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Lessons learned from accident investigation
Dubai 9 December 2015
Capt. Elias Nikolaidis
Chief Air Accident Investigator GCAA
ICAO HELIPORT SEMINAR
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AIR ACCIDENT INVESTIGATION SECTOR
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AIR ACCIDENT INVESTIGATION SECTOR
OVERVIEW
ACCIDENT INVESTIGATION (AAIS)
LESSONS LEARNED FROM OTHERS
LESSONS LEARNED FROM UAE
IMPROVEMENT AREAS
AIR ACCIDENT INVESTIGATION SECTOR
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AIR ACCIDENT INVESTIGATION SECTOR
INVESTIGATES ALL ACCIDENTS IN THE UAE
PARTICIPATES IN INVESTIGATIONS ABROAD
ISSUES REPORTS & SAFETY STUDIES
SAFETY RECOMMENDATIONS
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AAIS WEB SITE
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AAIS WEB SITE
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AAIS WEB SITE
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LESSONS LEARNED FROM OTHERS
NTSB (USA)
AAIB (UK)
ATSB (Australia)
AAIASB (Greece)
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Helicopter Accident number decline over the last 10 years but no reduction of fatal accidents
UNITED STATES OF AMERICA
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Crash fire and blunt force trauma FAA issued life saving rules in the 1980s & 1990s US helicopter fleet in the end of 2014
Only 16 % included crash-resistant fuel systems Only 10 % had energy absorbing seats.
UNITED STATES OF AMERICA
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The Rotorcraft Occupant Protection Working Group
UNITED STATES OF AMERICA
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Loss of Control Sundance Helicopters, AS350-B2, N37SH Safety issues identified: Improper reuse of degraded self-locking nuts. Maintenance personnel fatigue. Need for work cards with delineated steps. Lack of human factors training for maintenance personnel.
UNITED STATES OF AMERICA
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Loss of Control Sundance Helicopters, AS350-B2, N37SH Safety Recommendations: Establish duty-time regulations for maintenance personnel Encourage operators and manufacturers to develop and implement best practices for conducting maintenance. Require that personnel performing maintenance or inspections receive initial and recurrent training on human factors(the causes of human error, including fatigue, …)
UNITED STATES OF AMERICA
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North Sea Helicopter Accidents
AAIB (UNITED KINGDOM)
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Events over last 10 years Safety Recommendations/Safety Actions Impact of these Events Lessons Learned for Accident Investigation
AAIB (UNITED KINGDOM)
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20 Safety Actions 54 Safety Recommendations
AAIB (UNITED KINGDOM)
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Impact CAA Safety Review Feb 14 Airbus helicopters Helicopter Terrain Awareness and Warning System Rig landing systems Survivability
AAIB (UNITED KINGDOM)
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Lessons Learned Inshore water CVFDR recovery Underwater search and recovery plan Use of press statements and special bulletins Technical investigation work –time consuming and expensive Effect of grounding aircraft; Oil and Gas risks Understanding the culture of helo ops Dealing with survivors and bereaved next of kin expectations
AAIB (UNITED KINGDOM)
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Light utility helicopters safety Equipment improvements
ATSB (AUSTRALIA)
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1.1 helicopter accidents per year Number of accidents in 2002 2003 (same Operator) CAA Oversight Heliports oversight, risk assessment , equipment Operator’s training efficiency Helicopter equipment (ELT, search lights, CVR)
AAIASB (GREECE)
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8 Investigation reports involving helicopters (2008 – 2012) 20 Safety Recommendations 11 to the GCAA, 8 to Operators, 1 to an Airport 22 Safety Actions Taken
UNITED ARAB EMIRATES
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20 Safety Recommendations proposed changes to GCAA Regulations GCAA Oversight GCAA SMS acceptance process UAE ELT interface Offshore helideck requirements, certification & oversight Training requirements & processes
UNITED ARAB EMIRATES
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Short Term Oversight Enhanced Equipment Safer Helo Ops Longer Term Regulations Enhance Equipment Exercises – Working together
THE FUTURE
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Thank you for Listening