D H t i Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services
Overview Statistics IHST / EHEST Data Accident Examples Decision Making Theory Pre Departure Risk Assessment SMS and Decision Making Summary
Objectives Know that Decision Making is part of the accident chain There are two types of Decision Making theories with different characteristics Pre-flight RAs are excellent DM tool Mission critical decisions can be pre-planned Use RAs as long term metric Know that the RW community is different when it comes to RAs
IHST / EHEST Activities Goal (by 2016): Reduce accidents worldwide by 80% Method Analyze accidents for common causes Implement strategies to eliminate same Products Toolkits provided free of charge JHSAT JHSI T SMS, Training, Risk Assessment, HFDM, Mx D-V-E DVD Pilot Leaflet (DVE, LTE, Rollover, Vortex Ring State) (www.ihst.org) (www.easa.europa.eu/essi/ehest)
IHST Data Study analyzed 523 accidents in 2000, 2001 & 2006 Contributing Factors Pilot Judgment & Actions. 84% Data Issues. 73% Safety Management. 43% Ground Duties. 37% Pilot Situation Awareness. 31% Part / System Failure. 28% Maintenance. 20% Mission Risk. 19%
EHEST Study Study analyzed 311 accidents in 2000 ~ 2005 IHST Pilot Judgment & Actions 68% 84% Safety Management 52% 43% Ground Duties 40% 37% Data Issues 37% 73% Pilot Situation Awareness 34% 31% Mission Risk 28% 19% Part / System Failure 22% 28% Maintenance 14% 20%
Accident # 1 The Aircraft Single pilot, twin engine NVG capable The Pilot Ratings & hours unknown NVG trained The Environment Day VMC then Night IMC
Accident #1 The Flight Pick up hiker from mountain VFR flight plan The Accident Controlled flight into terrain Pilot, hiker killed Spotter survived
The Aircraft Single pilot, twin engine IFR equipped w/ autopilot NVG status unknown Accident #2 The Pilot Commercial, Instrument Helicopter 15+ years in area 8100 hours TPT The Environment Night VFR then Night (2100L) IMC Light Rain, Mist, Fog
Accident #2 The Flight Already offloaded patient Repositioning to base Radar track at 800 agl The Accident Controlled flight into water Debris path 70 long by 160 wide (at 525 deep) All major components accounted for at site Aircraft broke up Pilot, two flight nurses killed
Accident #3 The Aircraft Single pilot, twin engine IFR equipped w/ autopilot and coupled approach mode NVG capable but not in use, no TAWS The Pilot Commercial, Instrument Helicopter IFR qualified but not proficient 5200 hours TPT The Environment Night VFR then Night (2400L) IMC Fog
Accident #3 The Flight Diverting for weather to offload patient Called Approach for radar vectors to ILS On CL, GS, RoD increased from 500 fpm to 2000+ No level off at either MDA (LOC or ILS) The Accident On centerline 3 nm north of runway Impact 80 tree, debris path 164 long (50m) All major components accounted for at site Aircraft broke up Pilot, two medics, one patient killed One survivor (patient)
Accidents Summary Common elements (in no particular order) Single pilot Instrument rated Aircraft in good working order Weather started out OK, but went down quickly Decision to continue A/C capability not fully used (autopilot) Controlled flight into surface Nearly all killed
Decision Making Theory Analytical Decision Making Ideal for the following conditions clear goal or outcome plenty of time all conditions, factors are known From this, the decision maker can develop wide range of options evaluate and compare options choose the optimal path
Decision Making Theory Analytical Methods Example D detect the change E estimate need to react C choose desirable outcome I identify actions to manage change D do take action E evaluate effect on correcting situation Other aviation related analytical methods include IMSAFE, CARE, SADIE, TEAM, PAVE, 5Ps, 3Ss Do you use these? When? Which one(s)?
