us joint helicopter safety analysis team (jhsat) status march 2007 aiac12 – melbourne, australia

1JHSAT - March 2007

US Joint Helicopter Safety Analysis Team (JHSAT) Status

March 2007AIAC12 – Melbourne, Australia

Mark Liptak FAA ANE-110JHSAT Co-Chairperson

2JHSAT - March 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 - March 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 - March 2007

US JHSAT Team Membership:

FAA ANE co-chair HAI co-chair

Turbomeca Schweizer Helicopters

Bell Helicopter Silver State Helicopters

Sikorsky Bristow Group

NASA Rolls Royce

AHS/NASA Airmethods

FAA ASW US Eurocopter

5JHSAT - March 2007

JHSAT Status

Data Analysis

Engaging with the international community

Near term safety recommendations

6JHSAT - March 2007

Data Analysis

7JHSAT - March 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

8JHSAT - March 2007

Data Analysis:

All year 2000 accident data has been downloaded from the NTSB (~4000 files)

The US JHSAT team has completed initial analysis of all 197 accidents from the NTSB year 2000 dataset

For each accident the US 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

9JHSAT - March 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 Mission Categories

10JHSAT - March 2007

US Rotorcraft Accident Trends1986-2006

1715

10

1311

20

17

23

20 20

14

17

-5

0

5

10

15

20

25

30

35

40

45

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Feb

ruar

y

Mar

ch

Apr

il

May

June

July

Aug

ust

Sep

tem

ber

Month

Fre

qu

ency

Monthly Avg1986 - 2006

2000 Monthly Accident Count

Source: NTSB N-registered accidents, excluding amateur built

+2σ 1986 -

-2σ 1986 -

+3σ 1986 -

-3σ 1986 -


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


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


Results of full year 2000 dataset

Standard Problems & Accident Count by Primary Mission

210

170

145

101

92

74 68

53 51 48 47 44

32 30 24 17

37

27 28

12 16

13

9 8 9 6 10

6 4 4 5 3

0

50

100

150

200

250In

stru

ctio

nal /

Tra

inin

g

Per

sona

l / P

rivat

e

Aer

ial A

pplic

atio

n

Em

erge

ncy

Med

ical

Ser

vice

Com

mer

cial

Ope

rato

r

Law

Enf

orce

men

t

Offs

hore

Ext

erna

l Loa

d

Bus

ines

s -

Com

pany

ow

ns A

/C

Fire

fight

ing

Aer

ial O

bser

vatio

n / P

atro

l

Air

Tou

r

Sig

htse

eing

Ele

ctro

nic

New

s G

athe

ring

Logg

ing

Util

ities

Pat

rol a

nd C

onst

ruct

ion

Fre

qu

en

cy

SPSCount

AccidentCount



Standard Problem Primary Category Frequency

40

1

17

3

15

4

11

2

98

87

66

26

24

24

23

20

10

1

0

50

100

150

200

250

300

350

400

450P

ilot j

ud

gm

en

t &a

ctio

ns

Sa

fety

Cu

lture

Da

ta is

sue

s

Ma

inte

na

nce

Gro

un

d D

utie

s

Pilo

t situ

atio

na

wa

ren

ess

Pa

rt/s

yste

mfa

ilure

Po

st-c

rash

surv

iva

l

Co

mm

un

ica

tion

s

Mis

sio

n R

isk

Re

gu

lato

ry

Air

cra

ft D

esi

gn

Infr

ast

ruct

ure

Gro

un

dp

ers

on

ne

l

Fre

qu

en

cy



US JHSAT Intervention Categories

367

275

173143

119

43 33 28

050

100150200250300350400450

Tra

inin

g

Saf

ety

Man

agem

ent

Info

rmat

ion

Mai

nten

ance

Airc

raft

Des

ign

Reg

ulat

ory

Inst

ruct

iona

l

Infr

astr

uctu

re

Fre

qu

ency



Top 15 JHSAT Intervention Sub Categories156

100

68

49 4637 37 36

31 30 29 28 2620 20

0

20

40

60

80

100

120

140

160R

ecor

der

Ris

kas

sess

men

t

QA

Ris

km

anag

emen

t

Aut

orot

atio

n

CF

I

Mis

sion

spec

ific

Inve

stig

atio

n

Sim

ulat

ors

LTE

Pre

fligh

t

Coc

kpit

indi

catio

n

SO

P -

Wx

Airc

raft

perf

orm

ance

SO

P -

Pre

fligh

t

Fre

qu

ency


Data Analysis Status:

To date the accidents analyzed have covered a wide spectrum of helicopter types and operations.

1200+ scored problem statements/intervention findings have been developed

JHSAT currently working further categorization and prioritization of the results

Expect to offer recommendations for all major operational groups in the US helicopter community by June ‘07

Currently working to form recommendations from the data


Worldwide Helicopter Accidents/Year

1980 - 2005

0

100

200

300

400

500

600

700

800A

cc

ide

nts

/ye

ar

US Civil Registry Non-US Civil & Military US Military & USCG (ABC)



The 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 US JHSAT team is currently developing contacts and coordinating this activity.

Any entity that possess large helicopter accident datasets that could be processed by a JHSAT method is being considered.

EASA, Canada, Brazil, and India now moving toward joining in this initiative.



A 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.

US JHSAT and US JHSIT teams will be assist in training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness.


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

Military

US JHSAT

US JHSIT


JHSAT Lead Group Analysis of

International Data

Mark Liptak is JHSAT POC Seeking data rich partners Preliminary discussions with: Canada EASA (CAA-UK, France BEA) Brazil NZ, Australia Chile Canadian Military USN

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 Fleets

Somen 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


US CivilDataset

Selection (1/2 of

helicoptersWorldwide)

JSAT ProcessUnderstanding

Refining

JHSAT 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

Recs

Mar/Apr 06May/June 06

May-Jan 07May 07

2Q 07

1Q 08

TBD 08

TBD 07/08TBD 06/07

Sept 06

TechReview

Feb 07

IHST

JHSAT is now working to bring EASA, CA, AU, SA, India into the process

Current task

Current task


Potential Barriers:

JHSAT:Variation in dataset quality, languages, 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.


Offering near term safety recommendations


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.

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.


US 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)


In Summary

The IHST’s 80% accident reduction cannot be met without active involvement of the worldwide helicopter community.

The US JHSAT has adapted the CAST accident analysis process for use in the helicopter community.

We are currently working with EASA, Canada, Brazil and India to establish participating regions.

The AU/NZ region is rich with useful helicopter data, joining the IHST’s initiative would have significant positive impact on helicopter flight safety going forward.

The IHST looks forward to working with experts from the region to meet its worldwide goals.


JHSAT Workshop

This briefing is one piece of an effort to seek new partners in the IHST’s worldwide initiative.

Anyone from the AU regional helicopter community interested in participating in an analytical team, analyzing data from the Australian region is invited to continue the discussion this Friday.

Members of the US JHSAT are available to offer perspectives on regional data, provide a more detailed look at the accidentanalysis process and answer questions about the worldwide initiative.

Please see me after the meeting.


Questions?

us joint helicopter safety analysis team (jhsat) status march 2007 aiac12 – melbourne, australia

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