JHSAT Status
March 2007
HeliExpo – Orlando, FL
Mark Liptak FAA ANE-110
Jack Drake HAI
JHSAT - March 2007
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JHSAT Goal:
Provide intervention strategies to the IHST and
Joint Helicopter Safety Implementation Team
(JHSIT) that maximize the likelihood of
reducing worldwide helicopter accident rates
by 80 percent by 2016.
JHSAT - March 2007
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CAST (IHST)
Charters Activity
Basic CAST Process
JSAT (JHSAT)
Analyzes Data
Proposes most
effective interventions
JSIT (JHSIT)
Assesses feasibility of
interventions
works implementation
Continued data analysis,
measure intervention
effectiveness
JHSAT - March 2007
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JHSAT Team Membership:
Mark Liptak – FAA ANE co-chair
Jack Drake – HAI co-chair
Joan Gregoire - Turbomeca
Steve Gleason - Schweizer Helicopters
Roy Fox - Bell Helicopter
Ron Luhmann - Silver State Helicopters
Tony Alfalla - Sikorsky
Ray Wall & Tom Fleming – Bristow Group
Sandra Hart - NASA
Barry Rohm - Rolls Royce
Laura Iseler AHS/NASA
Clark Davenport & Matthew Rigsby – FAA ASW
Ed Stockhausen & Joe Lemma – Airmethods
Joe Syslo & Lindsay Cunningham – US Eurocopter
JHSAT - March 2007
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JHSAT Web Site
http://www.ihst.org/jhsat/jhsat_top.htm
User id – jhsat, password – helicoptersafe
Contents:
JHSAT charter and process docs
Dataset details
Meeting minutes/agenda
Presentations
Interim Recommendations
Resource documents
Not open to the public, restrict access for JHSIT needs only
JHSAT - March 2007
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JHSAT Status
Data Analysis
Engaging with the international community
Near term safety recommendations
JHSAT - March 2007
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Data Analysis
JHSAT - March 2007
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JHSAT currently working process
areas highlighted in yellow
Charter
Development
Score
Intervention
Ability/Usage
Establish
Team
Identify
Intervention
Strategies
Score
Problem
Validity &
Importance
Yes
Categorize and
Prioritize Data
Current task
JHSAT - March 2007
Conflicts?
Review
NTSB
Docket Data
Select
Data Set
No
Assign Std
Problem
Statements
Technical
Review
&
Expert
Validation
Report
Results
Develop
Event
Sequence
Identify
Problems
(what/why)
IHST
JHSIT
8
Data Analysis:
The accident data has been downloaded from the NTSB
(~4000 files)
The JHSAT team has completed processing all 197 accidents
from the NTSB year 2000 database
For each accident the JHSAT performs the following:
reconstruct the sequence of events
identify what went wrong and why it went wrong
assign an appropriate problem statement
identify appropriate corrective action(s)
score findings based on validity, importance, ability
and usage
JHSAT - March 2007
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Sample of event processing
Problem (what)
Event/Conditions
Contributing Factor SPS No Standard Problem
Statement
(why)
Popping noise
Engine power loss
Exhaust valve
failure - root cause
not determined
24010
Overflew wires, then
crashed onto street in
nose low, left skid low
attitude. Nosed downward
and turned CCW
Improper autorotation
or loss of control?
Lost of control when
making emerg/auto
to street
21074
Pilot had 3.2 hours in
R22 last 90 days;
marginal autorotations
on Com-helicopter
check 3.5 mos before
acdt.
Pilot had 67 hours in
helicopters.
Lack of recent
experience in M/M
and with
autorotations
13071
Pilot intentions and
actions unknown.
Flight/systems
information unkown.
JHSAT - March 2007
13070
Lack of total
helicopter
experience
Lack of information - 41020
flight and systems
information
Intervention
Recommendation
V
I A U
4 4
Mandate Textron
Lycoming SB388B to
reduce liklihood of
exhaust valve failure
Autorotation training 3 4
pilot control/handling,
inadequate autorotation aids, simulators etc
3 3
engine component
failure
3 2
Transition to aircraft
make/model
Develop company
policy and training
rqts for pilots
transitioning between
m/m
4 3
3 3
Pilot transition training
model specific
simulator training
4 3
2 3
information unavailable
to investigators
cockpit recording
devices
4 4
4 3
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JHSAT Scoring Criteria
Validity - How
valid do we think
the Problem
Statement is in
this accident based
on the available
accident
information?
Importance - How
important is this
particular Problem
Statement in the
causal chain in this
accident?
