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RISK AWARENESS: IMPROVING AIRCREW KNOWLEDGE

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Title: Incident ICAO report and simplified report Author: PIJ Last modified by: stc Created Date: 6/16/2005 9:11:43 AM Document presentation format – PowerPoint PPT presentation

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Title: RISK AWARENESS: IMPROVING AIRCREW KNOWLEDGE


1
RISK AWARENESSIMPROVING AIRCREW KNOWLEDGE
2
Heard at ISASI 2005
  • Risk for helicopters 10 x risk for airlines
  • Proposed strategies
  • Flight simulators
  • CVRs
  • EGPWS
  • Crash-resistance standards
  • NVG
  • HUMS
  • IS THIS ENOUGH ?
  • IS THIS REALISTIC ?

3
IMPEDIMENTS
  • Cost
  • Age of design
  • Size of companies
  • Variety of operations
  • New risks
  • Change in behavior (eg use of GPS)

4
IMPEDIMENTS (cont)
  • Lessons learnt but not assimilated

5
What if
6
What if
7
Jan. 2000 Jun. 2005
354 Accidents
BEA
  • 67 fatalities
  • 133 hull losses
  • Exposure difficult to assess
  • No significant trends

8
51 accidents with casualties
(4 undetermined)
9
Avoidable
55 of fatalities
10
New causes?
  • Unsafe acts / behavior
  • Abrupt maneuvers
  • Low flight
  • Negligent flight preparation
  • Load securing
  • Fuel
  • WB
  • Continuation of flight in marginal conditions
  • Failure to appropriately react to malfunction
  • Lower the collective
  • Reaction after hyd. loss

11
Specific helicopter factor
  • I can land anywhere if
  • I can better adjust to limits (weather)
  • Overconfidence
  • Accident ? It wont happen to me
  • VIP factor

12
Safety strategies
  • Safety devices
  • Hazard identification
  • Procedures
  • Improved training
  •  Closing the loop 
  • Tightening the loop

13
TRAINING HISTORY
H SLE L
  • Knowledge of Hardware
  • Knowledge of Software
  • Knowledge of Environment
  • Knowledge of Liveware
  • Knowledge of interactions
  • Knowledge of failure modes

14
WHO IS IMMUNE TO ACCIDENTS?
  • There are two sorts of pilots
  • Those who have landed gear up
  • Those who will
  • Bias in risk assessment experience
  • Extremely remote vs frequent

15
Investigation reports
  • Standardized
  • Based on facts
  • Non-punitive approach
  • All aspects reviewed (19 chapters)
  • Participation of several partners
  • Intended for prevention purposes
  • Many details
  • Lessons learnt

16
Ground lessons case study
  • Detailed study of circumstances and causes
  • Questions
  • Have we experienced anything similar?
  • Have we been close to experiencing anything
    similar?
  • What are the similarities?
  • What are the differences?
  • Are we immune to being involved in such a
    scenario?

17
Questions (cont)
  • What are our defenses? How could we improve them?
  • How robust are they in an ever-changing
    environment?
  • Can we precisely identify our defenses, the
    procedures?
  • Do we perceive any gap between our planned and
    actual practices?
  • Are we prone to defeating identified defenses?
  • What are the root causes that we can map in our
    organization / in my personality ?

18
Challenges
  • Selection of cases to study
  • Education of moderator / instructor
  • Adherence of personnel confidence-based
    environment
  • Address ALL actors, incl. Management
  • Create a culture
  • Time cost obvious, savings hidden

19
Conclusion
  • Close the loop proactive implementation
  • Teaches about strengths and weaknesses
  • A mindset
  • Can be implemented in ANY organization, with no
    delay
  • Investigating bodies are ready to help
  • initiate the process

20
Enhanced partnership
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