1. Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron...

1

Bell Helicopter Textron Inc. is a wholly owned subsidiary of Textron Inc. Bell Helicopter Textron Canada Limited is a wholly owned subsidiary of

Textron International Holding S.L, a wholly owned subsidiary of Textron Inc. Each company is a separate legal entity and a member of the Textron

family of companies. © 2015 Bell Helicopter Textron Inc. All registered trademarks are the property of their respective owners.

Mike Suldo

March, 2015

GABA IV WorkshopsSafety and Accident Investigation




“Aviation is not in itself inherently dangerous. But to an even greater degree than even the sea, it is terribly unforgiving of any

carelessness, incapacity or neglect.”




Do we always do the safest thing when flying?

Is safety the only thing that we worry about?




No !Because if it were, this is what would happen, we would not fly !




Safety is about accepting the fact that there are

risks in what we do, then trying to make those

risks as small as possible.




This is what we do not want




When an accident is investigated 4 areas are looked at:

The Aircraft Maintenance

Suitability for missionMechanical problems

The Pilot and CrewTrainingQualificationsPhysical and Mental condition

The EnvironmentWeatherTerrainHazards

The OperationHazardsWithin crew capabilities?




This one was mine

Cause: Refueled on aircraft carrier in Mediterranean Sea. Was pumped water instead of fuel. Resulted in dual engine flameout on takeoff from ship . All survived – no injuries




Another of my AccidentsNavy H-46




Cause of AccidentLack of a “cotter pin” to secure the nut on the actuator in the flight controls. The nut backed off of the bolt in 8 hours of flight time and then disconnected the pitch control rod in flight resulting in an “uncomanded “ loop. This caused the rear blades to sever the front blades and break the fuselage in half.




Supposed to look like this




The Cotter Key was left off




This nut backed off







The result of one Cotter Key

left off

3 Fatalities + 2 serious injuries




And especially these







19

Video - Bought Helicopter Can’t Fly




Accidents and Incidents Cost!

Direct costs• Loss of aircraft• Injuries to or death of

flight crewmembers, passengers

• Insurance deductibles• Costs not covered by

insurance

Indirect costs• Loss of use of equipment• Loss of staff

– Involved in accident issues– Lower productivity

• Investigation & clean-up• Legal claims• Fines• Misplaced/stranded passengers• Negative media exposure




Most Predominant Occurrences During Fatal Helicopter Accidents1. Loss of Control2. Visibility issues3. Fire (post-impact)4. Wire Strike5. System Component Failure

Other Frequent Occurrences During Fatal Helicopter AccidentsAutorotation (in practice & emergency)Controlled Flight Into TerrainFuel issueAbrupt ManeuverIcing




Why Do Most Helicopter Accidents Happen? This is true over the past 10 years • Probable cause. . . .

– “Pilot error” – 78% • Weather-related• Flight into the ground or objects

– Mechanical – 19% – Other – 2%– Undetermined – 2%

Pilot

Mechanical




From the U.S. Army (2011-12)




Where can you go for Help ?




IATA – Has a Beijing Office

Accident Investigation Course in Singapore - $2125. USD Nov 23-Nov 27, 2015

This course enables airline staff members to participate in an aircraft accident and serious incident investigation in accordance with ICAO Annex 13 standards. Special attention is given to understanding the underlying causes of accidents and incidents in order to improve safety and prevent future occurrences.Available as: Classroom & In-Company course Duration: 5 days (40 hours) Recommended level: Advanced and intermediate

The International Air Transport Association (IATA) is the trade association for the world’s airlines, representing some 250 airlines or 84% of total air traffic. We support many areas of aviation activity and help formulate industry policy on critical aviation issues.




