Post on 12-Jan-2016
transcript
1Federal AviationAdministration 1
International Helicopter Safety Symposium
September 26-29, 2005
US Civil Helicopter Emergency Medical Services Accident
Analysis
Presentation to:
International Helicopter Safety Symposium
Name: Matthew RigsbyDate: September 26 –29, 2005
Federal AviationAdministration
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International Helicopter Safety Symposium
September 26-29, 2005
FAA Aviation Safety (AVS)
International Helicopter Safety Symposium
September 26-29, 2005
Rotorcraft Directorate Standards Staff, Safety Management Group - ASW112, Southwest Region
• We are part of the service arm of the FAA family involved in the certification of new helicopters, modifications to and continued operational safety of existing helicopters.
• Our mission is to provide the safest, most efficient aerospace system in the world.
• Our vision is to continually improve the safety and efficiency of aviation, while being responsive to our customers and accountable to the public.
• Our values are based on a passion for Safety, Quality, Integrity, and People.
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International Helicopter Safety Symposium
September 26-29, 2005
FAA EMS Task Force Preliminary Findings
• The number of Helicopter Emergency Medical Service (HEMS) accidents have risen dramatically in recent years. In August 2004, an AVS task force was assembled to review these accidents, to determine causal factors and make recommendations to reduce them.
• Initial review shows that controlled flight into terrain, night operations, inadvertent IMC, and lack of operational control are predominant factors in the reviewed accidents.
• The majority of these accidents occurred beyond the geographic boundaries of the Certificate Holding District Office (CHDO).
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International Helicopter Safety Symposium
September 26-29, 2005
Civil Rotorcraft Accidents: 1998 1999 2000 2001 2002 2003 2004 2005*
Civil rotorcraft accidents: 166 172 182 177 192 207 171 120Civil Fatal rotorcraft accidents: 29 27 33 28 24 37 30 10
Operation Types:
External Load (Part 133): 12 12 11 9 8 13 5 2 Restricted Category (predominately Part 137): 25 25 25 14 14 19 11 9Air Medical (Part 91/135): 7 10 12 10 13 18 13 9Gulf of Mexico (Part 91/135): 3 9 9 8 6 16 10 6Air Tour Operators(Part 135): 2 4 5 5 5 6 4 4
2003 - 2005 Rotorcraft Wire Strikes: 11 9 7Fatal Wire Strikes 2 2 1Occurred during IMC 0 0 0
Data Sources: FAA, NTSB, HAI, and HSAC* 2005 Data through Aug. 31, 2005
U.S. Civil Type Certificated Rotorcraft AccidentsJanuary 1998 – August 2005
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International Helicopter Safety Symposium
September 26-29, 2005
“The airport runway is theMost important mainstreamIn any town.”-Norm Crabtree
0
50000
100000
150000
200000
250000
300000
350000
198019821984198619891991199319951997199920012003
Estimated Flight Hours Flown by EMS Operators
Data: Steve Ludwig, CJ Systems HAI presentation AMPA Nov 2002 & Multiple Sources
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International Helicopter Safety Symposium
September 26-29, 2005
US Civil Accidents Compared to HEMS Accidents1995 -2004
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International Helicopter Safety Symposium
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US Civil Fatal Accidents Compared to Fatal HEMS Accidents
1995 -2004
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International Helicopter Safety Symposium
September 26-29, 2005
Total HEMS accidents from Jan 1998 – Dec 2004 85Total HEMS Fatal Accidents 98-04 27Total Fatalities 74
Total Night HEMS Accidents 45Total Night Fatal Accidents 21
HEMS Accidents Involving Part 91 Operations(18 fatal) 59HEMS Accidents Involving Part 135 Operations(9 fatal) 26
HEMS Fatal Accidents VFR into IMC 11Twins 7Singles 4
HEMS Fatal Accidents IFR in IFR 1
HEMS US Rotorcraft Accidents 98’ – 04’
Data source: FAA EMS Task Force Analysis
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International Helicopter Safety Symposium
September 26-29, 2005
• All fatal accidents in VFR only aircraft.
(3 B-407’s, 1 B-206, 1 BO-105, 1 AS-350)
• None were equipped or using enhanced vision systems or terrain awareness warning system.
• All the HEMS fatal accidents occurred at night.
• Five of six of the fatal accidents appear to have CFIT characteristics.
• None of the programs with fatalities are CAMTS accredited.
• VFR only programs are the largest growth segment of the HEMS industry
2004 HEMS US Rotorcraft Accidents
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International Helicopter Safety Symposium
September 26-29, 2005
A quote heard several times at a recent air medical conference:
“….. EMS is the only commercial carrier where the passengers,may have no choice in whom transports them…..”
Why We are Here!!
