1JHSAT - January 2007
JHSAT StatusJanuary 2007
JHSIT Kickoff meetingAHS – Alexandria, VA
Mark Liptak FAA ANE-110
2JHSAT - January 2007
JHSAT Goal:
Provide intervention strategies to the IHST and Joint Helicopter Safety Implementation Team (JHSIT) that maximize the likelihood of reducing worldwide helicopter accident rates by 80 percent by 2016.
3JHSAT - January 2007
Basic CAST ProcessCAST (IHST)Charters Activity
JSAT (JHSAT)Analyzes DataProposes most
effective interventions
JSIT (JHSIT)Assesses feasibility of
interventions works implementation
Continued data analysis,measure intervention
effectiveness
4JHSAT - January 2007
JHSAT Team Membership:
Mark Liptak – FAA ANE co-chair Jack Drake – HAI co-chair
Joan Gregoire - Turbomeca Steve Gleason - Schweizer Helicopters
Roy Fox - Bell Helicopter Ron Luhmann - Silver State Helicopters
Tony Alfalla - Sikorsky Ray Wall & Tom Fleming – Bristow Group
Sandra Hart - NASA Barry Rohm - Rolls Royce
Laura Iseler AHS/NASA Clark Davenport & Matthew Rigsby – FAA ASW
Ed Stockhausen & Joe Lemma – Airmethods
Joe Syslo & Lindsay Cunningham – US Eurocopter
5JHSAT - January 2007
JHSAT Web Site
http://www.ihst.org/jhsat/jhsat_top.htmUser id – jhsat, password – helicoptersafe
Contents:
JHSAT charter and process docsDataset detailsMeeting minutes/agendaPresentationsInterim RecommendationsResource documents
Not open to the public, restrict access for JHSIT needs only
6JHSAT - January 2007
JHSAT Status
Data Analysis
Engaging with the international community
Near term safety recommendations
8JHSAT - January 2007
JHSAT currently working process areas highlighted in yellow
CharterDevelopment
EstablishTeam
Select Data Set
ReviewNTSB
Docket Data
DevelopEvent
Sequence
IdentifyProblems
(what/why)
Assign StdProblem
Statements
ScoreProblem
Validity &Importance
Identify InterventionStrategies
ScoreInterventionAbility/Usage
Categorize and Prioritize Data
TechnicalReview
&Expert
Validation
Conflicts? ReportResults
No
Yes
IHST
JHSITCurrent task
9JHSAT - January 2007
SPS No
Popping noise Engine power loss Exhaust valve failure - root cause not determined
24010 engine component failure
Mandate Textron Lycoming SB388B to reduce liklihood of exhaust valve failure
4 4 3 3
Overflew wires, then crashed onto street in nose low, left skid low attitude. Nosed downward and turned CCW
Improper autorotation or loss of control?
Lost of control when making emerg/auto to street
21074 pilot control/handling, inadequate autorotation
Autorotation training aids, simulators etc
3 4 3 2
Pilot had 3.2 hours in R22 last 90 days; marginal autorotations on Com-helicopter check 3.5 mos before acdt.
Lack of recent experience in M/M and with autorotations
13071 Transition to aircraft make/model
Develop company policy and training rqts for pilots transitioning between m/m
4 3 3 3
Pilot had 67 hours in helicopters.
Lack of total helicopter experience
13070 Pilot transition training model specific simulator training
4 3 2 3
Pilot intentions and actions unknown. Flight/systems information unkown.
Lack of information - flight and systems information
41020 information unavailable to investigators
cockpit recording devices
4 4 4 3
Event/Conditions Problem (what) Contributing Factor (why)
Standard Problem Statement
Intervention Recommendation UV I A
Sample of event processing
10JHSAT - January 2007
Data Analysis:The JHSAT team is currently processing 195 accidents from the NTSB year 2000 database
The accident data has been downloaded from the NTSB (~4000 files)
For each accident the JHSAT performs the following:reconstruct the sequence of eventsidentify what went wrong and why it went wrongassign an appropriate problem statementidentify appropriate corrective action(s)score findings based on validity, importance, ability
and usage
11JHSAT - January 2007
Data Analysis Status:To date the accidents analyzed have covered a wide spectrum of helicopter types and operations.