Decision Making Theory Analytical Method Characteristics Structured Time consuming Process breaks down with stress, limited time Analytical Methods Deliberate & thoughtful Better suited to Aircraft design Flight planning Aircraft purchasing
Decision Making Theory Intuitive Methods Fast Simple Memory based Work with limited information Option chosen probably OK, but not optimal Better suited to real time decision making g( (flying) and other dynamic, fast paced situations car driving, sports, combat
Decision Making Theory Naturalistic Decision Making (one intuitive DM process) Used in complex, fast paced situations Key features series of decisions interdependent (one affects the other) conditions constantly changing independently and as result of your action real time decision making (not planning) goals not well defined could be competing goals (safety vs ) decision maker is knowledgeable, experienced & professional (Peter Simpson)
Decision Making Theory Naturalistic Decision Making Not so much a method as the way we actually do things Step 1: Situation Assessment (SA) Problem definition identify problem goal(s) information sources needed to succeed prioritize incoming information disregard d ( park ) other stuff Risk assessment severity e & probability Time available
Decision Making Theory Naturalistic Decision Making Step 2: Course of faction (CoA) Potential solutions considered (in order of use) rule based one solution; procedure memory based; experience, sim, training choice options; this or that will work maybe memory but not always creative nothing obvious consider similar situations for solution Simulation mental test t of potential ti solutions and outcomes Act
Decision Making Types Comparison Factor Analytical Naturalistic Goals defined varied Pace (speed) slow fast Time available plenty limited Stakes low high Data complete incomplete Environment known changeable Participants many few Decisions as needed immediate Solution optimal OK
Naturalistic DM Errors Two basic areas Situation Assessment errors poor understanding of situation poor risk assessment misjudge time available Course of Action errors right rule, wrong time right rule, poor application choose wrong procedure or option In general More information, experience helps recognize the situation & solutions
Naturalistic DM Errors Contributing Factor: Motivations and Rationales Often competing goals Customer Financial Company Personal Peers Duty Rationales Justify the decision Macho Invincible Impulsive Resignation Anti authority Management must eliminate competing goals educate against rationales => Safety is primary goal => >Procedural compliance is key
Decision Making Errors People tend to.. Under estimate the situation Over estimate their ability
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SMS Basics Four Pillars of SMS Safety Policy Safety Risk Management Safety Assurance Safety Promotion ICAO Doc 9859, 2 nd Edition, 2008 Ref: FAA AC 120-92A 26
Safety Management Systems Safety Risk Management Risk Assessment Hazard Identification Methods Mitigation
Safety Management Systems Safety Risk Management Hazard Identification methods Audits Hazard reports Safety surveys Pre Departure Risk Assessments
Pre Flight Risk Assessment Many to choose from FAA Vendors Operators Industry groups HAI web site www.rotor.com/fra Most have the same categories Environment t/w Wx, Crew /HF, Operation /Flight, Aircraft
SMS Environment Flight SMS RISK ASSESSMENT Ops Human Factors Helicopter Some of this can be done at start of shift Directions for use 30
SMS Run checklist for mission + return SMS Major hazard Tally scores and check risk value Green = Go But major hazard needs mitigation Risk value Risk range 31
SMS Mitigation: Obstacles SMS Take credit on first page - 5 points Risk was 15 Now 10 Eurocopter rights reserved 32
SMS Mitigation codes Points deducted New risk value Eurocopter rights reserved 33
SMS Different conditions Weather is worse Pilot is less experienced Mitigation required What can we fix right now? Aircraft less capable Higher risk value Eurocopter rights reserved 34
SMS Mitigation: 1. Obstacles 2. Repair SMS Take credit on first page - 7 points Risk was 30 Now 23 Eurocopter rights reserved 35
SMS Mitigation details from page 2 SMS >20 with Mitigation. New risk Waiver score required! Eurocopter rights reserved 36
Final step on RA SMS If conditions get worse, then what? Pre-approved A chance to think it through in a no-threat environment Eurocopter rights reserved 37
SMS and Decision Making Review of DM process Analytical methods Ultimate goal in mind (safety) No threats at hand Time is not an issue Can think ahead Consult references, others Review multiple options Select optimum solutions Better suited to the planning process, so Do it before flying
Solutions may be the same on many flights Repeat is OK; it builds DM experience and consensus Experience is key element of good Naturalistic DM (SA & CoA) These serve as the limits or boundaries of what you can do Maybe not a lot of planning time but better than while flying Eurocopter rights reserved 39
Back to our SMS RA Waiver Approved! Use as briefing tool for crew Waiver Requested Keep RA with other paperwork Time to go flying Eurocopter rights reserved 40
