Transcript Document

JHSAT Status
November 2006
Carmel Meeting
Mark Liptak FAA ANE-110
Jack Drake HAI
JHSAT - October 2006
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JHSAT Status
Tenets of the CAST process
Data Analysis
Engaging with the international community
Interim safety recommendations
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Tenets of the CAST process
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CAST JSAT Basic Tenets:
Data Driven
Stakeholder’s develop consensus solutions
Actions can be measured
Each imbedded in the IHST JHSAT process
Process attributes adapted to helicopters:
standard problem statements
scoring criteria
Recommendation categorization
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Data Analysis
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Data Analysis:
The JHSAT team is currently processing 190 accidents
The accident data has been downloaded from the NTSB
(~4000 files)
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
The team has currently completed 161 of 195 accidents
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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
Prioritize by
Overall
Effectiveness
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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Sample of event processing
Event/Conditions
Problem (what)
Contributing Factor SPS No Standard Problem
Statement
(why)
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
Model specific
simulator training
4 3
3 3
SMS; formalize risk
mgt process and
oversight, recency of
experience
cockpit recording
devices
4 3
2 3
4 4
4 3
engine component
failure
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
Transition to aircraft
make/model
Lack of total
helicopter
experience
13070
Pilot transition training
Pilot intentions and
actions unknown.
Flight/systems
information unkown.
Lack of information - 41020
flight and systems
information
information unavailable
to investigators
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Intervention
Recommendation
3 2
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Data Analysis:
To date the accidents analyzed have covered a wide spectrum
of helicopter types and operations.
We expect to be able to offer the IHST and JHSIT a
comprehensive set of safety recommendations based on the
analyses.
The data has not been formally ranked by the JHSAT yet.
This will be accomplished as a final step prior to review with
experts in the affected recommendation areas.
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60
49
50
40
33
24 24
30
20
10
3
21
8
ay
Ju
ne
Ju
Au ly
gu
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Se
pt
O
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No
v
De
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Ja
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Fe
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M
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0
M
Number of events processes
JHSAT Event Processing
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Mission Breakdown - JHSAT 93 Accidents
Aerial Application (137)
Instructional / Training (61/91/141)
Personal / Private (91)
Public Use (91)
Air Medical Service (91)
Positioning / Ferry (91)
Commercial Air Tour (135)
External Load - Other (133)
Aerial Observation / Patrol (91)
Business (91)
Utilities Patrol and Construction (91)
Electronic New s Gathering (91)
Sightseeing (91)
Other Aerial Work (91)
Offshore (135)
Maintenance / Test Flight (91)
Air Taxi - Passenger (135)
0
2
4
6
8
10
12
14
16
18
Not necessarily representative of final JHSAT product
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JHSA T F r eq uency o f St and ar d Pr o b lems Id ent if ied
0
5
10
15
20
25
30
I nf or mat i on unavai l abl e t o i nvest i gat or s
35
40
38
Di sr egar ded cues t hat shoul d have l ed t o t er mi nat i on of act i on
18
A i r cr af t posi t i on and hazar ds. (P i l ot s' SA )
18
I nf or mat i on mi ssi ng/ i ncompl et e
16
P i l ot cont r ol / handl i ng def i ci enci es
13
P i l ot deci si on maki ng
12
I nadequat e consi der at i on of wx/ wi nd
11
Fai l ur e t o per f or m pr oper pr ocedur e
10
I nappr opr i at e E ner gy/ power management
10
9
I nadequat e aut or ot at i on, f or ced.
