Preliminary Results

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Preliminary Results

• EHEST Conference
• 13 October 2008
• Cascais, Portugal

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Contents

• Data set description
• General data
• Identified factors data
• Standard Problem Statements
• HFACS
• Intervention Recommendations
• Concluding Remarks Way forward

3
Data set description

• Preliminary Results

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Scope of analysis

• Based on a data driven approach
• Focus on
• Accidents (definition ICAO Annex 13)
• Date of occurrence year 2000 - 2005
• State of occurrence located in Europe
• For this purpose Europe is defined as the EASA
  Member States (27 EU plus Iceland,
  Liechtenstein, Norway and Switzerland)
• Only those accidents are being analysed where a
  final report from Accident Investigation Board is
  available

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Scope of preliminary dataset

• Total of 186 within timeframe 2000-2005 have been
  analysed
• Covers work from 9 Regional Teams across Europe
• Does not cover all accidents within timeframe
• Preliminary results, not fully representative of
  European accidents in the reference period
• The following slides present preliminary results
  based on these 186 accidents

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Proportion of analysed accidents
Estimated data for the 9 Regional Teams
currently participating
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General Data

• Preliminary Results

Picture Source Eurocopter
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General data
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General data
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General data
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General data
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General data
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General data
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General data
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General data
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General data
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General data
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Identified factors dataStandard Problem
Statements HFACS

• Preliminary Results

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Identified factors data

• Two models used for identification of factors
• SPS
• HFACS
• Standard Problem Statements
• In total 1067 factors identified for all 186
  accidents
• HFACS
• In total 445 factors identified for all 186
  accidents

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SPS level 1 All Accidents
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SPS level 1 compared with US JHSAT data
Correlation is .89
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SPS level 2 (top 10) All Accidents (excluding
Data Issues)
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HFACS model
Facilitate identification of the underlying
causes
Merely symptoms
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HFACS model upper levels
Unsafe Acts
Errors
Violations
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84
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HFACS model upper levels
Preconditions
Environmental Factors
Condition of Individuals
Personnel Factors
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60
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HFACS model upper levels
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HFACS model upper levels
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Going into more detail

• The following slides present the lowest level in
  the taxonomy level 3
• This provides a more detailed insight into the
  type of accidents occurring
• Results will be presented for the three main
  types of operation
• Commercial Air Transport
• Aerial Work
• General Aviation

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An example Commercial Air Transport scenario

• Once the patient was boarded the helicopter took
  off despite the degraded weather condition
  because an ambulance was waiting to bring the
  patient to the hospital.
• The helicopter hit the ground (snowed surface)
  with the right skid and nosed over just after
  take off in poor visibility due to falling and
  blowing snow.

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An example Commercial Air Transport scenario

• Once the patient was boarded the helicopter took
  off despite the degraded weather condition
  because an ambulance was waiting to bring the
  patient to the hospital.
• The helicopter hit the ground (snowed surface)
  with the right skid and nosed over just after
  take off in poor visibility due to falling and
  blowing snow.

Loss of Visual Reference
Inadequate decisions
Pilot felt pressure
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SPS level 3 (top issues)Commercial Air Transport
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HFACS level 3 (top issues)Commercial Air
Transport
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An example Aerial Work scenario

• During vertical take off with external cargo from
  a confined landing area in the forest, the
  helicopter started to rotate to the left after
  having cleared the tree tops.
• The helicopter lost altitude, contacted the
  surrounding trees and crashed.

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An example Aerial Work scenario

• During vertical take off with external cargo from
  a confined landing area in the forest, the
  helicopter started to rotate to the left after
  having cleared the tree tops.
• The helicopter lost altitude, contacted the
  surrounding trees and crashed.

Operated near maximum take-off mass
Obstacles
Pilot intensive
Tailwind
Loss of tail rotor effectiveness
Cargo not released
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SPS level 3 (top issues)Aerial Work
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HFACS level 3 (top issues)Aerial Work
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An example General Aviation scenario

• The helicopter was on a Visual Flight Rules
  flight. En route, it entered an area of rising
  terrain and low cloud base.
• Radar tracking indicates that the helicopter
  slowed down, and then made a sharp turn before
  disappearing off the screen.
• The helicopter then suffered an in-flight
  collision with terrain directly after the loss of
  radar contact.

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An example General Aviation scenario

• The helicopter was on a Visual Flight Rules
  flight. En route, it entered an area of rising
  terrain and low cloud base.
• Radar tracking indicates that the helicopter
  slowed down, and then made a sharp turn before
  disappearing off the screen.
• The helicopter then suffered an in-flight
  collision with terrain directly after the loss of
  radar contact.

