preliminary results ehest conference 13 october 2008 cascais, portugal

Preliminary Results

EHEST Conference13 October 2008

Cascais, Portugal

Preliminary Results 2

Contents

Data set descriptionGeneral dataIdentified factors data

Standard Problem StatementsHFACS

Intervention RecommendationsConcluding Remarks & Way forward


Data set description

Preliminary Results

Picture Source AgustaWestland


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


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


Proportion of analysed accidents

Estimated data for the 9 Regional Teams currently participating


General Data

Preliminary Results

Picture Source Eurocopter


General data

Number of Accidents per Type of Operation


General data


General data

Pivot chart of general info sheet

617

64

2430

3

14

17

11

0

10

20

30

40

50

60

70

Standing Taxi Take-off En route Manoeuvring Approach &Landing

Nu

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No Yes

Phase of Flight Distribution

In hover Not in hover


General data


5 3

2632 33

40

1

2

32

5

7

0

10

20

30

40

50

60

70

Standing Taxi Take-off En route Manoeuvring Approach &Landing

Nu

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ents

Non Fatal Fatal

Injury level Distribution per Phase of Flight


General data


0

10

20

30

40

50

60

70

0 - 1000 1001 -2000

2001 -3000

3001 -4000

4001 -5000

5001 -6000

6001 -7000

7001 -8000

8001 -9000

9001 -10000

Nu

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Pilot-in-Command Total Flight Experience in HoursAll Helicopter Types


General data


0

2

4

6

8

10

12

14

0 - 100 101 -200

201 -300

301 -400

401 -500

501 -600

601 -700

701 -800

801 -900

901 -1000

Nu

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0 – 1000 flight hours only


General data


0

20

40

60

80

100

120

0 - 1000 1001 - 2000 2001 - 3000 3001 - 4000 4001 - 5000 > 5000

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Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type


General data


0

5

10

15

20

25

30

35

40

45

0 - 100 101 -200

201 -300

301 -400

401 -500

501 -600

601 -700

701 -800

801 -900

901 -1000

Nu

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Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type0 – 1000 flight hours only


General data


0

5

10

15

20

25

30

35

40

0 - 1000 1001 -2000

2001 -3000

3001 -4000

4001 -5000

5001 -6000

6001 -7000

7001 -8000

8001 -9000

90001 -10000

Nu

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ents

Commercial Air Transport Aerial Work General Aviation


Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.


General data


0

10

20

30

40

50

60

0 - 1000 1001 - 2000 2001 - 3000 3001 - 4000 4001 - 5000 > 5000

Nu

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Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type

Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.


Identified factors dataStandard Problem Statements & HFACS

Preliminary Results

Picture Source AgustaWestland


Identified factors data

Two models used for identification of factors

SPS HFACS

Standard Problem StatementsIn total 1067 factors identified for all 186 accidents

HFACS In total 445 factors identified for all 186 accidents


SPS level 1 – All Accidents

Percent of Accidents in which SPS category (level 1) was identified at least once

2

8

8

13

15

16

20

28

35

35

38

48

68

24

0 10 20 30 40 50 60 70 80

Ground personnel

Infrastructure

Communications

Aircraft Design, Systems & Equipment

Maintenance

Post-crash survival

Regulatory

Part/system failure

Mission Risk

Ground Duties

Data issues

Pilot situation awareness

Safety Culture/Management

Pilot judgment & actions

SP

S C

ateg

ory

- le

vel 1

Percentage %


SPS level 1 compared with US JHSAT data

Percent of Accidents in which Top 5 SPS category (level 1) was identified at least onceEHEST data versus US JHSAT data

