Analysis & Implementation - the European Experience

Transcription

1 Analysis & Implementation - the European Experience IHSS 2009 John Vincent, EASA Marieke van Hijum, EASA Tony Eagles, CAA UK John Steel, CAA Ireland Michel Masson, EASA Martin Bernandersson, CAA Sweden

2 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS 4. CONCLUDING REMARKS Photo Vasco Morao IHSS 2009 European Helicopter Safety Team 2

3 EHEST is the helicopter component of ESSI and the European branch of IHST IHSS 2009 European Helicopter Safety Team 3

4 ESSI EUROPEAN STRATEGIC SAFETY INITIATIVE ECAST COMMERCIAL AVIATION SAFETY TEAM EHEST HELICOPTER SAFETY TEAM EGAST GENERAL AVIATION SAFETY TEAM EHSAT Core Team EHSIT Core Team Sub-group on Communication Regional Teams IHSS 2009 European Helicopter Safety Team 4

5 IS FI NO SE EASA Member States = IE DK EE LV LT 27 European Union States plus Norway, Iceland, Switzerland and Liechtenstein) UK NL PL BE LU DE CZ SK FR CH SI AT HU RO PT ES IT BG GR MT CY IHSS 2009 European Helicopter Safety Team 5

6 Why regional EHSAT analysis teams? Maximise usage of resources: working on local data, less travelling Relations between partners already established Team aware of local context Implementations/action plans also have to be implemented on regional level Languages used in accident investigation reports IHSS 2009 European Helicopter Safety Team 6

7 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS 4. CONCLUDING REMARKS Photo Eurocopter IHSS 2009 European Helicopter Safety Team 7

8 General Process By the European Helicopter Safety Analysis Team - EHSAT Analysis By the European Helicopter Safety Implementation Team - EHSIT Develop Safety Action Plans Implement Safety Action Plans Monitoring IHSS 2009 European Helicopter Safety Team 8

9 Scope of analysis Helicopter Accidents (definition ICAO Annex 13) Date of occurrence period State of occurrence located in Europe Where an Accident Investigation Board final report is available IHSS 2009 European Helicopter Safety Team 9

10 Approach Data driven approach Maintain international compatibility Reviewing accidents using a standard method adapted from IHST Added specific analysis on human factors (HFACS) Format allows comparison with data from other regions IHSS 2009 European Helicopter Safety Team 10

11 Analysis Methodology EHSAT 1. Collect general occurrence information 2. Describe and analyse the accident 3. Assign standard codes to factors Standard Problem Statements (SPS) and Human Factors Analysis and Classification System (HFACS) 4. Produce Intervention Recommendations (IR) IHSS 2009 European Helicopter Safety Team 11

12 Human Factors Analysis and Classification System (HFACS) HFACS by Wiegmann and Shappell Proven tool for analysing unsafe acts / human errors and their causes Human error is the start of HFACS classification not the conclusion Over 170 codes in 4 areas Organisational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts IHSS 2009 European Helicopter Safety Team 12

13 Benefits of using HFACS Human Factors (HF) need to be addressed if the objective of achieving an 80% reduction in helicopter accident rates by 2016 is to be realised HFACS is a well documented system based on a sound theoretical framework that addresses HF in a detailed and structured manner HFACS gives the opportunity to address errors and violations as well as organisational aspects Also gives the opportunity to address maintenance issues (HFACS ME) IHSS 2009 European Helicopter Safety Team 13

14 1. SETTING THE SCENE 2. METHODOLOGY 3. INTERIM RESULTS General Data SPS and HFACS Analysis Photo AgustaWestland Intervention Recommendations 4. CONCLUDING REMARKS IHSS 2009 European Helicopter Safety Team 14

15 Scope of interim dataset Total of 303 accidents within timeframe have been analysed (as of Aug 09) Covers work from 11 Regional Teams across Europe Estimated to be some 75% of the published reports available Standard Problem Statements In total 1775 statements recorded HFACS In total 818 factors recorded IHSS 2009 European Helicopter Safety Team 15

