1 International Helicopter Safety Team Latin America Regional - June 2007 Proven Helicopter Risk Reduction Measures June 2007 Latin America Regional International

1International Helicopter Safety Team Latin America Regional - June 2007

Proven Helicopter Risk Reduction Measures

June 2007

Latin America Regional International Helicopter Safety Symposium

ABRAPHE International Flight Safety Seminar

Sao Paulo, BrazilBob Sheffield

Shell Aircraft Ltd &IHST Executive Committee


Overview

• The current problem and the goal for improvement

• What’s been proven already• What remains to achieve the goal• Justifying the necessary risk mitigation

measures• Conclusions and summing up


Three Main Points

• The risk of flying in a helicopter is an order of magnitude greater than in an airliner– we have a problem

• Helicopter safety can be improved significantly – we can fix it:– Proven risk mitigations are available for helicopters.– We need new helicopters built to the latest design standards.

• To be effective at lowest possible cost requires a combined effort from:– Regulators– Manufacturers– Operators

– Their customers - we need your help


Cooperation is Key

• The best safety records come from those operations where either regulatory oversight or corporate care is highest.

• Corporate care is usually more expensive and less effective when the operators serve customers with different standards.

• If everyone in the industry (manufacturers, operators, regulators, and their customers) works together to implement the known, cost-effective solutions, these risk mitigations will be more effective and less costly.


Oversight and Air Safety Performance Currently Vary Greatly with

the Type of Operation

Fatal Accidents/million hrs• Commercial airline 0.6• Commuter airline 2.0• Offshore helicopter transportation 6.2• Helicopter support for seismic operations 23.0

… and across operators within a given type of operation


While this chart shows helicopter accident rates for the U.S. Gulf of Mexico (GOM) the same trend holds worldwide – the rate is getting worse.

GOM Offshore Accident Rate/100K Hours with 3 Year Moving Average

0.000.501.001.502.002.503.003.504.00

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Accidents 3 year moving average)

While airline safety trends are improving,

Helicopter safety trends are not improving.

We know we have a problem, and we are confident that we know how to fix it.


Opportunities for Safety Improvements

• The airline industry has made significant improvements in its safety record over the last 30 yrs through the introduction of: – Damage tolerant design; system redundancy; improved

reliability/crashworthiness– Modern flight simulators– Engine and vibration monitoring systems to identify incipient failures– Safety Management Systems and Quality Assurance to reduce human

errors– Flight data monitoring programs (FOQA)– Disciplined take-off and landing profiles (e.g. stabilised approach)– EGPWS/TAWS; TCAS

• All of these are available today for helicopter operations and are being implemented in some parts of the helicopter industry.

• However some helicopter industry segments have adopted few of these measures.

• We need to apply all these risk reduction measures to all helicopter operations.


The Helicopter Safety Goal

• OGP Safety Commitment: “The individual risk per period of flying exposure for an individual flying on OGP contracted business should be no greater than on the average global airline.”

• This goal coincides with IHST’s goal of reducing the current helicopter accident rate by 80%.

• This presentation will show you how this goal can be achieved.


Overview





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Log. (5 Year Moving Average)Target 2000 Target

2005

Shell’s Fatal Air Accident Rate

Target2008


>10~ 2


Overview





Shell Aircraft Analysed Accident Data to Evaluate Potential Risk Mitigations

• OGP published data on offshore accidents – GOM and Worldwide• NASA/TM – 2000-209579 – US Civil Helicopter Accidents 1963 – 1997• Individual NTSB/AAIB Accident Reports• Annual Business Turbine Accident Review 1993 through 2003 – Breiling

Associates• Design Reviews• FAA Final Rules – 14CFR Parts 27 and 29 and associated NPRMs

– Amendments 12 through 47 (Part 29)– Amendments 11 though 40 (Part 27)

• Type Certificate Data Sheets for offshore helicopters• Design certification reviews with Sikorsky and Eurocopter specialists on S76

and AS332• CAA Paper 2003/1 – Helicopter Tail Rotor Failures• UKCAA Mandatory Occurrence Reports for S76 and AS332• SINTEF Helicopter Safety Study 2 – Dec 99


In Sum - What Have We Learned?

