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GABA IV Workshops Safety and Accident Investigation

Mike Suldo March, 2015

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

“Aviation is not in itself inherently dangerous. But to an even greater degree than even the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.”

Do we always do the safest thing when flying?

Is safety the only thing that we worry about?

No !

Because if it were, this is what would happen, we would not fly !

Safety is about accepting the fact that there are risks in what we do, then trying to make those risks as small as possible.

This is what we do not want

When an accident is investigated 4 areas are looked at:

The Aircraft Maintenance Suitability for mission Mechanical problems The Pilot and Crew Training Qualifications Physical and Mental condition The Environment Weather Terrain Hazards The Operation Hazards Within crew capabilities?

This one was mine

Cause: Refueled on aircraft carrier in Mediterranean Sea. Was pumped water instead of fuel. Resulted in dual engine flameout on takeoff from ship .

All survived – no injuries

Another of my Accidents Navy H-46

Cause of Accident

Lack of a “cotter pin” to secure the nut on the actuator in the flight controls. The nut backed off of the bolt in 8 hours of flight time and then disconnected the pitch control rod in flight resulting in an “uncomanded “ loop. This caused the rear blades to sever the front blades and break the fuselage in half.

Supposed to look like this

The Cotter Key was left off

This nut backed off

The result of one Cotter Key left off 3 Fatalities + 2 serious injuries

And especially these

Video - Bought Helicopter Can’t Fly

Accidents and Incidents Cost!

• • • •

Direct costs Loss of aircraft Injuries to or death of flight crewmembers, passengers Insurance deductibles Costs not covered by insurance

• • • • • • •

Indirect costs Loss of use of equipment Loss of staff

– – Involved in accident issues Lower productivity

Investigation & clean-up Legal claims Fines Misplaced/stranded passengers Negative media exposure

Most Predominant Occurrences During Fatal Helicopter Accidents

1. Loss of Control 2. Visibility issues 3. Fire (post-impact) 4. Wire Strike 5. System Component Failure

Other Frequent Occurrences During Fatal Helicopter Accidents

Autorotation (in practice & emergency) Controlled Flight Into Terrain Fuel issue Abrupt Maneuver Icing Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

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Why Do Most Helicopter Accidents Happen? This is true over the past 10 years Probable cause. . . .

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“Pilot error” – 78%

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Weather-related

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Flight into the ground or objects

– – –

Mechanical – 19% Other – 2% Undetermined – 2%

Pilot

Mechanical

From the U.S. Army (2011-12)

Where can you go for Help ?

IATA – Has a Beijing Office

The International Air Transport Association (IATA) is the trade association for the world’s airlines, representing some 250 airlines or 84% of total air traffic. We support many areas of aviation activity and help formulate industry policy on critical aviation issues.

Accident Investigation Course in Singapore $2125. USD Nov 23-Nov 27, 2015

This course enables airline staff members to participate in an aircraft accident and serious incident investigation in accordance with ICAO Annex 13 standards. Special attention is given to understanding the underlying causes of accidents and incidents in order to improve safety and prevent future occurrences.

Available as: Classroom & In-Company course Duration: 5 days (40 hours) Recommended level: Advanced and intermediate Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

Safety Training Courses

Certificate Program in Aircraft Accident Investigation (AAI) Required Courses Aircraft Accident Investigation (AAI) Human Factors in Accident Investigations (HFAI) Plus any three from below

Aircraft Accident Investigation for Media Professionals ( AAIMP ) Aircraft Performance Investigation ( API ) Air Traffic Control Investigation ( ATCI ) Cabin Accident Investigation ( CAI ) Electronic Systems Investigation ( ESI ) Fire and Explosion Investigation ( FEI ) Fixed Wing Accident Investigation and Reporting ( FWIR ) Flight Data Analysis ( FDA ) Flight Reconstruction from GPS Data ( GPS ) Gas Turbine Accident Investigation ( GTAI ) Helicopter Accident Investigation ( HAI ) Investigation Total Immersion ( ITI ) Investigation Management ( IM ) Family Assistance Planning ( FAP ) Aircraft Maintenance Investigation ( AMI ) Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

SCSI Safety Courses - Long Beach, California

PREVENTION SERIES

Safety Management Systems - Complete 01-05 June Flight Safety Officer Course 08-12 June Investigation in Safety Management Systems 15 19 June Leading Change in SMS 22-26 June Human Factors in Aviation Maintenance 02-04 Sep Safety Management Systems - Complete 07-11 Sep Investigation in Safety Management Systems 14 18 Sep Leading Change in SMS 21-25 Sep Operational Risk Management 21-25 Jan

INVESTIGATION SERIES

Aircraft Accident Investigation 02-13 Feb Human Factors in Accident Investigation 16-20 Feb Helicopter Accident Investigation 23-27 Feb Gas Turbine Accident Investigation 02-06 Mar Aircraft Maintenance Investigation 09-13 Mar Investigation Management 16-20 Mar Cabin Accident Investigation 11-15 May Human Factors in Aviation Maintenance 30 Mar-01 Apr Aircraft Accident Investigation 06-17 July Human Factors in Accident Investigation 20-24 July Fire and Explosion Investigation 27-31 July Aircraft Performance Investigation 03-07 Aug Electronic Systems Investigation 10-14 Aug Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

Your Best Resource Country / Area Specific Sets up “Groups” in different countries or areas Already has produced things that you can use Working to Reduce World-Wide Helicopter Accidents Works to understand your past accidents and how you can prevent them in the future

Safety Bulletins

•Visibility • Inadvertent Entry into Cloud or Fog • Visibility: The Minimum You Should Know •Loss of Control • Gaining Control over Loss-of-Control Accidents • Emergency Decision Making: What Happens When You Lose a Critical System?

