Breaking the Accident Chain
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- Carmella Washington
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1 Breaking the Accident Chain Helitech International 2013 Safety Workshops 26 September 2013
2 Agenda CFIT Truths and Myths Breaking the Accident Chain Overview FAA Case Scenario HTAWS Truths and Myths HTAWS What you need to know Mandate Update
3 Good judgment comes from experience. Unfortunately, experience usually comes from bad judgment. Myths Only happens at night Only happens in low visibility conditions NVIS is all I need It can t happen to me Only happens when problem with aircraft Truths 50% of CFIT incidents occur in Day VFR Conditions Incidents involve both CFIT and Wires NVG s certainly increase safety but does not alert to hazards 2/1/12 3
4 CFIT to Environmental Conditions Clear Low Visibility
5 Relationship of CFIT Fatal vs. Non-Fatal Accidents
6 Breaking the Accident Chain NTSB Accident Number: NYC05MA039
7 Breaking the Accident Chain Mission: HEMS repositioning flight Departure point: Washington Hospital Center Helipad (DC08) Washington DC Destination: Stafford Regional Airport (RMN) Stafford, VA Flight distance: 38 NM
8 Breaking the Accident Chain Weather at the accident site (DCA Automated Weather Observation): Winds calm, Visibility 10NM, Broken clouds at 13,000 and 20,000, Temperature 45 F, Dew point 36 F, Altimeter ************************************************** Moon Illumination: None
9 Breaking the Accident Chain Pilot Information: Commercial Pilot ASEL, AMEL, Rotorcraft Helicopter, Instrument Helicopter Medical: Current, Second Class Pilot Experience: 1500 hours total time 42 hours in the last 90 days 12 hours in the last 30 days 1 hour in the last 24 hours 71 night landings total
10 Breaking the Accident Chain Aircraft: Eurocopter EC-135 P2 AFTT: Hours Maintained IAW FAA approved aircraft inspection program. This aircraft was being flown with a properly deferred inoperative radar altimeter.
11 Breaking the Accident Chain Departed 2304 Followed Helicopter Route 1 along the Anacostia River to Helicopter Route 4 and then flew south along the Potomac River.
12 Breaking the Accident Chain POINT A Washington tower traffic on a ten mile final is an Airbus
13 Breaking the Accident Chain HTAWS with Traffic Display
14 Breaking the Accident Chain POINT B Roger, we have him in sight and will be out of his way
15 Breaking the Accident Chain POINT C FATAL DESCENT
16 Breaking the Accident Chain POINT D IMPACT
17 Benefits of HTAWS Increase Situational Awareness by: Provides a display showing surrounding terrain, airports. Provides a display of obstacles (not all HTAWS display transmission lines). Provides a display of nearby traffic. Provides altitude awareness through the use of altitude callouts and GPWS alerts.
18 Breaking the Accident Chain Summary: The best trained pilot can t see everything. HTAWS contributes to situational awareness by helping the pilot to avoid dangers he may not see when he looks outside.
19 HTAWS Issues Nuisance Alerts Certification sign off Ease of Installation Liability of waiting Myths All HTAWS are the same Class A vs. Class B Options/Features Wire Database RadAlt Display Traffic Display Flight Plan Display NVIS 3 arc sec vs. 6 arc sec data
20 Questions to ask before purchasing HTAWS. Is the HTAWS, TSO C194 compliant? How does the system technically deal with nuisance alerts? Does the system have a wire database (transmission lines and towers)? What is required to install a solution and get it signed off/certified? STC, AML STC? No Field Approvals are authorized. What companies/operators/oems have installed the system, and what have the results been?
21 Certified HTAWS Options
22 Improving Safety in HEMS Operations Within Notice , the FAA recommends, and HAI endorses, the following actions be taken by industry to enhance safety for air medical operations: Terrain awareness warning systems (TAWS) Radar altimeters Night vision enhancement systems Night vision systems are proven tools that would significantly reduce the risk of controlled flight into terrain (CFIT) accidents. In 5 of the 6 accidents, the aircraft were operating in VMC conditions; only one was operating in reported IMC, and that aircraft was operating under VFR rather than IFR. These accidents might have been averted had the aircraft been equipped with TAWS and/or night vision systems. NTSB Safety Recommendation: A and -112, December 21, 2007
23 TSO 2012 Proposed FAA Changes Ground Proximity Warning/Glide slope deviation Alerting Equipment. False Alert: A warning or caution that occurs when the designed terrain or obstacle warning or caution threshold of the system is not exceeded. Nuisance Alert: An alert that occurs when there is no threat or is unnecessary for the intended operation. Applicants should consider providing a mode that will account for off-airfield operations that will still provide the pilot with essential alerts regarding terrain without nuisance alerts. Without a reduced protection or similar mode, nuisance alerts may lead to pilots ignoring or inhibiting the HTAWS at inappropriate times.
24
25 TSO 2012 Proposed FAA Changes Located in pilots primary field of view Compatibility evaluation of HTAWS equipment lighting with previous night vision imaging system (NVIS) lighting modifications and night vision goggle (NVG) compatibility. Operations into off-airfield locations should not trigger nuisance alerts The status of the inclusion of power lines in the obstacle database is currently under review since upwards of 50% of CFIT involves wires. Ask.
26 Mandate Timeline
27
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