Safety Partnership: 2008/2009 Achievement by the European Helicopter Safety Team (EHEST)

Transcription

1 Safety Partnership: 2008/2009 Achievement by the European Helicopter Safety Team (EHEST) 3 rd EASA Rotorcraft Symposium 2-3 Dec 2009, Cologne Michel Masson, EASA, Marieke van Hijum, EASA Andy Evans, AviateQ Intl., John Steel, CAA Ireland, and Gunter Carloff, neweha

2 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS 4. CONCLUDING REMARKS Photo Vasco Morao 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 2

3 EHEST is the helicopter component of ESSI and the European branch of IHST 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 3

4 ECAST COMMERCIAL AVIATION SAFETY TEAM EHEST HELICOPTER SAFETY TEAM EGAST GENERAL AVIATION SAFETY TEAM EHSAT Core Team EHSIT Core Team Sub-group on Communication Regional Teams EHSIT Specialist Teams 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 4

5 IS FI NO SE EASA Member States = IE DK EE LV LT 27 European Union States plus Norway, Iceland, Switzerland and Liechtenstein) UK NL PL BE LU DE CZ SK FR CH SI AT HU RO PT ES IT BG GR MT CY 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 5

6 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS 4. CONCLUDING REMARKS Photo Eurocopter 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 6

7 General Process By the European Helicopter Safety Analysis Team - EHSAT Review occurrences Develop Safety Action Plans By the European Helicopter Safety Implementation Team - EHSIT Implement Safety Action Plans Monitors 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 7

8 Scope of analysis Data driven approach Accidents (definition ICAO Annex 13) Date of occurrence year State of occurrence located in EASA Member States Where a final report from AIB is available 303 accidents within timeframe analysed (as of 20 Aug. 09) Estimated to be some 75% of the published reports Scope will be extended in a later stage 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 8

9 Analysis Methodology 1. Collect general occurrence information from accident report 2. Describe and analyse the accident Identify events (what happened) and factors (why it happened) in free text 3. Assign standard codes to factors Standard Problem Statements (SPS) from IHST taxonomy and HFACS 4. Produce Intervention Recommendations (IR) 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 9

10 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS General Data SPS and HFACS Analysis Photo AgustaWestland Intervention Recommendations 4. CONCLUDING REMARKS 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 10

11 Accident Distribution over Type of Operation EHSAT Dataset State Flight, 4% (e.g. Police, Military) Aerial Work, 32% (e.g. Fire Fighting, Sling/External Load) General Aviation, 45% (e.g. Pleasure, Training and Business flights) Commercial Air Transport, 19% (e.g. Passenger, HEMS, Offshore, CAT Training, CAT Positioning) 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 11

12 Accident Distribution over Phase of Flight EHSAT Dataset Fatal Non Fatal 35% 30% 25% % of Accidents 20% 15% 10% 5% 0% Standing Taxi y Take-off En route Approach & Landing Manoeuvring 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 12

13 Models used for identification of factors Standard Problem Statements, From the original, US team s methodology 1775 factors recorded Organisational Influences HFACS by Wiegmann and Shappell, Added by the European team for a complementary analysis of Human Factors 818 factors recorded Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 13

14 SPS analysis results % of Accidents where SPS level 1 has been identified at least once EHSAT Dataset Pilot judgement & actions Safety Culture/Management Ground Duties (Planning&Preparation) Pilot situation awareness Data issues Mission Risk Part/system failure Regulatory Maintenance Post-crash survival Aircraft Design Infrastructure Communications Ground personnel 1% 7% 9% 17% 16% 18% 25% 25% 27% 35% 35% 38% 51% 65% 0% 10% 20% 30% 40% 50% 60% 70% 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 14

15 Example scenarios Example accident scenarios presented for Commercial Air Transport General Aviation Scenarios illustrate the most identified SPS statements and HFACS codes for the types of operation 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 15

16 An example Commercial Air Transport scenario During a HEMS mission after the patient had been loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. The decision to continue was taken because an ambulance was waiting to transfer the patient to hospital. During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 16

17 An example Commercial Air Transport scenario During a HEMS mission after the patient had been loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. Loss of Visual Reference The decision to continue was taken because an ambulance Inadequate was decisions waiting to transfer the patient to hospital. Pilot felt pressure During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 17