• Essential Pre-requisites for Safe Operations– Safety culture supported by Quality and Safety Management systems

• Equipment fit– Appropriate to the operation– HUMS/EGPWS/TCAS and cabin egress modifications

• Pilot procedures– Helicopter Flight Data Monitoring (HFDM, also known as HOMP or FOQA)– Flight simulator training in LOFT scenarios emphasising CRM– Helideck performance profiles

• Helideck management– Helicopter Landing Officer and Helideck Assistant training– Helideck procedures

• System failure management– HUMS/VHM/EVMS– Engine monitoring– Flight Simulator training

• Human error in maintenance– Human factors training– Duplicate inspections/RIIs– HUMS/VHM/EVMS

• All these items are addressed in OGP’s Aircraft Management Guide, and will mitigate risk, but they are unlikely to achieve the long term safety goal.


All But The Latest Helicopters Have Significant Design Gaps

• “Most important issues would be to improve helicopter design and continuous airworthiness” - SINTEF

• “The evidence that tail rotors were … not meeting the spirit of airworthiness requirements, was stark and compelling” – UK CAA

• “ ..This means that the helicopter is not considered airworthy without HUMS installed and in function.” – Norwegian Committee for Review of Helicopter Safety

• Typical aircraft in common use today - AS-332 Super Puma, Bell 412, and S-76 were designed to requirements that are now over 25 years old

• Latest design requirements offer:– Improved performance with one engine inoperative– Redundant systems with flaw tolerance– Fail safe designs– Digital flight management systems to reduce pilot workload, improve situational

awareness, and help cope with emergencies– Crashworthy airframe, fuel cells, and passenger/crew seats


Old Cars & Vans

• How many of you are driving vehicles like these with:– No seat belts or shoulder harnesses– No anti-skid braking system (ABS)– No airbags– Low power engines with normally aspirated carburettors

• How many companies would use such vehicles to transport their workers?


Old Helicopters

• Yet many helicopter operations still use aircraft such as B212 and AS350 that were designed in a similar era (1960/70’s) and to equivalent safety standards.

• Whilst certification standards for new design aircraft have changed, these models have continued to be built to old certification standards under “grandfather rights.”


We Have Clear Opportunities for Improvement

•What has the airline industry done in the intervening years?

–Damage tolerant design, system redundancy, improved reliability

–Modern flight simulators

–Engine and vibration monitoring systems to identify incipient failures

–Safety Management Systems to reduce human errors

–Flight data monitoring programs (FOQA)

–Disciplined take-off and landing profiles (e.g. stabilised approach)

–EGPWS/TAWS; TCAS

•Helicopter mitigation available now or in the near future:

–Damage tolerant design, improved handling qualities, glass cockpit

–High fidelity simulators + LOFT with CRM

–HUMS/VHM/EVMS – resourced and managed

–Quality/SMS, Ops Controls, Helideck Management

–HOMP/HFDM – resourced and managed

–Performance Class1/2e & helideck operating profiles

–EGPWS/TCAS


New Types

EC 135 Agusta Westland 139

EC 225Sikorsky S92


Overview





0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

Tail Rotor Impact Warning

EGPWS/TCAS

Disciplined T/O & Ldg Profiles

Flight Data Monitoring

HUMS/VHM

Quality/SMS/Ops Controls

Simulator Training + CRM/LOFT

Latest Design Standards

Me

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Percentage accidents prevented

Seven KeyInitiatives

Requires development work

Percentage of Accidents Reported in NASA Study Preventable by Individual Mitigation Measures


Proving That Risk Reduction Measures are Justified

• Use a layered defence model in Microsoft Excel as a predictive tool to calculate the incremental risk reduction for a given measure.