Certificate Program in Aircraft Accident Investigation (AAI)

Required CoursesAircraft Accident Investigation (AAI)

Human Factors in Accident Investigations (HFAI)

Safety Training Courses

Aircraft Accident Investigation for Media Professionals (AAIMP) Aircraft Performance Investigation (API) Air Traffic Control Investigation (ATCI) Cabin Accident Investigation (CAI) Electronic Systems Investigation (ESI) Fire and Explosion Investigation (FEI) Fixed Wing Accident Investigation and Reporting (FWIR)

Flight Data Analysis (FDA) Flight Reconstruction from GPS Data (GPS) Gas Turbine Accident Investigation (GTAI) Helicopter Accident Investigation (HAI) Investigation Total Immersion (ITI) Investigation Management (IM) Family Assistance Planning (FAP) Aircraft Maintenance Investigation (AMI)

Plus any three from below




SCSI Safety Courses - Long Beach, California

PREVENTION SERIESSafety Management Systems - Complete 01-05 JuneFlight Safety Officer Course 08-12 JuneInvestigation in Safety Management Systems 15 19 JuneLeading Change in SMS 22-26 June Human Factors in Aviation Maintenance 02-04 SepSafety Management Systems - Complete 07-11 SepInvestigation in Safety Management Systems 14-18 SepLeading Change in SMS 21-25 SepOperational Risk Management 21-25 Jan

INVESTIGATION SERIESAircraft Accident Investigation 02-13 FebHuman Factors in Accident Investigation 16-20 FebHelicopter Accident Investigation 23-27 FebGas Turbine Accident Investigation 02-06 MarAircraft Maintenance Investigation 09-13 MarInvestigation Management 16-20 MarCabin Accident Investigation 11-15 MayHuman Factors in Aviation Maintenance 30 Mar-01 Apr Aircraft Accident Investigation 06-17 JulyHuman Factors in Accident Investigation 20-24 JulyFire and Explosion Investigation 27-31 JulyAircraft Performance Investigation 03-07 AugElectronic Systems Investigation 10-14 Aug




Your Best Resource

Country / Area Specific Sets up “Groups” in different countries or areas

Already has produced things that you can use

Working to Reduce World-Wide Helicopter Accidents

Works to understand your past accidents and how you can prevent them in the future




Safety Bulletins

•Visibility• Inadvertent Entry into Cloud or Fog• Visibility: The Minimum You Should Know

•Loss of Control• Gaining Control over Loss-of-Control Accidents• Emergency Decision Making: What Happens When You Lose a Critical System?• Density Altitude – The Invisible Factor of Helicopter Performance

•CFIT• Controlled Flight into Terrain Prevention with HTAWS• Controlled Flight into Terrain: How Does it Happen?

•Autorotations• Rotor Rooter – Autorotation Acronyms• How to Train to Survive a Real Autorotation• Energy in Autorotations – Using Energy for our Benefit

•Training• Instructional Safety: Training Safety or Training Safely? • Recurrent Training: Are You Current and Proficient?

•Safety Management• Internal Evaluation Program (IEP) Safety Assurance Check • Hazard Identification – If You See Something . Say Something • A Flight/Ground Risk Assessment Tool (FRAT/GRAT) • SMS for Certificated Flight Instructors • SMS: How to Get Started for the Small Operator

•Professionalism • Setting the Right Example • A Defensive Strategy for Helicopter Pilots • Precautionary Landings




Safety Leaflets

The Principles of Threat and Error Management (TEM) for Helicopter Pilots and Instructors

Helicopter Operations in Hilly and Mountainous Terrain

Using Advanced Navigation Technology Safely

Helicopter Airmanship

Helicopter Safety Considerations

Helicopter Airmanshiphttp://www.ushst.org/nbspnbspBulletinsnbsp.aspx

Off Airfield Land Site Operations

Single Pilot Decision Making

Risk Management in Training

Advantages of Simulators in Helicopter Flight Training



















Safety Management Systems (SMS)

Safety Management System is becoming a standard throughout the aviation industry worldwide. It is recognized by the Joint Planning and Development Office (JPDO), International Civil Aviation Organization (ICAO), and civil aviation authorities (CAA) and product/service providers as the next step in the evolution of safety in aviation.

