Transcript Document
JHSAT - January 2007
JHSAT Status
January 2007 JHSIT Kickoff meeting AHS – Alexandria, VA Mark Liptak FAA ANE-110
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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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Basic CAST Process
CAST (IHST) Charters Activity JSAT (JHSAT) Analyzes Data Proposes most effective interventions JSIT (JHSIT) Assesses feasibility of interventions works implementation Continued data analysis, measure intervention effectiveness JHSAT - January 2007
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JHSAT Team Membership:
Mark Liptak – FAA ANE co-chair Joan Gregoire - Turbomeca Roy Fox - Bell Helicopter Tony Alfalla - Sikorsky Sandra Hart - NASA Laura Iseler AHS/NASA Jack Drake – HAI co-chair Steve Gleason - Schweizer Helicopters Ron Luhmann - Silver State Helicopters Ray Wall & Tom Fleming – Bristow Group Barry Rohm - Rolls Royce Clark Davenport & Matthew Rigsby – FAA ASW Ed Stockhausen & Joe Lemma – Airmethods Joe Syslo & Lindsay Cunningham – US Eurocopter JHSAT - January 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 - January 2007
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JHSAT Status
Data Analysis Engaging with the international community Near term safety recommendations JHSAT - January 2007
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Data Analysis
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Charter Development
JHSAT currently working process areas highlighted in yellow
Establish Team Select Data Set Review NTSB Docket Data Score Intervention Ability/Usage Identify Intervention Strategies Score Problem Validity & Importance Develop Event Sequence Assign Std Problem Statements Identify Problems (what/why) Categorize and Prioritize Data Current task JHSAT - January 2007
Yes
Conflicts?
No
Technical Review & Expert Validation Report Results IHST JHSIT
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Sample of event processing
Event/Conditions Problem (what) Contributing Factor (why) SPS N o Standard Problem Statement Intervention Recommendation
V I A U
Popping noise Engine power loss Exhaust valve failure - root cause not determined 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 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.
Pilot intentions and actions unknown. Flight/systems information unkown.
Lack of recent experience in M/M and with autorotations Lack of total helicopter experience Lack of information - flight and systems information 24010 21074 13071 13070 41020 engine component failure pilot control/handling, inadequate autorotation Mandate Textron Lycoming SB388B to reduce liklihood of exhaust valve failure Autorotation training aids, simulators etc 4 4 3 4 Transition to aircraft make/model Pilot transition training information unavailable to investigators Develop company policy and training rqts for pilots transitioning between m/m model specific simulator training cockpit recording devices 4 3 4 3 4 4 3 3 3 2 3 3 2 3 4 3 JHSAT - January 2007
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Data Analysis:
The JHSAT team is currently processing 195 accidents from the NTSB year 2000 database 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 JHSAT - January 2007
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Data Analysis Status:
To date the accidents analyzed have covered a wide spectrum of helicopter types and operations. The team has currently completed 187 of 195 accidents 1200+ scored problem statements/intervention findings have been developed JHSAT currently doing some “cleanup” work, will start categorization and prioritization work at our Feb meeting Expect to offer recommendations for all major operational groups in the helicopter community JHSAT - January 2007
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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? Range: Guess = 0 Absolutely Sure = 4 Range: No importance = 0 Cause of accident = 4 Ability - How well can this particular Intervention mitigate the cause or contributing factors of this accident scenario? Range: No effect on Problem Statement = 0 Would Prevent Problem Statement = 4 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: No Utilization = 0 100% Utilization = 4 JHSAT - January 2007
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JHSAT Operational Categories (as of 1/07, still being worked)
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
Secondary
External Load Training Positioning/RTB Ferry Air Taxi - Cargo (135) Air Taxi - Passenger (135) Cargo (91) Public Use Maintenance/Test flight Evaluation flight JHSAT - January 2007
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JHSAT Intervention Frequency
Better Crew Decision Making Training Improved Operational SOPs Enhanced Data Recording Formal Risk Process & Oversight New In Cockpit Systems/Warnings Improved Data/Info to Pilots w x/lz/etc Enhanced Maintenance Proceedures Enhanced Reg Rqts/Guidance Disciplinary Action Enhanced CFI rqts 0 12 11 22 36 42 50 55 61 71 106 100 150 Snapshot after analysis of 90 accidents 173 200 211 JHSAT - January 2007
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250
JHSAT - January 2007 Snapshot after analysis of 90 accidents
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Engaging with the international community
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Worldwide Helicopter Accidents/Year 1980 - 2005 800 700 600 500 400 300 200 100 0 80 82 84
US Civil Registry
86 88 90 92 94
Non-US Civil & Military
96 98 00 02 04
US Military & USCG (ABC) JHSAT - January 2007
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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 - January 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 Process development using US NTSB data represents 48% of worldwide fleet
JHSAT Lead Group IHST Executive Committee Measure Accident Reductions Effectiveness Measure Implementation Effectiveness
Need to maintain a strong communication/feedback loop between IHST – JHSAT - JHSIT
JHSIT Lead Group JHSAT sends recommendations to JHSIT
Canada JHSAT EASA JHSAT Others?
JHSAT/JHSIT
Canada JHSIT
cross-talk
EASA JHSIT Region X, Y, Z JHSIT US/CAN/EASA Consolidated Recommendations ALEA group EMS group 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 JHSAT - January 2007
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Engaging with the International Community IHST Outreach/Marketing Emerging Fleets 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 (contacted, no reply) NZ (contacted, no reply) Australia Canadian Military Near-term: bring Canada on-line as a test case Consider EASA next 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 Chile USN JHSIT Lead Group Implementing Regional Solutions JHSIT will also have international partner management responsibilities: custom tailored regional solutions coordinated with JHSAT coordinated with IHST JHSAT - January 2007
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Coordinating JHSAT US and International Efforts
Current task US Civil Dataset Selection (1/2 of helicopters Worldwide) Mar/Apr 06 Identify FCAA & Military Partners Sept 06 JSAT Process Understanding Refining May/June 06 Train FCAA & Military Partners in JHSAT Process JHSAT Analysis May-Jan 07 Tech Review Feb 07 FCAA & Military Partners conduct JHSAT analyses on their accident data Expert Review/ Validation Apr 07 2Q 07 First Set US Mitigation Recs Mitigation Recs FCAA & Mil TBD 08 1Q 08 Mitigation Recs - Global TBD 06/07 TBD 07/08 Current task IHST JHSAT is now working to bring EASA and Canada into the process JHSAT - January 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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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) JHSAT - January 2007
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JHSAT - January 2007
Questions?
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