The team has currently completed 187 of 195 accidents
1200+ scored problem statements/intervention findings have been developed
JHSAT currently doing some “cleanup” work, will start categorization and prioritization work at our Feb meeting
Expect to offer recommendations for all major operational groups in the helicopter community
12JHSAT - January 2007
Validity - How valid do we think the Problem Statement is in this accident based on the available accident information?
Range:Guess = 0 Absolutely Sure = 4
Importance - How important is this particular Problem Statement in the causal chain in this accident?
Range:No importance = 0Cause of accident = 4
Ability - How well can this particular Intervention mitigate the cause or contributing factors of this accident scenario?
Range:No effect on Problem Statement = 0 Would Prevent Problem Statement = 4
Usage – Given this accident scenario, how confident are we that this Intervention will be utilized and will perform as expected in the real world?
Range:No Utilization = 0100% Utilization = 4
JHSAT Scoring Criteria
13JHSAT - January 2007
Primary Ops SecondaryAerial Application External Load Aerial Observation/patrol TrainingAir Tour Positioning/RTBSightseeing FerryBusiness - company owns a/c Air Taxi - Cargo (135)Corp/Exec - dedicated pilot Air Taxi - Passenger (135)EMS Cargo (91)ENG Public UseFirefighting Maintenance/Test flightInstructional/Training Evaluation flightLaw EnforcementLoggingCommercial OperatorExternal Load OffshoreOther Aerial Work Personal/PrivateUtilities - Patrol & Construction
JHSAT Operational Categories (as of 1/07, still being worked)
14JHSAT - January 2007
JHSAT Intervention Frequency
11
12
22
36
42
55
61
71
106
173
211
0 50 100 150 200 250
Enhanced CFI rqts
Disciplinary Action
Enhanced Reg Rqts/Guidance
Enhanced Maintenance Proceedures
Improved Data/Info to Pilots w x/lz/etc
New In Cockpit Systems/Warnings
Formal Risk Process & Oversight
Enhanced Data Recording
Improved Operational SOPs
Training
Better Crew Decision Making
Snapshot after analysis of 90 accidents
17JHSAT - January 2007
Worldwide Helicopter Accidents/Year
1980 - 2005
0
100
200
300
400
500
600
700
800A
ccid
ents
/yea
r
US Civil Registry Non-US Civil & Military US Military & USCG (ABC)
18JHSAT - January 2007
Engaging with the international communityThe preceding slide shows worldwide accident trends for the last 26 years. The criticality of working with the international community to reduce worldwide rates is readily apparent since the US accounts for only 35 to 40% of accidents on an annual basis.
On-going efforts to identify other partners from Asia, South America, Oceania, etc.
The JHSAT team is developing contacts and coordinating this activity. Matt Rigsby from FAA-ASW will be acting as the contact point for identifying overseas and military partners.
Any entity that possess large helicopter accident datasets that could be processed by the JHSAT method should be considered.
EASA and Canada moving toward partnering with us in this process.
19JHSAT - January 2007
Engaging with the international communityA structured approach will be used to manage the analytical and implementation work sponsored by the IHST.
Key attributes:
All recommendations will be data driven
Regional ownership - Data is owned and analyzed by those most familiar with it. Safety recommendations will be implemented by teams most familiar with local needs.
JHSAT and JHSIT lead teams will be responsible for training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness.
20JHSAT - January 2007
JHSAT/JHSIT
cross-talk
IHST Safety InitiativeAnalysis, Implementation and Metrics Management Structure
IHSTExecutive Committee
JHSATLead Group
JHSITLead Group
Canada JHSAT
EASA JHSAT
Canada JHSIT
EASA JHSIT
Region X, Y, Z JHSIT
US/CAN/EASA Consolidated
Recommendations
JHSAT sends recommendations to JHSIT
US/CAN/EASA/X,Y,Z Implementation
Results
Need to maintain a strongcommunication/feedback loopbetween IHST – JHSAT - JHSIT
Process development usingUS NTSB datarepresents 48% ofworldwide fleet
Measure Accident Reductions
Effectiveness
Measure Implementation
Effectiveness
Regions X, Y, Z defined as those pockets of operation not ableto staff a full JHSAT team and are willing to work implementation of US/CAN/EASA findings to benefit their fleets
Others?
