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Preliminary Results
EHEST Conference13 October 2008
Cascais, Portugal
Preliminary Results 2
Contents
Data set descriptionGeneral dataIdentified factors data
Standard Problem StatementsHFACS
Intervention RecommendationsConcluding Remarks & Way forward
Preliminary Results 3
Data set description
Preliminary Results
Picture Source AgustaWestland
Preliminary Results 4
Scope of analysis
Based on a data driven approach
Focus on:
Accidents (definition ICAO Annex 13)
Date of occurrence year 2000 - 2005
State of occurrence located in Europe For this purpose Europe is defined as the EASA Member States
(27 EU + plus Iceland, Liechtenstein, Norway and Switzerland)
Only those accidents are being analysed where a final report from Accident Investigation Board is available
Preliminary Results 5
Scope of preliminary dataset
Total of 186 within timeframe 2000-2005 have been analysed
Covers work from 9 Regional Teams across Europe
Does not cover all accidents within timeframe
Preliminary results, not fully representative of European accidents in the reference period
The following slides present preliminary results based on these 186 accidents
Preliminary Results 6
Proportion of analysed accidents
Estimated data for the 9 Regional Teams currently participating
Preliminary Results 7
General Data
Preliminary Results
Picture Source Eurocopter
Preliminary Results 8
General data
Number of Accidents per Type of Operation
Preliminary Results 9
General data
Preliminary Results 10
General data
Pivot chart of general info sheet
617
64
2430
3
14
17
11
0
10
20
30
40
50
60
70
Standing Taxi Take-off En route Manoeuvring Approach &Landing
Nu
mb
er o
f A
ccid
ents
No Yes
Phase of Flight Distribution
In hover Not in hover
Preliminary Results 11
General data
Pivot chart of general info sheet
5 3
2632 33
40
1
2
32
5
7
0
10
20
30
40
50
60
70
Standing Taxi Take-off En route Manoeuvring Approach &Landing
Nu
mb
er o
f A
ccid
ents
Non Fatal Fatal
Injury level Distribution per Phase of Flight
Preliminary Results 12
General data
Pivot chart of general info sheet
0
10
20
30
40
50
60
70
0 - 1000 1001 -2000
2001 -3000
3001 -4000
4001 -5000
5001 -6000
6001 -7000
7001 -8000
8001 -9000
9001 -10000
Nu
mb
er o
f A
ccid
ents
Pilot-in-Command Total Flight Experience in HoursAll Helicopter Types
Preliminary Results 13
General data
Pivot chart of general info sheet
0
2
4
6
8
10
12
14
0 - 100 101 -200
201 -300
301 -400
401 -500
501 -600
601 -700
701 -800
801 -900
901 -1000
Nu
mb
er o
f A
ccid
ents
Pilot-in-Command Total Flight Experience in HoursAll Helicopter Types
0 – 1000 flight hours only
Preliminary Results 14
General data
Pivot chart of general info sheet
0
20
40
60
80
100
120
0 - 1000 1001 - 2000 2001 - 3000 3001 - 4000 4001 - 5000 > 5000
Nu
mb
er o
f A
ccid
ents
Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type
Preliminary Results 15
General data
Pivot chart of general info sheet
0
5
10
15
20
25
30
35
40
45
0 - 100 101 -200
201 -300
301 -400
401 -500
501 -600
601 -700
701 -800
801 -900
901 -1000
Nu
mb
er o
f A
ccid
ents
Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type0 – 1000 flight hours only
Preliminary Results 16
General data
Pivot chart of general info sheet
0
5
10
15
20
25
30
35
40
0 - 1000 1001 -2000
2001 -3000
3001 -4000
4001 -5000
5001 -6000
6001 -7000
7001 -8000
8001 -9000
90001 -10000
Nu
mb
er o
f A
ccid
ents
Commercial Air Transport Aerial Work General Aviation
Pilot-in-Command Total Flight Experience in HoursAll Helicopter Types
Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.
Preliminary Results 17
General data
Pivot chart of general info sheet
0
10
20
30
40
50
60
0 - 1000 1001 - 2000 2001 - 3000 3001 - 4000 4001 - 5000 > 5000
Nu
mb
er o
f A
ccid
ents
Commercial Air Transport Aerial Work General Aviation
Pilot-in-Command Flight Experience on Type in HoursAccident Helicopter Type
Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.
