US Army Aviation Safety Investment Strategy Team (ASIST)

US Army Aviation Safety Investment US Army Aviation Safety Investment

Strategy Team (ASIST)Strategy Team (ASIST)

Russell PeuschRussell Peusch

System Safety EngineerSystem Safety Engineer

US Army Aviation and Missile CommandUS Army Aviation and Missile Command

2005 International Helicopter Safety 2005 International Helicopter Safety SymposiumSymposium

6/24/05

Analysis Team • Army Aviation CenterArmy Aviation Center

– Aviation SafetyAviation Safety

– Combat DevelopmentsCombat Developments

– Training Developments & Training Developments & SimulationSimulation

– Aviation Training BrigadeAviation Training Brigade

– Evaluation & StandardizationEvaluation & Standardization

• Aeromedical Research Aeromedical Research LaboratoryLaboratory– Aircrew ProtectionAircrew Protection

– Aircrew Health & PerformanceAircrew Health & Performance

• Army Research LaboratoryArmy Research Laboratory– Human EngineeringHuman Engineering

• Program Executive Officer - Program Executive Officer - AviationAviation

• Aviation & Missile CommandAviation & Missile Command– DSA/Program ManagementDSA/Program Management– Aviation Research Development & Aviation Research Development &

EngineeringEngineering– Systems EngineeringSystems Engineering– System SafetySystem Safety

• Army Safety Center (Now CRC)Army Safety Center (Now CRC)– Aviation Systems & InvestigationsAviation Systems & Investigations– Risk Management IntegrationRisk Management Integration– Operations Research & AnalysisOperations Research & Analysis

• Air Force Institute of Air Force Institute of TechnologyTechnology– Operations ResearchOperations Research

“Cause Factors” vs “Hazards”

• Individual issues

• Mistake-based

• Privileged data

• Blame focus

• Unit level

interventions

• Systemic issues

• Risk-based

• Non-sensitive

• Prevention focus

• Army-wide

investments

Environment(Leadership)- OPTEMPO-Culture-Experience

Machine (Aircraft) - Complexity - Failures - Uncertain causes

Environment (Mission) - Multi-ship - Over water - NVG

Crew - Proficiency - Coordination - System Under- standing

- - Structure for hazard statements:

•(human conditions)+(machine conditions)+(environmental conditions) during (mission tasks) resulting in (articulation of effects on the system)

•articulate hazards from the perspective of the operator applying conditions to “Source-Mechanism-Outcome” model

Identifying Hazards

“Cause: Human Error”• Pilot failed to follow properprocedures due to complacency& over-confidence.• Pilot improperly diagnosedemergency due to high anxiety.

Hazard(s) 1. Task saturation during a simulated engine failure (SEF) may result wrong throttle position at termination 2. Crew’s ability to perform successful maneuver is limited by inherent aircraft handling characteristics. 3. During the accident sequence dynamic forces may exceed injury threshold.

Risk Management of Simulated Engine Failure (SEF)

Training

ASIST Database Structure

AccidentExperience

Table(all aircraft)

Hazard Assignment Table (one for each a/c

system)


system)


system)


system)

Hazard Assignment

Table

Book of Hazards

(all aircraft)


system)


system)


system)


system)

Control Assignment

Table

Book of Controls

(all aircraft)

1 ∞ 1 1

1

∞

∞ ∞

Hazard(s) 1. Task saturation during a simulated engine failure (SEF) may result wrong throttle position at termination 2. Crew’s ability to perform successful maneuver is limited by inherent aircraft handling characteristics. 3. During the accident sequence dynamic forces may exceed injury threshold.

Potential Controls Doctrine - Increase minimum entry altitude for SEF training Organization - Increase flying hour program Training - Enhanced Crew Coordination Training - Emergency procedures simulator Materiel - Autorotational characteristics - Crashworthy seats Leadership - Integrate RM into institutional training & Edu Personnel - Facilities -

Risk Management of Simulated Engine Failure (SEF)

Training

Control Effectiveness Guidelines & Control Values

Controls

1. ~~ 2. ~~ 3. ~~ . . . . . .

