Transcript Document

Today’s challenges
Tomorrow’s opportunities
Solakonferansen
Stavanger, 13-14 September 2011
David Learmount
Operations & Safety Editor
Challenge & Opportunity
 We have an opportunity to overcome safety
challenges
 If we overcome the challenges, new
opportunities will open up.
The objective
 Review where safety performance is today
compared with recent years
 Review what kind of accidents are still
happening in the rotary wing and airline
world
 …and why they are still happening,
according to EHEST/IHST/US JHSAT
 Analysis of accident causes
(EHEST/JHSAT)
IHST/EHEST: Who/what?
 Set up in 2005
 Objective: reduce global helicopter accident
rate by 80% by 1 January 2016
 Only four years to go, and no sign of a trend
that would meet that objective by that date
 Limitations of research programme so far: it
has taken several years to dig out the data
required to understand the problem
The global problem
Trend? There isn’t one!
US civil helicopter accident trend
compared with target
US JHSIT: better, or coincidence?
Commercial helicopter accidents:
Europe and rest of world
 Commercial operators > 2250kg
Where we’re at (Airlines)
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Fatal accidents only, simple numbers not rates
All types of airline operation including passenger, freight,
positioning, ferry, training etc
Jet, turbo-prop and (occasionally) piston
Where we’re at (Airlines)(2)
 IATA figures, western-built jets
 Hull losses
 The bars are IATA carrier figures, the line the global
average
Can we get better? YES!
Loss of/lack of control accidents
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2010 Afriqiya Airways, Tripoli, Libya
2010 Ethiopian Airlines 737-800, Mediterranean Sea near Beirut
2009 Turkish Airlines 737-800, Amsterdam
2009 Colgan Air Dash 8 Q400, Buffalo
2009 Yemenia Airbus A310-300, Indian Ocean near the Comoros Islands
2009 Air France A330-200, South Atlantic
2007 Adam Air 737-400, Java Sea near Sulawesi
2006 Armavia A320, Black Sea near Sochi
2004 Flash Airlines 737-300, Red Sea near Sharm el-Sheikh
2000 Gulf Air A320, Arabian Gulf near Bahrain
These ten accidents have killed a total of 1,137 people in ten
years. Every single one was completely avoidable!
The message
 Almost all the accidents that have happened in the
last ten years, could have been prevented by the
application of normal pilot skills. The problem is
that those skills have been eroded by lack of
practice.
 Modern aeroplanes are highly reliable and
beautifully built. They are also easy to fly, but very,
very complex electronically. They can – and do –
lull pilots – and airlines - into a false sense of
security.
Can accidents be eliminated?
 Most of today’s serious
accidents could easily
be eliminated
 There will always be a
few accidents that can’t
be prevented because
they will result from
circumstances - or
combinations of
circumstances - that we
have not yet
encountered or
predicted. But these
will be rare.
Even a good airline can have a bad
day (1)
Accidents can still happen to really good airlines. But only the type of
accident I just described, where the causal factors have not previously been
encountered or predicted.
Example: British Airways Boeing 777 (G-YMMM) on 17 January 2008 at
London Heathrow. Hull loss, no fire, one passenger injury, no fatalities
What happened? Forced landing 350m short of runway threshold when, one
minute before landing, engine power was reduced by a sudden blockage of the
fuel supply. Water ice crystals that had adhered to the fuel pipe walls during
cruise were suddenly flushed into the fuel that was being delivered to the
engines when the auto-throttle demanded power during final approach.
Comment: This had never happened before in the history of aviation, and it
had not been predicted either. The crew could not have done anything more
than they did to save the aircraft.
Moral of the story: even good airlines need insurance.
Plus: a good example of the durability of modern airframes. This 777 hit the
ground very hard, but didn’t break up and didn’t catch fire.
Even a good airline can have a bad
day (2)
Another example: 4 November 2010, Qantas Airbus A380 (VH-OQA)
What happened? Uncontained failure of No 2 Rolls-Royce Trent 900
engine. High velocity metal fragments penetrated wing leading edge,
cutting fuel and hydraulic lines and piercing forward wing spar. Multiple
electrical and hydraulic systems failures. Crew had to deal with nearly
150 systems alerts on the electronic centralised aircraft monitor. The
crew recovered the aircraft to Singapore where it landed safely. Major
partial damage to engine and airframe, no injuries or fatalities.
Comment: Stuff happens. Rolls didn’t know this was going to happen,
so Qantas certainly didn’t. Investigation still proceeding.
Moral of the story:
1. Train your crews, like Qantas does, to act as crews, and not to lose
sight of the basics (airspeed, attitude, altitude, navigation) while dealing
with multiple unforeseen technical problems.