I nadequat e A ut or ot at i on - P r act i ce
8
Wi l l f ul di sr egar d f or r ul es and SOP s
8
I nadequat e and unt i mel y CFI act i on t o cor r ect st udent act i on
8
8
Reduced vi si bi l i t y--f og, r ai n, snow
Ri sk M anagement i nadequat e
7
I nadequat e consi der at i on of A cf t per f or mance
6
M i ssi on r qmt s/ cont i ngenci es pl anni ng i nadequat e
6
I ncor r ect f uel pl anni ng/ cal cul at i ons
6
A i r cr af t P r e f l i ght i nadequat e
6
Not necessarily representative of final JHSAT product
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JHSAT Intervention Frequency
211
Better Crew Decision Making
Training
173
Improved Operational SOPs
106
71
Enhanced Data Recording
New Designs/components
68
Formal Risk Process & Oversight
61
55
New In Cockpit Systems/Warnings
Improved Data/Info to Pilots w x/lz/etc
42
Enhanced Maintenance Proceedures
36
22
Enhanced Reg Rqts/Guidance
Disciplinary Action
12
Enhanced CFI rqts
11
0
50
100
150
200
250
Not necessarily representative of final JHSAT product
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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.
Any entity that possess large helicopter accident datasets that could
be processed by the JHSAT method should be considered.
Working with EASA and TC.
Working JHSAT formation in Australia (Mar meeting),
Working May/June meeting in Sao Paulo for SA.
India contacts established.
China? CIS?
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Engaging with the international community
A structured approach needs to 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
US
JHSAT
EASA
EHSAT
Region X, Y, Z
JHSIT
US/EASA/X,Y,Z
Consolidated
Recommendations
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JHSAT/JHSIT
cross-talk
US
JHSIT
EASA
EHSIT
Region X, Y, Z
JHSIT
US/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 (contacted, no reply)
Australia
Chile
Canadian Military
USN
Near-term: bring Canada & EASA on-line
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
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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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Potential Barriers for JHSAT function:
Variation in dataset quality, definitions, etc, around the world
may complicate use of standardized JHSAT approach.
Military involvement may not be available.
Lack of fleet hours may complicate ability to measure and/or
normalize results.
Regional teams may be difficult to staff with sufficient level of
expertise representing manufacturers, operators and regulatory
interests.
Regional teams may have difficulty working to IHST/JHSAT
timing and milestones
Some of these issues may also apply to the JHSIT function
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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
JSAT Process
Understanding
Refining
JHSAT
Analysis
Tech
Review
May 06 - Jan 07
Mar 07
May/June 06
Train FCAA
&
Military
Partners
in JHSAT
Process
TBD 06/07
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
TBD 08
Mitigation
Recs - Global
TBD 07/08
TBD 07/08
IHST
JHSAT is on schedule to deliver US recommendations early 2Q07
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Interim safety recommendations
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Interim safety recommendations
The JHSAT has developed recommendations from a series of existing
helicopter safety reports. (listed on the next slide)
These recommendations are being submitted to the IHST at this
meeting so that the JHSIT will have several well founded general
recommendations to work with.
This should allow for JHSIT implementation strategizing and targeting
who should be on the team.
The JHSAT plan to issue its full set of analytical results by early 2Q07.
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JHSAT reviewed the following reports:
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
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JHSAT Observations
Based on the teams review of year 2000 accident data:
Develop strategy to promote Safety Management
Systems approach in helicopter community
Helicopter community should align with
international trends in adopting Safety
Management Systems
Petition the NTSB to:
fully investigate helicopter accidents
develop training curricula to show how accident
data can be used to improve helicopter safety
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Review of existing Safety Reports
Proximity detection equipment for helicopters
Wire detection systems (EM, radar)
Radio altimeters (confined to what is directly below the
helicopter within direct line of sight of the sensor)
Hover systems employing RADALT, doppler or other
means to measure lateral drift
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Review of existing Safety Reports
Develop and require real-time performance monitoring
Adopt new technologies to provide crash info to
accident investigators
New, cost effective products available, adapt to specific
ops
Keep over burdensome government requirements out.
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Review of existing Safety Reports
Web Site - Safety/Accident awareness – data &
dissemination
feedback
Keep fresh safety info on an easily accessed web site
Keep current accident/incident statistics
Leverage NASA safecopter site
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Review of existing Safety Reports
Aeronautical decision making training
JHSIT develop a strategy to target and apply ADM
training across the operational community.
Include training using simulators and fixed base
training devices
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Questions?
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