Preliminary Results 18
Identified factors dataStandard Problem Statements & HFACS
Preliminary Results
Picture Source AgustaWestland
Preliminary Results 19
Identified factors data
Two models used for identification of factors
SPS HFACS
Standard Problem StatementsIn total 1067 factors identified for all 186 accidents
HFACS In total 445 factors identified for all 186 accidents
Preliminary Results 20
SPS level 1 – All Accidents
Percent of Accidents in which SPS category (level 1) was identified at least once
2
8
8
13
15
16
20
28
35
35
38
48
68
24
0 10 20 30 40 50 60 70 80
Ground personnel
Infrastructure
Communications
Aircraft Design, Systems & Equipment
Maintenance
Post-crash survival
Regulatory
Part/system failure
Mission Risk
Ground Duties
Data issues
Pilot situation awareness
Safety Culture/Management
Pilot judgment & actions
SP
S C
ateg
ory
- le
vel 1
Percentage %
Preliminary Results 21
SPS level 1 compared with US JHSAT data
Percent of Accidents in which Top 5 SPS category (level 1) was identified at least onceEHEST data versus US JHSAT data
0 10 20 30 40 50 60 70 80
Ground Duties
Data issues
Pilot situationawareness
SafetyCulture/Management
Pilot judgment &actions
SP
S C
ateg
ory
- le
vel 1
Percentage %
US JHSAT data EHEST dataCorrelation is: .89
Preliminary Results 22
SPS level 2 (top 10)– All Accidents (excluding Data Issues)
Percent of Accidents in which SPS category (level 2) was identified at least once
15
16
16
18
19
20
20
25
29
31
0 5 10 15 20 25 30 35
Human Factors - Other
Visibility/Weather
Procedure Implementation
Mission Risk - Terrain/Obstacles
Inadequate Pilot Experience
Landing Procedures
Flight Profile unsafe
External Environment Awareness
Mission Planning
Human Factors - Pilot's Decision
SP
S c
ateg
ory
- le
vel 2
Percentage %
Preliminary Results 23
Organisational Influences
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
HFACS model
Merely symptoms
Facilitate identification of the underlying causes
Preliminary Results 24
Unsafe Acts
Errors Violations
16%84%
60%
Skill-based Errors
Perceptual Errors
Judgement & Decision-Making Errors
12%
28%
HFACS model – upper levels
Preliminary Results 25
Preconditions
Environmental Factors
17%
Condition of Individuals
60%
Personnel Factors
23%
HFACS model – upper levels
Preliminary Results 26
Supervision
Failure to Correct Known Problem
Planned Inappropriate
Operations
Inadequate Supervision
41% 59%Supervisory Violations
0%
0%
HFACS model – upper levels
Preliminary Results 27
Organisational Influences
Resource Management
Organisational Climate
Organisational Process
64% 24% 12%
HFACS model – upper levels
Preliminary Results 28
Going into more detail
The following slides present the lowest level in the taxonomy: level 3This provides a more detailed insight into the type of accidents occurringResults will be presented for the three main types of operation
Commercial Air TransportAerial WorkGeneral Aviation
Preliminary Results 29
An example Commercial Air Transport scenario
Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow.
Preliminary Results 30
An example Commercial Air Transport scenario
Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow.
Loss of Visual Reference
Inadequate decisions
Pilot felt pressure
Preliminary Results 31
SPS level 3 (top issues)–Commercial Air Transport
Percent of Accidents in which SPS category (level 3) was identified at least once
COMMERCIAL AIR TRANSPORT
0 5 10 15 20 25
Failure to enforce company SOPs
Inadequate consideration of aircraft operational limits
Management disregard of known safety risk
Selection of inappropriate landing site
Pilot experience leads to inadequate planningregarding weather/wind
Pilot inexperienced with area and/or mission
Reduced visibility--whiteout, brownout
Pilot’s flight profile unsafe for conditions
Pilot-In-Command self induced pressure
Pilot decision making
SP
S c
ateg
ory
- le
vel 3
Percentage % of CAT Accidents
Preliminary Results 32
HFACS level 3 (top issues)–Commercial Air Transport
Percent of Accidents in which HFACS category (level 3) was identified at least once
COMMERCIAL AIR TRANSPORT
0 2 4 6 8 10 12 14 16
Procedural Guidelines / Publications (OI)
Limited Recent Experience (S)
Inattention (PC)
Mission Planning (PC)
Excessive Motivation to Succeed (PC)
Procedural Error (UA)
Risk Assessment - During Operation (UA)
Pressing (PC)
Communication Critical Information (PC)
Decision-Making During Operation (UA)
Brownout / whiteout (PC)
HF
AC
S c
ateg
ory
- le
vel 3
Percentage % of CAT Accidents
Preliminary Results 33
An example Aerial Work scenario
During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. The helicopter lost altitude, contacted the surrounding trees and crashed.