16 Accident Distribution over Type of Operation Accident Distribution over Type of Operation EHSAT EHSAT Dataset State Flight, 4% (e.g. Police, Military) Aerial Work, 32% (e.g. Fire Fighting, Sling/External Load) General Aviation, 45% (e.g. Pleasure, Training and Business flights) Commercial Air Transport, 19% (e.g. Passenger, HEMS, Offshore, CAT Training, CAT Positioning) IHSS 2009 European Helicopter Safety Team 16

17 Accident Distribution over Phase of Flight EHSAT Dataset Fatal Non Fatal 35% 30% 25% % of Accidents 20% 15% 10% 5% 0% Standing Taxi Take-off En route Approach & Landing Manoeuvring IHSS 2009 European Helicopter Safety Team 17

18 % of Accidents where SPS level 1 has been identified at least once EHSAT Dataset Pilot judgement & actions Safety Culture/Management Ground Duties (Planning&Preparation) Pilot situation awareness Data issues Mission Risk Part/system failure Regulatory Maintenance Post-crash survival Aircraft Design Infrastructure Communications Ground personnel 1% 7% 9% 17% 16% 18% 25% 25% 27% 35% 35% 38% 51% 65% 0% 10% 20% 30% 40% 50% 60% 70% IHSS 2009 European Helicopter Safety Team 18

19 Correlation is: 0.87 Comparison of EHSAT data with US JHSAT data SPS level 1, Top 4 US JHSAT data EH SAT data Pilot Judgement & Action Safety/Culture Management Ground Duties Pilot Situation Awareness 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Percentage of Accidents High correlation with US results on SPS level 1 Lower levels SPS show some differences IHSS 2009 European Helicopter Safety Team 19

20 Example scenarios Example accident scenarios presented for Commercial Air Transport Aerial Work General Aviation Pleasure Flight General Aviation Training Scenarios illustrate the most identified SPS statements and HFACS codes for the types of operation IHSS 2009 European Helicopter Safety Team 20

21 An example Commercial Air Transport scenario During a HEMS mission after the patient had been loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. The decision to continue was taken because an ambulance was waiting to transfer the patient to hospital. During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. IHSS 2009 European Helicopter Safety Team 21

22 An example Commercial Air Transport scenario During a HEMS mission after the patient had been loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. Loss of Visual Reference The decision to continue was taken because an ambulance Inadequate was decisions waiting to transfer the patient to hospital. Pilot felt pressure During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. IHSS 2009 European Helicopter Safety Team 22

23 An example Commercial Air Transport scenario SPS Pilot decision making Self induced pressure Failed to follow procedures Flight profile unsafe Inadequate oversight Reduced visibility Selection of inappropriate landing site Management Failure to enforce company SOPs HFACS Decision Making - Operation Risk assessment Operation Skill-based errors Whiteout/Vision restricted Channelized attention Communication critical information/planning Pressing Procedural Guidelines IHSS 2009 European Helicopter Safety Team 23

24 An example Aerial Work scenario A Pilot had been tasked to carry out aerial application of a field using the helicopter. Prior to commencing the aerial work task the pilot did not carry out an inspection of the intended operating area. During the course of the sortie the wind direction changed and the pilot was forced to adjust his spraying pattern. As result his new flight path brought him into conflict with some trees. While trying to manoeuver to avoid the trees the pilot struck a power line and as a result the helicopter lost control and crashed. IHSS 2009 European Helicopter Safety Team 24

25 An example Aerial Work scenario A Pilot had been tasked to carry out aerial application of a field using the helicopter. Inadequate pre flight preparation Prior to commencing the aerial work task the pilot did not carry out an inspection of the intended operating area. Distracted by presence of trees During the course of the sortie the wind direction changed and the pilot was forced to adjust his spraying pattern. Pressure to complete task As result his new flight path brought him into conflict with some trees. While trying to manoeuver to avoid the trees the pilot struck a power line and as a result the helicopter lost control and crashed. IHSS 2009 European Helicopter Safety Team 25