• Apply the risk reduction in question to the expected exposure; i.e., number of helicopters, flying hours per year, and number of passengers per flight.

• Use the incremental cost to calculate the implied cost of avoiding a fatality (ICAF) and the individual risk of fatality per annum (IRPA).

• Compare these outcomes to your company’s risk management guidelines; e.g., ICAF of $50 million, IRPA of 1 in 10,000.


Mitigation Potential – NASA Data for Generic Twin1 Pilot related (in air) % Level 1

MitigationMF1 Level 2


MitigationMF3 Overall

MFAccidents prevented

In flight collision with object 14.3 % Airport/helipad/fence 5.7 IW 0.50 SMS/QA/OC 0.43 HOMP 0.38 0.82 4.65 Wire 4.3 EGPWS/TCAS 0.75 SMS/QA/OC 0.43 HOMP 0.38 0.91 3.94 Other-trees, brush, acft 4.3 EGPWS/TCAS 0.75 IW 0.43 Training 0.34 0.90 3.92Loss of control 14.7 Handling 6.3 DR/HQ 0.60 HOMP 0.43 Training 0.34 0.85 5.37 Loss of reference/disorientation3.0 Training 0.45 DR/HQ 0.51 HOMP 0.38 0.83 2.49 System deficiency 2.3 DR 0.50 HOMP 0.43 Training 0.34 0.81 1.89 Misc/undetermined 3.0 Training 0.45 HOMP 0.43 PC 1/2e 0.49 0.84 2.51In flight collision with terrain 5.7 EGPWS/TCAS 0.75 HOMP 0.43 Training 0.34 0.90 5.12Weather 4.0 Training 0.45 SMS/QA/OC 0.43 PC 1/2e 0.49 0.84 3.35On ground/water collision with object3.3 IW 0.50 SMS/QA/OC 0.43 Training 0.34 0.81 2.70Hard landing 2.7 Training 0.45 PC 1/2e 0.55 DR/HQ 0.45 0.86 2.30Mid air collision 2.0 EGPWS/TCAS 0.75 Training 0.38 HOMP 0.38 0.90 1.81Rollover/Noseover 1.3 HOMP 0.50 DR/HQ 0.51 Training 0.34 0.84 1.11Subtotal % 48.0 % 41.160.00

2 TechnicalLoss of engine power 13.0 Engine structure 5.0 DR 0.50 PC 1/2e 0.55 HUMS 0.49 0.89 4.43 Fuel system related 5.7 PC 1/2e 0.65 DR 0.43 SMS/QA/OC 0.38 0.87 4.95 Other 2.3 PC 1/2e 0.65 DR 0.43 HUMS 0.49 0.90 2.09Airframe component/system 29.6 Main rotor 6.3 DR 0.50 HUMS 0.55 SMS/QA/OC 0.38 0.86 5.44 Main rotor drive train 4.3 DR 0.50 HUMS 0.55 Training 0.34 0.85 3.69 Main rotor control system3.7 DR 0.50 HUMS 0.55 Training 0.34 0.85 3.12 Tail rotor 3.3 DR/HQ 0.60 HUMS 0.55 SMS/QA/OC 0.38 0.89 2.96 Tail rotor drive train 6.3 DR/HQ 0.60 HUMS 0.55 Training 0.34 0.88 5.58 Tail rotor control system 2.3 DR/HQ 0.60 HUMS 0.55 Training 0.34 0.88 2.05 Other airframe 3.3 DR 0.50 SMS/QA/OC 0.43 Training 0.34 0.81 2.70Fire/explosion 1.7 DR 0.50 SMS/QA/OC 0.43 Training 0.34 0.81 1.34Gear collapsed 2.0 DR 0.50 SMS/QA/OC 0.43 Training 0.34 0.81 1.62Subtotal % 46.3 % 38.36

3 OtherRotor contact -person 2.7 SMS/QA/OC 0.50 SMS/QA/OC 0.43 Training 0.34 0.81 2.16Misc/other 3.0 HOMP 0.50 Training 0.38 SMS/QA/OC 0.38 0.81 2.42Subtotal % 5.7 % 4.58

Factor 0.85 Factor 0.75

Total accidents prevented (= % effectivity of mitigation measures) 84.10

Effectiveness of mitigation measures % Key

Risk mitigation measures applied to accident causes with 3 levels of diminishing efficacy.


