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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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CHC Safety & Quality Summit 2009
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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CHC Safety & Quality Summit 2009
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IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
CHALLENGESNot the same for helicopters as for airplanes
Increased versatility of helicopters
requires diverse actions to
address challenges
vs.
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
~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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
SEEKING THE RIGHT BALANCE
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
IMPLEMENTATION SCHEDULE
It Has
Begun!!
Continuing To Grow!!!
• ROI Training
• AHS/CRI
• CAMTS
• Workshops
• InsuranceEducation
• Toolkits
• FOQA
• Media
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
Return On Investment for Safety & Health Investments
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
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Present results to your management:
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
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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CHC Safety & Quality Summit 2009
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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CHC Safety & Quality Summit 2009
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
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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CHC Safety & Quality Summit 2009
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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CHC Safety & Quality Summit 2009
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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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CHC Safety & Quality Summit 2009
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SPACE SHUTTLE
CHALLENGERJanuary 28, 1986
COLUMBIAFebruary 1, 2003
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
•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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CHC Safety & Quality Summit 2009
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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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CHC Safety & Quality Summit 2009
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IHST.org
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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CHC Safety & Quality Summit 2009
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IHST.org
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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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
• 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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CHC Safety & Quality Summit 2009
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IHST.org
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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CHC Safety & Quality Summit 2009
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IHST.org
Responsibility & AccountabilityResponsibility & Accountability
And It Begins With US!!
SAFETY
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CHC Safety & Quality Summit 2009
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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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CHC Safety & Quality Summit 2009
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CHC Safety & Quality Summit 2009
Vancouver, B.C.
IHST.org
Questions??
Larry BuehlerFAACO-CHAIR US [email protected]
Fred BrisboisSikorsky AircraftCorporationCO-CHAIR US [email protected]