Transcript Document

U.S. Rotorcraft
Accident Data & Statistics
International Helicopter
Safety Team
Lee Roskop, FAA
Scott Tyrrell, FAA
•
•
•
Rotorcraft Standards Staff
Rotorcraft Standards Staff
U.S. JHIMDAT Government Co-Chair
January 23, 2013
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Overview
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Accident Data and Trends
Industry Sector Analysis
Analysis by NTSB Finding Code
Recent Concerns
IHST Review
SPSs, IRs, Occurrences
U.S. JHIMDAT Current Actions
Questions and Answers
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U.S. Rotorcraft
Accident and Fatal Accident Counts
250
205
Accident Count
200
187
175
185
171
169
154
150
152
143
148
134
129
100
50
28
38
25
31
25
24
35
24
29
19
23
18
0
01
02
03
04
05
06
07
08
09
10
11
12
Calendar Year
Accidents
Fatal Accidents
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U.S. Rotorcraft
Accident & Fatal Accident Rates
12.00
9.97
10.00
9.60
Accident Rate
8.96
8.00
6.67
6.05
6.00
5.27
4.00
4.10
5.06
4.47
4.44
3.94
2.00
1.43
1.78
1.33
1.22
0.79
0.73
0.85
1.09
0.74
0.63
0.51
0.00
01
02
03
04
05
06
07
Calendar Year
Accident Rate per 100,000 hours
08
3.68
09
10
0.64
11
12
Fatal Accident Rate per 100,000 hours
*Rates estimated using flight hours from the FAA’s GA & Part 135 Activity Survey
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Current Accident Rates vs. IHST Goal
12.00
9.97
10.00
9.60
Accident Rate
8.96
8.00
6.67
6.05
6.00
5.27
4.47
4.00
4.10
5.06
4.44
3.94
3.68
2.00
IHST’s U.S. Goal by 2016: 1.8 accidents per 100,000 flight hours
0.00
01
02
03
04
05
06
07
Calendar Year
08
09
10
11
12
Accident Rate per 100,000 hours
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Measuring Significance of
Improvements
• 5 Year Snapshots by Month
– Plotted average accidents by month 2001-2005
• Superimposed lines for 2 x standard deviation
– Observed progress based on 5 year increments
• Plotted 2006-2010
• Plotted 2011-2015
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Average Accidents/Month: 2001-2005
30
Total Accidents
25
20
15
10
5
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
5 Yr Avg: CY01-05
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Average Accidents/Month:
2001-2005 with 2 x Standard Deviation
35
30
Total Accidents
25
20
15
10
5
0
Jan
Feb
Mar
Apr
5 Yr Avg: CY01-05
May
Jun
Jul
+ 2 Std Dev
Aug
Sep
Oct
Nov
Dec
- 2 Std Dev
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Average Accidents/Month:
Comparing 2001-2005 with 2006-2010
35
30
Total Accidents
25
20
15
10
5
0
Jan
Feb
Mar
Apr
5 Yr Avg: CY01-05
May
Jun
+ 2 Std Dev
Jul
Aug
- 2 Std Dev
Sep
Oct
Nov
Dec
5 Yr Avg: CY06-10
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Average Accidents/Month:
Comparing 2001-2005 with 2011-2015
35
30
Total Accidents
25
20
15
10
5
0
Jan
Feb
Mar
Apr
5 Yr Avg: CY01-05
May
Jun
+ 2 Std Dev
Jul
Aug
- 2 Std Dev
Sep
Oct
Nov
Dec
5 Yr Avg: CY11-15
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Industry Sector Analysis
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IHST Industry Analysis:
2000, 2001, 2006: 523 Accidents
Electronic News
Gathering 1.7%
Personal/Private 18.5%
Utilities
Patrol/Construction
2.1%
External Load 2.7%
Logging 2.7%
Firefighting 3.6%
Instructional/Training
17.6%
Offshore 4.2%
Aerial Observation 4.2%
Business 4.8%
Aerial Application 10.3%
Air Tour / Sightseeing
5.9%
Emergency Medical
Services 7.6%
Law Enforcement 6.5%
Commercial 7.5%
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FAA Follow Up On Industry Analysis:
2010-2012: 411 Accidents
Logging 0.5%
Electronic New s
Gathering 0.5%
Firefighting 0.7%
Air Tour / Sightseeing
2.2%
Personal/Private 24.6%
Offshore 2.2%
External Load 3.2%
Business 3.6%
Utilities Patrol /
Construction 3.9%
Aerial Observation 4.1%
Instructional/Training
19.7%
Com m ercial 4.9%
Law Enforcem ent 6.3%
Em ergency Medical
Services 6.6%
Aerial Application 17.0%
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IHST Industry Analysis
2000, 2001, 2006: 84 Fatal Accidents
Air Tour /
Sightseeing 3.6%
Business 2.4%
Personal/Private
22.6%
Electronic News
Gathering 3.6%
Utilities
Patrol/Construction
3.6%
Aerial Application
4.8%
Logging 4.8%
Offshore 4.8%
Emergency Medical
Services 11.9%
Law Enforcement
6.0%
Aerial Observation
7.1%
Instructional/Training
8.3%
Firefighting 8.3%
Commercial 8.3%
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FAA Follow Up On Industry Analysis:
2010-2012: 69 Fatal Accidents