0 10 20 30 40 50 60 70 80

Ground Duties

Data issues

Pilot situationawareness

SafetyCulture/Management

Pilot judgment &actions

SP

S C

ateg

ory

- le

vel 1

Percentage %

US JHSAT data EHEST dataCorrelation is: .89


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


15

16

16

18

19

20

20

25

29

31

0 5 10 15 20 25 30 35

Human Factors - Other

Visibility/Weather

Procedure Implementation

Mission Risk - Terrain/Obstacles

Inadequate Pilot Experience

Landing Procedures

Flight Profile unsafe

External Environment Awareness

Mission Planning

Human Factors - Pilot's Decision

SP

S c

ateg

ory

- le

vel 2

Percentage %


Organisational Influences

Unsafe Supervision

Preconditions for Unsafe Acts

Unsafe Acts

HFACS model

Merely symptoms

Facilitate identification of the underlying causes


Unsafe Acts

Errors Violations

16%84%

60%

Skill-based Errors

Perceptual Errors

Judgement & Decision-Making Errors

12%

28%

HFACS model – upper levels


Preconditions

Environmental Factors

17%

Condition of Individuals

60%

Personnel Factors

23%



Supervision

Failure to Correct Known Problem

Planned Inappropriate

Operations

Inadequate Supervision

41% 59%Supervisory Violations

0%

0%



Organisational Influences

Resource Management

Organisational Climate

Organisational Process

64% 24% 12%



Going into more detail

The following slides present the lowest level in the taxonomy: level 3This provides a more detailed insight into the type of accidents occurringResults will be presented for the three main types of operation

Commercial Air TransportAerial WorkGeneral Aviation


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.


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


SPS level 3 (top issues)–Commercial Air Transport


COMMERCIAL AIR TRANSPORT

0 5 10 15 20 25

Failure to enforce company SOPs

Inadequate consideration of aircraft operational limits

Management disregard of known safety risk

Selection of inappropriate landing site

Pilot experience leads to inadequate planningregarding weather/wind

Pilot inexperienced with area and/or mission

Reduced visibility--whiteout, brownout

Pilot’s flight profile unsafe for conditions

Pilot-In-Command self induced pressure

Pilot decision making

SP

S c

ateg

ory

- le

vel 3

Percentage % of CAT Accidents


HFACS level 3 (top issues)–Commercial Air Transport

Percent of Accidents in which HFACS category (level 3) was identified at least once

COMMERCIAL AIR TRANSPORT

0 2 4 6 8 10 12 14 16

Procedural Guidelines / Publications (OI)

Limited Recent Experience (S)

Inattention (PC)

Mission Planning (PC)

Excessive Motivation to Succeed (PC)

Procedural Error (UA)

Risk Assessment - During Operation (UA)

Pressing (PC)

Communication Critical Information (PC)

Decision-Making During Operation (UA)

Brownout / whiteout (PC)

HF

AC

S c

ateg

ory

- le

vel 3

Percentage % of CAT Accidents


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.


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

Loss of tail rotor effectiveness

Tailwind

Pilot intensiveObstacles

Cargo not released


SPS level 3 (top issues)–Aerial Work


AERIAL WORK

0 5 10 15 20 25

Inadequate training on avoidance, recognition andrecovery of Vortex ring state or LTE

Inadequate response to Loss of tail rotor effectiveness

Risk Management inadequate

Diverted attention, distraction

Inadequate consideration of obstacles

Low flight near wires

Mission requires low/slow flight


Mission involves flying near hazards, obstacles, wires

SP

S c

ateg

ory

- le

vel 3

Percentage % of Aerial Work Accidents


HFACS level 3 (top issues)–Aerial Work


AERIAL WORK

0 5 10 15 20 25 30

Limited Total Experience (S)

Overconfidence (PC)

Windblast (PC)

Fatigue - Physiological / Mental (PC)

Excessive Motivation to Succeed (PC)

Misperception of Operational Condition (PC)

Inattention (PC)

Error due to misperception (UA)



Channelized Attention (PC)


HF

AC

S c

ateg

ory

- le

vel 3

Percentage % of Aerial Work Accidents


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.


