Preliminary Results

1. Preliminary Results EHEST Conference 13 October 2008 Cascais, Portugal

2. Contents • Data set description • General data • Identified factors data • Standard Problem Statements • HFACS • Intervention Recommendations • Concluding Remarks & Way forward

3. Data set description Preliminary Results Picture Source AgustaWestland

4. Scope of analysis • Based on a data driven approach • Focus on: • Accidents (definition ICAO Annex 13) • Date of occurrence year 2000 - 2005 • State of occurrence located in Europe • For this purpose Europe is defined as the EASA Member States (27 EU + plus Iceland, Liechtenstein, Norway and Switzerland) • Only those accidents are being analysed where a final report from Accident Investigation Board is available

5. Scope of preliminary dataset • Total of 186 within timeframe 2000-2005 have been analysed • Covers work from 9 Regional Teams across Europe • Does not cover all accidents within timeframe • Preliminary results, not fully representative of European accidents in the reference period • The following slides present preliminary results based on these 186 accidents

6. Proportion of analysed accidents Estimated data for the 9 Regional Teams currently participating

7. General Data Preliminary Results Picture Source Eurocopter

8. Number of Accidents per Type of Operation General data

9. General data

10. Phase of Flight Distribution In hover Not in hover General data

11. Injury level Distribution per Phase of Flight General data

12. Pilot-in-Command Total Flight Experience in Hours All Helicopter Types General data

13. Pilot-in-Command Total Flight Experience in Hours All Helicopter Types 0 – 1000 flight hours only General data

14. Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type General data

15. Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type 0 – 1000 flight hours only General data

16. Pilot-in-Command Total Flight Experience in Hours All Helicopter Types Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type. General data

17. Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type. General data

18. Identified factors dataStandard Problem Statements & HFACS Preliminary Results Picture Source AgustaWestland

19. Identified factors data • Two models used for identification of factors • SPS • HFACS • Standard Problem Statements • In total 1067 factors identified for all 186 accidents • HFACS • In total 445 factors identified for all 186 accidents

20. SPS level 1 – All Accidents

21. SPS level 1 compared with US JHSAT data Correlation is: .89

22. SPS level 2 (top 10)– All Accidents (excluding Data Issues)

23. Unsafe Supervision Organisational Influences Unsafe Acts Preconditions for Unsafe Acts HFACS model Facilitate identification of the underlying causes Merely symptoms

24. 60% Judgement & Decision-Making Errors 28% Skill-based Errors 12% Perceptual Errors HFACS model – upper levels Unsafe Acts Errors Violations 16% 84%

25. HFACS model – upper levels Preconditions Environmental Factors Condition of Individuals Personnel Factors 17% 60% 23%

26. Supervision 0% Inadequate Supervision Planned Inappropriate Operations Failure to Correct Known Problem 0% Supervisory Violations 41% 59% HFACS model – upper levels

27. Organisational Influences Organisational Process Organisational Climate Resource Management 24% 64% 12% HFACS model – upper levels

28. Going into more detail • The following slides present the lowest level in the taxonomy: level 3 • This provides a more detailed insight into the type of accidents occurring • Results will be presented for the three main types of operation • Commercial Air Transport • Aerial Work • General Aviation

29. An example Commercial Air Transport scenario • Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. • The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow.

30. An example Commercial Air Transport scenario • Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. • The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow. Loss of Visual Reference Inadequate decisions Pilot felt pressure

31. SPS level 3 (top issues)–Commercial Air Transport

32. HFACS level 3 (top issues)–Commercial Air Transport

33. An example Aerial Work scenario • During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. • The helicopter lost altitude, contacted the surrounding trees and crashed.

34. An example Aerial Work scenario • During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. • The helicopter lost altitude, contacted the surrounding trees and crashed. Operated near maximum take-off mass Obstacles Pilot intensive Tailwind Loss of tail rotor effectiveness Cargo not released

35. SPS level 3 (top issues)–Aerial Work

36. HFACS level 3 (top issues)–Aerial Work

37. An example General Aviation scenario • The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. • Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. • The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact.

38. An example General Aviation scenario • The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. • Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. • The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact. No weather forecast obtained No flight plan filed No contact established with ATC Inadvertent IMC Limited experience

39. SPS level 3 (top issues)–General Aviation

40. HFACS level 3 (top issues)–General Aviation

41. Intervention Recommendations Preliminary Results Picture Source Jaume Bosch

42. Intervention Recommendations In total 11 Intervention Recommendation categories identified The categories help identify areas for working groups of EHSIT Note: some categories do overlap but they do succeed in suggesting areas to focus

43. Intervention Recommendation Categories – All Accidents Flight Ops & Safety Management/Culture Intervention Recommendations for All Accidents

44. Regulatory Flight Ops & Safety Management/Culture Training/Instructional Overview of top categories

45. Example IRs Within each IR type there are a wide range of different interventions that have already been identified so far The following are some un-prioritised examples from across all operational categories:

46. IRs Examples: Training/Instruction • Better training for specific missions & operating environments • E.g.: Improve training for mountain operations specifically for landing on snow covered surfaces • Better training for inadvertent entry in IMC condition • Better training on type specific issues and operational limits. • Special training supervision arrangements should be considered when dealing with slow learning students who are taking longer to complete the PPL(H) syllabus.

47. IRs Examples: Training/Instruction Instructors/examiners be updated more regularly by TRTOs. Establish measures to avoid culture of non-compliance Include risk assessment training Encourage organising private helicopter pilots into flying clubs etc for mutual support and better exchange of experiences / safety information

48. IRs Examples: Flight Ops & Safety Management/Culture Develop safety management system (SMS) Promoting a safety culture vs. ‘getting the job done regardless’ Investigate the user-friendliness of checklists Manage human factors risk especially regarding routine violation Use a Flight Data Monitoring system to give feedback to pilots Increased oversight of new pilots During the mission preparation, the management should take into account the experience of each crew member and mix the different skills. Better planning especially for higher risk missions Increase awareness of obstacles & provision of Wire Strike Protection System

49. IR Examples: Regulatory • Require greater flight data recording usage to assist in future occurrence investigation • Promote research inexpensive, lightweight, airborne flight data and voice recording equipment for smaller helicopters • VFR flight criteria for helicopters and licence privileges for pilots should be reviewed to reduce the risk from flight in a Degraded Visual Environment • Review the deck markings on ships involved in winching operations with the aim of including a requirement to clearly display the dimensions of the 'manoeuvring zone', such that it can be clearly seen by the helicopter crew. • Establish specific training requirements for operational crew members other than flight crew required for aerial works operations.

50. Other Selected IR Examples Improve crashworthiness & survivability Improve OEM manufacturing quality assurance Establish safe limits of helideck movement for helicopters operating offshore Validated, simplified weight and balance process should be made available Provide better information on aircraft fuel consumption for pilots to safely plan flights on the basis of verified fuel contents. Type specific airworthiness improvements Making specific safety enhancing equipment part of the build standard Making specific equipment available for operators to adapt aircraft for specific missions / environments