IHSS 2011 Canadian Update 1
JHSAT(C)-Joint Helicopter Safety Analysis Team (Canada) Canadian Operations Overview Results of Analysis: 2000 vs 2006 Recommendations to JHSIT (C) 2
Canadian Operations Overview Canada population approx. 31 million Arctic population 100,000 - area larger than the size of Western Europe 3
Data set: 2000 & 2006 2000 2006 52 Helicopter accidents 50 Civil accidents analyzed 1 DND Accident 1 accident in US 56 Helicopter accidents 54 Civil accidents analyzed 1 DND Accident 2 accidents in US DND: Department of National Defence 4
Helicopter Accidents -Fatal 12.0 10.0 8.0 6.0 Fatal Accidents 4.0 2.0 Fatal Accidents/100K 0.0 5
Percentage of Accidents By Primary Mission Other non-specific Commercial External Load Personal / Private Instructional / Training 2006 2000 Aerial Observation / Patrol Law Enforcement Aerial Application 0 10 20 30 40 50 60 70 6
Flight Hours by Type 900000 800000 700000 600000 500000 400000 300000 200000 100000 FAR 27 SingleTurbine FAR 29 Twin Turbine FAR 27 Piston FAR 29 Single Turbine FAR 27 Twin Turbine FAR 29 Piston Total Flight Hours 0 7
Accidents by Type 60 50 40 FAR 27:Single Turbine FAR 29:Twin Turbine 30 FAR 27:Single Piston FAR 29:Single Turbine 20 FAR 27:Twin Turbine FAR 29:Single Piston 10 Total Accidents 0 8
Accident Rate/100K by Type 30 25 20 15 10 FAR 27:Single Turbine FAR 29:Twin Turbine FAR 27:Single Piston FAR 29:Single Turbine 5 0 9
Interventions Yr 2006 Interventions 800 Safety Management 123 900 Training 110 200 Information 100 Aircraft Design 60 60 500 Maintenance 19 300 Infrastructure 13 700 Regulatory 9 600 No Recommendation 6 400 Instructional 1 0 20 40 60 80 100 120 140 10
Interventions Yr 2000 & 2006 Interventions 800 Safety Management 900 Training 200 Information 100 Aircraft Design 500 Maintenance 300 Infrastructure yr 2000 yr 2006 700 Regulatory 600 No Recommendation 400 Instructional 0 20 40 60 80 100 120 140 160 11
SPS vs. Interventions: What to focus on 2000 Data 12
SPS vs. Interventions: What to focus on 2006 Data 13
Top 5 Intervention Categories 1) Training Pilot mission planning Preflight risk assessment In-Flight risk assessment to adapt for unexpected mission changes. Use of training devices (e.g., decision making) Training area selection Improve auto-rotational proficiency for trainers. Formal training for qualification of company training pilots. Pilot recognition of critical cues and recovery (LTE, Inadvertent IMC, dynamic rollover, VRS) Increase pilot aircraft type specific knowledge Pilot Decision Making and Crew Resource Management Task priority management (i.e., when multi-tasking) Threat and error management Plan and monitor aircraft performance to minimize risk exposure (e.g., HOGE, H-V, and WAT charts) Competency based training program for specific operations Obstacle proximity awareness Customer training on operational limitations. Safety Management program training 14
Top 5 Intervention Categories 2) Safety Management Industry Association to develop best practices specific to operational activities. (Heli-logging, EMS, Oil & Gas, Fire Fighting, etc.) Ensure a company safety management system that will Establish a company risk management process. Involve clients in risk management process Establish duty day limitations based on operational intensity for Aircrew, Aircraft Maintenance Engineers and Ground Crew. Establish operational oversight protocols for remote operations Establish company SOP s based on industry best practices, for all areas of operational activities to encompass: Specific limitations (e.g., Weather, duty, obstacle clearance) Unprepared landing zone standards. Identifying the role of management, flight, ground crews, and clients Provide pilots with tools to assess and predict aircraft performance. Provide pilots with tools to assess specific operational risk. Required safety equipment and clothing to be worn for flight conditions (e.g., helmets, safety glasses, boots, fire retardant flight suits. 15
Top 5 Intervention Categories 3) Aircraft Design & Manufacture Effective design performance monitoring to identify in-service difficulties with trend monitoring through the use of Service Difficulty Reporting system. Operators and industry associations to promote development and installation of systems for all helicopters to warn of impending failures. (e.g., HUMS, simpler vibration monitoring for airframe dynamic and engine components. Industry committee to be established to address a strategy to require new derivative designs and legacy production aircraft to incorporate safety enhancements specified in later design standards. Industry associations to encourage design and installation of equipment to improve pilot situational awareness Devices to indicate to pilot that control limitations are being approached, either through aural or visual cues Tail rotor guard or proximity detection warning device Introduce automatic recording means to record operating usage data to be used to determine the life of components and associated maintenance.. 16
