u.s. joint helicopter safety implementation team … brisbois_ chc 2009...u.s. joint helicopter...

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CHC Safety & Quality Summit 2009

Vancouver, B.C.

IHST.org

U.S. Joint Helicopter SafetyImplementation Team

(JHSIT)

Larry BuehlerFAACO-CHAIR US [email protected]

Fred BrisboisSikorsky Aircraft CorporationCO-CHAIR US [email protected]

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Vancouver, B.C.

IHST.org

IHST CHALLENGE

Reduce the helicopter worldwide accident rate by80 percent in the next ten years (2016)

Improve the safety image of all helicoptersworldwide

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IHST MODELBased On Proven CAST Process

IHST (CAST)Charters Activity

JHSAT (JSAT)Analyzes Accident Data

Proposes mosteffective interventions

JHSIT (JSIT)Assesses feasibility of

interventionsworks implementation

Continued data analysis,measure intervention

effectiveness (JIMDAT)

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U.S. JHSIT CORE MEMBERSHIP

Airsure Limited, Aviation Claims SpecialistMarty Rincon

Association of Air Medical Services, Government Relations ManagerChris Eastlee

Bell Helicopter, Communications DirecterJames McKenna

FlightSafety International, Manager, Rotorcraft Special ProgramsTerry Palmer

Executive Director, Life Flight of MaineTom Judge

HAI, Director Flight Operations & Technical ServicesHarold Summers

Airborne Law Enforcement Association, Safety ManagerKeith Johnson

Arkansas Children's Hospital, Director of OperationsBJ Raysor

PHI, Chief PilotMike Hurst

Bristow Western Hemisphere Helicopter Services, Director Quality & SafetyDenise Uhlin

American Eurocopter, Accident InvestigatorLindsay Cunningham

Sikorsky Aircraft Corporation, Director, Aviation & Product SafetyFred BrisboisCo-Chair

FAA, 135 Air Carrier Operations BranchLarry BuehlerCo-Chair

OrganizationName

~17 Additional Individual Working Group Members

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U.S. JHSIT WORKING GROUPSInitial Organization Aligned With JHSAT Categories

Safety Management Systems (24): Keith Johnson, Denise Uhlin

Training: (9) Terry Palmer, Marty Rincon

Systems / Equipment / Information (8/2): Lindsay Cunningham, BJ Raysor

Maintenance (4) Harold Summers

Regulatory (5) Mike Hurst, Chris Eastlee

Infrastructure (5) Tom Judge

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Review JHSATRecommendations& Assign Number

JHSAT OverallEffectivenessValue (OE)

Assign JHSITAverage

Feasibility Value

PrioritizeRecommendations

(OE x F)

GroupRecommendations

By CommonTheme

PreparePreliminary

SafetyEnhancement

Plan

Prepare DetailedSafety

ImplementationPlan

Execute andMonitor Progress

Of SafetyImplementation

Plan

Initiate Top Level Safety Intervention Actions(e.g. promoting IHST, SMS, Infrastructure changes)

IHST Approval

IHST Approval

U.S. JHSIT PROCESS MODEL

√√ √ √

√

√

√

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Technical Feasibility: The ability of the project to take advantage of the current state of technology inpursuing further development.3 - Off-the-shelf technology, no development required2 - Some development required, not currently in public use1 - Major technology development effort required

Financial Feasibility: Should consider the total cost of the implementation, including the planningprocess. Financial feasibility also involves the capability of the participating organizations (FAA,Manufacturers, and Airlines and Operators) to provide the appropriate funding needed to implement theproject.3 - Relatively low cost to implement2 - Relatively medium cost to implement1 - Relatively high cost to implement

Operational Feasibility: Involves the “practicality” of the project within the context of the operatingenvironment, including NAS, ground operations, maintenance, inspection, etc. Considers whichorganizations within the aviation system are impacted.3 - Minimal change to entities within the operating environment2 - Modest change to operating environment1 - Major change to operating environment

Schedule Feasibility: Can the project to contribute to achieving the goal in a selected timeframe? Mustconsider implementation schedule by project.3 - Less than 2 years to full implementation2 - Full implementation in 2-5 years1 - Longer than 5 years to full implementation

Regulatory Feasibility: Should be evaluated against current rules and certificationprocess. Could be a deterrent due to a long approval process.3 - No policy change2 - Guidance change only (orders, handbooks, policy)1 - Rule change

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JHSIT EVALUATION MATRIXExample

JHSAT

Effectiveness

JHSIT

Feasibility

FINAL

RANKING JHSAT FLEET RECOMMENDATION

3 2.95 8.86 SM4 Make proactive use of safety information to create

awareness of known hazards and reduce the risk of accidents

3 2.82 8.46 TN4 Expand training in aeronautical decision making (ADM) and

risk management3 2.79 8.36 SM14 Provide for non-punitive safety event reporting.