Ability - How well
can this particular
Intervention mitigate
the cause or
contributing factors of
this accident
scenario?
Usage – Given this
accident scenario,
how confident are we
that this Intervention
will be utilized and
will perform as
expected in the real
world?
Range:
Guess = 0
Absolutely Sure =
4
Range:
No importance = 0
Cause of accident =
4
Range:
No effect on Problem
Statement = 0
Would Prevent
Problem Statement =
4
Range:
No Utilization = 0
100% Utilization = 4
JHSAT - March 2007
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Data Analysis Status:
To date the accidents analyzed have covered a wide spectrum
of helicopter types and operations.
1200+ scored problem statements/intervention findings have
been developed
JHSAT currently doing some data “cleanup” work, will started
categorization and prioritization work at our Feb meeting
Expect to offer recommendations for all major operational
groups in the helicopter community
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JHSAT Mission Categories
Primary Ops
Aerial Application
Aerial Observation/patrol
Air Tour
Sightseeing
Business - company owns a/c
Corp/Exec - dedicated pilot
EMS
ENG
Firefighting
Instructional/Training
Law Enforcement
Logging
Commercial Operator
External Load
Offshore
Other Aerial Work
Personal/Private
Utilities - Patrol & Construction
JHSAT - March 2007
Secondary
External Load
Training
Positioning/RTB
Ferry
Air Taxi - Cargo (135)
Air Taxi - Passenger (135)
Cargo (91)
Public Use
Maintenance/Test flight
Evaluation flight
13
50
0
JHSAT - March 2007
53
51
48
47
44
32
30
9
8
9
6
10
6
4
4
Offshore
External Load
Business - Company owns A/C
Firefighting
Air Tour
Sightseeing
Electronic News Gathering
Utilities Patrol and Construction
Logging
3 17
92
145
170
210
SPS
Count
5 24
68
13
Law Enforcement
Aerial Observation / Patrol
74
16
Commercial Operator
101
100
12
28
Aerial Application
150
Emergency Medical Service
27
200
Personal / Private
37
250
Instructional / Training
Frequency
SPS & Accident Count by Primary Mission
Accident
Count
Results of full year 2000 dataset
14
JHSAT - March 2007
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23
20
10
Mission Risk
Regulatory
Aircraft Design
Infrastructure
1
24
Communications
Ground
personnel
26
Post-crash
survival
66
87
Pilot situation
awareness
0
98
50
Ground Duties
100
Part/system
failure
154
112
150
Maintenance
Data issues
250
200
173
400
350
401
450
Safety Culture
Pilot judgment &
actions
Frequency
SPS Frequency by Primary Category Descriptor
300
Results of full year 2000 dataset
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Engaging with the international community
JHSAT - March 2007
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Worldwide Helicopter Accidents/Year
1980 - 2005
800
700
Accidents/year
600
500
400
300
200
100
US Civil Registry
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Non-US Civil & Military
04
02
00
98
96
94
92
90
88
86
84
82
80
0
US Military & USCG (ABC)
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Engaging with the international community
The preceding slide shows worldwide accident trends for the last 26
years. The criticality of working with the international community to
reduce worldwide rates is readily apparent since the US accounts for
only 35 to 40% of accidents on an annual basis.
On-going efforts to identify other partners from Asia, South America,
Oceania, etc.
The JHSAT team is developing contacts and coordinating this activity.
Matt Rigsby from FAA-ASW will be acting as the contact point for
identifying overseas and military partners.
Any entity that possess large helicopter accident datasets that could
be processed by the JHSAT method should be considered.
EASA and Canada moving toward partnering with us in this process.
JHSAT - March 2007
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Engaging with the international community
A structured approach will be used to manage the analytical
and implementation work sponsored by the IHST.
Key attributes:
All recommendations will be data driven
Regional ownership - Data is owned and analyzed by those
most familiar with it. Safety recommendations will be
implemented by teams most familiar with local needs.
JHSAT and JHSIT lead teams will be responsible for
training/coaching regional teams, measuring the results of the
safety recommendations and implementation effectiveness.
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IHST Safety Initiative
Analysis, Implementation and Metrics Management Structure
IHST
Executive
Committee
Process
development
using
US NTSB data
represents 48%
of
worldwide fleet
Measure
JHSAT
Accident Reductions
Lead Group
Effectiveness
Need to maintain a strong
communication/feedback loop
between IHST – JHSAT - JHSIT
Measure
Implementation
Effectiveness
JHSIT
Lead Group
JHSAT sends recommendations to JHSIT
Canada
JHSAT
EASA
JHSAT
US/CAN/EASA
Consolidated
Recommendations
JHSAT - March 2007
Others?
