International Helicopter Safety Team IHST Update November 2010 Turbomeca Safety Conference Brazil South America Ana Claudia Malagrino Galvao - IHST Brazil JHSAT Co-Chair 1

IHST Goal: To reduce worldwide helicopter accident rate by 80% by 2016! Reduce accidents…save lives!!!

This is where we were… Make the case for change 20+ years of accident trends across the US, Military and International fronts Levels are unacceptable Need unique solutions to break the trend Need participation from all sectors, civil, military and international This is where we were…

IHST is a worldwide effort with over 300 volunteers All IHST participants using a process adapted from CAST. Key attributes: All recommendations directly rooted in accident data. Regional ownership – - Data is owned and analyzed by those most familiar with it. - Safety recommendations are implemented by teams most familiar with local needs and challenges. US JHSAT and JHSIT lead teams are responsible for training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness 4

Joint Helicopter Safety Safety enhancement development Results measurements Data analyses IHST Joint Helicopter Safety Analysis Team (JHSAT) Implementation Team (JHSIT) Joint Helicopter Implementation Measurement Data Analysis Team (JHIMDAT) International Helicopter Safety Team (IHST) We need to use proven methods to identify problems and put necessary changes into place. The CAST initiative developed a method that has great success in the commercial aviation world. We’re adapting it for use with helicopters. Three basic tenants: Based on real accident data Solutions developed by helicopter community stakeholders Actions taken can be measured for effectiveness. IHST is following a proven model

Worldwide participation is key to success 48% of helicopters fly in North America However, we wont make our target if we don’t engage with the worldwide community. Source : IHST– Dec 2009 Worldwide participation is key to success 6

IHST Program - Regional Process Tracking 2006 2007 2008 2009 2010 IHSS Formed Excom Formed US Europe Canada TBD Metrics Brazil Australia Mid East Today Japan Russia 1 2 3 4 Regional Kickoff Meeting JHSAT Team Formed Key: Accident Dataset Established JHSAT Report Issued 5 6 JHSIT Formed JHSIT Process Refined E 7 JHSIT SEs complete 8 JHSIT DIPs complete India IHST Program - Regional Process Tracking Program staffing, sales, marketing, management, communications, international outreach Regional “exploratory” mtg

IHST Worldwide Progress Toward 80% Goal (Through August 2010) 2005 2007 2009 9.4 1.9 Note accident rate is lower the year following fall IHSSs IHST Metrics - Flight Hours 10 August 2010 8

IHST US Registered Progress Toward 80% Goal (Through August 2010) 2007 2009 2005 9.1 1.8 Note accident rate is lower the year following fall IHSSs IHST Metrics - Flight Hours 10 August 2010 9

IHST Metrics - Flight Hours 10 August 2010 Accident Rates Vary by Region of the World Civil registered helicopter accidents and flight hours from IHST data Pre-IHST (2001-2005) accident rates vs. 2010 through August accident rates North America Pre: 9.3 2010: 4.8 South America Pre: 9.7 2010: 7.4 Europe Pre: 7.1 2010: 6.6 Africa Pre: 12.9 2010: 7.9 Asia Pre: 9.4 2010: 8.3 Oceania Pre: 17.5 2010: 14.0 Accuracy of flight hour exposure estimate improves every year. World 2010 August: 6.1 Accidents per 100K flt hrs 27 Sep 2010 IHST Metrics - Flight Hours 10 August 2010 10

International Regional Partners IHSS 2010 - Cascais, Portugal Updates from EHEST, US, Japan, Canada, Brazil, India and Middle East EHEST – EHSAT 2000-2005 Report US – JHSAT 2006 Report Panel Discussion – Regional Leads Sharing data and partnership Implementation Challenges

Another way of determining where the problem reside, this time by category rather than mission. 13

