Upload
elkan
View
58
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Safety Enhancement in Helicopter Operations. IHST Regional Conference Delhi, India Hosted by DGCA, COSCAP SA & RWSI Somen Chowdhury Executive Committee Member, IHST VP Internationl, AHS. Contents. Why IHST : Background Objectives, Goals & Implementation Montreal Conference IHSS 2005 - PowerPoint PPT Presentation
Citation preview
Safety Enhancement in Helicopter Operations
IHST Regional Conference
Delhi, IndiaHosted by DGCA, COSCAP SA & RWSI
Somen ChowdhuryExecutive Committee Member, IHST
VP Internationl, AHS
Contents
• Why IHST : Background• Objectives, Goals &
Implementation• Montreal Conference IHSS 2005• IHST Regional Cooperation• Safety : Every Step of the Way• IHSS 2007• Conclusions
Background: Current State of AffairsToo many
Accidents 2005- 565/year worldwide Lives lost Poor Public imageBusiness loss Injuries Too expensive
UNACCEPTABLE
24,294 Worldwide Civil Helicopters
Worldwide distribution by country
India (140)0.53%
South Africa (563)2.14%
Germany (698)2.65%France (796)
3.03%England (1080)
4.11% Canada (1801)6.85%
Brazil (435)1.65%
Australia (1215)4.62%
Others (4386)16.67%
New Zealand (642)2.44%
Mexico (368)1.40%
Japan (799)3.04%
Italy (642)2.44%
United States (12743)48.44%
Worldwide Helicopter Accidents/ year
1980-2005 Worldwide Helicopter Accidents/Year
1980 - 2005
0
100
200
300
400
500
600
700
800
Ac
cid
en
ts/y
ea
r
US Civil Registry Non-US Civil & Military US Military & USCG (ABC)
Source : Roy Fox Bell Helicopter
Accident rates in India
Source: RWSI : AVM Sridharan
Accidents rates per 100,000 hr
• As per AUA ( Mike Kriebel):– 2,225,000 total helicopter hours in USA in
2004– Accident rate per 100,000 flight hours : 8.09– Fatal rate 1.48– Turbine civil accident rate : 5.11– By contrast : U.S. Air carrier rate : 0.159
• Data shows no change in rate over 24 years
• India rate: distributed average @ 400 hrs/yr– 8.9 per 100,000 hrs for 2004
Need to bring down helicopter accident rates
Aircraft issues14%
Non-AW (human, etc.)74%
Unknown12%
Unknown5%
Aircraft issues
32%
Non-AW (human,
etc.)63%
Civil Helicopter Accident, IndiaSource: AVM Sridharan, RWSI
Bell Civil turbine WorldwideSource: Roy Fox, Bell Helicopter Textron
Comparative Accidents Data
The Real Challenge Iceberg Theory
Hidden or Unseen Conditions are Below The Surface
The BIG Picture
1
300
1200
10
Heinrich Ratio
Serious Incidents
Accidents
Incidents
Near Misses
The Danger…
- is all around us!!!
Need to Act
• Can the industry do better ?
• How ?
• Need a mitigation Strategy
IHSS 2005 was held in Montreal to kick- off the process
IHSS 2005 Montreal Conference
• Four day program– Training Sessions
• Management• Military• Maintenance
– Invited Speakers– Paper sessions
• Military & Civil missions• Human Performance &
Training• Design & Maintenance• Accidents & Regulation• Management & Economics
– Discussion panels – Plenary session
• Results–Attendance ~250–International
• 13 countries • 5 continents
–Industry wide• Government
•Regulatory•Accident Investigators
• OEMs• Mission groups• Operators•Pilots•Maintainers•Aviation PressIHST set up
IHSTMission
To provide government, industry and operator leadership to develop and focus implementation of an integrated, data-driven strategy to improve helicopter aviation safety worldwide, both military and civil.
VisionTo achieve the highest levels of safety in the international helicopter communities by focusing on appropriate initiatives prioritized to result in the greatest improvement in helicopter aviation safety. Goal
To reduce helicopter accidents by 80%by 2016
Executive Committee
IHSTIHST
JHSATJHSAT JHSITJHSIT
Subcommittees Subcommittees
Secretariat
IHST Organisation
JHSAT - Joint Helicopter Safety Analysis TeamJHSIT - Joint Helicopter Safety Implementation Team
CAST (commercial aviation safety team) was considered a good model to follow
Implementation Process
Influence Safety Enhancements -
Worldwide
DataAnalysis
Set SafetyPriorities
Achieve consensus onpriorities
Integrate into existing work and distribute
Implement Safety Enhancements - U.S.
Agree onproblems and interventions
IHST Regional CooperationInternational Cooperation is essential
– Regulators
– Operators
– OEMS
In all regions of the world.