18 An example Commercial Air Transport scenario SPS Pilot decision making Self induced pressure Failed to follow procedures Flight profile unsafe Inadequate oversight Reduced visibility Selection of inappropriate landing site Management Failure to enforce company SOPs HFACS Decision Making - Operation Risk assessment Operation Skill-based errors Whiteout/Vision restricted Channelized attention Communication critical information/planning Pressing Procedural Guidelines 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 18

19 An example General Aviation - Training scenario The dual exercise was for the student to practise emergency and autorotational landings. The landing area selected for the exercise was muddy with a forecast wind speed of 26 kts. As part of the exercise the flight instructor simulated an engine failure without any prior warning. During the subsequent autorotation the instructor allowed the rotor RPM to drop below the minimum. The helicopter contacted the ground with a high sink rate and rolled over. 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 19

20 An example General Aviation - Training scenario The dual exercise was for the student to practise emergency Mission planning and autorotational regards terrain landings. weather The landing area selected for the exercise was muddy with a forecast Insufficient wind speed briefing of 26 of kts. the student As part of the exercise on the the training flight instructor plan simulated an engine failure without any prior Student warning. control inputs uncoordinated During the subsequent autorotation the instructor allowed the rotor RPM to drop below the minimum. The flight instructor interacted too late The helicopter contacted the ground with a high sink rate and rolled over. 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 20

21 An example General Aviation - Training scenario SPS Inadequate and untimely CFI action to correct student action Pilot decision making Perceptual judgment errors Inadequate mission planning: Weather and wind Training program management: CFI preparation and planning Inadequate landing procedures HFACS Risk assessment Operation Procedural error Overcontrol/Undercontrol Overconfidence Necessary action Delayed Mission briefing Leadership/Supervision/ Oversight inadequate Training Program/Guidelines 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 21

22 Intervention Recommendations Total number of Intervention Recommendations (Level 1) Operations 497 Training_Instructional Training/Instructional 472 Regulatory 214 Data_or_Information_Issues Issues 175 Maintenance 77 Aircraft_System_Equipment_Design Aircraft_Design Research Manufacturing Infrastructure Search_and_Rescue and rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 22

23 Specialist Teams on SMS/Operations and on Training Intervention recommendations aggregated and consolidated by the EHSIT And handed over to Specialist Teams tasked to develop safety enhancements ST SMS / Operations ST Training 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 23

24 Specialist Team SMS/Operations Consolidated recommendations: SMS: Encourage the use of SMS based on real safety culture including risk management and codes of practice. SOPs: Operators should be encouraged to establish and apply SOPs for all activities that they undertake. RISK ASSESSMENT/PRE-FLIGHT PREPARATION: Emphasise the importance of Risk Assessment in mission planning 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 24

25 Specialist Team SMS/Operations Consolidated recommendations: SAFETY CULTURE: Develop an engagement/ communication plan to promote adherence to: the core principles of basic airmanship risk assessment rule compliance AIRCRAFT PERFORMANCE: Reinforce familiarity with Flight Manual through awareness campaign and consider formal examination during annual flying check 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 25

26 Specialist Team Training Consolidated recommendations INEXPERIENCED PILOTS: Training syllabus for ab-initio pilots should cover in more detail: Mission planning Vortex Ring / LTE Autorotation and other emergencies Passenger management DEGRADED FLIGHT CONDITIONS: Specific training to improve decision making process for pilot before and after inadvertent entry into IMC 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 26

27 Specialist Team Training Consolidated recommendations TRAINING / HUMAN FACTORS: Enhance instructor training in: Monitoring students Application of human factors principles Instructor intervention criteria 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 27

28 IHST Toolkits In parallel, IHST has published toolkits on: SMS Helicopter Training Helicopter Flight Data Monitoring Freely accessible on: 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 28

29 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS 4. CONCLUDING REMARKS Photo Eurocopter 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 29

30 Concluding remarks European wide analysis results produced by 11 regional teams Work continues within EHSIT: STs on SMS / Operations and Training Next ST will address Regulatory matters Attention on communication with stakeholders EHEST Website and Newsletter EHEST Communications Sub-Group established Liaising with EGAST (common challenges) Continued cooperation within IHST 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 30

31 The challenge now is to develop, implement and monitor effective measures to meet the 80% accident rate reduction target Thank you for your attention Questions? To join the initiative: Photos AgustaWestland and Eurocopter 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 31

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33 Annex Number of Helicopter Accidents per Year EASA MS Registered, CAT+AeW+GA Source: EASA Annual Safety Review Number of accidents Year 3 rd EASA Rotorcraft Symposium, 2-3 Dec 2009 European Helicopter Safety Team 33