presentation ihst-cis 2016 ihst-cis_201… · • absence of effective sms • superficial approach...

HELICOPTER ACCIDENTS: Statistics, Trends and CausesPrepared by Helicopter Safety Analysis Team of IHSTI-CIS

IHST Regional Partners PanelMarch 2, 2016, Louisville, Kentucky, USA

Commercial air travel and aerial work

14

10

21

16

13

9 10 119

12 11

6 6

9 107

5 4 5

2

5 5

21

27

30

53

38

21

6

23

28

38

27

0

10

20

30

40

50

60

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Registered Accidents and Fatal Accidents

Accidents

Fatal Accidents

Fatalities

Accidents 136Fatal accidents 65Fatalities 312

2.55

1.89

2.22.1

2.5

2.17

1.72 1.75

1.53

1.99

2.79

1.09 1.151.03

1.38 1.4

0.91

0.690.79

0.34

0.91

1.27

0

0.5

1

1.5

2

2.5

3

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Accident Rate per 100,000 hours

Accidents Fatal Accidents

Reduction of accidents by 9,5%

Reduction of fatal accidents by 24%


7.62%5.10%

14.60%

7%

38.20%

3.20%1.30%

0.65% 5.10%

12.70%

1.30% 3.20%

Percentage of Accidents by Activity

Training

Positioning/ferry

Air travel

Agricultural work

Passenger/Cargo (aerial work)

External load

Aerial observation

Air tour/sightseeing

Emergency medical services

Utilities patrol

SAR

Other


Errors38%

Violations33%

System failure22%

Other7%

Percentage of Accidents by Immediate Cause


18.20%

8%

4%

21%

2.80%2.80%

34.70%

8.50%

Percentage of Accidents by Error

Misassessment of weather

Misjudgment of landing aria

Not going around

Flight below minimum safe altitude

Overload

Not considering wind

Inadequate pilot judgment

Poor circumspection


Violation of minimum safe altitude55%

Violation of weather minima30%

Other15%

Percentage of Accidents by Violation


75.90%

3.40%

3.40%

3.40%3.40%

3.40%3.40% 3.40%

Percentage of Accidents by System Failure

Engine failure

Main gear box fire

Tail rotor blade breakage

Directional control failure

Pitch control failure

Tail boom breakage

Tail rotor pylon breakage

Trimming failure


• Absence of effective SMS • Superficial approach to selection of flight personnel for

commissioning as PIC• Deficiencies in training and not transfer of skills, professional care

and the ability to make decisions• Shortcomings in interaction between simulator training centers and

flight management of helicopter companies• Insufficient experience of instructors• Lack of attention to the training in decision-making for departure

with taking into account the possible complications of flight conditions

• Low requirements of PIC to crew members, failure to keeping work technique

• Inadequate use of FDR/CVR data for flight quality control • Weak safety culture

CAUSES OF ERRORS AND VIOLATIONS


General aviation

7

11

9

11

13

45

4

6 6

4

98

13

17

0

2

4

6

8

10

12

14

16

18

20

2011 2012 2013 2014 2015


Accidents

Fatal accidents

Fatalities

Accidents 57Fatal accidents 25Fatalities 51

Note:

Due to lack of accurate flight hour information, it is not possible to estimate accident rate per 100,000 hours with acceptable confidence level.

22.20%

38.90%

22.20%

5.00% 11.70%


Wrong pilot's technique

Violations

Spatial disorientation

System failure due tofaulty design

For these reasons, there were approximately 24% of accidents of CFIT category, 17% due to inadvertent flight from VFR to IMC, 6% due to collision with power lines, 20% due to system component failures, initiated by flight or technical personnel.

There have been some accidents resulted from deliberate violations of flight rules by pilots such as maneuvering at extremely low altitudes and transfer of the aircraft controls to outsiders.