Data set – NTSB Accident Dockets US JHSAT Data set – NTSB Accident Dockets U.S. civil registered helicopters Type certificated (amateur built helicopters excluded) Includes ‘Public Use’ and restricted category Total of 523 helicopter accidents analyzed CY2000 - 197 accidents (Report issued IHSS 2007) CY2001 - 174 accidents (Report issued IHSS 2009) CY2006 - 152 accidents (Report issued IHSS 2010) We all know about the Jim Reason’s Swiss Cheese model. The JHSAT uses a similar concept. They analyze the NTSB accident docket and any other information that may be available for an accident. Google Earth is an excellent source to see how terrain may have factored in to an accident. The JHSAT does not second guess the NTSB’s Probable Cause, instead they identify where an action, or inaction, is documented that eventually led to the accident. These actions are then tabulated as a Standard Problem Statement (SPS). The thought being that each SPS is like a hole in the Swiss cheese. When the holes line up, the accident occurs. This theory is such that by covering that hole the accident may have been avoided. So what is the ‘best’ way of covering the hole? The team decides on the best Intervention Recommendation (IR) for that particular circumstance. When all accidents have been analyzed, the SPSs and IRs are totaled and prioritized by Frequency. Again, what are the most common problems that resulted in an accident and what are the most common Interventions that will have the greatest impact on the Accident Rate.

Recommendations Top 10 from CY2006 Report Install Cockpit Recording Devices, 88 Improve Quality and Depth of NTSB Investigation and Reporting, 76 Training Emphasis for Maintaining Awareness of Cues Critical to Safe Flight, 26 Autorotation Training Program, 21 Follow ICA Procedures with Confirmation of Compliance, 18 In-flight Power/Energy Management Training, 17 Recommend Enforcement Action–Certificate Suspension/Revocation, 16 Mission Specific Risk Management Program, 16 ADM Training, 16 Establish mission Specific SOP and Flight OPS Oversight Program, 15 In CY2006, the JHSAT made 858 recommendations for the 152 accidents analyzed. When duplicates were collected and rolled up, there were 165 different recommendations. Obviously not all 165 can be acted on by the JHSIT is a given year, so the report tabulates the Top 20. To keep this chart readable, only the Top 10 are presented here. Leading this list is the recommendation to install cockpit recording devises – HFDM. This recommendation was made in 88 of the 152 accidents. Follow ICA Procedures was recommended in 18 of the 152 accidents. You can find the complete chart in the CY2006 Report.

IHST Toolkits – Developed by US JHSIT IWGs www.IHST.org - Safety resources - IHST Toolkits Maintenance toolkit forthcoming Updates to SMS, FDM, and Training Toolkits - February 2011 16

Current US JHSIT Toolkits Answers 8 of the Top 10 US Intervention Recommendations (IRs) Supports Worldwide Regional Team Interim IRs Helicopter Flight Data Monitoring Toolkit Install Cockpit Recording Devices Training Toolkit Training Emphasis for Maintaining Awareness of Cues Critical to Safe Flight Autorotation Training Program In-flight Power/Energy Management Training ADM Training SMS Toolkit Mission Specific Risk Management Program Establish mission Specific SOP and Flight OPS Oversight Program Maintenance Toolkit Follow ICA Procedures with Confirmation of Compliance This chart shows how the toolkits address the JHSAT’s recommendations. Of the Top 10 we just looked at, their Toolkits cover 8 of them already.

Sub-group on Communication EHSIT Specialist Teams Core Team EHSAT Sub-group on Communication Regional Teams EHSIT Specialist Teams ESSI is a 10 year programme (2006-2016) aimed at improving aviation safety in Europe, and for the European citizen worldwide Partnership, with more than 150 organisations Powered by industry and facilitated by EASA Launched on 14 November 2006, EHEST brings together manufacturers, operators, research organisations, regulators, accident investigators and a few military operators from across Europe. EHEST is the helicopter branch of the ESSI, and also the European component of the International Helicopter Safety Team. More than fifty organisations participate in EHEST to date, of which around thirty are actively involved in EHSAT and EHSIT.

Scope of analysis Data driven approach Accidents (definition ICAO Annex 13) Date of occurrence year 2000 - 2005 State of occurrence located in EASA MS Final report from AIB available Preliminary results presented Oct 2008 186 accidents Final report results presented October 2010 311 accidents Available www.IHST.org The EHSAT analysis scope has been initially limited to accidents (definition ICAO Annex 13) reported by the accident investigation boards, with date of occurrence between 2000 and 2005 and State of occurrence located in Europe. In order not to interfere with ongoing accident investigation board investigations, only those accidents are analysed where a final investigation report is available. For this purpose Europe is defined as the EASA Member States (27 EU + plus Iceland, Liechtenstein, Norway and Switzerland) Important to note that this initiative combines European wide data. 19

EHSIT Products Two products are ready: Safety consideration for helicopter pilots leaflet Degraded Visual Environment (DVE) Vortex Ring State Loss of Tail rotor Effectiveness (LTE) Static and dynamic rollover Video on Degraded Visual Environment (DVE) http://vimeo.com/15479359 View both on IHST website (www.IHST.org)