3 2.78 8.34 TN5Provide comprehensive training on aircraft performance

3 2.69 8.08 SM19 Ensure that training policies and SOPs enhance training for

crew awareness of critical flight systems, operational risk

management and appropriate Aeronautical Decision Making

(ADM) training.

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CHALLENGESNot the same for helicopters as for airplanes

Increased versatility of helicopters

requires diverse actions to

address challenges

vs.

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~1694

Accidents Avoided~1132

Fatalities/SeriousInjuries Avoidedsource: Bell Worldwide Database

2001-2

005

avg 2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Worldw

ide

Accid

ent

Rate

per

100,0

00

flig

ht

hours

10

9

8

7

6

5

4

3

2

1

0

Year

Trend projection if no action takenStartStart –– 9.59.5Per 100K hours

GoalGoal –– 1.91.9Per 100K hours

SAME OBJECTIVE…Save Lives

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1 to 5 ship operators

Insurance

Maintainers

Trainers IndustryPubs

FSDO

Pathways to Influence Change

ABCGroups

AccreditationProgs

We need to find high leverage means to influence the small ops community

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SEEKING THE RIGHT BALANCE

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Vancouver, B.C.

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MANAGING SAFETY = MANAGING BUSINESS

SafetyAchievement

Finance Plan

Targets & Objectives

Budget

Accountabilities

Levels of Authority

Procedures

Safety Plan

Targets & Objectives

Budget

Line ManagementAuthorities

Accountabilities

Procedures

Financial Management System Safety Management System

AccountantsAuditPlan

Checks and Balances

AuditsBalanceSheets

Audits

Monitoring/Line Checks

Audit PlanSafety

Committee

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IMPLEMENTATION SCHEDULE

It Has

Begun!!

Continuing To Grow!!!

• ROI Training

• AHS/CRI

• CAMTS

• Workshops

• InsuranceEducation

• Toolkits

• FOQA

• Media

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ROHSEI

Return On Health Safety and EnvironmentalInvestment

WHAT THE HELL DO WE KNOW ABOUTFINANCE? WE KNOW ROHSEI!ReturnonInvestment (ROI): This iscalculatedby dividing thenet present valueby thepresent

valueof theproject costs. Thenet present value iscalculatedbysubtracting thepresent valueofproject costs fromthepresent valueof project benefits. Themodel calculatesROI basedoncosts, benefits, andthediscount rate that areenteredby theuser.

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Vancouver, B.C.

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Return On Investment for Safety & Health Investments

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Vancouver, B.C.

IHST.org

Present results to your management:

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IHST.org

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OrganizationalFactors

ACTIVE vs. LATENT FAILURES*

Latent Conditions

Procedures incomplete

Poor layout/configuration

Accident & InjuryMaintenance problem

Aircraft crashed

UnsafeSupervision

Latent Conditions

Poor task planning

Parts/tools improperly labeled

Active Conditions

Omitted procedural step

Distraction/Interruption

Inadequate task knowledge

Poor technique

Latent Conditions

Inadequate lighting

Equipment inappropriate for task

Preconditionsfor

Unsafe Acts

UnsafeActs

Failed orAbsent Defenses

* Reason, 1990

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SafetyManagement

(24)

JHSIT WORKING GROUPSStrategic Areas of Intervention

Accident* Reason, 1990

Training(9) Systems,

Equipment &Information

(10)Maintenance

(4)Regulatory

(5)

Infrastructure(5)

X

X

X

X

X

X

X

Communications & Marketing

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Vancouver, B.C.

IHST.org

SAFETY MANAGEMENT

2007• Sep SMS Tool Kit Published• Oct Exxon Mobil announces IHST Toolkit SMS attributes

will form part of all future contractual technical specifications.

