1JHSAT - May 2007

JHSAT StatusMay 2007

AHS Forum 63 – Virginia Beach, VA

Mark Liptak FAA ANE-110Jack Drake HAI

2JHSAT - May 2007

Basic CAST ProcessIHST (CAST) Charters Activity

JHSAT (JSAT)Analyzes DataProposes most

effective interventions

JHSIT (JSIT)Assesses feasibility of

interventions works implementation

Continued data analysis,measure intervention

effectiveness

3JHSAT - May 2007

JHSAT Goal:

Provide intervention strategies to the IHST and Joint Helicopter Safety Implementation Team (JHSIT) that maximize the likelihood of reducing worldwide helicopter accident rates by 80 percent by 2016.

4JHSAT - May 2007

JHSAT Team Membership:

FAA ANE co-chair HAI co-chair

Turbomeca Schweizer Helicopters

Bell Helicopter Silver State Helicopters

Sikorsky Bristow Group

NASA Rolls Royce

AHS/NASA Airmethods

FAA ASW US Eurocopter

5JHSAT - May 2007

JHSAT Status

Data Analysis

Engaging with the international community

Interim safety recommendations

6JHSAT - May 2007

Data Analysis

7JHSAT - May 2007

JHSAT Process Overview

CharterDevelopment

EstablishTeam

Select Data Set

ReviewNTSB

Docket Data

DevelopEvent

Sequence

IdentifyProblems

(what/why)

Assign StdProblem

Statements

ScoreProblem

Validity &Importance

Identify InterventionStrategies

ScoreInterventionAbility/Usage

Categorize and Prioritize Data

TechnicalReview

&Expert

Validation

Conflicts? ReportResults

No

Yes

IHST

JHSITCurrent task

8JHSAT - May 2007

Data Analysis:The year 2000 accident data has been downloaded from the NTSB (~4000 files)

The JHSAT team has completed processing all 197 accidents from the dataset

For each accident the JHSAT has:reconstructed the sequence of eventsidentified what went wrong and why it went wrongassigned an appropriate problem statementidentified appropriate corrective action(s)scored findings based on validity, importance, ability

and usage

9JHSAT - May 2007

US Rotorcraft Accident Trends1986-2006

1715

10

1311

20

17

23

20 20

14

17

-5

0

5

10

15

20

25

30

35

40

45O

ctob

er

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

April

May

June

July

Augu

st

Sept

embe

r

Month

Freq

uenc

y

Monthly Avg1986 - 2006

2000 Monthly Accident Count

Source: NTSB N-registered accidents, excluding amateur built

+2σ 1986 - 2006

-2σ 1986 - 2006

+3σ 1986 - 2006

-3σ 1986 - 2006

10JHSAT - May 2007

Validity - How valid do we think the Problem Statement is in this accident based on the available accident information?

Range:Guess = 0 Absolutely Sure = 4

Importance - How important is this particular Problem Statement in the causal chain in this accident?

Range:No importance = 0Cause of accident = 4

Ability - How well can this particular Intervention mitigate the cause or contributing factors of this accident scenario?

Range:No effect on Problem Statement = 0 Would Prevent Problem Statement = 4

Usage – Given this accident scenario, how confident are we that this Intervention will be utilized and will perform as expected in the real world?

Range:No Utilization = 0100% Utilization = 4

JHSAT Scoring Criteria

11JHSAT - May 2007

SPS No

Popping noise Engine power loss Exhaust valve failure - root cause not determined

24010 engine component failure

Mandate Textron Lycoming SB388B to reduce liklihood of exhaust valve failure

4 4 3 3

Overflew wires, then crashed onto street in nose low, left skid low attitude. Nosed downward and turned CCW

Improper autorotation or loss of control?

Lost of control when making emerg/auto to street

21074 pilot control/handling, inadequate autorotation

Autorotation training aids, simulators etc

3 4 3 2

Pilot had 3.2 hours in R22 last 90 days; marginal autorotations on Com-helicopter check 3.5 mos before acdt.

Lack of recent experience in M/M and with autorotations

13071 Transition to aircraft make/model

Develop company policy and training rqts for pilots transitioning between m/m

4 3 3 3

Pilot had 67 hours in helicopters.

Lack of total helicopter experience

13070 Pilot transition training model specific simulator training

4 3 2 3

Pilot intentions and actions unknown. Flight/systems information unkown.