26 An example Aerial Work scenario SPS Mission involves flying near hazards Mission requires low/slow flight Inadequate consideration of obstacles Pilot decision making Diverted attention, distraction Selection of inappropriate landing site Customer/company pressure HFACS Risk assessment - Operation Decision making Operation Channelized att./inattention Misperc. of operational cond. Mission Planning Excessive motivation to succeed Fatigue Supervision inadequate Doctrine IHSS 2009 European Helicopter Safety Team 26

27 An example General Aviation Pleasure flight 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. Shortly after the loss of radar contact the helicopter suffered an in-flight collision with terrain. IHSS 2009 European Helicopter Safety Team 27

28 An example General Aviation Pleasure flight scenario The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. No weather forecast obtained No flight plan filed Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. No contact established with ATC Shortly after the loss of radar contact the helicopter suffered an in-flight collision with terrain. Inadvertent IMC Limited experience IHSS 2009 European Helicopter Safety Team 28

29 An example General Aviation Pleasure flight scenario SPS Pilot inexperienced Mission planning Pilot decision making Inadequate standards and regulations Wilful disregard for rules and SOPs Inadvertent entry into IMC Failed to recognise cues to terminate course of action HFACS Risk assessment Operation Overcontrol/Undercontrol Procedural error Violation Lack of discipline Mission planning Overconfidence Vision restricted by meteorological conditions Limited total experience IHSS 2009 European Helicopter Safety Team 29

30 An example General Aviation - Training scenario The dual exercise was for the student to practise emergency and autorotational landings. The landing area selected for the exercise was muddy with a forecast wind speed of 26 kts. As part of the exercise the flight instructor simulated an engine failure without any prior warning. During the subsequent autorotation the instructor allowed the rotor RPM to drop below the minimum. The helicopter contacted the ground with a high sink rate and rolled over. IHSS 2009 European Helicopter Safety Team 30

31 An example General Aviation - Training scenario The dual exercise was for the student to practise emergency Mission planning and autorotational regards terrain landings. weather The landing area selected for the exercise was muddy with a forecast Insufficient wind speed briefing of 26 of kts. the student As part of the exercise on the the training flight instructor plan simulated an engine failure without any prior Student warning. control inputs uncoordinated During the subsequent autorotation the instructor allowed the rotor RPM to drop below the minimum. The flight instructor interacted too late The helicopter contacted the ground with a high sink rate and rolled over. IHSS 2009 European Helicopter Safety Team 31

32 An example General Aviation - Training scenario SPS Inadequate and untimely CFI action to correct student action Pilot decision making Perceptual judgment errors Inadequate mission planning: Weather and wind Training program management: CFI preparation and planning Inadequate landing procedures HFACS Risk assessment Operation Procedural error Overcontrol/Undercontrol Overconfidence Necessary action Delayed Mission briefing Leadership/Supervision/ Oversight inadequate Training Program/Guidelines IHSS 2009 European Helicopter Safety Team 32

33 Intervention Recommendations In total 11 Intervention Recommendation categories identified The categories help identify areas for working groups of EHSIT Note: some categories overlap but this suggests areas for additional focus IHSS 2009 European Helicopter Safety Team 33

34 Total number of Intervention Recommendations (Level 1) Operations 497 Training_Instructional Training/Instructional 472 Regulatory 214 Data_or_Information_Issues Issues 175 Maintenance 77 Aircraft_System_Equipment_Design Aircraft_Design Research Manufacturing Infrastructure Search_and_Rescue and IHSS 2009 European Helicopter Safety Team 34