Prioritized Controls

Priority Value

1. ~~ x%2. ~~ y%3. ~~ z% . . . . . .

Cost Assessment High

MediumLow

EffectivenessAssessment

Design Safety Devices

Warning DevicesProcedures & Training

KW Example Results

Common Hazards Across Timeframes* for US Army Rotary Wing Aircraft

0%

1%

2%

3%

4%

5%

6%

7%

8%

Hazard Value

Hazard ID

*Three timeframes: FY94-98, FY99-03 (non OEF/OIF), and OEF/OIF

Airframe Influence on Common Hazards US Army Rotary Wing Aircraft

0%

1%

2%

3%

4%

5%

6%

7%

8%

Hazard Value

Hazard ID

At any level of command, not using established controls is selective enforcement of standards and may result in aircraft damage or personnel injuries.

A/C System RankH-60 1H-47 1AH-64 5OH-58D 9

Unit personnel may lack experience, wisdom, or seasoned leadership to apply risk management to the unit's mission resulting in uncontrolled hazards.

A/C System RankH-60 4AH-64 6 OH-58D 10H-47 32

Lack of factual and timely information, or lack of understanding of the available range of controls to manage high risk behavior, at any level of command, may result in damage to aircraft or personnel injuries.

A/C System RankOH-58D 4AH-64 4H-60 7H-47 12

Timeframe Breakout of Common Hazards Across US Army Rotary Wing Aircraft

FY94-98

FY99+

OEF/OIF0%

2%

4%

6%

8%

10%

12%

14%

16%

Hazard Value

Hazard ID

Note: FY99+ analysis does not include OEF/OIF cases


FY94-98

FY99+

OEF/OIF0%

2%

4%

6%

8%

10%

12%

14%

16%

Hazard Value

Hazard ID

Rotary wing operations in close proximity to unimproved surfaces may result in degraded visual environment (brownout or whiteout) leading to loss of situational awareness (LOSA) and control loss with aircraft damage or personnel injury.

A/C System Rank OEF/OIFH-60 2 1AH-64 8 1OH-58D 7 2H-47 NR

Maneuvering among obstacles while landing to unimproved or unfamiliar terrain under degraded visual environment (NVG, low illumination) increases workload may result in loss of situational awareness (LOSA) and undetected obstacle strike.

A/C System Rank OEF/OIFH-47 2 1H-60 15 20AH-64 23 28OH-58D NR


FY94-98

FY99+

OEF/OIF0%

2%

4%

6%

8%

10%

12%

14%

16%

Hazard Value

Hazard ID

Combining multiple stressors (fatigue, OPTEMPO, high winds, low contrast, lack of training, family situation) with mission operations (sling load) in high workload environment can cause LOSA (divided attention) resulting in aircraft or equipment damage.

A/C System Rank OEF/OIFH-47 2 4H-60 22 26AH-64 NROH-58D NR

Aircraft operations in degraded visual environment (night aided over water) may result in loss of situational awareness (LOSA) resulting in the aircraft striking an object.

A/C System Rank OEF/OIFH-47 3 3H-60 75 77AH-64 NROH-58D NR

Other Significant Hazards by Aircraft System

Hazard Value & (Ranking within System)

Hazard ID Hazard Statement RW OH-58D H-60 H-47 AH-64

22Unknown accident cause involving aircraft flight into terrain

with no survivors or witnesses.

4.4% (3)

0.8% (29)

7.6% (3)

0.10% (88)

6.8% (1)

11

Use of the Abbreviated Aviation Accident Report (AAAR) for aviation accidents does not provide adequate accident information to apply risk management to the accident investigation process.

3.5% (6)

3.1% (7)

7.0% (5)

1.5% (16)

0.9% (33)

5

Hovering in close proximity to terrain in a degraded visual cue environment and high workload may result in loss of situational awareness (LOSA) causing inadvertent hover drift and collision with terrain or obstacles.

