (1994-2003)

Airworthiness14%

Non-AW (human, etc.)74%

Unknown12%

Source : Roy Fox, Bell Helicopter Textron

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

• Absence of any concerted plan so far

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

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

Charters Joint Helicopter Safety Analysis Team (JHSAT) Charter:

Conduct, review and approve detailed accident report analysis and identify causal factors;

Investigate and recommend improvements and develop mitigation strategies to allow goal achievement and 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 strategies;

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 : DGCA : support from Jt.Sec Sanjay Kumar, DG & Jt.DG of DGCA

USA

BellBoeingSikorskyRRPratt & WhitneyGEHoneywell

EuropeEurocopterAugusta-WestandTurbomeca

CanadaCHC Helicopters

Need all operators to buy-in