Transcript Document

JHSAT Status
May 2007
AHS Forum 63 – Virginia Beach, VA
Mark Liptak FAA ANE-110
Jack Drake HAI
JHSAT - May 2007
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IHST (CAST)
Charters Activity
Basic CAST Process
JHSAT (JSAT)
Analyzes Data
Proposes most
effective interventions
JHSIT (JSIT)
Assesses feasibility of
interventions
works implementation
Continued data analysis,
measure intervention
effectiveness
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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.
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JHSAT Team Membership:
FAA ANE co-chair
HAI co-chair
Turbomeca
Schweizer Helicopters
Bell Helicopter
Silver State Helicopters
Sikorsky
Bristow Group
NASA
Rolls Royce
AHS/NASA
Airmethods
FAA ASW
US Eurocopter
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JHSAT Status
Data Analysis
Engaging with the international community
Interim safety recommendations
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Data Analysis
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JHSAT Process Overview
Charter
Development
Score
Intervention
Ability/Usage
Establish
Team
Identify
Intervention
Strategies
Score
Problem
Validity &
Importance
Yes
Categorize and
Prioritize Data
Current task
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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
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Data Analysis:
The year 2000 accident data has been downloaded from the
NTSB (~4000 files)
The JHSAT team has completed processing all 197 accidents
from the dataset
For each accident the JHSAT has:
reconstructed the sequence of events
identified what went wrong and why it went wrong
assigned an appropriate problem statement
identified appropriate corrective action(s)
scored findings based on validity, importance, ability
and usage
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US Rotorcraft Accident Trends
1986-2006
45
40
35
30
Frequency
25
20
2000 Monthly
Accident Count
+3σ 1986 - 2006
Monthly Avg
1986 - 2006
23
+2σ 1986 - 2006
20
20
17
20
17
15
17
15
14
13
10
5
11
10
-2σ 1986 - 2006
-3σ 1986 - 2006
Source: NTSB N-registered
accidents, excluding amateur
built
0
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August
July
June
September
Month
May
April
March
February
January
December
November
October
-5
9
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
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Sample of event processing
Event/Conditions
Problem (what)
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.
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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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Data Analysis Status:
To date the accidents analyzed have covered a wide spectrum
of helicopter types – 15 basic mission types.
1200+ scored problem statements/intervention findings have
been developed
JHSAT currently interpreting the analysis results.
overall fleet issues
by mission issues
Expect to offer recommendations for all major operational
groups and overall US fleet by June 07.
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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
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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
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53
51
48
47
44
32
30
8
9
6
10
6
4
4
External Load
Business - Company owns A/C
Firefighting
Air Tour
Sightseeing
Electronic News Gathering
Utilities Patrol and Construction
Logging
3 17
145
170
210
SPS
Count
5 24
68
9
Offshore
Aerial Observation / Patrol
74
13
Law Enforcement
92
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
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23
20
10
Mission Risk
Regulatory
Safety
Aircraft Design
Equipment
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
200
173
400
401
450
Safety Culture
Pilot judgment &
actions
Frequency
SPS Frequency by Primary Category
350
300
250
Results of full year 2000 dataset
15
367
275
173
43
33
28
Regulatory
Instructional
Infrastructure
119
Aircraft
Safety
Equipment
Design
Maintenance
Information
143
Safety
Management
450
400
350
300
250
200
150
100
50
0
Training
Frequency
JHSAT Intervention Categories
Results of full year 2000 dataset
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0
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28
20
20
20
SOP - Preflight
26
Aircraft
performance
SOP - Wx
30
Cockpit
indication
31
Preflight
36
LTE
37
Simulators
37
Investigation
40
Mission
specific
49
CFI
60
Autorotation
80
Risk
management
156
QA
Risk
assessment
Recorder
Frequency
160
Top 15 JHSAT Intervention Sub Categories
140
120
100
100
68
46
Results of full year 2000 dataset
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Engaging with the international community
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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.
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.
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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
AU/India
JHSAT
Canada
JHSAT
EASA
JHSAT
US/CAN/EASA
Consolidated
Recommendations
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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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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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Interim 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 foundational intervention areas to consider.
The JHSAT plan to issue its full set of analytical results by 2Q07 which
will significantly augment these foundational areas.
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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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