Maintenance Toolkit The Maintenance Toolkit will address Comprehensive guidelines for cost-effective maintenance Self-assessment guideline The Toolkit is scalable for all sizes and types of helicopter operators Expected publication date – 1st Quarter 2011 On the IHST website

SMALL OPERATOR’S INVOLVEMENT WORLDWIDE Holding factors Possible factors for success Difficult economical situation Limited financial and human resources Complexity of rules and regulations High personnel costs Non educated to Safety Customers Communication Motivation Support

IHST Communications Update IHST is engaged with the European Helicopter Safety Team’s communications group to revitalise the IHST website. SKYbrary Partnership – Helicopter Safety Portal FAA Safety.gov – FAASTeam Link to WINGS Program and Helicopter Training Products Global HFDM Committee Multi-lingual Website and Toolkits Please put a link to the IHST website (www.IHST/org) on your own website. Communication Support

IHST Supports Accreditation Program (s) HAI, EHA, BHA announced June 09, 2010 their partnership with IS-BAO/IBAC on development and management of the Helicopter Version of the IS-BAO Standard European CEN Standard Covers more than SMS Bob Sheffield (IHST Exec Director) –HE Standards Workgroup Chairman Motivation Support

Insurers’ Support for IHST We are presenting IHST recommendations and toolkits at various insurance industry conferences in North America and worldwide. IHST Insurance Liaison to facilitate Insurance Education forums, sponsored by HAI Discussions on sharing data and partnership Motivation Support

Heli-Expo 2010 - A Call for Action by Helicopter Owners In a ringing endorsement of the IHST safety initiative, the Chief Executive Officers of AgustaWestland, Bell Helicopter Textron, Eurocopter and Sikorsky Aircraft gathered at Heli-Expo to sign a joint letter captioned “A Call for Action by Helicopter Owners.” The letter calls upon “all those who operate our products to implement the safety enhancements recommended by the International Helicopter Safety Team (IHST).” The four areas cited in the letter are the adoption of: Safety Management Systems (SMS) Improved Training Use of advanced systems/equipment Flight data monitoring systems (FDM) Health monitoring systems (HUMS) Use of mission-specific equipment Night vision goggles Avionics to avoid controlled flight into terrain Strict compliance with manufacturer’s maintenance program Industry Support The four areas of concentration cited in the letter are the adoption of Safety Management Systems (SMS); improvements in training; the use of advanced systems and equipment, such as flight data monitoring systems (FDM); the use of health monitoring systems; and the use of mission-specific equipment, such as night vision goggles for night flying and avionics to avoid controlled flight into terrain; and strict compliance with the manufacturer’s maintenance program.

IHSS 2010 - A Call for Action by Off Shore Operators In a ringing endorsement of the IHST safety initiative, the following ten offshore operators signed a joint letter of commitment captioned “A Call to Action by and for Offshore Helicopter Operators” -- Bond, Bristow, BIH, CHC, Cougar, Dancopter, Era, Heli-Union, Inaer, and PHI. The letter calls upon “all those who operate helicopters in the offshore environment to implement the manufacturers’ recommended maintenance and flight operations practices and the safety enhancements recommended by the IHST”. The four areas cited in the letter are the adoption of: Safety Management Systems (SMS) Improved Training Use of advanced systems/equipment Flight data monitoring systems (FDM) Health monitoring systems (HUMS) Cultural/Behavioural Change, and Crew Resource Management (CRM) Programs Industry Support The four areas of concentration cited in the letter are the adoption of Safety Management Systems (SMS); improvements in training; the use of advanced systems and equipment, such as flight data monitoring systems (FDM); the use of health monitoring systems; and the use of mission-specific equipment, such as night vision goggles for night flying and avionics to avoid controlled flight into terrain; and strict compliance with the manufacturer’s maintenance program.

Thank you for your attention The challenge now is to expand our efforts worldwide and continue the development and implementation of effective measures to meet and some day exceed the 80% accident rate reduction target Thank you for your attention Questions? 28

Sue Gardner – IHST Program Director sue.gardner@faa.gov Telephone: (630) 880-5834 Ana Claudia Galvão – Co-chair JHSAT-Brazil ana.galvao@chc.ca Telephone: +55 21 2189-0050