Example: Old vs. New Design1 Pilot related (in air) % Level 1 Mitigation MF1 Level 2


MitigationMF3 Overall

MFAccidents prevented

In flight collision w ith object14.3 %

Airport/helipad/fence 5.7 IW 0.00 SMS/ QA/ OC 0.43 HOMP 0.38 0.64 3.63

Wire 4.3 EGPWS/ TCAS 0.75 SMS/ QA/ OC 0.43 HOMP 0.38 0.91 3.94

Other-trees, brush, acft 4.3 EGPWS/ TCAS 0.75 IW 0.00 Training 0.34 0.83 3.61

Loss of control 14.7

Handling 6.3 DR/ HQ 0.60 HOMP 0.43 Training 0.34 0.85 5.37

Loss of reference/disorientation3.0 Training 0.45 DR/ HQ 0.51 HOMP 0.38 0.83 2.49

System deficiency 2.3 DR 0.50 HOMP 0.43 Training 0.34 0.81 1.89

Misc/undetermined 3.0 Training 0.45 HOMP 0.43 PC 1/ 2e 0.49 0.84 2.51

In flight collision w ith terrain5.7 EGPWS/ TCAS 0.75 HOMP 0.43 Training 0.34 0.90 5.12

Weather 4.0 Training 0.45 SMS/ QA/ OC 0.43 PC 1/ 2e 0.49 0.84 3.35

On ground/ w ater collision w ith object3.3 IW 0.00 SMS/ QA/ OC 0.43 Training 0.34 0.62 2.06

Hard landing 2.7 Training 0.45 PC 1/ 2e 0.55 DR/ HQ 0.45 0.86 2.30

Mid air collision 2.0 EGPWS/ TCAS 0.75 Training 0.38 HOMP 0.38 0.90 1.81

Rollover/ Noseover 1.3 HOMP 0.50 DR/ HQ 0.51 Training 0.34 0.84 1.11

Subtotal % 48.0 % 39.200.002 Technical

Loss of engine pow er 13.0

Engine structure 5.0 DR 0.50 PC 1/ 2e 0.55 HUMS 0.49 0.89 4.43

Fuel system related 5.7 PC 1/ 2e 0.65 DR 0.43 SMS/ QA/ OC 0.38 0.87 4.95

Other 2.3 PC 1/ 2e 0.65 DR 0.43 HUMS 0.49 0.90 2.09

Airframe component/ system29.6

Main rotor 6.3 DR 0.50 HUMS 0.55 SMS/ QA/ OC 0.38 0.86 5.44

Main rotor drive train 4.3 DR 0.50 HUMS 0.55 Training 0.34 0.85 3.69

Main rotor control system 3.7 DR 0.50 HUMS 0.55 Training 0.34 0.85 3.12

Tail rotor 3.3 DR/ HQ 0.60 HUMS 0.55 SMS/ QA/ OC 0.38 0.89 2.96

Tail rotor drive train 6.3 DR/ HQ 0.60 HUMS 0.55 Training 0.34 0.88 5.58

Tail rotor control system 2.3 DR/ HQ 0.60 HUMS 0.55 Training 0.34 0.88 2.05

Other airframe 3.3 DR 0.50 SMS/ QA/ OC 0.43 Training 0.34 0.81 2.70

Fire/explosion 1.7 DR 0.50 SMS/ QA/ OC 0.43 Training 0.34 0.81 1.34

Gear collapsed 2.0 DR 0.50 SMS/ QA/ OC 0.43 Training 0.34 0.81 1.62

Subtotal % 46.3 % 38.36

3 Other

Rotor contact -person 2.7 SMS/ QA/ OC 0.50 SMS/ QA/ OC 0.43 Training 0.34 0.81 2.16