2008• May ALEA Adopts IHST SMS Toolkit• July SMS .PPT Workshop developed• 19 SMS Presentations and Workshops

at 15 Different Conferences / Venues

• 30 Articles promoting Safety and SMS in Air Beat Magazine

2009• Interactive Computerized SMS Training Tool (courtesy AvStar)• SEP Tool Kit Revision – expanded and aligned with FAA 120-92A• Mentoring Program – 5 operators

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Vancouver, B.C.

IHST.org

TRAINING2008

Nov Educational meeting with insurance underwriter managementCompile resources for flight training and flight simulation training devices

2009• APR: Exportable Educational Program for insurance underwriters• MAY: Follow-up meeting with insurance underwriters• APR – AUG: Regional insurance and Government educational sessions• MAY: Follow up educational meeting with insurance underwriter management• SEP: Training Toolkit including resource material• OCT: Rewrite best practices and resources for CAMTS

• DEC: New simulater makes and models including single engine• Provide extensive initial and recurrent training in helicopter emergencies.

Performance, flight planning, aeronautical decision making (ADM), risk management,inadvertent IMC, make & model transition and specialized mission training

• New training programs – OEMS, professional training organizations, associations andsimulator providers - ongoing 2008 - 2010

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Vancouver, B.C.

IHST.org

SYSTEMS, EQUIPMENT & INFORMATION

2007JUL: Checklist for Helicopter Accident Investigation delivered to NTSB

2008DEC: Project planning meeting with Flight Safety Foundation to implement HEMS

FOQA Program

2009JAN: Follow-up face-to-face meeting with FSF on HEMS FOQA ProjectFEB: Presentation at NTSB EMS Hearing on recording equipmentFEB: Follow-up meeting with FSI on EMS FOQA projectFEB: Launch HEMS FOQA Project with Flight Safety Foundation at Heli-ExpoFEB: Flight Data Monitoring Workshop to take place at CHC Safety SummitSEP: Flight Data Monitoring Workshop to take place at IHSSSEP: Flight Data Monitoring ToolkitOCT; Flight Data Monitoring Workshop and HEMS FOQA Project Meeting to take placeat AMTC

2010Monitoring/recording systems standard equipment on major airframe OEMs

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Vancouver, B.C.

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2009 DELIVERABLE PRODUCTS

• Interactive Computerized SMS Training Tool

• APR Exportable Educational Program for insurance underwriters

• SEP SMS Tool Kit Revision – expanded and aligned with FAA 120-92A

• SEP Training Toolkit including resource material

• OCT Rewrite of best practices and resources for CAMTS

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Vancouver, B.C.

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PROBABILITY FREQUENT PROBABLE OCCASIONAL REMOTE IMPROBABLE

SEVERITY A B C D E

I - CATASTROPHIC 1 2 4 8 12II - CRITICAL 3 5 6 10 15III - MARGINAL 7 9 11 14 17IV - NEGLIGIBLE 13 16 18 19 20

IMPROVING PERFORMANCE

PercentOccurrence

OutcomesPerfect Good Okay Awful CatastrophicReal

Good

Not SoBad

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Vancouver, B.C.

IHST.org

OPERATIONAL RISK

RISK

Single engine (Non-turbine)Single pilotNot IFR capableNo autopilotNo terrain avoidance systemNo de-ice capability

No CRM / Formal training

Dual engine turbine engineDual pilotIFR capableAutopilot, fully coupledTerrain Avoidance Warning SystemAll weather capable

Training / CRM

WHO IS INVOLVED INDECISION MAKING,RISK ACCEPTANCE,RISK MITIGATION?

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Vancouver, B.C.

IHST.org

WHO APPROVES CONFIGURATION?

YesYesWeather Radar

NoNoHUMS

NoYesSkywatch / TCAS

NoYesSingle Action Door Release

NoYes (Customer)Flight Following System

NoNoHEELS

Yes (Customer)YesGPS

CVR onlyYesFDR / CVR

NoYesExternal Life Raft

NoNoEGPWS

NoYesCyclic Warning System

NoNoAuto Float Deployment (AFDS)

NoYesAft Orientation Bar

NoYesFwd / Aft Cabin Push Out window

NoNo406 Enabled ELT / Auto Deployed ELT

NoYes4 Point Upper Restraint Cabin Seats

S-76A++ (1984)S-76C+ (2000)

YesYesWeather Radar

NoNoHUMS

NoYesSkywatch / TCAS

NoYesSingle Action Door Release

NoYes (Customer)Flight Following System

NoNoHEELS

Yes (Customer)YesGPS

CVR onlyYesFDR / CVR

NoYesExternal Life Raft

NoNoEGPWS

NoYesCyclic Warning System

NoNoAuto Float Deployment (AFDS)

NoYesAft Orientation Bar

NoYesFwd / Aft Cabin Push Out window

NoNo406 Enabled ELT / Auto Deployed ELT

NoYes4 Point Upper Restraint Cabin Seats

S-76A++ (1984)S-76C+ (2000)

Contractor Changed – Impacting Level Of Safety

Was Risk Assessment At Appropriate Level?