• Density Altitude – The Invisible Factor of Helicopter Performance •CFIT • Controlled Flight into Terrain Prevention with HTAWS • Controlled Flight into Terrain: How Does it Happen?

•Autorotations • Rotor Rooter – Autorotation Acronyms • How to Train to Survive a Real Autorotation • Energy in Autorotations – Using Energy for our Benefit Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners. •Training • Instructional Safety: Training Safety or Training Safely? • Recurrent Training: Are You Current and Proficient? •Safety Management • Internal Evaluation Program (IEP) Safety Assurance Check • Hazard Identification – If You See Something . Say Something • A Flight/Ground Risk Assessment Tool (FRAT/GRAT) • SMS for Certificated Flight Instructors • SMS: How to Get Started for the Small Operator •Professionalism • Setting the Right Example • A Defensive Strategy for Helicopter Pilots • Precautionary Landings

Safety Leaflets

The Principles of Threat and Error Management (TEM) for Helicopter Pilots and Instructors Helicopter Operations in Hilly and Mountainous Terrain Using Advanced Navigation Technology Safely Helicopter Airmanship Helicopter Safety Considerations Helicopter Airmanshiphttp://www.ushst.org/nbspnbspBulletinsnbsp.aspx

Off Airfield Land Site Operations Single Pilot Decision Making Risk Management in Training Advantages of Simulators in Helicopter Flight Training Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

Safety Management Systems (SMS)

Safety Management System is becoming a standard throughout the aviation industry worldwide. It is recognized by the Joint Planning and Development Office (JPDO), International Civil Aviation Organization (ICAO), and civil aviation authorities (CAA) and product/service providers as the next step in the evolution of safety in aviation. In the US, You need an SMS if: Many foreign countries such as Canada, France, Australia require it for all operations with other to follow

Safety Management Strategies

Reactive (Past)

Responds to events that have already happened, such as incidents and accidents

Proactive (Present)

Actively seeks the identification of hazardous conditions through the analysis of the organization’s processes

Predictive (Future)

Analyzes system processes and environment to identify potential future problems

Safety Management Systems

Mandated by FAA for 121 operations, recommended for others.

A system (documented) to manage aviation risks using Leadership and Accountability. It requires Pro-active Hazard identification, risk management, information control, auditing, and training. It must start at the top, with a commitment from the leaders of the business.

A good SMS will provide tools to analyze problems And save money and lives

System Analysis (Design) Hazard Identification Risk Analysis Risk Assmt Risk Control

Risk Assessment

Risk assessment determines the level of risk to use in making a bottom line decision.

Risk Likelihood Frequent Occasional Remote Improbable Extremely improbable Risk Severity Catastrophic Hazardous A B 5 4 3 2 1 5A 4A 3A 2A 1A 5B 4B 3B 2B 1B Major C 5C 4C 3C 2C 1C Minor D 5D 4D 3D 2D 1D Negligible E 5E 4E 3E 2E 1E

A risk matrix is a tool used for risk assessment. It can vary in form yet it accomplishes the same purpose.

All needed sample documents to set up a functional SMS can be found on the HAI website for free or you can pay a safety consulting company to come in and set one up.

Flight Data Monitoring (FDM)

An Example - Appareo Flight Data Monitoring Equipment

Weight and Size Matter !!

• Size - 3”x4”x6” • Weight – under 2 lbs • 1 wire hookup

ALERTS Installed Aircraft: 51

January flight time: 1855.91

January flights: 5086 January valid events: 1008

January 2008 - Ev e nt Totals (All Type s)

Settling/Power, 0% Steep Turn, 0% Prem ature Departure Turn, 3% Exces s ive Bank, 5% Exces s ive Clim b, 1% Low Turn to Final, 3% Low Cruis e, 22% Exces s ive Clim b 407, 0% Exces s ive Des cent <500ft., 39% Exces s ive Yaw Rate, 1% Exces s ive Pitch T/O, 9% Exces s ive Pitch Landing, 0% Exces s ive Pitch, 2% Exces s ive Des cent >500ft, 15% Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

With satellite data automatically added

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of 48 CP HDG

N AV VS

ILS ALT

DECEL P 50% 90% 100% VOR H o n e y w e ll APR 1 BC

IAS

SBY ALT PRE

GA 2 C S ERVOS NO.1 OFF HOIST UP ENG - TRIM NO.2 OFF DOWN AFT TRIM ARND GO #1 #2

North Sea Results:

FDRs Required

Flight Data Monitoring Cirat Videos from Bell 429

Simulator Training From Simple to Complex

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of 51

Training in autos to the water

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of 52

It is Important to Have the Right People, the Right Training, the Right Safety systems, and the Right Attitude. BUT… it is also important to have the Right Equipment in the Aircraft to make them Safer.

Recommended Aircraft / Helicopter Safety Equipment

• • • • • • • • • • • The Right Avionics (dual communications radios) Radar – on bigger helicopters and aircraft Night Vision on helmet – on many helicopters Enhanced Ground Warning System or helicopter terrain awareness and warning systems (HTAWS) Helicopter Wire Strike Protection Radar Altimeter GPS navigation with obstruction database Flight data monitoring equipment Air traffic collision avoidance systems Satellite aircraft tracking Health Usage (Vibration) Monitoring Equipment (HUMS) Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.