In the US, You need an SMS if:

Many foreign countries such as Canada, France, Australia require it for all operations with other to follow







Safety Management StrategiesReactive(Past)

Responds to events that have already happened, such as incidents and accidents

Proactive(Present)Actively seeks the identification ofhazardous conditionsthrough the analysis of the organization’s processes

Predictive(Future)

Analyzes systemprocesses and environment to identify potential future problems




Safety Management SystemsMandated by FAA for 121 operations, recommended for others.

A system (documented) to manage aviation risks using Leadership and Accountability. It requires Pro-active Hazard identification, risk management, information control, auditing, and training. It must start at the top, with a commitment from the leaders of the business.




A good SMS will provide tools to analyze problems And save money and lives




SystemAnalysis(Design)

HazardIdentification

RiskControl

RiskAssmt

RiskAnalysis

Extremely improbable

Improbable

Remote

Occasional

Frequent

Risk Likelihood Negligible

EMinor

DMajor

CHazardous

BCatastrophic

A

1E1D1C1B1A1

2E2D2C2B2A2

3E3D3C3B3A3

4E4D4C4B4A4

5E5D5C5B5A5

Risk Severity

Risk AssessmentRisk assessment determines the level of risk to use in making a bottom line decision.

A risk matrix is a tool used for risk assessment. It can vary in form yet it accomplishes the same purpose.




All needed sample documents to set up a functional SMS can be found on the HAI website

for free or you can pay a safety consulting company to come in and set one up.




Flight Data Monitoring (FDM)




Weight and Size Matter !!

• Size - 3”x4”x6”• Weight – under 2

lbs• 1 wire hookup

An Example - Appareo Flight Data Monitoring Equipment




ALERTS Installed Aircraft: 51 January flight time: 1855.91 January flights: 5086 January valid events: 1008

January 2008 - Event Totals (All Types)

Excessive Pitch, 2%

Excessive Pitch Landing, 0%

Excessive Pitch T/O, 9%

Excessive Yaw Rate, 1%

Low Cruise, 22%

Excessive Descent <500ft., 39%

Steep Turn, 0% Settling/Power, 0%

Premature Departure Turn, 3%

Low Turn to Final, 3%

Excessive Bank, 5%

Excessive Descent >500ft, 15%

Excessive Climb 407, 0%

Excessive Climb, 1%




With satellite data automatically added

46




47




48

APR IAS ALT PRE

GASBYBC

H o n e y w e llVOR

HDG

NAV ILS

VS ALT

DECEL

ON ON ON

ONCAPARM

CAPARM

CAPARM GSARM CAPARM

CAPARM

ON ON

NO.2 OFF

SERVOSNO.1 OFF

HOISTUP

DOWN

ENG - TRIM

#1 - #2TRAINFWD

AFT

L R

LT

GOARND

RELTRIM

50% 90% 100%

1 2

CP P

C




FDRs Required

North Sea Results:

49




Flight Data MonitoringCirat Videos from Bell 429




51

Simulator Training From Simple to Complex




52

Training in autos to the water




It is Important to Have the Right People, the Right

Training, the Right Safety systems, and the Right

Attitude. BUT… it is also important to have the Right

Equipment in the Aircraft to make them Safer.




• The Right Avionics (dual communications radios)

• Radar – on bigger helicopters and aircraft

• Night Vision on helmet – on many helicopters

• Enhanced Ground Warning System or helicopter terrain awareness and warning systems

(HTAWS)

• Helicopter Wire Strike Protection

• Radar Altimeter

• GPS navigation with obstruction database

• Flight data monitoring equipment

• Air traffic collision avoidance systems

• Satellite aircraft tracking

• Health Usage (Vibration) Monitoring Equipment (HUMS)

Recommended Aircraft / Helicopter Safety Equipment




55




Thank you for your Attention…

Any Questions?

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