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SPACE SHUTTLE

CHALLENGERJanuary 28, 1986

COLUMBIAFebruary 1, 2003

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•Lesson Learned: Well-intentioned people and high-risk organizationscan become desensitized to deviations from the norm

– Vaughan's book, The Challenger Launch Decision, called this“Normalization of Deviance”

– Board identified this as a major factor in Columbia mishap, much likeChallenger disaster

– "Unexpected becomes the expected which becomes theaccepted"

– In both Challenger, Columbia: "The machine was talking to us, butnobody was listening"

– Small anomalies may be symptomatic of larger problems -failure toaddress could be disastrous

– System effects take years to develop and cause failures

CHALLENGER ACCIDENT INVESTIGATION

Diane Vaughan, risk specialist and sociology professor Boston College

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Vancouver, B.C.

IHST.org

RAISE THE BAR VIA PUSH –PULL STRATEGY

WE NEED TO CREATE THE ‘PULL’ FROM CLIENTSTO

MAKE THE ‘PUSH’ TO OPERATORS EASIER

ACCEPTABLE STANDARDS

Clients ExecutiveLevelDemands

Operators

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Drinking

Then - Otis Campbell / the Andy Griffith Show

Now - MADD / Drinking and Driving

Now – Enabling is out…

Smoking

Then - “Dive Bomber” starring Errol Flynn

and Fred MacMurry

Now – Second hand smoke / restaurants

and bars

Now - Advertising

Seat belt use in automobiles

Then – “Sissy”

Now – Unacceptable not to use them

CULTURAL CHANGE

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Nearly every states/province already had laws against:

drinking to excess

driving drunk

selling liquor to minors

The changes were not driven by laws. The basicprohibitions were already in place

Enforcement policy change.

Tobacco, fewer prohibitions existed, but more havedeveloped as a result of the cultural change.

Seat Belts – Manufacturing, use by example, userequirements led to a cultural change; phase-in byattrition

CULTURAL CHANGE

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• Framework for Cultural Change - Safety ManagementSystem

– Scalable

– Adaptable

– Integrated

– Compliant

• Cultural Change Timeline

– Generational

– Significant Emotional Event

SAFETY MANAGEMENT SYSTEM

Framework For Cultural Change

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REDUCING RISKChanging the Standard

STRATFORD, Conn., May 28, 2004 -- SikorskyAircraft established another rotorcraft industryfirst by standardizing its new S-76 and S-92helicopter safety baseline to include EnhancedGround Proximity Warning Systems (EGPWS) inall civil aircraft configurations.

STRATFORD, Conn., May 28, 2004 -- SikorskyAircraft established another rotorcraft industryfirst by standardizing its new S-76 and S-92helicopter safety baseline to include EnhancedGround Proximity Warning Systems (EGPWS) inall civil aircraft configurations.

HUMS

CVR/FDR

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Responsibility & AccountabilityResponsibility & Accountability

And It Begins With US!!

SAFETY

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Conclusions:

We have a problem – Unanimity in the worldwide helicoptercommunity; long term accident trends are unacceptable.

We know how to fix it – Using a data driven, stakeholderconsensus process we’ve identified the drivers behindhelicopter accidents. Implementation of SMS, training,information and maintenance enhancements are thetop priority targets. Effectiveness measures will be used.

We can’t do it alone – Any entity with accident data willing touse the IHST analysis and implementation process is a viablecandidate to join this worldwide initiative.

ihst.org

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Questions??

Larry BuehlerFAACO-CHAIR US [email protected]

Fred BrisboisSikorsky AircraftCorporationCO-CHAIR US [email protected]

u.s. joint helicopter safety implementation team … brisbois_ chc 2009...u.s. joint helicopter...

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