Safety Enhancement in Helicopter
Operations
IHST Regional Conference
Delhi, India
Hosted by DGCA, COSCAP SA & RWSI
Somen Chowdhury
Executive 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:
Too many
 Accidents
worldwide
 Lives lost
Business loss
 Injuries
Current State of Affairs
2005- 565/year
Poor Public image
Too expensive
UNACCEPTABLE
24,294 Worldwide Civil Helicopters
Worldwide distribution by country
Italy (642)
2.44%
Japan (799)
3.04%
Mexico (368)
1.40%
New Zealand (642)
2.44%
United States
(12743)
48.44%
India (140)
0.53%
South Africa (563)
2.14%
Germany (698)
2.65%
France (796)
3.03%
England (1080)
4.11%
Others (4386)
16.67%
Canada (1801)
6.85%
Australia (1215)
4.62%
Brazil (435)
1.65%
Worldwide Helicopter Accidents/ year
1980-2005
Worldwide Helicopter Accidents/Year
1980 - 2005
800
700
Accidents/year
600
500
400
300
200
100
US Civil Registry
Source : Roy Fox Bell
Helicopter
Non-US Civil & Military
04
02
00
98
96
94
92
90
88
86
84
82
80
0
US Military & USCG (ABC)
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
Comparative Accidents Data
Unknown
5%
Aircraft
issues
32%
Non-AW
(human,
etc.)
63%
Civil Helicopter Accident, India
Source: AVM Sridharan, RWSI
Unknown
12%
Aircraft issues
14%
Non-AW (human, etc.)
74%
Bell Civil turbine Worldwide
Source: Roy Fox, Bell Helicopter Textron
The Real Challenge
Iceberg Theory
Serious Incidents
1
10
Incidents
300
Accidents
Near Misses
1200
Heinrich Ratio
The BIG Picture
Hidden or Unseen
Conditions are
Below The Surface
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
• Results
– Training Sessions
–Attendance ~250
–International
• Management
• Military
• Maintenance
• 13 countries
• 5 continents
– Invited Speakers
– Paper sessions
–Industry wide
• Government
• Military & Civil missions
• Human Performance &
Training
• Design & Maintenance
• Accidents & Regulation
• Management & Economics
– Discussion panels
– Plenary session
IHST set up
•Regulatory
•Accident Investigators
• OEMs
• Mission groups
• Operators
•Pilots
•Maintainers
•Aviation Press
IHST
Mission
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.
Vision
To 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
IHST
Organisation
Executive Committee
Secretariat
IHST
JHSAT
JHSIT
Subcommittees
Subcommittees
JHSAT - Joint Helicopter Safety Analysis Team
JHSIT - Joint Helicopter Safety Implementation Team
CAST (commercial aviation safety team) was considered
a good model to follow
Implementation Process
Data
Analysis
Implement Safety
Enhancements - U.S.
Set Safety
Priorities
Agree on
problems and
interventions
Achieve consensus on
priorities
Influence Safety
Enhancements Worldwide
Integrate into existing
work and distribute
IHST Regional Cooperation
International Cooperation is essential
– Regulators
– Operators
– OEMS
In all regions of the world.
We start with S Asia
We are all in it together
Safety: Every Step of the Way
Continuing Airworthiness
Safety
Failure Prevention
technologies
Design
Reliability
-anti corrosion
-- reduce vibration
SMS
3 years
Operational
regulations
Maintenance
Quality Assurance
- No Flaw
Manufacturing
Survivability
technologies
-ext. airbag
-Crash worthy seats
& fuel tanks
-- floatation gear
-- egress
Airworthy
Product
Short term
Action
SMS
Field
Operation
Human Factors
-Training of all parties
--Pilot aids
-Mission comprehension
SMS
20-30 years
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
Nuisance
FAR 25
PROBABILITY
(REF. ONLY)
EFFECT ON
AIRCRAFT AND
OCCUPANTS
Normal
Operating
limitations;
emergency
procedures
Significant
reduction
in safety margins;
difficult for crew to
cope with adverse
conditions:
passenger injuries
Large reductio in
safety maragins;
crew
extended because of
work load or environmental conditions,
serious injury or
death of small number of occupants
Multiple
deaths,
usually with
loss of
aircraft
EXTREMELY
PROBABLE
IMPROBABLE
IMPROBABLE
EXTREMELY
JAR 25
PROBABILITY
PROBABLE
IMPROBABLE
REASONABLY
PROBABLE
FREQUENT
10
CATEGORY
OF
EFFECT
IMPROBABLE
0
10
-1
10
-2
10
MINOR
-3
10
-4
10
EXTREMELY
REMOTE
REMOTE
-5
10
-6
MAJOR
10
-7
10
-8
HAZARDOUS
10
-9
CATASTROPHE
Failure risk mitigation strategy
HAZARD SEVERITY
HAZARD
PROBABILITY
Catastrophic
Level 1
Critical
Level 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
Field Operations
Maintenance
Definition:
A periodic maintenance
task 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
RETURN
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 Operations
Human Factors
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
The door opened in flight!
