Safety Enhancement in Helicopter Operations

1. 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

2. Contents • Why IHST : Background • Objectives, Goals & Implementation • Montreal Conference IHSS 2005 • IHST Regional Cooperation • Safety : Every Step of the Way • IHSS 2007 • Conclusions

3. Background: Current State of Affairs • Too many • Accidents 2005- 565/year worldwide • Lives lost Poor Public image • Business loss • Injuries Too expensive UNACCEPTABLE

6. 24,294 Worldwide Civil Helicopters

7. Worldwide Helicopter Accidents/ year1980-2005 Source : Roy Fox Bell Helicopter

8. Accident rates in India Source: RWSI : AVM Sridharan

9. 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

10. Comparative Accidents Data

11. The Real Challenge Iceberg Theory 1 Accidents 10 Serious Incidents 300 Incidents 1200 Near Misses Heinrich Ratio The BIG Picture Hidden or Unseen Conditions are Below The Surface

12. The Danger… - is all around us!!!

13. Need to Act • Can the industry do better ? • How ? • Need a mitigation Strategy IHSS 2005 was held in Montreal to kick- off the process

14. IHSS 2005 Montreal Conference • Results • Attendance ~250 • International • 13 countries • 5 continents • Industry wide • Government • Regulatory • Accident Investigators • OEMs • Mission groups • Operators • Pilots • Maintainers • Aviation Press • 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 IHST set up

15. Mission • 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. • Vision • To 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. IHST Goal To reduce helicopter accidents by 80% by 2016

16. Executive Committee IHST Secretariat JHSAT JHSIT Subcommittees Subcommittees IHST Organisation JHSAT - Joint Helicopter Safety Analysis Team JHSIT - Joint Helicopter Safety Implementation Team CAST (commercial aviation safety team) was considered a good model to follow

17. Data Analysis Implement Safety Enhancements - U.S. Set Safety Priorities Agree on problems and interventions Influence Safety Enhancements - Worldwide Achieve consensus on priorities Integrate into existing work and distribute Implementation Process

18. IHST Regional Cooperation International Cooperation is essential • Regulators • Operators • OEMS In all regions of the world. We start with S Asia We are all in it together

23. Safety Failure Prevention technologies Operational regulations Maintenance Quality Assurance - No Flaw Airworthy Product • Reliability • anti corrosion • - reduce vibration • Survivability • technologies • ext. airbag • Crash worthy seats • & fuel tanks • - floatation gear • - egress • Human Factors • Training of all parties • -Pilot aids • Mission comprehension S M S S M S S M S 3 years 20-30 years Safety: Every Step of the Way Continuing Airworthiness Short term Action

24. 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

25. Probability and Severity Relationships

26. HAZARD SEVERITY HAZARD PROBABILITY Catastrophic Level 1 Critical Level 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 Failure risk mitigation strategy

27. Manufacturing • Flawless manufacturing • Reduce MDRs • Improved inspection technologies • Reduced variability RETURN

28. Field OperationsMaintenance Definition: A periodic maintenance task established during the certification of the aircraft as an operating limitation of the type design certificate. RETURN

29. 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 RETURN

30. 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

31. Field & Flight OperationsHuman Factors 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 The door opened in flight! RETURN

32. IHSS 2007 • Montreal • Dates –September 17 to 20, 2007 • Action Plans from JHSAT, JHSIT will be discussed • Report on worldwide participation

33. 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

34. 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

35. Questions? Please check out the IHST website: www.ihst.org

38. The ‘Swiss Cheese’ Model Successive layers of defenses, barriers, & safeguards Barriers are Safety Nets Some holes due to active failures (present in use) Hazards When barriers fail Other holes due to latent conditions (present, not visible) ACCIDENT

39. Training Sessions 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 Key Components 1) Safety management plan 2) Document management 3) Safety oversight 4) Training 5) Quality Assurance 6) Emergency Preparedness

40. Training Sessions 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! • Army Cumulative Risk Model Risk Management Process - hazard identification, - severity & probability Military 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

41. Training Sessions Maintenance - Grey Owl & HAI Human Factors!!! The Dirty Dozen 1. Lack of Communication 2. Complacency 3. Lack of Knowledge 4. Distraction 5. Lack of Teamwork 6. Fatigue 7. Lack of Resources 8. Pressure 9. Lack of Assertiveness 10. Stress 11. Lack of Awareness 12. Norms • Maintenance Resource Management (MRM) • improving communication skills • decision making • effectiveness and safety in aircraft maintenance operations • Non-technical training • Operational Integrity • Situational Awareness • Error Chain Recognition • Communication Skills • Briefings • Synergy / Team Concepts • Leadership • Conflict Resolution • Decision Making • Stress Management

42. Invited Speakers • Dr. Forster - HAI Reflecting 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, HAI There 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

43. 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

44. 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,

45. 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

46. JHSAT Analyze accidents to determine what solutions can prevent & mitigate the problems JHSIT Determine how to best implement the solutions recommended by the JHSAT. The way forward… Measure success via the diminishing accident rate! JHSAT - Joint Helicopter Safety Advisory Team JHSIT - Joint Helicopter Safety Implementation Team

47. Australia Brazil Canada Columbia France Germany India Italy Japan Netherlands Switzerland United Kingdom United States Who’s Next?? Buy-in worldwide

48. Training Panel Summary • Training 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

49. 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 ?!

50. 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