U.S. Joint Helicopter Safety Implementation Team (JHSIT)

Transcription

1 U.S. Joint Helicopter Safety Implementation Team (JHSIT) Larry Buehler FAA CO-CHAIR US JHSIT Fred Brisbois Sikorsky Aircraft Corporation CO-CHAIR US JHSIT 1

2 IHST CHALLENGE Reduce the helicopter worldwide accident rate by 80 percent in the next ten years (2016) Improve the safety image of all helicopters worldwide 2

3 IHST MODEL Based On Proven CAST Process IHST (CAST) Charters Activity JHSAT (JSAT) Analyzes Accident Data Proposes most effective interventions JHSIT (JSIT) Assesses feasibility of interventions works implementation Continued data analysis, measure intervention effectiveness (JIMDAT) 3

4 CHALLENGES Not the same for helicopters as for airplanes Increased versatility of helicopters requires diverse actions to address challenges vs. 4

5 SAME OBJECTIVE Save Lives 10 Start 9.5 Per 100K hours 9 Worldwide Accident Rate per 100,000 flight hours Trend projection if no action taken ~1694 Accidents Avoided ~1132 Fatalities/Serious Injuries Avoided source: Bell Worldwide Database Goal 1.9 Per 100K hours avg Year

6 U.S. JHSIT PROCESS MODEL Review JHSAT Recommendations & Assign Number JHSAT Overall Effectiveness Value (OE) Initiate Top Level Safety Intervention Actions (e.g. promoting IHST, SMS, Infrastructure changes) Assign JHSIT Average Feasibility Value Prioritize Recommendations (OE x F) Group Recommendations By Common Theme Prepare Preliminary Safety Enhancement Plan IHST Approval Prepare Detailed Safety Implementation Plan IHST Approval Execute and Monitor Progress Of Safety Implementation Plan 6

7 Technical Feasibility: The ability of the project to take advantage of the current state of technology in pursuing further development. 3 - Off-the-shelf technology, no development required 2 - Some development required, not currently in public use 1 - Major technology development effort required Financial Feasibility: Should consider the total cost of the implementation, including the planning process. Financial feasibility also involves the capability of the participating organizations (FAA, Manufacturers, and Airlines and Operators) to provide the appropriate funding needed to implement the project. 3 - Relatively low cost to implement 2 - Relatively medium cost to implement 1 - Relatively high cost to implement Operational Feasibility: Involves the practicality of the project within the context of the operating environment, including NAS, ground operations, maintenance, inspection, etc. Considers which organizations within the aviation system are impacted. 3 - Minimal change to entities within the operating environment 2 - Modest change to operating environment 1 - Major change to operating environment Schedule Feasibility: Can the project to contribute to achieving the goal in a selected timeframe? Must consider implementation schedule by project. 3 - Less than 2 years to full implementation 2 - Full implementation in 2-5 years 1 - Longer than 5 years to full implementation Regulatory Feasibility: Should be evaluated against current rules and certification process. Could be a deterrent due to a long approval process. 3 - No policy change 2 - Guidance change only (orders, handbooks, policy) 1 - Rule change 7

8 JHSIT EVALUATION MATRIX Example JHSAT Effectiveness JHSIT Feasibility FINAL RANKING JHSAT FLEET RECOMMENDATION SM4 Make proactive use of safety information to create awareness of known hazards and reduce the risk of accidents TN4 Expand training in aeronautical decision making (ADM) and risk management SM14 Provide for non-punitive safety event reporting TN5Provide comprehensive training on aircraft performance SM19 Ensure that training policies and SOPs enhance training for crew awareness of critical flight systems, operational risk management and appropriate Aeronautical Decision Making (ADM) training. 8

9 MANAGING BUSINESS = MANAGING SAFETY Financial Management System Safety Management System Finance Plan Safety Plan Targets & Objectives Targets & Objectives Budget Budget Accountabilities Levels of Authority Procedures Accountabilities Line Management Authorities Procedures Checks and Balances Monitoring/Line Checks Audit Plan Accountants Audit Plan Safety Committee Audits Balance Sheets Audits Safety Achievement 9

10 U.S. JHSIT CORE MEMBERSHIP Larry Buehler Co-Chair Fred Brisbois Co-Chair Name Lindsay Cunningham Denise Uhlin Mike Hurst Chris Eastlee BJ Raysor Keith Johnson Harold Summers Tom Judge Terry Palmer Marty Rincon Organization FAA, 135 Air Carrier Operations Branch Sikorsky Aircraft Corporation, Director, Aviation & Product Safety American Eurocopter, Accident Investigator Bristow Western Hemisphere Helicopter Services, Director Quality & Safety PHI, Chief Pilot Association of Air Medical Services, Government Relations Manager Arkansas Children's Hospital, Director of Operations Airborne Law Enforcement Association, Safety Manager HAI, Director Flight Operations & Technical Services Executive Director, Life Flight of Maine FlightSafety International, Manager, Rotorcraft Special Programs Airsure Limited, Aviation Claims Specialist 10