General aviation

• Imperfection of legislation regulating the GA activities• Lack of supervision over GA operators• Failure to identify and illuminate the causes of accidents• Poor quality of pilot training• Imperfect aircraft certification system• Lack of control for maintaining the aircraft airworthiness• Inadequate safety ensuring at landing sites• Inadequate meteorological support• Insufficient experience of training personnel • Low effectiveness of search and rescue system• Pathological safety culture

SYSTEMIC DEFICIENCIES ADVERSELY AFFECTING SAFETY:

General aviation

Light helicopters

7

6

10

11

2

8

6

10 10

12

11

3 3

4

3

2

1

3

5

3

6

3

5

8

11

7

6

2

3

10

6

15

8

0

2

4

6

8

10

12

14

16

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015


Accidents

Fatal accidents

Fatalities

Note:- Not all accidents are

registered- Commercial and non-

commercial flights are not separated

- Light helicopters are mainly operated in GA sector and by private owners

Accidents 93Fatal Accidents 36Fatalities 81

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

2009 2010 2011 2012 2013 2014 2015*

Accident rate per registered aircraft

Accident/Fleet Fatal accident/Fleet

Reduction of accidents by 30%

Reduction of fatal accidents by 44%

Light helicopters

Fleet losses(2006 - 2014г)

Manufacturer Civil aircraft register Destroyed

Robinson 443 35 (1:13)

Eurocopter 151 8 (1:19)

Bell Helicopter 40 3 (1:13)

Aerospatiale 26 2 (1:13)

AgustaWestland 16 2 (1:8)

MD Helicopters 6 0

Aerocopter 5 0

Schweizer 5 1

Other 19 0

Total: 711 50 (1:14)

Light helicopters

52.60%

23.70%

18.40%

2.60% 2.60%


VFR flight in IMC

Lost of control in VMC

CFIT (power lines orterrain/water)Running out of fuel

Midair collision

In ¼ of fatal accidents pilots were under the influence of alcohol

Light helicopters

Every second accident occurred in VFR flight in instrument meteorological conditions!

• All – on helicopters not certified for IFR:R-44 (11), R-66 (1), Bell-407 (2), AS-350/355 (3), AW-119 (1), MD-600 (1), EC-120 (1)

• Causes:– “return home syndrome”– pressure on pilot by customer– the complexity of instrument piloting – erroneous transfer of experience gained on Russian made helicopters – disorientation in reduced visibility (night, featureless terrain, soft background)– inability to recognize entering into instrument MC– whiteout– snow whirlwind at takeoff

Every third accident occurred due to the loss of control in visual meteorological conditions!

• Causes:– aggressive maneuvering– main rotor speed decay

Light helicopters

CONCLUSION

o In the commercial sector, safety performance for the period of 2005 -2015 experienced a gradual improvement, but it was unstable.

o In GA and aircraft owner sectors, where light helicopters are the most widely used, registered accident number for the 2005-2015 period has been showing an upward trend and tend to increase. Number of accidents per registered aircraft for the period from 2009 to 2015 had been decreasing and tend to decrease.

o The current state of safety does not satisfy the professional community and the public both in Russia and in other CIS countries.

o The causes of the accidents with helicopters that took place in Russia and the CIS in the 2005-2015 period, are basically the same as the causes identified by JHSAT and EHEST.

o Recommendations for accident and fatal accident prevention developed by U.S. JHSAT and EHEST, contained in their records, are universal and basically coincide with the recommendations proposed by the analytical group of IHST-CIS.

SUGGESTIONS

o In the absence of reliable data on flight hours in GA and aircraft owner sectors, we suggest to calculate helicopter accident rate per number of registered aircraft and to use this rate as an additional criterion for assessing safety performance trend in these sectors. At the same time, we believe that it is possible and appropriate to make the necessary changes to aviation rules, establishing airworthiness procedures, that would allow to collect and process information ensuring calculation of accidents per 100,000 flight hours.

o In connection with systemic differences in the organization of commercial aviation, GA and aircraft owner sectors, the root causes of accidents and fatal accidents in these sectors also differ, even in respect of the same types of helicopters. In this regard, we believe that it is appropriate to specifically focus preventive work in each of the sectors in accordance with their characteristics. For example, in Russia these sectors could be specified according to the requirements in respect of certain categories of operators: FAR-246 for commercial air transport, the FAR -249 for aerial work, FAR 147 for general aviation, chapters 1 and 3 of FAR-128 for operators of light and ultralight helicopters..

THANK YOU FOR YOUR ATTENTION

presentation ihst-cis 2016 ihst-cis_201… · • absence of effective sms • superficial approach...

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