Preliminary Results 34
An example Aerial Work scenario
During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. The helicopter lost altitude, contacted the surrounding trees and crashed.
Operated near maximum take-off mass
Loss of tail rotor effectiveness
Tailwind
Pilot intensiveObstacles
Cargo not released
Preliminary Results 35
SPS level 3 (top issues)–Aerial Work
Percent of Accidents in which SPS category (level 3) was identified at least once
AERIAL WORK
0 5 10 15 20 25
Inadequate training on avoidance, recognition andrecovery of Vortex ring state or LTE
Inadequate response to Loss of tail rotor effectiveness
Risk Management inadequate
Diverted attention, distraction
Inadequate consideration of obstacles
Low flight near wires
Mission requires low/slow flight
Pilot decision making
Mission involves flying near hazards, obstacles, wires
SP
S c
ateg
ory
- le
vel 3
Percentage % of Aerial Work Accidents
Preliminary Results 36
HFACS level 3 (top issues)–Aerial Work
Percent of Accidents in which HFACS category (level 3) was identified at least once
AERIAL WORK
0 5 10 15 20 25 30
Limited Total Experience (S)
Overconfidence (PC)
Windblast (PC)
Fatigue - Physiological / Mental (PC)
Excessive Motivation to Succeed (PC)
Misperception of Operational Condition (PC)
Inattention (PC)
Error due to misperception (UA)
Decision-Making During Operation (UA)
Mission Planning (PC)
Channelized Attention (PC)
Risk Assessment - During Operation (UA)
HF
AC
S c
ateg
ory
- le
vel 3
Percentage % of Aerial Work Accidents
Preliminary Results 37
An example General Aviation scenario
The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact.
Preliminary Results 38
An example General Aviation scenario
The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact.
No weather forecast obtained
No flight plan filed
Limited experience
Inadvertent IMC
No contact established with ATC
Preliminary Results 39
SPS level 3 (top issues)–General Aviation
Percent of Accidents in which SPS category (level 3) was identified at least once
GENERAL AVIATION
0 5 10 15 20 25
Failed to recognize cues to terminate current course ofaction or manoeuvre
Disregard of known safety risk
External Environment Awareness – Other
Pilot misjudged own limitations/capabilities
Pilot control/handling deficiencies
Pilot inexperienced
Inadequate consideration of weather/wind
Mission Planning – Other
Pilot decision making
SP
S c
ateg
ory
- le
vel 3
Percentage % of GA Accidents
Preliminary Results 40
HFACS level 3 (top issues)–General Aviation
Percent of Accidents in which HFACS category (level 3) was identified at least once
GENERAL AVIATION
0 5 10 15 20 25 30 35
Misperception of Operational Condition (PC)
Get-Home-Itis/Get-There-Itis (PC)
Channelized Attention (PC)
Error due to misperception (UA)
Inadvertant Operation (UA)
Violation - Lack of Discipline (UA)
Overcontrol/Undercontrol (UA)
Decision-Making During Operation (UA)
Mission Planning (PC)
Procedural Error (UA)
Vision Restricted by Meteorological Conditions(PC)
Overconfidence (PC)
Risk Assessment - During Operation (UA)
HF
AC
S c
ateg
ory
- le
vel 3
Percentage % of GA Accidents
Preliminary Results 41
Intervention Recommendations
Preliminary Results
Picture Source Jaume Bosch
Preliminary Results 42
Intervention Recommendations
In total 11 Intervention Recommendation categories identifiedThe categories help identify areas for working groups of EHSITNote: some categories do overlap but they do succeed in suggesting areas to focus
Preliminary Results 43
Intervention Recommendations for All Accidents
Pivot chart of Analysis sheet - IR
4
11
15
19
40
58
70
169
252
307
0 50 100 150 200 250 300 350
Infrastructure (aerodrome, heliport, ATC, ...)