International Helicopter Safety Symposium
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International Helicopter Safety Symposium
September 26-29, 2005
“The airport runway is theMost important mainstreamIn any town.”-Norm Crabtree
Pyote, TX March 20044 Fatal
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International Helicopter Safety Symposium
September 26-29, 2005
Evansville, IN April 20041 Fatal
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International Helicopter Safety Symposium
September 26-29, 2005
Newberry, SC July 20044 Fatal
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International Helicopter Safety Symposium
September 26-29, 2005
Battle Mt., NV 20045 Fatal
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International Helicopter Safety Symposium
September 26-29, 2005
Santa Rosa, FL October 20043 Fatal
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International Helicopter Safety Symposium
September 26-29, 2005
Apache Junction, AZ. 1 Fatal
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International Helicopter Safety Symposium
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How the Helicopter Emergency Medical Services (HEMS) Community has Grown
• From the mid 1990’s to present, HEMS increased +100%
• Currently, there are approximately 660 RW aircraft flying HEMS, that number is increasing daily.
• Estimates of +300,000/hrs annually.
• Approximately 300,000 patients transported annually.
• An EMS aircraft takes off every 90 seconds in the United States.
• No formal method of tracking, hours, missions, usage.
• Single engine, non-IFR certified a/c is where HEMS is going.
• HEMS medical is changing to the “Independent Provider” model.
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International Helicopter Safety Symposium
September 26-29, 2005
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International Helicopter Safety Symposium
September 26-29, 2005
FAA EMS Task Force Initial Recommendations
• Industry cooperation and participation is critical to resolving the
issues.
• Joint FAA/Industry working group for accident root cause
analysis and Intervention Strategies.
• Apply System Safety Risk Management principles to HEMS
operations.
• Improve FAA oversight/knowledge.
• Approved Enhanced Vision programs.
• Investigate technology enhancements. (Aircraft & Infrastructure)
• FAA/Industry Part 135 Aviation Rulemaking Committee (ARC).
• Enhanced training and pilot pool.
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International Helicopter Safety Symposium
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• Developed Helicopter Air Ambulance Accident Analysis and Recommendations (Remains in Draft)
• Received support from Mgr Flight Standards (AFS-1) to partner with the air medical community to resolve HEMS issues and reduce the number of Accidents.
• Developed & Released Flight Standards Notice 8000.293; Helicopter Emergency Medical Services operations
• Participate in Air Medical Community Working Groups.Air Medical Transport ConferenceAAMEs Safety Committee & HAI Air Medical CommitteeAAME’s NVG Safety SymposiumAir Medical Safety Advisory Committee (AMSAC)
FAA EMS Task Force Initial Initiatives
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International Helicopter Safety Symposium
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On-going FAA EMS Task Force Activities • Continue cooperation and development of intervention strategies with the EMS community.
• EMS Task Force developing example Risk Assessment tools.
• AAMS NVG Symposium, FAA / Industry Participation
• Complete Air Medical Resource Management Advisory Circular.
• Completed Risk Management Notice 8000.301.
• Participate in the AMTC conference, FAA System Safety Risk Mgt. presentations.
• Complete a review of HEMS VFR Operations Specification A021(c) weather requirements.
• Complete a Notice for Controlled Flight Into Terrain (CFIT) accident avoidance.
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International Helicopter Safety Symposium
September 26-29, 2005
On-going FAA EMS Task Force Activities (cont’d)
• Complete a Notice for Loss of Control Accident Avoidance.• Decision-making training• Emergency IFR Recovery Procedures • Qualifications/Checking• Based on existing aircraft equipment and technology
• Complete a Notice for Part 142 Training Centers which Conduct
training for HEMS Operators. • Risk Assessment• CFIT Accident Avoidance • Loss Of Control Accident Avoidance
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International Helicopter Safety Symposium
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2005 Jan - Aug HEMS Accidents
• EC-135- N135NW; Native Air/Omni Flight- Maintenance, lower right lateral control link bolt came out in flight. Two pilots on-board, non-fatal.
• AS-350D – N350RM, Air Methods. The pilot fatal.
• EC-135 – N136LN, Air Methods, Aircraft over the Potomac River below 200ft, impacted the water unknown circumstances. Pilot and Flight Nurse fatal, paramedic survived.
• AS-350B3 – N351LG, PHI Air Medical, Reposition flight under NVGs pilot became disorientated and impacted terrain. Pilot non-fatal.
• B206L-1 – N5734M, Air Evac Lifeteam, Aircraft spun on departure, impacted terrain hard. Patient fatal.
• A119 – N403CF, Tri-State Care Flight, on approach, rapid decent witnessed, impacted terrain hard. Pilot, paramedic, and flight nurse fatal.* The information herein is preliminary
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International Helicopter Safety Symposium
September 26-29, 2005
2005 Jan - Aug HEMS Accidents
• BK117B-2 - N440HH; Hermann Hospital- Airframe component (door) failure. flight. No injuries.
• AS-365N – N365S, CJ Systems, loss of “tail rotor” control, impacted heliport rolled over. No injuries.
• BK117B-1 – N117US, CJ Systems, No. 1 engine lost power, on landing rolled over. No injuries.
* The information herein is preliminary
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International Helicopter Safety Symposium
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Questions?
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International Helicopter Safety Symposium
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Contact Information
matthew.rigsby@faa.gov
or
Southwest Region Aircraft Certification
Helicopter Directorate Safety Management Group
9-ASW-ROTOR-SAFE@faa.gov