2.8% (7)

16.2% (1)

1.8% (20)

2

Maneuvering among obstacles in a degraded visual environment causes an escalation of workload and increases fatigue which may result in a collision with terrain or obstacles.

2.3% (9)

1.5% (18)

0.6% (4)

6.7% (2)

195Loss of situational awareness (LOSA) during formation

flight may result in a midair collision.

2.3% (10)

6.7% (6)

58

Flight into known deteriorating weather may result in loss of situational awareness (LOSA) or spatial disorientation and loss of aircraft control.

2.3% (11)

1.2% (22)

2.3% (11)

3.4% (9)

218

During an accident sequence, the aircraft structure may transmit loads that exceed human tolerance resulting in injury or trauma, in an otherwise non-injurious environment.

1.6% (12)

11.4% (2)

DOTMLPF Control Analysis

DoctrineControl

ID ControlRW Control

Value

28Standardize mission risk assessment

and briefing process 3.1%

20Establish a new flying hour category for

individual task flight training hours 2.1%

304Standardize doctrine and operational

procedures for mulit-ship operations 0.3%

574Design and develop an interactive

electronic technical manual 0.3%

OrganizationControl


Value

26 Increase and structure pilot flight hours 7.1%

13

Evaluate and resource the maintenance force structure to match present aviation requirements 0.9%

TrainingControl


Value

33Develop, field, and sustain an enhanced

crew coordination training program. 7.2%

384Establish and mandate risk management

training program,. 4.0%

537

Evaluate increasing the minimum requirements for attending the IPC/MOI course 3.3%

536

Implement a Hazard Based Investigation Process, which includes an assessment of risk management application effecting the accident. 3.1%

Leadership & EducationControl


Value

416

Establish minimum operational experience and flight time requirements for selection as aviation commander 3.8%

15

Modify Aviation Branch Officer Career Model AR 600-3 to develop experience, tactical & technical proficiency. 3.2%

18

Provide commanders guidance and training for crew selection, mission tailoring, and balancing of resources to do the mission. 2.8%

621

Evaluate unit crew rest and endurance policy with regards to unit duty day in a combat environment. 2.1%

DOTMLPF Control Analysis (cont)

MaterielControl


Value

46

Install Digital Source Collector (DSC) to support accident investigation, aircrew training, maintenance, and accident prevention. (MFOQA) 14.0%

8

Modernize flight control system to improve aircraft stability, control, and guidance throughout the flight envelope for all environments 11.6%

7

Develop and install new Night Vision Systems with improved acuity and field of view (2nd Gen FLIR). 4.5%

1Develop and issue new Night Vision Goggles

with improved acuity and field of view. 4.4%

622Instrument Flight cueing to inform the pilot of

movement over a given point in a DVE 3.1%

1155

Develop a situational awareness technology to inform the pilot of movement over a given point in a DVE 2.5%

369

Develop an automated approach landing system through improvements to the flight control system (FCS). 2.1%

318

Establish a command information system which tracks all forms of high risk behavior and marginal performance. (MFOQA) 1.9%

Personnel

Control ID Control

544

Modify the Army's screening process for flight school to identify individuals that are more compatible with modern aircraft and mission complexity (i.e., multitasking in glass cockpits).

70Modify -10 to mandate 4th crew member for H-47

sling load operations.

Note: Personnel controls shown as examples from aircraft analyses.

Conclusions

• Hazard identification is key to accident reduction

• Hazards experienced in OEF/OIF were not “new” to the RW community

• No single “silver bullet” to combat the hazards, but–Controls to reduce workload and bridge the

experience gap through MFOQA - go a long way

• Need to close the loop on risk management

ASIST Process Improvements

• Data driven hazard “outcomes”

• Articulation of risk by hazard severity and probability

• Risk reduction estimates through system safety rules for control application

Questions?Questions?

Russell PeuschRussell Peusch

Commercial (256) 842-8632Commercial (256) 842-8632

[email protected]@redstone.army.mil

Documents

US Army Aviation Safety Investment Strategy Team (ASIST)