11 JHSIT WORKING GROUPS Strategic Areas of Intervention Safety Management (24) X X Training Communications & Marketing (9) Systems, Equipment & Information (10) Maintenance X (4) Regulatory (5) X Infrastructure X (5) X * Reason, 1990 X Accident 11

12 IMPROVING PERFORMANCE PROBABILITY FREQUENT PROBABLE OCCASIONAL REMOTE IMPROBABLE SEVERITY A B C D E I - CATASTROPHIC II - CRITICAL III - MARGINAL IV - NEGLIGIBLE Percent Occurrence Perfect Real Good Okay Not So Awful Catastrophic Good Bad Outcomes 12

13 ON LINE IHST COMPLIANCE EVALUATION Self Assessment of Recommendations (17) JHSAT FLEET RECOMMENDATION Not compliant or in place Partially implemented but no defined schedulefor full implementation Partially implemented with plan and schedule for full implementation Fully implemented SAFETY MANAGEMENT Safety Management System documented and in place. Provide for non-punitive safety event reporting and make proactive use of safety information to create awareness of known hazards and reduce the risk of accidents Documented SOPs and policies that cover crew awareness of critical flight systems, operational risk management and appropriate Aeronautical Decision Making (ADM) training. SOPs developed for preflight preparation, maneuver briefings for training flights, weather launch / abort criteria, selection and ground survey of remote or unimproved sites, ground / landing zone crew coordination, operation of external load equipment, and inadvertent flight into IMC. Evaluate the continuing performance of employees and operations as well as adherence to maintenance policy and procedures and compliance with Instructions for Continued Airworthiness (ICA). Establish oversight and training as required based on those evaluations. x x x x 13

14 ON LINE IHST COMPLIANCE EVALUATION Relative Risk Assessment SCORE SUMMARY Not compliant Partially Partially Fully % COMPLIANCE WITH IHST RECOMMENDATIONS 84% 14

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17 Call to Action It s time for the industry to recognize its maturity, and formalize its safety and training. The theme of the JHSIT products begins with implementation of an SMS. Along with that, the use of Flight Data Monitoring (FDM) has come of age and is viable for helicopter operators. Through FDM, you will see flaws in standardization, operational procedures, and training. You can now use the "just culture" and, if needed, appropriate, identifiable training to improve your overall operation. 17

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19 OPERATIONAL RISK Single engine (Non-turbine) Single pilot Not IFR capable No autopilot No terrain avoidance system No de-ice capability RISK WHO IS INVOLVED IN DECISION MAKING, RISK ACCEPTANCE, RISK MITIGATION? No CRM / Formal training Dual engine turbine engine Dual pilot IFR capable Autopilot, fully coupled Terrain Avoidance Warning System All weather capable Training / CRM 19

20 U.S. JHSIT CORE MEMBERSHIP Larry Buehler Co-Chair Fred Brisbois Co-Chair Name Lindsay Cunningham Denise Uhlin Mike Hurst Chris Eastlee BJ Raysor Keith Johnson Harold Summers Tom Judge Terry Palmer Marty Rincon James McKenna Organization FAA, 135 Air Carrier Operations Branch Sikorsky Aircraft Corporation, Director, Aviation & Product Safety American Eurocopter, Accident Investigator Bristow Western Hemisphere Helicopter Services, Director Quality & Safety PHI, Chief Pilot Association of Air Medical Services, Government Relations Manager Arkansas Children's Hospital, Director of Operations Airborne Law Enforcement Association, Safety Manager HAI, Director Flight Operations & Technical Services Executive Director, Life Flight of Maine FlightSafety International, Manager, Rotorcraft Special Programs Airsure Limited, Aviation Claims Specialist Bell Helicopter 20

21 SEEKING THE RIGHT BALANCE 21

22 22 Return on Investment (ROI): This is calculated by dividing the net present value by the present value of the project costs. The net present value is calculated by subtracting the present value of project costs from the present value of project benefits. The model calculates ROI based on costs, benefits, and the discount rate that are entered by the user. ( )( ) ( ) ( ) ( ) ( ) ROI = = = = = = = B C n r C n r B n r C n r C n r i i i i i t i i i t i i i i t i i i i t i i i i t i ( ) ( ) ( ) ( ) ( ) WHAT THE HELL DO WE KNOW ABOUT FINANCE? WE KNOW ROISHI!