We start with S Asia
We are all in it together
Design FieldOperation
Airworthy
Product
S M S S M SS M S
3 years 20-30 years
SafetyFailure Prevention
technologies
Reliability-anti corrosion
-- reduce vibration
Survivabilitytechnologies-ext. airbag
-Crash worthy seats& fuel tanks
-- floatation gear-- egress
Quality Assurance- No Flaw
Operational regulations Maintenance
Human Factors-Training of all parties
--Pilot aids-Mission comprehension
Manufacturing
Safety: Every Step of the Way Continuing
Airworthiness
Short term
Action
Design• Failure Prevention Technologies
– Fail safe design vs safe life design/ CPR for evolutionary design– Composite structures : prevents catastrophic failures– HUMS : DPHM; embedded sensors– Pilot situational awareness technolgies for operational risks
• Reliability– Corrosion control– No single point failure for critical components : 10-9 probability– FMEA
• Survivability– Energy absorbing seats– Crash worthy fuel tanks– Energy absorbing structures– Egress capability
RETURN
Probability and Severity Relationships
EF
FE
CT
ON
AIR
CR
AF
T A
ND
OC
CU
PA
NT
S
Normal Nuisance Operatinglimitations;emergencyprocedures
Significant reductionin safety margins;difficult for crew tocope with adverseconditions:passenger injuries
Large reductio insafety maragins; crewextended because ofwork load or environ-mental conditions,serious injury ordeath of small num-ber of occupants
Multipledeaths,usually withloss ofaircraft
FA
R 2
5P
RO
BA
BIL
ITY
(RE
F.
ON
LY)
PROBABLEEXTREMELY
IMPROBABLE
JAR
25
PR
OB
AB
ILIT
Y
PROBABLE
REASONABLYPROBABLE
EXTREMELY
IMPROBABLE
CA
TE
GO
RY
OF
EF
FE
CT
MINOR MAJOR HAZARDOUSCATA-
STROPHE
IMPROBABLE
IMPROBABLE
FREQUENT REMOTEEXTREMELY
REMOTE
100 10-1 10-2 10-3 10-4 10-5 10-6 10-7 10-8 10-9
Failure risk mitigation strategy
HAZARD SEVERITY
HAZARDPROBABILITY
Catastrophic
Level 1
CriticalLevel 2
Significant
Level 3
Negligible
Level 4
Frequent – Level A 1A = EXTREMELY HIGH
2A = EXTREMELY HIGH
3A = HIGH 4A = MEDIUM
Probable – Level B 1B = EXTREMELY HIGH
2B = HIGH 3B = MEDIUM
4B = LOW
Occasional – Level C
1C = HIGH 2C = HIGH 3C = MEDIUM
4C = LOW
Remote/Seldom - Level D
1D = MEDIUM 2D = MEDIUM 3D = MEDIUM
4D = LOW
Improbable/Unlikely - Level E
1E = LOW 2E = LOW 3E = LOW 4E = LOW
Manufacturing
• Flawless manufacturing– Reduce MDRs– Improved inspection technologies– Reduced variability
RETURN
RETURN
Field OperationsMaintenance
Definition:
A periodic maintenancetask established during the certification of the aircraft as an operating limitation of the type design certificate.
RETURN
Continuing Airworthiness Function
Airworthy:
In respect of an aeronautical product, in a fit and safe state of flight and in conformity with the type design
Field Operations• Continuing Airworthiness :
– fielded aircraft must meet regulatory compliance to retain certificate of AW : specified through ICAS
– Compliance with service bulletins and directives – Develop a SDR system : electronic data base (ICAO
Annex 8 Part II chapter 4, paras 4.3.5 & 4.3.6)– Develop common data base; FAA, TCCA, Australia
are already engaged in the process– Reliable data base is key to mitigation strategies– Country of registry needs to develop a strong
engineering group overseeing CAW activities – coordinate with OEM and certificating state– Must share incident data and failed components with
OEM immediately
Develop trust: Safety is everyone’s responsibility ; OEMs know their aircraft best
Field & Flight OperationsHuman Factors
RETURN
The door opened in flight!
Human Factors is cause of 75% accidents
It is critical to enhanced safety
Need to integrate HF in maintenance
Provide smarter maintenance aids
Need to Provide increased situational awareness aids to pilots
IHSS 2007• Montreal• Dates –September 17 to 20, 2007• Action Plans from JHSAT, JHSIT will be discussed• Report on worldwide participation
Conclusions• Safety is a way of life : Safety is to be
practised at every step: all the time• Need to develop safety management systems• We need to reduce helicopter accidents : meet
the 80% reduction goal• Short term focus : operations and human
factors• Continuing airworthiness is critical to the
process• Need reliable data; accident investigations
must be done by an independent body• Support the IHST initiative
Recommendations
• Create independent safety boards in each country; reporting to parliament. Need to ensure accident findings are unbiased
• Develop continuing AW organisation with strong understanding of the engineering of the product.