Top 5 Intervention Categories 4) Information Industry and operators promote the use of: Flight recording devices appropriate to the design and operation of the aircraft. In-flight monitoring systems. Transportation Safety Board should: Develop procedures, policies and tools to enable the timely collection and recording of all available relevant data for all Canadian accidents. (i.e., similar to Transport Canada s web-based reporting of Service Difficulty Reports) Make accident data readily accessible and searchable to all operators in support of their safety management risk assessment process. Promote the development of an international database to share accident information. 17
Top 5 Intervention Categories 5) Maintenance Develop Industry Best Practice for maintenance on the following topics: Oversight of maintenance At remote locations Fatigue management plan for personnel Introduction of annual compliance monitoring and recurrent training Establish industry best practices. Oversight of mechanics in training (apprentice) The conduct of maintenance Develop and introduce use of Stage/Task Cards Release of aircraft for flight after maintenance. Briefing of Pilots after maintenance has occurred. Completion of paperwork. Care and use of equipment particularly from third parties. Refueling equipment Maintenance tools To ensure proper quality of fuel at all sources. 18
JHSAT Conclusion CDN data analyzed for the years 2000 and 2006 have identified the same Top 5 interventions Categories with similar specific interventions. The above interventions are similar to those identified by other participating Regions. Canadian Challenge will continue to be our remoteness and diversity of operations as provided by medium and small companies. 19
JHSIT Canada Alex Holliday Ft. Worth November 2011 20
JHSIT Canada Canadian JHSIT(C) Team Membership: 1. Rob Freeman- Transport Canada Co-chair 2. Alex Holliday Alpine Helicopters Co-chair 3. Geoff Goodyear Universal Helicopters Ltd. 4. Greg Wyght CHC 5. Sylvain Seguin Canadian Helicopters 6. Fred Brisbois Sykorsky Helicopters 21
JHSIT Canada % of Accidents That SPS Category is Cited At Least Once Pilot Judgement 73 Data Issues 52 Mission Risk 44 Pilot Situational Awareness 42 SPS Categories Safety Management Ground Duties Part/System Failure Maintenance Standards 23 23 29 42 Systems & Equipment Design 15 Post Crash Survival 13 Regulatory 10 Infrastructure 6 Communications 6 Ground Personnel 0 0 10 20 30 40 50 60 70 80 22
JHSIT Canada Interventions Training 900 151 Safety Management 800 Aircraft Design/Manufacture Information 200 44 63 110 Maintenance 500 26 Infrastructure 300 Instructional 400 Regulatory 700 8 14 11 No Recommendation 600 3 0 50 100 150 200 23
JHSIT Canada PltJudgment SafetyCulture PilotSitAwareness DataIssues MissionRisk Maintenance GrndDuties Parts/SystFailure PostCrashSurvival A/CDesign Regulatory Communication Infrastructure GroundPersonnel TotalInterventions StandardProblemStatement VS Interventions Training 72 19 31 15 8 1 1 1 3 151 SafetyManagement 27 31 5 1 13 3 18 1 6 1 2 1 109 A/CDesign&Manufacture 3 4 13 6 5 10 6 15 62 Information 1 1 37 1 2 2 44 Maintenance 1 24 1 26 Infrastructure 2 3 1 1 3 2 2 14 Instructional 10 1 11 Regulatory 1 1 2 4 8 NoRecommendation 1 1 1 3 TotalStandardProblemStatements 104 68 53 38 36 32 28 16 17 16 7 5 4 4 24
JHSIT Canada Pilot Judgment Training Pilot Situational Awareness Training Safety Culture Safety Management Data Issues Information Pilot Judgment Safety Management 25
JHSIT Canada Top 5 Intervention Categories 1) Training 2) Safety Management 3) Aircraft Design and Manufacture 4) Information 5) Maintenance 26
JHSIT Canada JHSAT Reports: US JHSAT Year 2000 Report US JHSAT Year 2001 Report US JHSAT Year 2006 Report EHSAT Report 2000-2005 CDN JHSAT Year 2000 Report Safety Resources and Products: HAI Safety Videos FAASTeam Training Materials Skybrary Portal Global HFDM Website Helicopter Safety.org FAA Human Factors Web Portal Calendar of Events JHSIT Products: US SMS Toolkits (1 st and 2 nd addition) US SMS Video (HAI/IHST) US Training Toolkit US HFDM Toolkiit EHEST Maintenance Toolkit (April 2011) EHEST Training leaflet EHEST Training Video IHST Self Risk Assessment Toolkit IHST Helicopter Safety Recommendation Summary for Small Operators IHST Tri-Fold Flyer IHST Presentations and Publications 27
JHSIT Canada Challenges - Marketing Strategy - Identify the Message Training & SMS - Identify the Target Small Operators < 5 - Identify Venue /delivery vehicle Convened March 2011 at H.A.C. Vancouver 28
JHSIT Canada H.A.C. Convention & Website CHC Safety Symposium TC Aviation Safety Newsletter Trade Publications 29
-22- Questions? 30