23 Return On Investment for Safety & Health Investments 23

24 ACTIVE vs. LATENT FAILURES* Organizational Factors Latent Conditions Procedures incomplete Poor layout/configuration Unsafe Supervision Latent Conditions Poor task planning Parts/tools improperly labeled Preconditions for Unsafe Acts Latent Conditions Inadequate lighting Equipment inappropriate for task Failed or Absent Defenses * Reason, 1990 Unsafe Acts Active Conditions Omitted procedural step Distraction/Interruption Inadequate task knowledge Poor technique Accident & Injury Maintenance problem Aircraft crashed 24

25 RECOGNIZING RISK 25

26 WHO APPROVES CONFIGURATION? 4 Point Upper Restraint Cabin Seats 406 Enabled ELT / Auto Deployed ELT Fwd / Aft Cabin Push Out window Aft Orientation Bar Auto Float Deployment (AFDS) Cyclic Warning System EGPWS External Life Raft FDR / CVR GPS HEELS Flight Following System Single Action Door Release Skywatch / TCAS Weather Radar S-76C+ (2000) Yes No Yes Yes No Yes No Yes Yes Yes No Yes (C ustomer) Yes Yes Yes S-76A++ (1984) No No No No No No No No CVR only Yes (C ustomer) No No No No Yes HUMS No No Contractor Changed Impacting Level Of Safety Was Risk Assessment At Appropriate Level? 26

27 SPACE SHUTTLE CHALLENGER January 28, 1986 COLUMBIA February 1,

28 CHALLENGER ACCIDENT INVESTIGATION Lesson Learned: Well-intentioned people and high-risk organizations can become desensitized to deviations from the norm Vaughan's book, The Challenger Launch Decision, called this Normalization of Deviance Board identified this as a major factor in Columbia mishap, much like Challenger disaster "Unexpected becomes the expected which becomes the accepted" In both Challenger, Columbia: "The machine was talking to us, but nobody was listening" Small anomalies may be symptomatic of larger problems -failure to address could be disastrous System effects take years to develop and cause failures Diane Vaughan, risk specialist and sociology professor Boston College 28

29 RAISE THE BAR VIA PUSH PULL STRATEGY Clients Executive Level Demands ACCEPTABLE STANDARDS Operators WE NEED TO CREATE THE PULL FROM CLIENTS TO MAKE THE PUSH TO OPERATORS EASIER 29

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31 CULTURAL CHANGE Drinking Then - Otis Campbell / the Andy Griffith Show Now - MADD / Drinking and Driving Now Enabling is out Smoking Then - Dive Bomber starring Errol Flynn and Fred MacMurry Now Second hand smoke / restaurants and bars Now - Advertising Seat belt use in automobiles Then Sissy Now Unacceptable not to use them 31

32 CULTURAL CHANGE Nearly every states/province already had laws against: drinking to excess driving drunk selling liquor to minors The changes were not driven by laws. The basic prohibitions were already in place Enforcement policy change. Tobacco, fewer prohibitions existed, but more have developed as a result of the cultural change. Seat Belts Manufacturing, use by example, use requirements led to a cultural change; phase-in by attrition 32

33 CULTURAL BEHAVIORAL NORMS & SAFETY Acceptable Risk Peacetime vs. combat environment Acceptable Behavior Do you think we can get through? Management/Stockholder/Customer Expectations The cost of cancellations/late flights vs. the primary and secondary costs of accidents Braniff On Time Clock Peer Pressure Competitive vs. Supportive Non-punitive or Just Culture 33

34 SAFETY MANAGEMENT SYSTEM Framework For Cultural Change Framework for Cultural Change - Safety Management System Scalable Adaptable Integrated Compliant Cultural Change Timeline Generational Significant Emotional Event 34

35 REDUCING RISK Changing the Standard STRATFORD, Conn., May 28, Sikorsky Aircraft established another rotorcraft industry first by standardizing its new S-76 and S-92 helicopter safety baseline to to include Enhanced Ground Proximity Warning Systems (EGPWS) in in all civil aircraft configurations. 35

36 SAFETY Responsibility & Accountability And It Begins With US!! 36

37 Questions?? Larry Buehler FAA CO-CHAIR US JHSIT Fred Brisbois Sikorsky Aircraft Corporation CO-CHAIR US JHSIT

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39 SAFETY MANAGEMENT SYSTEM (SMS) IWG Chairman: Keith Johnson, Safety Program Manager, Airborne Law Enforcement Association Members: Denise Uhlin, Bristow Group Fred Brisbois, Sikorsky Aircraft, Director Aviation & Product Safety Dr. Peter Gardiner, President and CEO of the Southern California Safety Institute J. Heffernan, HAI Director of Safety Eric Lugger, Director of Safety Air Methods Richard Komarniski, Grey Owl Aviation Consultants Inc. Susan Brisbois, Education Resources, LLC 39