• Develop a worldwide common SDR data base• Increased training in maintenance and flight operations• Implement SMS • Achieve ownership by increased delegation of regulatory
responsibility : essential to develop a matured process• Gradually move away from “authorising” and “mandating” to
consensus. : Replace “control” to “manage” • Manage compliance via strong audit process • Share failed components and accident investigations easily
with OEMs
Build on trust; we are in it all together
Questions?
Please check out the IHST website:
www.ihst.org
The ‘Swiss Cheese’ Model
Some holes dueto active failures(present in use)
Other holes due tolatent conditions
(present, not visible)
Successive layers of defenses, barriers, & safeguards
Hazards
ACCIDENT
Barriers areSafety Nets
When barriers fail
Safety Management Systems - Transport Canada, FAA A systematic, explicit and comprehensive process for the management of safety risks
that integrates operations and technical systems with financial and human resource management for all activities
Benefits - a) Financial Benefit b) Legal Compliance & Protection c) Improved Business Management
d) Ethical Obligation
• Policy must address compliance, non- punitive reporting, continuous improvement and prevention
• SMS will not be effective in the absence of senior management commitment • Roles and responsibilities within the organization must be clearly understood • Communication and employee involvement are both crucial. • Require safety objectives and goals • Measures must be set up to track performance • A formal review is conducted to assure that the SMS is working
SMS will be implemented in all regulated Canadian civil aviation orgs by 2007
Training Sessions
Key Components1) Safety management plan 2) Document management 3) Safety oversight 4) Training 5) Quality Assurance 6) Emergency Preparedness
Military • Navy
Leadership, Training, Equipment, Culture
Kaki Risk Management (KRM)
Human Factors Analysis & Classification System Skill based errors & Decision errors
Crew Resource Management (CRM) Hard (letter of the law) & soft (spirit of the law) processes Human factors - understanding people!
• ArmyCumulative Risk Model
Risk Management Process - hazard identification, - severity & probabilityMilitary Flight Operations Quality Assurance (MFOQA)
Proactive and systematic collection and analysis of operational data from aircraft for use in the continuous improvement of flight operations and readiness, specifically in the areas of Operations, Training, Maintenance and Safety
Aviation Safety Investment Strategy Team Risk management - identify hazards & determine prevention & mitigation strategies Shift focus from blame to prevention, from individual to system
Hazard Tracking Data Base Web-based, provide customizable or standard briefing charts
Training Sessions
Maintenance - Grey Owl & HAI
Human Factors!!!The Dirty Dozen
1. Lack of Communication2. Complacency3. Lack of Knowledge4. Distraction5. Lack of Teamwork6. Fatigue7. Lack of Resources8. Pressure9. Lack of Assertiveness10. Stress11. Lack of Awareness12. Norms
Training Sessions
Maintenance Resource Management (MRM)
–improving communication skills–decision making–effectiveness and safety in aircraft maintenance operations–Non-technical training
Operational IntegritySituational AwarenessError Chain RecognitionCommunication SkillsBriefingsSynergy / Team ConceptsLeadershipConflict ResolutionDecision MakingStress Management
• Dr. Forster - HAIReflecting on the ICAO and its success, we determined that the issue of rotorcraft safety requires the
initiation of a similar community-wide and international, military and civil collaborative effort to reduce
the accident rate in the vertical flight community – both military and civil. • Mr. Resavage - President, HAIThere have been many safety initiatives but few of them have been coordinated and that identifying
safety interventions, alone, is not enough, “they must be implemented.” “there is more than one path to safety. We must explore the potential for improvement through R&D and technological improvements but recognize that these are long term approaches and must be accompanied with interventions that can improve safety immediately through leadership, cultural change, improved
internal systems and behavioral approaches for short term gains.” • Marinus Heijl, Deputy Director, Air Navigation Bureau, ICAO
– xxx
• BG Joseph Smith, US Army, Director of Army Safety/ Commanding General, U.S. Army Combat Readiness Center – xxx
Invited Speakers
• Paul Arslanian, Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile (BEA)– xxx
• Steve Finger, President, Sikorsky Aircraft Corp. – xxx
• Mike Blake, Executive Vice President and Chief Operating Officer, Commercial Products, Bell Helicopter Textron, Inc. – xxx
• Richard Healing, Former Member of the National Transportation Safety Board (NTSB) – xxx
Invited Speakers
• Bob Sheffield, Managing Director, Shell Aircraft International – xxx
• Sylvain Allard, President and CEO, CHC Helicopter Corp.– xxx
• Tom Judge, President, AAMS - USA – different issues than rest of helicopter industry - business model, medical & aviation
issues, reviewed Flight Operations database for AMS
• Werner Marty, Flight Safety Officer and Pilot, Swiss Air Ambulance (REGA)
– large operator (Safety program - management driven, reporting system, anti-collision, remove
unused cables, review & revise SOPs, training, regulations, design,
Invited Speakers
IHST Executive Committee
Government Co-Chair Dave Downey, FAA
Industry/Operator Co-Chair Matt Zucarro, HAI
Secretariat Rhett Flater, AHS
Member Bob Sheffield, Shell Aircraft
Member Somen Chowdhury, IHSS Chair
Member Don Sherritt, Transport Canada
The way forward…
JHSATAnalyze accidents to determine whatsolutions can prevent &
mitigatethe problems
JHSITDetermine how to
best implement the
solutions
recommended by
the JHSAT.