Logging 2.9%
Air Tour / Sightseeing
2.9%
Offshore 2.9%
Business 4.3%
Utilities Patrol /
Construction 5.8%
Personal/Private 31.9%
Law Enforcem ent 5.8%
Aerial Observation 7.2%
Instructional/Training
7.2%
Em ergency Medical
Services 11.6%
Aerial Application 8.7%
Com m ercial 8.7%
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Accident Rate Estimates
(per 100,000 flight hours)
2000, 2001, 2006
Personal/Private
Instructional/Training
Aerial Application
Helicopter EMS
2010-2012
31.99
7.84
11.35
3.70
Personal/Private
25.71
Instructional/Training
Aerial Application
4.96
16.99
Helicopter EMS
1.87
1. Flight hours from CYs 2000, 2001, 2006, 2010 extracted from FAA’s GA & Part
135 Activity Survey.
2. Flight hours from CYs 2011 and 2012 estimated using historical flight hour
increase of 3% per year over CY 2010 hours.
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Fatal Accident Rate Estimates
(per 100,000 flight hours)
2000, 2001, 2006
2010-2012
Personal/Private
6.27
Personal/Private
5.60
Instructional/Training
0.60
Instructional/Training
0.31
Aerial Application
0.84
Aerial Application
1.46
Helicopter EMS
0.93
Helicopter EMS
0.55
1. Flight hours from CYs 2000, 2001, 2006, 2010 extracted from FAA’s GA & Part
135 Activity Survey.
2. Flight hours from CYs 2011 and 2012 estimated using historical flight hour
increase of 3% per year over CY 2010 hours.
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NTSB Findings from 2008-2012
• NTSB Methodology
– Assigns multiple “Findings” to each accident
– Since 2008, each “Finding” uses a 10 digit “Finding Code”
– Each 2 digits in the code drills down to a more specific factor
• For example:
0303403582
40
03
03
Environmental Physical
environment
issues
Terrain
35
Snowy/icy
82
Effect on
operation
– Analyzed most frequently used “Finding Codes”
• Codes in place for 479 of the rotorcraft accidents from 2008-2012
• May show best opportunities for improving safety
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Top 2 digit “Finding Codes”
• Personnel Issues:
– Cited in 77% of accidents
• Aircraft:
– Cited in 71% of accidents
• Environmental Issues:
– Cited in 40% of accidents
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Top 10: 4 digit “Finding Codes”
2 Digit
Aircraft
Personnel issues
Personnel issues
Environmental issues
Environmental issues
Personnel issues
Aircraft
Aircraft
Not determined
Aircraft
4 Digit
Aircraft oper/perf/capability
Task performance
Action/decision
Physical environment
Conditions/weather/phenomena
Psychological
Aircraft power plant
Aircraft propellor/rotor
Not determined
Aircraft systems
Frequency of
Use
43%
43%
35%
24%
19%
18%
12%
10%
9%
6%
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Top 10: 6 digit “Finding Codes”
2 Digit
Aircraft
Personnel issues
Personnel issues
Personnel issues
Environmental issues
Environmental issues
Not determined
Personnel issues
Environmental issues
Aircraft
4 Digit
Aircraft oper/perf/capability
Task performance
Action/decision
Psychological
Physical environment
Conditions/weather/phenomena
Not determined
Action/decision
Physical environment
Aircraft propellor/rotor
6 Digit
Performance/control parameters
Use of equip/info
Action
Attention/monitoring
Object/animal/substance
Wind
(general)
Info processing/decision
Terrain
Main rotor system
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Frequency of
Use
41%
30%
28%
15%
14%
10%
9%
8%
8%
5%
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Recent Trends: 2012 closes poorly
• Oct-Dec 2012
– Accidents
• 60% higher than same period in 2011
• Highest Oct – Dec total in 5 years
• Tied, 2nd highest Oct – Dec total last 10 years
– Fatal Accidents
• 57% higher than same period in 2011
• Highest Oct – Dec total in 5 years
• Tied, highest Oct – Dec total last 10 years
– Mitigation efforts by FAA, HAI, AOPA, and IHST
• Mass media effort in mid October after 4 fatal accidents in 8 days
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Recent Trends: 2013 starts poorly
• January 2013
– Record setting accident pace during first 9 days
• 7 accidents, 3 fatal accidents, 11 fatalities
• If sustained, pace was for 24 accidents, 9 fatal accidents,
38 fatalities
• Projection would have far exceeded highest total for any
January the last 30 years
– Accident pace slowed during mid month
• Still projected to have a high total, but not record setting
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What has changed?