RETURN
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
Successive layers of defenses, barriers, & safeguards
Some holes due
to active failures
(present in use)
When barriers
fail
ACCIDENT
Barriers are
Safety Nets
Hazards
Other holes due to
latent conditions
(present, not visible)
Training Sessions
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
Key Components
Benefits a) Financial Benefit
b) Legal Compliance & Protection
c) Improved Business Management
d) Ethical Obligation
1) Safety management plan
2) Document management
3) Safety oversight
4) Training
5) Quality Assurance
6) Emergency Preparedness
• 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
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!
• Army
Cumulative Risk Model
Risk Management Process - hazard identification, - severity & probability
Military 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 Communication
2. Complacency
3. Lack of Knowledge
4. Distraction
5. Lack of Teamwork
6. Fatigue
7. Lack of Resources
8. Pressure
9. Lack of Assertiveness
10. Stress
11. Lack of Awareness
12. Norms
Maintenance Resource
Management (MRM)
–improving communication skills
–decision making
–effectiveness and safety in aircraft
maintenance operations
–Non-technical training
Operational Integrity
Situational Awareness
Error Chain Recognition
Communication Skills
Briefings
Synergy / Team Concepts
Leadership
Conflict Resolution
Decision Making
Stress Management
Invited Speakers
•
Dr. Forster - HAI
Reflecting 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, HAI
There 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,
IHST Executive Committee
Government Co-Chair
Industry/Operator Co-Chair
Secretariat
Member
Member
Member
Dave Downey, FAA
Matt Zucarro, HAI
Rhett Flater, AHS
Bob Sheffield, Shell Aircraft
Somen Chowdhury, IHSS Chair
Don Sherritt, Transport Canada
The way forward…
JHSAT
JHSIT
Analyze accidents
to determine what
solutions can
prevent &
mitigate
the problems
Determine how to
best implement the
solutions
recommended by
the JHSAT.
Measure success via the diminishing accident rate!
JHSAT - Joint Helicopter Safety Advisory Team
JHSIT - 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 Summary
Training 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 Data
2000- 2005
• Civil & Military uses
– 3049 accidents
– 2643 fatalities
– 1027 serious injuries
– 5439 minor/ no injuries
ICAs
Feedback to Manufacturer
OPERATOR
OPERATOR
MAINTENANCE
PROGRAM
In-Service
Monitoring
Monitoring
PRINCIPAL MAINTENANCE
INSPECTOR
Operator Reliability
Program
Regulatory
Approval
Bell civil turbine accident causes worldwide
(1994-2003)
Unknown
12%
Airworthiness
14%
Non-AW (human,
etc.)
74%
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
• 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
Bell
Boeing
Sikorsky
RR
Pratt & Whitney
GE
Honeywell
Europe
Eurocopter
Augusta-Westand
Turbomeca
• Europe
– BEA - Bureau d'Enquêtes et d'Analyses pour
la Sécurité de l'Aviation Civile
– EHA - European Helicopter Association
Canada
CHC Helicopters
• Canada
– TCCA - Transport Canada Civil Aviation
– TSB - Transportation Safety Board of Canada
Need all operators
buy-in
• India : DGCA : support from Jt.Sec Sanjay
Kumar, DG & Jt.DG of DGCA
to