No weather forecast obtained
No flight plan filed
No contact established with ATC
Inadvertent IMC
Limited experience
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SPS level 3 (top issues)General Aviation
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HFACS level 3 (top issues)General Aviation
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Intervention Recommendations

• Preliminary Results

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Intervention Recommendations

• In total 11 Intervention Recommendation
  categories identified
• The categories help identify areas for working
  groups of EHSIT
• Note some categories do overlap but they do
  succeed in suggesting areas to focus

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Intervention Recommendations for All Accidents
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Overview of top categories
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Example IRs

• Within each IR type there are a wide range of
  different interventions that have already been
  identified so far
• The following are some un-prioritised examples
  from across all operational categories

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IRs Examples Training/Instruction

• Better training for specific missions operating
  environments
• E.g. Improve training for mountain operations
  specifically for landing on snow covered surfaces
• Better training for inadvertent entry in IMC
  condition
• Better training on type specific issues and
  operational limits.
• Special training supervision arrangements should
  be considered when dealing with slow learning
  students who are taking longer to complete the
  PPL(H) syllabus.

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IRs Examples Training/Instruction

• Instructors/examiners be updated more regularly
  by TRTOs.
• Establish measures to avoid culture of
  non-compliance
• Include risk assessment training
• Encourage organising private helicopter pilots
  into flying clubs etc for mutual support and
  better exchange of experiences / safety
  information

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IRs Examples Flight Ops Safety
Management/Culture

• Develop safety management system (SMS)
• Promoting a safety culture vs. getting the job
  done regardless
• Investigate the user-friendliness of checklists
• Manage human factors risk especially regarding
  routine violation
• Use a Flight Data Monitoring system to give
  feedback to pilots
• Increased oversight of new pilots
• During the mission preparation, the management
  should take into account the experience of each
  crew member and mix the different skills.
• Better planning especially for higher risk
  missions
• Increase awareness of obstacles provision of
  Wire Strike Protection System

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IR Examples Regulatory

• Require greater flight data recording usage to
  assist in future occurrence investigation
• Promote research inexpensive, lightweight,
  airborne flight data and voice recording
  equipment for smaller helicopters
• VFR flight criteria for helicopters and licence
  privileges for pilots should be reviewed to
  reduce the risk from flight in a Degraded Visual
  Environment
• Review the deck markings on ships involved in
  winching operations with the aim of including a
  requirement to clearly display the dimensions of
  the 'manoeuvring zone', such that it can be
  clearly seen by the helicopter crew.
• Establish specific training requirements for
  operational crew members other than flight crew
  required for aerial works operations.

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Other Selected IR Examples

• Improve crashworthiness survivability
• Improve OEM manufacturing quality assurance
• Establish safe limits of helideck movement for
  helicopters operating offshore
• Validated, simplified weight and balance process
  should be made available
• Provide better information on aircraft fuel
  consumption for pilots to safely plan flights on
  the basis of verified fuel contents.
• Type specific airworthiness improvements
• Making specific safety enhancing equipment part
  of the build standard
• Making specific equipment available for operators
  to adapt aircraft for specific missions /
  environments

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Intervention Recommendations - Way forward

• It is expected the EHSIT will need to prioritise
  the Interventions Recommendations based on safety
  benefit and practicality
• Different types of EHSIT organisations can be
  envisaged
• By type of operation
• By type of recommendation
• By type of activity
• Mix of the above
• Other
• Centralised or regional-based

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Concluding Remarks Way forward

• Preliminary Results

Picture Source Eurocopter
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Concluding remarks

• EHSAT analysis covers European wide helicopter
  accident data
• Preliminary results already provide indication of
  type of accidents
• Preliminary results will be used by EHSIT
• And shared with IHST

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Concluding remarks

• Main accident factors are operational. The top 3
  are
• Pilot judgment actions
• Safety management /culture
• Pilot situation awareness
• High correlation with US results
• Different patterns for
• Commercial Air Transport
• Aerial Work
• General Aviation

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Concluding remarks

• HFACS provided a complementary perspective on
  these factors and together with SPS, was used to
  produce recommendations
• The top 3 intervention recommendation categories
  are
• Flight Operations and Safety Management/Culture
• Regulatory
• Training / Instructional

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Way forward

• EHSAT will continue analysis to complete
  2000-2005 timeframe
• Intervention recommendations will be handed over
  to the implementation team, the EHSIT
• EHSIT will be launched after this Conference
• And we would like you to join

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Thank you for your attention Questions?