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

Limited experience

Inadvertent IMC

No contact established with ATC


SPS level 3 (top issues)–General Aviation


GENERAL AVIATION

0 5 10 15 20 25

Failed to recognize cues to terminate current course ofaction or manoeuvre

Disregard of known safety risk

External Environment Awareness – Other

Pilot misjudged own limitations/capabilities

Pilot control/handling deficiencies

Pilot inexperienced

Inadequate consideration of weather/wind

Mission Planning – Other


SP

S c

ateg

ory

- le

vel 3

Percentage % of GA Accidents


HFACS level 3 (top issues)–General Aviation


GENERAL AVIATION

0 5 10 15 20 25 30 35

Misperception of Operational Condition (PC)

Get-Home-Itis/Get-There-Itis (PC)

Channelized Attention (PC)

Error due to misperception (UA)

Inadvertant Operation (UA)

Violation - Lack of Discipline (UA)

Overcontrol/Undercontrol (UA)



Procedural Error (UA)

Vision Restricted by Meteorological Conditions(PC)

Overconfidence (PC)


HF

AC

S c

ateg

ory

- le

vel 3

Percentage % of GA Accidents


Intervention Recommendations

Preliminary Results

Picture Source Jaume Bosch


Intervention Recommendations

In total 11 Intervention Recommendation categories identifiedThe categories help identify areas for working groups of EHSITNote: some categories do overlap but they do succeed in suggesting areas to focus


Intervention Recommendations for All Accidents

Pivot chart of Analysis sheet - IR

4

11

15

19

40

58

70

169

252

307

0 50 100 150 200 250 300 350

Infrastructure (aerodrome, heliport, ATC, ...)

Research

Manufacturing

Aircraft Design

Aircraft System/Equipment Design

Maintenance

Data/Information Issues

Regulatory

Operations

Training/Instructional

Number of IR categories

Intervention Recommendation Categories – All Accidents

Flight Ops & Safety Management/Culture


Overview of top categories

Pivot chart of Analysis sheet - IR

0

50

100

150

200

250

300

Training/Instructional Operations Regulatory

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Rec

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Flight Ops & Safety Management/Culture

RegulatoryTraining/Instructional


Example IRs

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


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.


IRs Examples: Training/Instruction

Instructors/examiners be updated more regularly by TRTOs.Establish measures to avoid culture of non-complianceInclude risk assessment trainingEncourage organising private helicopter pilots into flying clubs etc for mutual support and better exchange of experiences / safety information


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 checklistsManage human factors risk especially regarding routine violationUse a Flight Data Monitoring system to give feedback to pilotsIncreased 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 missionsIncrease awareness of obstacles & provision of Wire Strike Protection System


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 EnvironmentReview 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.


Other Selected IR Examples

Improve crashworthiness & survivabilityImprove OEM manufacturing quality assuranceEstablish safe limits of helideck movement for helicopters operating offshoreValidated, simplified weight and balance process should be made availableProvide better information on aircraft fuel consumption for pilots to safely plan flights on the basis of verified fuel contents.Type specific airworthiness improvementsMaking specific safety enhancing equipment part of the build standardMaking specific equipment available for operators to adapt aircraft for specific missions / environments


Intervention Recommendations - Way forward

It is expected the EHSIT will need to prioritise the Interventions Recommendations based on safety benefit and practicalityDifferent types of EHSIT organisations can be envisaged:

By type of operationBy type of recommendationBy type of activityMix of the aboveOtherCentralised or regional-based


Concluding Remarks & Way forward

Preliminary Results

Picture Source Eurocopter


Concluding remarks

EHSAT analysis covers European wide helicopter accident dataPreliminary results already provide indication of type of accidentsPreliminary results will be used by EHSITAnd shared with IHST


Concluding remarks

Main accident factors are operational. The top 3 are:

Pilot judgment & actionsSafety management /culturePilot situation awareness

High correlation with US resultsDifferent patterns for:

Commercial Air TransportAerial Work General Aviation


Concluding remarks

HFACS provided a complementary perspective on these factors and together with SPS, was used to produce recommendationsThe top 3 intervention recommendation categories are:

Flight Operations and Safety Management/CultureRegulatoryTraining / Instructional


Way forward

EHSAT will continue analysis to complete 2000-2005 timeframeIntervention recommendations will be handed over to the implementation team, the EHSITEHSIT will be launched after this ConferenceAnd we would like you to join


Thank you for your attention

Questions?

European Helicopter Safety Team

EHEST

preliminary results ehest conference 13 october 2008 cascais, portugal

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