RISK AWARENESS:IMPROVING AIRCREW

KNOWLEDGE

Risk for helicopters = 10 x risk for airlines Proposed strategies :

Flight simulators CVRs…

Heard at ISASI 2005

EGPWS Crash-resistance standards NVG HUMS

IS THIS ENOUGH ?IS THIS REALISTIC ?

Cost Age of design Size of companies Variety of operations New risks Change in behavior (eg : use of GPS)

IMPEDIMENTS

Lessons learnt but not assimilatedIMPEDIMENTS (cont)

What if…

What if…

Jan. 2000 – Jun. 2005

153

201

BEAForeign

354 Accidents

67 fatalities 133 hull losses Exposure : difficult to assess No significant trends

BEA

51 accidents with casualties

2 2 2 3 4 4 4 5

12 13

(+4 undetermined)

Avoidable

handling24%collisions

25%

outside of limits35%

inevitable16%

55% of fatalities

Unsafe acts / behavior Abrupt maneuvers Low flight

Negligent flight preparation Load securing Fuel W&B

Continuation of flight in marginal conditions

Failure to appropriately react to malfunction Lower the collective Reaction after hyd. loss

New causes?

I can land anywhere if… I can better adjust to limits (weather)

Overconfidence

Accident ? It won’t happen to me VIP factor

Specific helicopter factor

Safety strategies

Safety devices Hazard identification Procedures Improved training « Closing the loop » Tightening the loop

Knowledge of Hardware Knowledge of Software Knowledge of Environment Knowledge of Liveware Knowledge of interactions Knowledge of failure modes