• 5 years of steady progress
– Consistent improvement, despite lagging the
IHST’s desired 80% accident rate reduction
• 4 consecutive months of regression
– Especially concerning since we are in the
traditionally “lower accident” months
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Recent FAA Safety Alert for Operators
(SAFO)
• Increased manual handling errors for Air Carrier pilots
• Effects of modern aircraft technology
– Pro: Enables precision, improves workload management
– Con: Continuous use can lead to degraded pilot ability to quickly recover the
a/c from an undesired state
• Recommendations:
– More training on when to use automated systems
– More exercise of manual flying skills
• Lesson:
– Technology and Training must compliment each other
– Cockpit advances should facilitate (not replace) basic pilot skills/decisions
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IHST Review
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US-JHSAT: Past Efforts
• Data set – NTSB Accident Dockets
– U.S. civil registered helicopters
– Type certificated (amateur built helicopters excluded)
– Includes ‘Public Use’ and restricted category
• Total of 523 helicopter accidents analyzed
–
–
–
–
CY2000 - 197 accidents (Report issued IHSS 2007)
CY2001 - 174 accidents (Report issued IHSS 2009)
CY2006 - 152 accidents (Report issued IHSS 2010)
Compendium Report – 3 year roll up/summary (Report issued 2011)
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US Accidents by SPS Lvl 1 - Compendium
Standard Problem Statements (SPSs) Level 1
84%
Standard Problem Statement (SPS)
Pilot judgment & actions
73%
Data issues
43%
Safety Management
37%
Ground Duties
31%
Pilot Situational Awareness
28%
Part/system failure
20%
Maintenance
19%
Mission Risk
13%
Post-crash survival
Regulatory
9%
Communications
9%
7%
Safety Systems and Equipment
Infrastructure
Personnel - Non Crew
0%
5%
2%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Percentage of Accidents (523 Total Accidents)
Note: Each of the 523 accidents analyzed typically had multiple Standard Problem Statements.
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US Accidents by IR Lvl 1 - Compendium
Intervention Recommendation (IR)
Intervention Recommendations (IRs), Level 1
Training/Instructional
79%
76%
Data/Information
Safety Management
64%
Systems and Equipment
37%
Maintenance
23%
Regulatory
18%
Infrastructure
9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Percentage of Accidents (523 Total Accidents)
Note: Each of the 523 accidents analyzed typically had multiple Intervention Recommendations
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US Accidents by Occurrence Types
Compendium
-
Accidents by Occurrence Category
Data
74%
LOC - Loss of Control
41%
AUTO - Autorotation
32%
SCF - System Component Failure
28%
STRIKE
16%
Occurrence Category
VIS - Visibility
11%
ARC - Abnormal Runway Contact
8%
FUEL
8%
LZ - Landing Zone
7%
UNK - Unknown/Other
7%
FIRE
6%
EXTL - External Load
5%
AMAN - Abrupt Manuever
4%
CFIT - Controlled Flight into Terrain
3%
DITCH - Ditching
2%
ADRM - Airport
2%
ICE - Icing
1%
RAMP
1%
WSTRW - Windshear/Thunderstorm
Less than 1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percentage of Accidents (523 Total)
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Loss of Control Details - Compendium
Loss of Control Occurrence Category (227 Total Accidents)
Note: 29 Fatal Accidents in Red, 198 Non-Fatal Accidents in Yellow
5
PM - Perform ance Managem ent
3
DR - Dynam ic Rollover
OL - Exceeding Operating Lim its
LTE - Loss of T/R Authority
74
28
6
21
2
21
6
EP - Em ergency Procedures
INT - Interference w ith Controls 1
16
UNK - Unknow n
6
GR - Ground Resonance
5
TD - Tie-dow ns/hoses
4
SP - Settling w / pow er
3
0
17
9
10
20
30
40
50
60
70
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80
90
31
Intervention Recommendations - IR3
Top 10 from “Compendium” Report
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Install cockpit recording devices
Improve quality and depth of NTSB investigation and reporting
Autorotation Training Program
Follow ICA procedures with confirmation of compliance
Simulator Training - Advanced Maneuvers
Personal Risk Management Program (IMSAFE)
Training emphasis for maintaining awareness of cues critical to safe flight
Better Mx QA oversight to ensure adherence to the ICA/Manual
Mission Specific Risk Management Program