Lack of information - flight and systems information

41020 information unavailable to investigators

cockpit recording devices

4 4 4 3

Event/Conditions Problem (what) Contributing Factor (why)

Standard Problem Statement

Intervention Recommendation UV I A

Sample of event processing

12JHSAT - May 2007

Data Analysis Status:To date the accidents analyzed have covered a wide spectrum of helicopter types – 15 basic mission types.

1200+ scored problem statements/intervention findings have been developed

JHSAT currently interpreting the analysis results.overall fleet issuesby mission issues

Expect to offer recommendations for all major operational groups and overall US fleet by June 07.

13JHSAT - May 2007

Primary Ops SecondaryAerial Application External Load Aerial Observation/patrol TrainingAir Tour Positioning/RTBSightseeing FerryBusiness - company owns a/c Air Taxi - Cargo (135)Corp/Exec - dedicated pilot Air Taxi - Passenger (135)EMS Cargo (91)ENG Public UseFirefighting Maintenance/Test flightInstructional/Training Evaluation flightLaw EnforcementLoggingCommercial OperatorExternal Load OffshoreOther Aerial Work Personal/PrivateUtilities - Patrol & Construction

JHSAT Mission Categories

14JHSAT - May 2007

Results of full year 2000 dataset

SPS & Accident Count by Primary Mission

210

170

145

101

92

74 68

53 51 48 47 44

32 30 24 17

37 27 28

12 16 13 9 8 9 6 10 6 4 4 5 3

0

50

100

150

200

250In

stru

ctio

nal /

Tra

inin

g

Pers

onal

/ Pr

ivat

e

Aeria

l App

licat

ion

Emer

genc

y M

edic

al S

ervi

ce

Com

mer

cial

Ope

rato

r

Law

Enf

orce

men

t

Offs

hore

Exte

rnal

Loa

d

Busi

ness

- C

ompa

ny o

wns

A/C

Fire

fight

ing

Aeria

l Obs

erva

tion

/ Pat

rol

Air T

our

Sigh

tsee

ing

Elec

troni

c N

ews

Gat

herin

g

Logg

ing

Utili

ties

Patro

l and

Con

stru

ctio

n

Freq

uenc

y

SPSCount

AccidentCount

15JHSAT - May 2007

Results of full year 2000 dataset

SPS Frequency by Primary Category

401

173

154

112

98 87

66

26 24 24 23 20 10 1050

100150200250300350400450

Pilo

t jud

gmen

t &ac

tions

Saf

ety

Cul

ture

Dat

a is

sues

Mai

nten

ance

Gro

und

Dut

ies

Pilo

t situ

atio

naw

aren

ess

Par

t/sys

tem

failu

re

Pos

t-cra

shsu

rviv

al

Com

mun

icat

ions

Mis

sion

Ris

k

Reg

ulat

ory

Airc

raft

Des

ign

Infra

stru

ctur

e

Gro

und

pers

onne

l

Freq

uenc

y

Saf

ety

Equ

ipm

ent

16JHSAT - May 2007

Results of full year 2000 dataset

JHSAT Intervention Categories

367

275

173143

119

43 33 28

050

100150200250300350400450

Trai

ning

Saf

ety

Man

agem

ent

Info

rmat

ion

Mai

nten

ance

Airc

raft

Des

ign

Reg

ulat

ory

Inst

ruct

iona

l

Infra

stru

ctur

e

Freq

uenc

y

Saf

ety

Equ

ipm

ent

17JHSAT - May 2007

Results of full year 2000 dataset

Top 15 JHSAT Intervention Sub Categories156

100

68

49 4637 37 36 31 30 29 28 26

20 20

0

20

40

60

80

100

120

140

160R

ecor

der

Ris

kas

sess

men

t

QA

Ris

km

anag

emen

t

Auto

rota

tion

CFI

Mis

sion

spec

ific

Inve

stig

atio

n

Sim

ulat

ors

LTE

Pref

light

Coc

kpit

indi

catio

n

SOP

- Wx

Airc

raft

perfo

rman

ce

SOP

- Pre

flight

Freq

uenc

y

18JHSAT - May 2007

Engaging with the international community

19JHSAT - May 2007

Worldwide Helicopter Accidents/Year

1980 - 2005

0

100

200

300

400

500

600

700

800A

ccid

ents

/yea

r

US Civil Registry Non-US Civil & Military US Military & USCG (ABC)

20JHSAT - May 2007

Engaging with the international communityThe preceding slide shows worldwide accident trends for the last 26 years. The criticality of working with the international community to reduce worldwide rates is readily apparent since the US accounts for only 35 to 40% of accidents on an annual basis.