40 SMS IWG ACTIVITIES 2007 Sep SMS Tool Kit Published Oct Exxon Mobil announces IHST Toolkit SMS attributes will form part of all future contractual technical specifications May ALEA Adopts IHST SMS Toolkit July SMS.PPT Workshop developed 19 SMS Presentations and Workshops at 15 Different Conferences / Venues 30 Articles promoting Safety and SMS in Air Beat Magazine 2009 FEB Interactive Computerized SMS Training Tool (courtesy AvStar) SEP Tool Kit Revision expanded and aligned with FAA A Mentoring Program 5 operators 40

41 SYSTEMS, EQUIPMENT & INFORMATION IWG Chairpersons: Lindsay Cunningham, JHSIT, American Eurocopter BJ Raysor, JHSIT, Arkansas Children s Hospital Members: Dick Healing, R3 Consulting Mike Hurst, JHSIT Resource, PHI Stuart Lau, CAPACG Jim Morgan, Bristow Robert Vandel, FSF William Voss, FSF Robert Dodd, NTSB Bob Whetsell, Aerobytes Thomas Longridge, Resource, FAA FOQA Doug Farrow, Resource, FAA FOQA 41

42 SYSTEMS, EQUIPMENT & INFORMATION JUL: Checklist for Helicopter Accident Investigation delivered to NTSB DEC: Project planning meeting with Flight Safety Foundation to implement HEMS FOQA Program 2009 JAN: Follow-up face-to-face meeting with FSF on HEMS FOQA Project FEB: Presentation at NTSB EMS Hearing on recording equipment FEB: Follow-up meeting with FSI on EMS FOQA project FEB: Launch HEMS FOQA Project with Flight Safety Foundation at Heli-Expo FEB: Flight Data Monitoring Workshop to take place at CHC Safety Summit SEP: Flight Data Monitoring Toolkit OCT; Flight Data Monitoring Workshop and HEMS FOQA Project Meeting to take place at AMTC 2010 Monitoring/recording systems standard equipment on major airframe OEMs 42

43 TRAINING IWG Chairperson: Terry Palmer, FlightSafety Members: Marty Rincon, AirSure Jack Hustwit, ERA Med Tom Ramirez, AvStar Media Elden Mayo, ERA maintenance Paul Osterman, American Eurocopter Sue Brisbois, Education Resources LLC 43

44 TRAINING IWG ACTIVITIES 2008 Nov Educational meeting with insurance underwriter management Compile resources for flight training and flight simulation training devices 2009 APR: Exportable Educational Program for insurance underwriters MAY: Follow-up meeting with insurance underwriters APR AUG: Regional insurance and Government educational sessions MAY: Follow up educational meeting with insurance underwriter management SEP: Training Toolkit including resource material OCT: Rewrite best practices and resources for CAMTS DEC: New simulator makes and models including single engine Provide extensive initial and recurrent training in helicopter emergencies. Performance, flight planning, aeronautical decision making (ADM), risk management, inadvertent IMC, make & model transition and specialized mission training New training programs OEMS, professional training organizations, associations and simulator providers - ongoing

45 INFRASTRUCTURE Chairperson: T. Judge, LifeFlight of Maine Members: Eric Lugger: Air Methods Corporation Rex Alexander: Omniflight Rachael Miller, MS: Researcher Jeni OBryon: recently left position as lead Aviation Planner for Maine DOT Greg Thompson, National Center for Atmospheric Research Ralph Petragnani: Belfort Instruments Chris Eastlee: Air Medical Operators Association Dan Norman: Satellite Technologies Incorporated. 45

46 INFRASTRUCTURE IWG ACTIVITIES 2008: Completed work on Pilot Records and Improvement Act Recommendation 2009: Identify what needs to happen and budget to move HEMS ADDS tool from experimental to operational Assess national grid of existing AWOS federal, state Assess national grid of other weather sources Assess national grid of GPS approaches Assess mechanisms to tie other weather sources into FAA grid Assess what is needed to establish a low level IFR infrastructure 46

47 U.S. JHSIT WORKING GROUPS Co-Chairs SMS Training Larry Buehler Fred Brisbois Keith JohnsonDenise Uhlin Terry Palmer Marty Rincone Systems, Equipment & Information Regulatory Infrastructure Maintenance Lindsay Cunningham Evans BJ Raysor Mike Hurst Chris Eastlee Tom Judge Harold Summers 47