Misc/other 3.0 HOMP 0.50 Training 0.38 SMS/ QA/ OC 0.38 0.81 2.42

Subtotal % 5.7 % 4.58Factor 0.85 Factor 0.75


Expected FAR =3.05 permillion flying hours

Expected FAR = 1.25 permillion flying hours

1 Pilot related (in air) % Level 1 Mitigation MF1 Level 2 Mitigation

MF2 Level 3 Mitigation

MF3 Overall MF

Accidents prevented

In flight collision w ith object14.3 %

Airport/helipad/fence 5.7 IW 0.00 SMS/ QA/ OC 0.43 HOMP 0.00 0.43 2.41

Wire 4.3 EGPWS/ TCAS 0.38 SMS/ QA/ OC 0.43 HOMP 0.00 0.64 2.77

Other-trees, brush, acft 4.3 EGPWS/ TCAS 0.38 IW 0.00 Training 0.34 0.59 2.54

Loss of control 14.7

Handling 6.3 DR/ HQ 0.00 HOMP 0.00 Training 0.34 0.34 2.14

Loss of reference/disorientation3.0 Training 0.45 DR/ HQ 0.00 HOMP 0.00 0.45 1.35

System deficiency 2.3 DR 0.00 HOMP 0.00 Training 0.34 0.34 0.79

Misc/undetermined 3.0 Training 0.45 HOMP 0.00 PC 1/ 2e 0.00 0.45 1.35

In flight collision w ith terrain5.7 EGPWS/ TCAS 0.38 HOMP 0.00 Training 0.34 0.59 3.32

Weather 4.0 Training 0.45 SMS/ QA/ OC 0.43 PC 1/ 2e 0.00 0.68 2.74

On ground/ w ater collision w ith object3.3 IW 0.00 SMS/ QA/ OC 0.43 Training 0.34 0.62 2.06

Hard landing 2.7 Training 0.45 PC 1/ 2e 0.00 DR/ HQ 0.00 0.45 1.20

Mid air collision 2.0 EGPWS/ TCAS 0.38 Training 0.38 HOMP 0.00 0.61 1.23

Rollover/ Noseover 1.3 HOMP 0.00 DR/ HQ 0.00 Training 0.34 0.34 0.45

Subtotal % 48.0 % 24.330.002 Technical

Loss of engine pow er 13.0

Engine structure 5.0 DR 0.00 PC 1/ 2e 0.00 HUMS 0.49 0.49 2.44

Fuel system related 5.7 PC 1/ 2e 0.00 DR 0.00 SMS/ QA/ OC 0.38 0.38 2.13

Other 2.3 PC 1/ 2e 0.00 DR 0.00 HUMS 0.49 0.49 1.14

Airframe component/ system29.6

Main rotor 6.3 DR 0.00 HUMS 0.55 SMS/ QA/ OC 0.38 0.72 4.56

Main rotor drive train 4.3 DR 0.00 HUMS 0.55 Training 0.34 0.70 3.05

Main rotor control system 3.7 DR 0.00 HUMS 0.55 Training 0.34 0.70 2.58

Tail rotor 3.3 DR/ HQ 0.00 HUMS 0.55 SMS/ QA/ OC 0.38 0.72 2.40

Tail rotor drive train 6.3 DR/ HQ 0.00 HUMS 0.55 Training 0.34 0.70 4.45

Tail rotor control system 2.3 DR/ HQ 0.00 HUMS 0.55 Training 0.34 0.70 1.64

Other airframe 3.3 DR 0.00 SMS/ QA/ OC 0.43 Training 0.34 0.62 2.06

Fire/explosion 1.7 DR 0.00 SMS/ QA/ OC 0.43 Training 0.34 0.62 1.03

Gear collapsed 2.0 DR 0.00 SMS/ QA/ OC 0.43 Training 0.34 0.62 1.24

Subtotal % 46.3 % 27.46

3 Other

Rotor contact -person 2.7 SMS/ QA/ OC 0.50 SMS/ QA/ OC 0.43 Training 0.34 0.81 2.16