Research
Manufacturing
Aircraft Design
Aircraft System/Equipment Design
Maintenance
Data/Information Issues
Regulatory
Operations
Training/Instructional
Number of IR categories
Intervention Recommendation Categories – All Accidents
Flight Ops & Safety Management/Culture
Preliminary Results 44
Overview of top categories
Pivot chart of Analysis sheet - IR
0
50
100
150
200
250
300
Training/Instructional Operations Regulatory
Nu
mb
er o
f In
terv
enti
on
Rec
om
men
dat
ion
s
Commercial Air Transport Aerial Work General Aviation
Flight Ops & Safety Management/Culture
RegulatoryTraining/Instructional
Preliminary Results 45
Example IRs
Within each IR type there are a wide range of different interventions that have already been identified so farThe following are some un-prioritised examples from across all operational categories:
Preliminary Results 46
IRs Examples: Training/Instruction
Better training for specific missions & operating environments• E.g.: Improve training for mountain
operations specifically for landing on snow covered surfaces
• Better training for inadvertent entry in IMC condition
Better training on type specific issues and operational limits.Special training supervision arrangements should be considered when dealing with slow learning students who are taking longer to complete the PPL(H) syllabus.
Preliminary Results 47
IRs Examples: Training/Instruction
Instructors/examiners be updated more regularly by TRTOs.Establish measures to avoid culture of non-complianceInclude risk assessment trainingEncourage organising private helicopter pilots into flying clubs etc for mutual support and better exchange of experiences / safety information
Preliminary Results 48
IRs Examples: Flight Ops & Safety Management/Culture
Develop safety management system (SMS) Promoting a safety culture vs. ‘getting the job done regardless’Investigate the user-friendliness of checklistsManage human factors risk especially regarding routine violationUse a Flight Data Monitoring system to give feedback to pilotsIncreased oversight of new pilots During the mission preparation, the management should take into account the experience of each crew member and mix the different skills.Better planning especially for higher risk missionsIncrease awareness of obstacles & provision of Wire Strike Protection System
Preliminary Results 49
IR Examples: Regulatory
Require greater flight data recording usage to assist in future occurrence investigation• Promote research inexpensive, lightweight,
airborne flight data and voice recording equipment for smaller helicopters
VFR flight criteria for helicopters and licence privileges for pilots should be reviewed to reduce the risk from flight in a Degraded Visual EnvironmentReview the deck markings on ships involved in winching operations with the aim of including a requirement to clearly display the dimensions of the 'manoeuvring zone', such that it can be clearly seen by the helicopter crew.Establish specific training requirements for operational crew members other than flight crew required for aerial works operations.
Preliminary Results 50
Other Selected IR Examples
Improve crashworthiness & survivabilityImprove OEM manufacturing quality assuranceEstablish safe limits of helideck movement for helicopters operating offshoreValidated, simplified weight and balance process should be made availableProvide better information on aircraft fuel consumption for pilots to safely plan flights on the basis of verified fuel contents.Type specific airworthiness improvementsMaking specific safety enhancing equipment part of the build standardMaking specific equipment available for operators to adapt aircraft for specific missions / environments
Preliminary Results 51
Intervention Recommendations - Way forward
It is expected the EHSIT will need to prioritise the Interventions Recommendations based on safety benefit and practicalityDifferent types of EHSIT organisations can be envisaged:
By type of operationBy type of recommendationBy type of activityMix of the aboveOtherCentralised or regional-based
Preliminary Results 52
Concluding Remarks & Way forward
Preliminary Results
Picture Source Eurocopter
Preliminary Results 53
Concluding remarks
EHSAT analysis covers European wide helicopter accident dataPreliminary results already provide indication of type of accidentsPreliminary results will be used by EHSITAnd shared with IHST
Preliminary Results 54
Concluding remarks
Main accident factors are operational. The top 3 are:
Pilot judgment & actionsSafety management /culturePilot situation awareness
High correlation with US resultsDifferent patterns for:
Commercial Air TransportAerial Work General Aviation
Preliminary Results 55
Concluding remarks
HFACS provided a complementary perspective on these factors and together with SPS, was used to produce recommendationsThe top 3 intervention recommendation categories are:
Flight Operations and Safety Management/CultureRegulatoryTraining / Instructional
Preliminary Results 56
Way forward
EHSAT will continue analysis to complete 2000-2005 timeframeIntervention recommendations will be handed over to the implementation team, the EHSITEHSIT will be launched after this ConferenceAnd we would like you to join
Preliminary Results 57
Thank you for your attention
Questions?
European Helicopter Safety Team
EHEST