2. Also a testament to the structural durability and systems redundancy in
the latest generation of airliners
Even a good airline can have a bad
day (3)
“Sully” Sullenberger and the US Airways A320 that he ditched in the
Hudson River near New York after a birdstrike had made his aircraft a
glider. The aircraft’s flight envelope protection was not required: Sully
flew the descent to ditching with respect for normal flight parameters
Hull loss, but no injuries or fatalities
Moral of the story: train your pilots for more than ordinary flying,
because the day they have to take the autopilot out because things
have gone wrong is the day they earn their money.
We can get better!
The message from the airlines is:
 We have already got much better than we were
 …but we seem to have stopped getting better and are still
having preventable accidents, but…
 …some airlines don’t have accidents at all, or only have the
ones that could not possibly have been avoided
 So we can all be like them if we think and train like them!
Now back to the safety stone-age: helicopters
(with apologies to the North Sea oil-support sector which has
made massive improvements over the last 20 years)
Helicopters: why get better?
 High cost and poor safety (relatively) means
that people only choose helicopter travel
when there is no alternative
 The market for helicopters and helicopter
operations is being artificially restricted by a
perception that helicopters are not safe.
 Costs are difficult to reduce, so safety is the
low-hanging fruit for those who wish to sell
more helicopters or expand their operations
in the long term.
EHSAT: top 3 problems/top 3
solutions
Problems
 Pilot judgement and actions
 Safety culture/management
 Ground duties
Solutions (intervention strategies)
 Flight operations and safety management
culture
 Training/instructional
 Regulatory/standards/guidelines
Top worries: European Commercial
helicopters
Top Standard Problem Statements
Top HFACS* issues
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Pilot decision making
Pilot-in-Command self induced pressure
Inadequate oversight by the Authority
Failed to follow procedures
Selection of inappropriate landing site
Reduced visibility – whiteout, brownout•
Pilot’s flight profile unsafe for conditions
Inadequate government/industry
standards and regulations
Disregarded cues that should have led
to termination of current course of action
or manoeuvre
Aircraft position and hazards
Pilot inexperienced with area and/or
mission
Mission involves operations at high
density altitudes
Management disregard of known safety
risk
Inadequate consideration of obstacles
Inattention
Decision-making during operation
Channelized attention
Brownout/whiteout
Risk assessment – during operation
Overcontrol/Undercontrol
Procedural Guidelines/Publications
Communication Critical Information
Mission Briefing
Error due to misperception
Technical/Procedural knowledge
Pressing
Cognitive task oversaturation
Misperception of operational condition
Distraction
Excessive motivation to succeed
* Human factors analysis and classification
system
Top strategies (Europe)
 SOPs: operators should be encouraged to
establish and apply effective SOPs for all
activities that they undertake
 Safety culture: operators should develop an
engagement/communication plan (videos,
meetings, surveys, internet etc) to promote
the development of a safety culture, risk
assessment and rule compliance.
Top strategies 2 (Europe)
 Run a closed-loop safety management
system
 Create a mission preparation and execution
template against which every mission is
checked before departure. Risk assessment
will be central to this.
 Risk assessment should be taught as a part
of everyone’s job.
US accidents by operational sector
JHSIT separates offshore from other commercial ops
US JHSAT: accidents by occurrence
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Loss of control (41%)
Autorotation (32%)
System/component failure (28%)
Strike (16%)
Visibility (11%)
etc
Top US intervention
recommendations (IR)
 Improve training at all levels
 Improve investigation and accident/incident
reporting (lack of data is a serious
impediment to improvement)
 Improve safety management, with risk
assessment and the application of SOPs
high on the list
(note that this pretty well harmonises with the
EHEST recommendations)
How to intervene (US JHSAT)
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Install cockpit recording devices - to record the actions of the flight crew.
Data can be used as immediate feedback to trainers, operators and flight
crews as well as accident investigation
Improve quality and depth of NTSB investigation. “Many accidents do
not receive in-depth investigation. Investigations are being performed by
telephone interview or by personnel who are not accident investigators.
Autorotation training programme. Improve autorotation training in both
primary and advanced flight training and develop simulator programs to
improve autorotation skills.
Confirm engineering compliance. Ensure that maintainers and operators
are aware of the importance of following the manufacturer’s maintenance
manuals and practices, and enforce this practise where required.
Simulator Training - advanced manoeuvres. Incorporate simulator
training in dynamic rollover, emergency procedures training, ground
resonance, quick stop manoeuvres, targeting approach procedures and
practice in pinnacle approaches, unimproved landing areas, and elevated
platforms .
US civil helicopter accident trend
compared with target
US JHSIT: better, or coincidence?
The message
 Airlines have improved but can still easily do much
better
 Helicopters operators worldwide have not really
started improving yet. It’s as if they didn’t even
know the improvement option existed. But now the
IHST is digging up the facts about helicopter
accidents, so the backsliders’ arguments will be
defeated.
 All helicopter operations could be as safe as those
achieved by North Sea oil support operators. They
may not be perfect, but they are way ahead of the
rest.
Thank you for your attention
www.flightglobal.com/blogs/learmount