35 EHSIT data preparation Refinement of the Intervention Recommendations Level 2 categorisation has been created 1591 IRs undergoing consolidation by EHSIT Plenary Specialist teams on SMS/Operations and Training launched so far Photo Martin Bernandersson IHSS 2009 European Helicopter Safety Team 35

36 Consolidated IRs SMS/Operations SMS: Should be adopted and applied by all operators SOPs: Should be prepared and applied for all activities RISK ASSESSMENT/PRE-FLIGHT PREPARATION: Emphasise the importance of Risk Assessment in mission planning IHSS 2009 European Helicopter Safety Team 36

37 Consolidated IRs SMS/Operations SAFETY CULTURE: Develop an engagement/ communication plan to promote adherence to: the core principles of basic airmanship risk assessment rule compliance AIRCRAFT PERFORMANCE: Reinforce familiarity with Flight Manual through awareness campaign and consider formal examination during annual flying check IHSS 2009 European Helicopter Safety Team 37

38 Consolidated IRs - Training INEXPERIENCED PILOTS: Training syllabus for ab-initio pilots should cover in more detail: Mission planning Vortex Ring / LTE Autorotation and other emergencies Passenger management DEGRADED FLIGHT CONDITIONS: Specific training to improve decision making process for pilot before and after inadvertent entry into IMC IHSS 2009 European Helicopter Safety Team 38

39 Consolidated IRs - Training TRAINING PSYCHOLOGY/HUMAN FACTORS: Enhance instructor training in: Monitoring students Application of human factors principles Instructor intervention criteria IHSS 2009 European Helicopter Safety Team 39

40 Concluding remarks The top 4 identified SPS areas are: Pilot judgment & actions Safety culture/management Ground duties/mission preparation Pilot situation awareness High correlation with US results on SPS level 1 Differences can be observed for the various types of operation HFACS enhances the analysis of human factor issues IHSS 2009 European Helicopter Safety Team 40

41 Concluding remarks Work continues within EHSIT: The first two specialist teams (SMS/Operations and Training) were launched in September 2009 Data driven analysis ECAST SMS and various safety culture material available for consideration Attention on communication with stakeholders Private pilots, organisations, regulators EHEST Communications Sub-Group established Liaising with EGAST (common challenges) IHSS 2009 European Helicopter Safety Team 41

42 The challenge now is to develop, implement and monitor effective measures to meet the 80% accident rate reduction target Thank you for your attention Questions? Mailbox: IHSS 2009 European Helicopter Safety Team 42 Photos AgustaWestland and Eurocopter

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44 Annex IHSS 2009 European Helicopter Safety Team 44

45 Number of Helicopter Accidents per Year EASA MS Registered, CAT+AeW+GA Source: EASA Annual Safety Review Number of accidents Year IHSS 2009 European Helicopter Safety Team 45

46 HFACS Overall Picture Organisational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts IHSS 2009 European Helicopter Safety Team 46

47 HFACS model upper levels % of Accidents that involved at least one instance of an HFACS category Unsafe Acts 72% Errors Violations 66% 15% Judgement & Decision-Making Errors 41% Skill-based Errors Perceptual Errors 31% 9% IHSS 2009 European Helicopter Safety Team 47

48 HFACS model upper levels % of Accidents that involved at least one instance of an HFACS category Preconditions 74% Condition of Individuals 59% Personnel Factors 26% Environmental Factors 20% IHSS 2009 European Helicopter Safety Team 48

49 HFACS model upper levels % of Accidents that involved at least one instance of an HFACS category Supervision 24% Planned Inappropriate Operations Inadequate Supervision Failure to Correct Known Problem 1% 16% 10% Supervisory Violations 2% IHSS 2009 European Helicopter Safety Team 49

50 HFACS model upper levels % of Accidents that involved at least one instance of an HFACS category Organisational Influences 18% Organisational Process Organisational Climate Resource/ Acquisition Management 12% 5% 3% IHSS 2009 European Helicopter Safety Team 50