Enhanced Aircraft Performance & Limitations Training
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Current JHSIT Toolkits
“Addresses” 8 of the Top 10 IRs
•
Helicopter Flight Data Monitoring Toolkit
–
•
Install Cockpit Recording Devices
Training Toolkit
–
–
–
–
•
Training Emphasis for Maintaining Awareness of Cues Critical to
Safe Flight
Autorotation Training Program
In-flight Power/Energy Management Training
ADM Training
SMS Toolkit
–
–
•
Mission Specific Risk Management Program
Establish mission Specific SOP and Flight OPS Oversight Program
Maintenance Toolkit
–
Follow ICA Procedures with Confirmation of Compliance
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From JHSAT to JHIMDAT
• Goals of analysis evolved in 2011
– JHSAT complete: Identified problems and recommended interventions
– JHIMDAT initiated: Measure progress of implementation actions
• Economic realities = more resource constrained effort
– Economic downturn resulted in reduced industry participation
– Original meetings of once/month reduced to 3-4 times annually
• Detailed analysis on every accident not performed
– Time consuming process not feasible with more limited meeting times
– More strategic effort toward specific targeted areas
• Industry may need to lead in areas where deeper study is desired
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Current US JHIMDAT Analysis Efforts
• Assess Progress by Analyzing Recent Years
– Data set from CY2009 – 2011
– High level analysis has categorized:
• Industry where a/c is used
• Activity being performed when accident occurred
• Occurrence/Sub-Occurrence Code defined “What
Happened?”
– Compare CY09-11 results to data in Compendium
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U.S. JHIMDAT Future Efforts
• Targeted Industry Outreach
– ALEA
– Ag Ops
• NTSB Finding Codes
– Compare findings from recent accidents to Compendium
• Improved tracking of System Component Failures
– Classify system failures using established taxonomies
• Air Transport (ATA)/Joint Aircraft System/Component (JASC)
– Update to Compendium, compare recent accidents
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IHST Upcoming Action Items
• Launch Regional Teams
– North America Helicopter Safety Team
(NAHEST)
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Questions?
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Back-up IHST Slides
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US Accidents by Operation
80%
70%
60%
50%
2000
40%
2001
2006
30%
20%
10%
0%
Par t 91
Par t 137
Par t 135
Par t 133
Publ i c Use
Other
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Pe
rs o
na
l/
Ins Priva
t/T
t
rai e
nin
g
Ob EMS
s/P
atr
A ir o l
La Co m To ur
w E me
rcia
nfo
Ex r cem l
ter
n a en t
lL
Ae oad
ria
l
Bu App
si
Fir n ess
efi
gh
t
Of ing
fs h
o
Lo r e
gg
ing
Uti
lP
atr ENG
o l/
Co
nst
US Accidents by Mission
25%
20%
15%
10%
2000
2001
2006
5%
0%
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US Accidents by SPS Lvl 1
100%
90%
Percentage of Accidents
80%
70%
60%
50%
2000
40%
2001
30%
2006
20%
10%
0%
l
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tru
ct
io
D
na
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Sa
rm
fe
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io
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M
Sy
an
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ai
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Percentage of Accidents
US Accidents by IR Lvl 1
90%
80%
70%
60%
2000
50%
2001
40%
2006
30%
20%
10%
0%
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rmal
ntrol
Fue l
nta c
t
Land
ing Z
one
Unkn
ow n
/O th
er
way
Co
Vis ib
ility
Strik
e
rotat
i on
pone
nt Fa
ilure
Ru n
Co m
Auto
of Co
Fire
Exte
r nal
Load
Abru
pt M
Cont
anue
rolle
ver
d Fli
ght i
nto T
erra i
n
Airp
ort
Ditch
ing
Ram
p
Wind
shea
Icing
r/Thu
nder
storm
Abno
Sys t
em
Los s
US Accidents by Occurrence Types
50%
45%
40%
35%
30%
25%
2000
20%
2001
15%
2006
10%
5%
0%
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llov e
r
Sett l
ing w
/ pow
er
oses
wns/
h
ce
Reso
na n
Tie-d
o
Grou
nd
Unk n
ow n
g Op
erat i
ng L
imits
Eme
rgen
cy P
roce
dure
s
Loss
of T/
R Au
thori
Inter
ty
f eren
ce w
ith C
ontro
ls
Exce
e din
men
t
Dy na
mic
Ro
ce M
anag
e
rman
Perfo
Loss of Control Details
20.0%
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2000
2001
2006
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