JHSAT/JHSIT Canada
JHSIT
cross-talk
ALEA group
EMS group
Military
EASA
JHSIT
Region X, Y, Z
JHSIT
US/CAN/EASA/X,Y,Z
Implementation
Results
Regions X, Y, Z defined as those pockets of operation not able
to staff a full JHSAT team and are willing to work implementation
of US/CAN/EASA findings to benefit their fleets
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IHST
Outreach/Marketing
Emerging Fleets
Engaging with the International Community
Somen is the IHST POC
Identify emerging/high growth markets
Develop strategy to:
Foster participation
Benefit from IHST knowledge base
Candidates:
China
India
CIS?
JHSAT Lead Group
Analysis of
International Data
Matt Rigsby is JHSAT POC
Seeking data rich partners
Preliminary discussions with:
Canada
EASA (CAA-UK, France BEA)
Brazil
NZ, Australia
Chile
Canadian Military
USN
Interim Goal: have Canada/EASA present status
at the 2007 IHSS Symposium in Montreal
Demonstrate that this is an international
effort, and it has momentum
JHSAT - March 2007
JHSIT Lead Group
Implementing
Regional Solutions
JHSIT will also have international partner
management responsibilities:
custom tailored regional solutions
coordinated with JHSAT
coordinated with IHST
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Coordinating JHSAT US and International Efforts
US Civil
Dataset
Selection
(1/2 of
helicopters
Worldwide)
Mar/Apr 06
Identify
FCAA &
Military
Partners
Sept 06
Current task
JSAT Process
Understanding
Refining
JHSAT
Analysis
May-Jan 07
Tech
Review
Feb 07
May/June 06
Train FCAA
&
Military
Partners
in JHSAT
Process
TBD 06/07
Current task
FCAA & Military
Partners
conduct
JHSAT
analyses
on their
accident data
Expert
Review/
Validation
Apr 07
Mitigation
Recs
FCAA & Mil
2Q 07
First Set
US Mitigation
Recs
1Q 08
Mitigation
Recs - Global
TBD 08
TBD 07/08
IHST
JHSAT is now working to bring EASA and Canada into the process
JHSAT - March 2007
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Potential Barriers:
JHSAT:
Variation in dataset quality, definitions, etc, around the world
may make use of a standardized JHSAT approach more difficult.
Military data may not be available.
Lack of fleet hours will complicate ability to measure results.
Regional teams may be difficult to staff with sufficient level of
expertise representing manufacturers, operators and regulatory
interests.
JHSIT:
Regional operations and regulations may make some
implementation actions difficult.
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Offering near term safety recommendations
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Interim recommendations
Reports reviewed by the JHSAT:
NASA - U.S. Civil Rotorcraft Accidents, 1963 Through 1997
NASA - Analysis of US Civil Rotorcraft Accidents from 1990 to 1996 and Implications for a Safety Program
NASA - ASRS Rotorcraft Incident Study - Draft Data Summary Aviation Safety Reporting System
NASA - Helicopter Accident Analysis Team
AMPA - A Safety Review and Risk Assessment in Air Medical Transport
CRS - Report for Congress - Military Aviation Safety
OGP - Safety Performance of Helicopter Operations in the Oil and Gas Industry - 2000 Data
TSB Canada - Lessons Learned from TSB Investigation of Helicopter Accidents (1994 - 2003)
Bell Textron - History of Helicopter Safety
Other NTSB and international reports may be considered.
The JHSAT has identified important recommendations from a series of
existing helicopter safety reports. (listed on the next slide)
These recommendations were submitted to the IHST in November so
that the JHSIT would have several well founded general
recommendations to work with.
The JHSAT plan to issue its full set of analytical results by 2Q07.
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US JHSAT interim recommendations:
1. – Promote the adoption of Safety Management Systems in the helicopter
community.
2. – More consistent and comprehensive NTSB involvement and investigation
needed in helicopter accidents.
3. – Reestablish the collection of worldwide helicopter fleet hour data as previously
performed by the FAA.
4. – Establish a helicopter safety website to disseminate important information
5. – Use proximity detection equipment in helicopters.
6. – Use flight recording devices and cockpit image recording systems in
helicopters.
7. – Develop a strategy to improve pilot Aeronautical Decision Making.
(NB: this listing is not intended to indicate prioritization)
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Questions?
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