TRAINING HISTORY

C a rac té r is t iq u esp h ys iq u e s

L im ita tion ss en so rie lles

A u tres

PH YSIQ UE

S an t é /Fo rm e/

M od e d e vie

M a lad ieIn c a p ac ité

I llu sio n s

Fa tig u e /vig ila n ce

A u tres

PHYSIOL OG IQ UE

A c tio n /E rre u r

P lan if ic at ion

Traite m e n td e l' in fo rm atio n /P r is e d e d é c is ion

A tte n t ion /P erce p tion /S u p e rv isio n

C o m p é ten c etec h n iq u e/C a p ac ité

D isc e rn e m e n t

A c q u is it iond e co n n a iss a n ce

C on sc ien c ed e la

sit u at io n

P ers on n alitée t a tt itu d es

E ta t m e n ta l/é m o tion n el

PSYCH OL O G IQUE

H ié ra rc h is a t io nd es tâ ch es

Tim in g

D é lé g a tio n /P arta g e d e

tâ ch e s

D is t rib u t io nd es tâ ch es

A u tres

GE ST IO N D E LACHARG E D E

TR AVAIL

E xp é rie n c eet

q u a lif ic atio n

P rat iq u eré ce n te

C on n a is s an ce s

EXPERIENC EQUAL IF ICATIO NS

PR AT IQUE RE CE NT EET C ON NAISSAN CES

CO M P OSA NTE HUM AINE

C o m m un ic atio nsverb ale s

C o m m un ic atio nséc ri te s ou lu es

S ig nau xvis uels

COM M UNICAT IONS

Q ua li ficat io n s d el'éq u ipa ge/

C RM

C o ordina t ionform elle

Ch an ge m e ntde p oste /d 'é q uip e

re lè ve

A u tre sin terac tion s

EC HANG ES/QU AL IFICAT IO NS /

CRM /T RM

S u pe rv isio nopé ration n elle

S u pervis ion auc ours d e laform ation

C on t rô le d espe rform an c es

et d e la q u alité

S tan d a rds

SUPER VISION

S tan d ardsré g le m en ta ires

P roc éd u re sré g le m en ta ires

R é g lem e n tat ion

In sp ect ion s/V é rificat ion s

G es t ion

S u rv eillan c e

A u di t

V é ri ficat ion s

ACT IVITE SREG L EM EN TAI RE S

AUT RESINT ER AC TIONS

HO M M ES/ HO M M ES

INT ER A CT IO NSH O M M ES/ HO M M E S

A m é n a g em en t e tc on c ep t io n d u

p os te d e p ilotag e

E q u ip em en ts a u tre sq u e c eu x d u p os te

d e p il otag e

E q u ip em en ts d em a in te n a n c e

E rg on om ie e t c on c e p tionp o u r le s a c tion s

d e form at io n

E q u ip m en tsA TC

E rg on om ie e t c on c e p tionp o u r le s a c tion sd e m a in ten a n c e

IN T E RFAC EHOM M E -M ACHINE

S o u rc es d ed on n é e s

M oy en s d eco m m u n ic a tion

SOURCES D E DONN EE SET INFOR M AT IONS

S u p po rt s lo g ic ielsd ' in fo rm a tio n s et

d 'aid e à la d é c is ion

S o ftw are

SOF TW ARE/FIRM W ARE

C on ce p tion etfon ctio n n al it é s d es

s ys tè m e s au to m at iq u es

U t ili sa ti on d esau tom at is m e s

AU T OM AT ISM E S

A larm es d u p os ted e p ilotag e

M is e en g a rd e d use rvi ce d e c on trô le/

ale rt es

A u t res p rotec t io n set a larm e s

PROT E CT IONSAUTOM AT IQUES /

AL ARM E S

M an u els , c h ec k lis ts ,d on n é e s

op é ra ti on e lle s

M até rie lop é ra tion e l A TC

M até rie l d em a in te n an ce

A u tres

AU TRE M ATE RIE LOPERAT IONE L

INTE RF AC EHO M M E -M ACH IN EHO M M E-S YSTE M E

A é ro d ro m e/S ite d 'a t té rriss ag e

o u d e d éc ollag e

Servic e d ucon t rô leaé rien

In fo rm atio n s C on di tion sm é té oro log iq ues /

V isib il ité

E n viron ne m en tdu p oste d e

t ra vail

Au tres

EN VIR ON NEM E NTPHY SIQU E

Sa tisfa ct iond ans letravai l

M otivat ion/m ora l

As pe c tscu ltu re ls

V ie P r ivé e

A u tre

E NVIRO NN EM EN TPSYCH OSOC IAL

Press ion s R ela tion sdan s letrava il

G es tion desress ou rc e shu m a in es

En cad re m en t /g est io n d up ers onn el

Pol it iq ues etprat iq u es

ré glem enta iresd es au to ri té s

ENC AD REM ENT/RE GLE SET PR AT IQU ES DE LA

C OM PA GN IE

C h arg e d et ravai lé levé e

P ress ion stem p ore lles

P ress ionm en ta le

o pé ration ne lle

Form at ion /con t rô le /

vér if ic ation

Au tres tâ ch esop érat ion n elles

EX IG ENC ESOPER AT ION NELLES

INT ERA C T ION SHO M M E -E NVIR ON NE M E NT

P ro c é d u re sop éra t ion n elles

s tan d ard

P ro c é d u re sd 'u rg e n ce etd e se cou rs

P ro c é d u re sA TC

P ro c é d u re sA é rod ro m e

P roc é d u re s d em a in ten a n c e

P ro c é d u re sau s e in d el'en tre p r ise

A u tresp rocé d u re s

PROCEDURES

Fo rm atio nd e b ase

F orm a tion e ns im u late u r

Fo rm atio nP ratiq u es itu at io n

Fo rm atio nau x situ a t io n

d 'u rg e n ce

Fo rm atio nCR M /TR M

Fo rm atio nré cu rre n te

P rob lè m esd ive rs lié s àla form a tion

FORM AT ION AUTRES

IN T E RA CT IO NSHO M M E /

SY ST E M ES D E SOU T IE N E T D'A ID EHSLEL

WHO IS IMMUNE TO ACCIDENTS?

There are two sorts of pilots : Those who have landed gear up Those who will

Bias in risk assessment : experience Extremely remote vs frequent

Investigation reports Standardized Based on facts Non-punitive approach All aspects reviewed (19 chapters) Participation of several partners Intended for prevention purposes Many details Lessons learnt

Ground lessons : case study

Detailed study of circumstances and causes Questions :

Have we experienced anything similar? Have we been close to experiencing anything similar? What are the similarities? What are the differences?

Are we immune to being involved in such a scenario?

Questions (cont)

What are our defenses? How could we improve them?

How robust are they in an ever-changing environment?

Can we precisely identify our defenses, the procedures? Do we perceive any gap between our planned and actual practices?

Are we prone to defeating identified defenses? What are the root causes that we can map in our organization / in my

personality ?

Challenges

Selection of cases to study Education of moderator / instructor Adherence of personnel : confidence-based environment Address ALL actors, incl. Management

Create a culture Time cost obvious, savings hidden

Conclusion Close the loop : proactive implementation Teaches about strengths and weaknesses A mindset Can be implemented in ANY organization, with no delay Investigating bodies are ready to help

initiate the process

Enhanced partnership