Misc/other 3.0 HOMP 0.50 Training 0.38 SMS/ QA/ OC 0.38 0.81 2.42

Subtotal % 5.7 % 4.58Factor 0.85 Factor 0.75



ICAF and IRPA

• ICAF = Incremental Cost per Annum divided by the Incremental Lives Saved per Annum– Incremental Lives Saved per Annum =

(Incremental Reduction in Fatal Accident Rate) * (Flying Hours per Annum) * (Average Number of Occupants) * (Average Percentage of Occupants Killed in Fatal Accidents)

• IRPA = (Fatal Accident Rate) * (Individual Flying Hours per Annum) * (Average Percentage of Occupants Killed in Fatal Accidents)


Shell’s Helicopter Replacement Plan

Early Model Types Mid-Generation Types

S76 A/B, B212, B214ST, S61N, AS365N etc

A109 Power, AS332L, B412EP, S76C etc

Exposure Hours

(per annum) 1200 +As soon as reasonably

practicable, AND no later than next contract renewal.

By 1 Apr 2008

600 < 1200By 1 Apr 2008 By 1 Apr 2011

< 600By 1 Apr 2011 By 1 Apr 2013


Overview





How To Achieve the Air Safety Goal

• Customers must commit to the goal and contract for higher standards.• Manufacturers must support HUMS/VHM/EVMS, the latest design

standards (FAR 29 - 47) and provide affordable solutions for legacy aircraft.

• Operators must adopt proven global best practices as their minimum standard

• Regulators must support proven global best practices.• All stakeholders must support these initiatives:

– Transition to new aircraft built to the latest design standards on new contracts.

– Require annual training in flight simulators to practice crew coordination during emergency procedures.

– Equip all helicopters with Vibration & Health and Engine Monitoring Systems such as HUMS/VHM/EVMS

– Require operators to implement quality and safety management systems.– Require operators to implement HFDM (HOMP).– Require operators to fly profiles that minimize the risks of engine failure.– Equip all helicopters with EGPWS/TAWS (or AVAD) and TCAS/ACAS


We have many imperatives to make these improvements!

• Respect for people – the disparity between helicopter safety and airline safety

• ALARP – we know what can be done and that the cost is not disproportionate to the benefits to be gained

• The Ford Pinto story• The “Red Face” test• Good business sense – safer operations will attract more

customers.


OGP’s Life-Saving Target Set in 2005• In 10 years of OGP offshore and seismic helicopter operations with

– Fatal accident rate – 6.4 per million hours – 23 per million hours• 51 fatal accidents – 15 fatal accidents• 250 fatalities – 40 fatalities

• In 10 years of OGP offshore and seismic helicopter operations with– Fatal accident rate – 2.0 per million hours (like current North Sea

record)• 18 fatal accidents – 0.8 fatal accidents • 78 fatalities – 2.3 fatalities Lives saved – 172 and 38

• In 10 years of OGP offshore and seismic helicopter operations with– Fatal accident rate – 1.0 per million hours

• 9 fatal accidents – 0.4 fatal accidents• 39 fatalities – 1.1 fatalities Lives saved – 211 and 39


My Plea To All of You

• Please join the IHST and contribute your knowledge and data to the process.

• Help us “raise the bar” for all helicopter operators.– Make helicopter safety a feature that attracts

customers.– Make the best risk reduction measures more

affordable.

• Support IHST goal of reducing helicopter accidents by 80% and by implementing the risk reduction measures featured in this presentation.


Questions?

Documents

1 International Helicopter Safety Team Latin America Regional - June 2007 Proven Helicopter Risk Reduction Measures June 2007 Latin America Regional International