ALEA groupEMS group
21JHSAT - January 2007
JHSAT Lead Group Analysis of
International DataMatt Rigsby is JHSAT POC Seeking data rich partners Preliminary discussions with: Canada EASA (CAA-UK, France BEA) Brazil (contacted, no reply) NZ (contacted, no reply) Australia Chile Canadian Military USN Near-term: bring Canada on-line as a test case Consider EASA next Interim Goal: have Canada/EASA present status at the 2007 IHSS Symposium in Montreal Demonstrate that this is an international effort, and it has momentum
JHSIT will also have international partnermanagement responsibilities: custom tailored regional solutions coordinated with JHSAT coordinated with IHST
IHSTOutreach/Marketing
Emerging FleetsSomen is the IHST POCIdentify emerging/high growth marketsDevelop strategy to: Foster participation Benefit from IHST knowledge baseCandidates: China India CIS?
Engaging with the International Community
JHSIT Lead Group Implementing
Regional Solutions
22JHSAT - January 2007
US CivilDataset
Selection (1/2 of
helicoptersWorldwide)
JSAT ProcessUnderstanding
RefiningJHSAT
Analysis
IdentifyFCAA &MilitaryPartners
Train FCAA &
Military Partners in JHSATProcess
FCAA & Military Partners conductJHSAT
analyses on their
accident data
Expert Review/
Validation
MitigationRecs - Global
MitigationRecs
FCAA & Mil
Coordinating JHSAT US and International Efforts
First SetUS Mitigation
RecsMar/Apr 06
May/June 06May-Jan 07 Apr 07
2Q 07
1Q 08
TBD 08TBD 07/08TBD 06/07
Sept 06
TechReview
Feb 07
IHST
JHSAT is now working to bring EASA and Canada into the process
Current task
Current task
23JHSAT - January 2007
Potential Barriers:
JHSAT:Variation in dataset quality, definitions, etc, around the world may make use of a standardized JHSAT approach more difficult.
Military data may not be available.
Lack of fleet hours will complicate ability to measure results.
Regional teams may be difficult to staff with sufficient level of expertise representing manufacturers, operators and regulatory interests.
JHSIT:Regional operations and regulations may make some implementation actions difficult.
25JHSAT - January 2007
Interim recommendationsReports reviewed by the JHSAT:NASA - U.S. Civil Rotorcraft Accidents, 1963 Through 1997NASA - Analysis of US Civil Rotorcraft Accidents from 1990 to 1996 and Implications for a Safety Program NASA - ASRS Rotorcraft Incident Study - Draft Data Summary Aviation Safety Reporting SystemNASA - Helicopter Accident Analysis TeamAMPA - A Safety Review and Risk Assessment in Air Medical TransportCRS - Report for Congress - Military Aviation SafetyOGP - Safety Performance of Helicopter Operations in the Oil and Gas Industry - 2000 DataTSB Canada - Lessons Learned from TSB Investigation of Helicopter Accidents (1994 - 2003)Bell Textron - History of Helicopter SafetyOther NTSB and international reports may be considered.
The JHSAT has identified important recommendations from a series of existing helicopter safety reports. (listed on the next slide)
These recommendations were submitted to the IHST in November so that the JHSIT would have several well founded general recommendations to work with.
The JHSAT plan to issue its full set of analytical results by 2Q07.
26JHSAT - January 2007
JHSAT interim recommendations:
1. – Promote the adoption of Safety Management Systems in the helicopter community.
2. – More consistent and comprehensive NTSB involvement and investigation needed in helicopter accidents.
3. – Reestablish the collection of worldwide helicopter fleet hour data as previously performed by the FAA.
4. – Establish a helicopter safety website to disseminate important information
5. – Use proximity detection equipment in helicopters.
6. – Use flight recording devices and cockpit image recording systems in helicopters.
7. – Develop a strategy to improve pilot Aeronautical Decision Making.
(NB: this listing is not intended to indicate prioritization)