On-going efforts to identify other partners from Asia, South America, Oceania, etc.

Any entity that possess large helicopter accident datasets that could be processed by the JHSAT method should be considered.

EASA and Canada moving toward partnering with us in this process.

21JHSAT - May 2007

Engaging with the international communityA structured approach will be used to manage the analytical and implementation work sponsored by the IHST.

Key attributes:

All recommendations will be data driven

Regional ownership - Data is owned and analyzed by those most familiar with it. Safety recommendations will be implemented by teams most familiar with local needs.

JHSAT and JHSIT lead teams will be responsible for training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness.

22JHSAT - May 2007

JHSAT/JHSIT

cross-talk

IHST Safety InitiativeAnalysis, Implementation and Metrics Management Structure

IHSTExecutive Committee

JHSATLead Group

JHSITLead Group

Canada JHSAT

EASA JHSAT

Canada JHSIT

EASA JHSIT

Region X, Y, Z JHSIT

US/CAN/EASA Consolidated

Recommendations

JHSAT sends recommendations to JHSIT

US/CAN/EASA/X,Y,Z Implementation

Results

Need to maintain a strongcommunication/feedback loopbetween IHST – JHSAT - JHSIT

Process development usingUS NTSB datarepresents 48% ofworldwide fleet

Measure Accident Reductions

Effectiveness

Measure Implementation

Effectiveness

Regions X, Y, Z defined as those pockets of operation not ableto staff a full JHSAT team and are willing to work implementation of US/CAN/EASA findings to benefit their fleets

Others?

ALEA groupEMS group

Military

AU/India JHSAT

23JHSAT - May 2007

Potential Barriers:

JHSAT:Variation in dataset quality, definitions, etc, around the world may make use of a standardized JHSAT approach more difficult.

Military data may not be available.

Lack of fleet hours will complicate ability to measure results.

Regional teams may be difficult to staff with sufficient level of expertise representing manufacturers, operators and regulatory interests.

JHSIT:Regional operations and regulations may make some implementation actions difficult.

24JHSAT - May 2007

Interim Recommendations

25JHSAT - May 2007

Interim recommendationsReports reviewed by the JHSAT:NASA - U.S. Civil Rotorcraft Accidents, 1963 Through 1997NASA - Analysis of US Civil Rotorcraft Accidents from 1990 to 1996 and Implications for a Safety Program NASA - ASRS Rotorcraft Incident Study - Draft Data Summary Aviation Safety Reporting SystemNASA - Helicopter Accident Analysis TeamAMPA - A Safety Review and Risk Assessment in Air Medical TransportCRS - Report for Congress - Military Aviation SafetyOGP - Safety Performance of Helicopter Operations in the Oil and Gas Industry - 2000 DataTSB Canada - Lessons Learned from TSB Investigation of Helicopter Accidents (1994 - 2003)Bell Textron - History of Helicopter SafetyOther NTSB and international reports may be considered.

The JHSAT has identified important recommendations from a series of existing helicopter safety reports. (listed on the next slide)

These recommendations were submitted to the IHST in November so that the JHSIT would have foundational intervention areas to consider.

The JHSAT plan to issue its full set of analytical results by 2Q07 which will significantly augment these foundational areas.

26JHSAT - May 2007

US JHSAT interim recommendations:

1. – Promote the adoption of Safety Management Systems in the helicopter community.

2. – More consistent and comprehensive NTSB involvement and investigation needed in helicopter accidents.

3. – Reestablish the collection of worldwide helicopter fleet hour data as previously performed by the FAA.

4. – Establish a helicopter safety website to disseminate important information

5. – Use proximity detection equipment in helicopters.

6. – Use flight recording devices and cockpit image recording systems in helicopters.

7. – Develop a strategy to improve pilot Aeronautical Decision Making.

(NB: this listing is not intended to indicate prioritization)

27JHSAT - May 2007

Questions?