Measure success via the diminishing accident rate!
JHSAT - Joint Helicopter Safety Advisory TeamJHSIT - Joint Helicopter Safety Implementation Team
Buy-in worldwide
• Australia• Brazil• Canada• Columbia• France• Germany• India
• Italy• Japan
• Netherlands• Switzerland
• United Kingdom• United States
• Who’s Next??
Training Panel SummaryTraining Objectives:•Review present flight review requirement standards/minimum requirements
•Review international regulations (JAA, TC, ICAO) •Review inadvertent IFR training requirements
•Develop/explore distance learning instruction (HAI, Diamond endorsements) for Mx, Pilot, management • Increase use of synthetic (simulator-based) training
•Synthetic auto-rotation training • Emphasis on IFR training• Review long term training objective
•Current certification criteria for pilots and mechanics•CRM, MRM, safety culture
Training Panel Summary (cont.)• OEM develop training standards that should be
verified by audit process– Training Recurrent and Initial schedules
• Training for new technology – FITS training model as guideline
• Better accident/incident statistics are necessary– Self disclosure program
• HOW DO WE PROVIDE INCENTIVES FOR OPERATORS TO ADOPT SAFETY GUIDELINES ?!
Training Panel Summary (cont.)OEM :•OEM develop training standards that should be verified by audit process
Training Recurrent and Initial schedules
• Survey by OEMs on training issues for HeliExpo, other conventions and mailing• Heliprops-type program for maintainers
Review Medallion program or similar programs (HAI platinum) for roadmap Encourage membership in similar programs
Last Six Years Data2000- 2005
• Civil & Military uses
– 3049 accidents– 2643 fatalities– 1027 serious injuries– 5439 minor/ no injuries
PRINCIPAL MAINTENANCEINSPECTOR
ICAs
OPERATOR
OPERATORMAINTENANCE
PROGRAM
Operator ReliabilityProgram
Feedback to Manufacturer
In-ServiceMonitoring
Monitoring
RegulatoryApproval
Bell civil turbine accident causes worldwide (1994-2003)
Airworthiness14%
Non-AW (human, etc.)74%
Unknown12%
Source : Roy Fox, Bell Helicopter Textron
Need to Act
• Helicopter operations are essential• There is a need to have a
comprehensive hard look as to how we operate and do business
• Absence of any concerted plan so far
• IHSS 2005 was held in Montreal to kick – off the process
CAST (commercial aviation safety team) was considered a good model to follow
Charters Joint Helicopter Safety Analysis Team (JHSAT) Charter:
Conduct, review and approve detailed accident report analysis and identify causal factors;
Investigate and recommend improvements and develop mitigation strategies to allow goal achievement and periodic status measurements;
Draft action plans to determine intervention strategies and milestones for IHST approval.
Joint Helicopter Safety Implementation Team (JHSIT) Charter:
Develop and prioritize implementation strategies;
Carry out rigorous cost-benefit analysis for implementation strategies to achieve IHST goals;
Develop action plans;
Coordinate implementation of IHST-approved strategies;
Develop and track performance; Determine progress in meeting major milestones and effectiveness of
interventions.
Buy-in Worldwide: Government, Military & Civil Groups, OEMs
• USA– AHS - American Helicopter Society
International– AAMS - Association of Air Medical Services– FAA - Federal Aviation Administration – FSF - Flight Safety Foundation Inc.– HAI - Helicopter Association International– NAVAIR - U.S. Navy - Naval Safety Center– NTSB - National Transportation Safety Board– U.S. Army Combat Readiness Center
• Europe– BEA - Bureau d'Enquêtes et d'Analyses pour
la Sécurité de l'Aviation Civile
– EHA - European Helicopter Association
• Canada– TCCA - Transport Canada Civil Aviation– TSB - Transportation Safety Board of Canada
• India : DGCA : support from Jt.Sec Sanjay Kumar, DG & Jt.DG of DGCA
USA
BellBoeingSikorskyRRPratt & WhitneyGEHoneywell
EuropeEurocopterAugusta-WestandTurbomeca
CanadaCHC Helicopters
Need all operators to buy-in