Decision Making Points shown here for Now you are flying... Patient is on board discussion. We do NOT pull out the RA and recalculate Condition is critical and getting worse Flight plan is changing Weather is getting worse (300 and 1 nm) 2 > 4 Destination hospital is now closed for weather 2 > 4 Diverting to new hospital; unknown to you 0 > 2 At 90 % limit for fuel burn 0 > 1 Duty day extended to Back of the Clock 0 > 5 Previous total: 23 + 12 = 35 + 12 Risk matrix ORANGE band 20 ~ 39 goes RED at 40
Decision Making Cascading changes things are backing up Conditions deteriorating but still manageable However, fatigue is setting in still have to land, refuel and return you are busy with radio, GPS, fuel planning not the ideal time to make decisions But this is exactly when a decision is needed (Situation Awareness) You reached your preset limits
Decision Making What to do? (Course of Action) You are now well into the ORANGE band One more item puts you in the RED Land? Land and transfer patient? Keep going? Previous RA planning a) weather below FOM minimums LAND! b) 2 or more conditions changed for the worse LAND! Coord with ground unit; guide them to you
Decision Making It is recognized you cannot pre-plan for everything However we know that Real time decisions are hard to get right As conditions get worse, risks increase Recognizing the change (SA) is key, then Execute the well known, pre-planned planned decision (CoA) Under SMS We still Plan the Flight, Fly the Plan But, we also, under certain circumstances, Plan to Land, Land to Plan
Accident #1 NTSB Report The National Transportation Safety Board determines that the probable cause of this accident was the pilot s decision to take off from a remote, mountainous landing site in dark (moonless), night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot s fatigue, self-induced Decision ecso making pressure to conduct the flight, and situational stress. Also contributing to the accident were Competing goals deficiencies in the [operator s] safety-related policies, including lack of a requirement for a risk assessment at any point during the mission i No Risk Assessment
Accidents Revisited Three fatal CFIT accidents discussed previously VFR at beginning of flight Then deteriorated to IMC Decision made to continue Could use aircraft automation But, decided to continue visually Using this RA & DM briefing sheet Weather below FOM minimums: Land & Wait (Or, if IFR capable, go IFR)
Fables! Eurocopter rights reserved 47
The Camel The camel, kneeling, waited patiently for his master to finish loading him. One sack, two sacks, three, four When is he going to stop? the camel said to himself. Finally, the man clicked his tongue and the camel stood up. Let us go, said the master, pulling on the bridle. But the camel did not move. Come on! cried the man, jerking the rope. But the camel dug in his feet and stayed where he was. I see, said his master, and with a sigh he took two sacks down from the camel s back.
That, I think, is a fair weight, murmured the camel to himself, and at once began to move. They walked all day at a good speed and the man thought they would be able to reach the village. But, at a certain point the camel stopped. Courage, said the master, only a few more miles and we are there. The camel s only response was to lie down on the ground. My legs tell me, he said to himself, that we have walked enough for today. And the man was obliged to unload and to camp beside the camel in the desert. Fables of Leonardo Da Vinci, Hubbard Press, 1973.
Summary Decision making errors are real Well known part of accident causation Decision making is a dynamic activity Successful decision making is difficult on the go SMS activities can facilitate successful decision making The RA is a good tool for that Works as an excellent crew briefing tool We can modify the way we make decisions Try to make at least some of them in advance if this happens, then I will do that
(May need separate one for X-country) Consider Morning or Afternoon Modify Modify Different equipment Fire Fighting Morning No night ops No IFR ops Fire base Dip pond Days ON (more days, more points) Longline Bambi bucket (Inspected) 51
Implementation Question How to get this to (past) the pilots? More than a box checking exercise Builds situational assessment Good briefing tool Gives you an (honest) out Defends you if things go wrong Past management? Long term improvements System wide situational i assessment 52
Closing Comments What to do with all those Risk Assessments? Risk Assessments NOV 2009 15% 5% Ops Normal Mitigate, Waiver STOP WORK! 80% 53 53 Eurocopter rights reserved
SMS Tips: Safety Assurance Pre - Departure Risk Assessment Review 30 days worth 80 in the green 15 in the yellow 05 in the red What caused risky scores? Are there systemic factors? Develop corrective, preventive actions 54
SMS Tips: Safety Assurance 80 70 Risk Assessments Last 6 Months 60 50 40 30 Ops Normal Waiver, Mitigate STOP WORK 20 10 0 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 55
Safety Assurance This metric shows you are looking ahead at hazards reviewing i them for trends tracking efforts at continuous improvement This is a cornerstone of SMS
Thank You