Objectives of Safety Investigations Current Investigation Process ACCIDENT/INCIDENT INVESTIGATION PANEL Objectives of Safety Investigations Current Investigation Process Adequacy of Investigation Resources Data Collection and Archiving Advocating for Change Investigation Tools General Welcome to the Accident/Incident Investigation Panel Objective of the International Helicopter Safety Seminar To reduce the number of helicopter accidents by 80% in 10 years Objective of the Accident/Incident Investigation Panel How can we, the members of the Accident/Investigation investigation community, contribute to the IHSS Goal Specifically, what are the Action Items that we can undertake to contribute to this goal. How can we generate ownership within our investigation areas Present suggested solutions to the rest of the members of this IHSS and the helicopter community. To focus our work for this morning, I will present some background information on the points depicted on this slide. Self introductions from the attendees.

Advance Transportation Safety Conduct Safety Investigations OBJECTIVES OF SAFETY INVESTIGATIONS Advance Transportation Safety Conduct Safety Investigations Safety Significant Events Unsafe Acts & Unsafe Conditions Underlying Factors Validating Safety Deficiencies OBJECTIVES OF SAFETY INVESTIGATIONS The basic objective of safety investigations is: To advance flight safety through The conduct of independent safety investigations by: Determining the safety significant events that lead to the accident or incident Defining the unsafe acts and conditions involved in these events Uncovering the underlying factors that contributed to each safety significant event Validating the safety deficiencies by doing A Risk Assessment A Defence analysis A Control Options Analysis

Issue Safety Communications Distribute Investigation Reports Briefings OBJECTIVES OF SAFETY INVESTIGATIONS Advocate for Change Issue Safety Communications Distribute Investigation Reports Briefings Seminars Working Groups ADVOCATING FOR CHANGE Issuing safety communications Investigation teams issue: Recommendations Advisories Safety Bulletins, and etc Directed at those who are in the best position to implement corrective actions Containing compelling arguments for changes that will mitigate the risks and recurrence Distributing Investigation Reports That contain compelling safety information To educate the helicopter community Holding briefings and conducting seminars To motivate the helicopter community Participating in Working Groups To review investigation data and reports To deepen research of the issues To develop more risk control options To make further recommendations for change

What should we investigate? To what extent do we investigate? CURRENT INVESTIGATION PROCESS What should we investigate? To what extent do we investigate? Should we look beyond this specific accident? DECIDING WHAT TO INVESTIGATE Driven by the level of resources available The investigation community has to make tough decisions Which occurrences do we investigate, We can’t do them all Do we only investigate accidents? Should we also investigate serious incidents? How deeply and thoroughly should we investigate Do we investigate more than just Finding out what happened Finding the one who was responsible for the unsafe acts and unsafe conditions? Determining the technical cause Finding a quick local fix to the problem Do we restrict investigation to only one occurrence: Should the investigation consider at other occurrences Should the investigation conduct research in its efforts to look for Trends, other risk control options

Independent Safety Investigations Dedicated, Trained Human Resources ADEQUACY OF INVESTIGATION RESOURCES Safety Culture Independent Safety Investigations Dedicated, Trained Human Resources Investigation Tools ADEQUACY OF INVESTIGATION RESOURCES Although I briefly mentioned resources when I talked about the decision as to what and how deeply we should investigate The issue of resources goes beyond the simple money issue We also have to look at: Does the industry as a whole or the involved companies have: The safety culture necessary for the conduct of independent safety investigations The number of personnel required to conduct investigations Trained personnel The tools required

Data Storage & Retrieval System Data Accessibility DATA COLLECTION AND ARCHIVING Correct & Quality Data Data Storage & Retrieval System Data Accessibility DATA COLLECTION AND ARCHIVING Do our investigations collect and record the correct and enough safety data Do we have adequate systems to store and retrieve investigation data What are the appropriate levels of control for an investigation data system: To much control makes the data useless To little control could compromise the integrity and independence of the investigation process Could restrict openness and willingness of persons to provide the investigation with accurate and complete information

Compelling Arguments for Change Effectiveness of Communications ADVOCATING FOR CHANGE Compelling Arguments for Change Effectiveness of Communications Tracking Actions Taken Degree of Risk Mitigation ADVOCATING FOR CHANGE Compelling Arguments for Change The success of our investigations, safety communications and reports will hinge on our ability to present compelling arguments for change that are based on accurate data, and flawless assessments and clear conclusions. The recommendations must also be based on thorough consideration of the risks, defences and control options. Effectiveness of Communications The effectiveness of our communications can be judged by: The level of acceptance of our recommendations; and The quality of the actions taken by stakeholders Tracking Actions Taken To evaluate the effectiveness of our recommendations investigators have to: Track the actions taken Degree of Risk Mitigation To complete the quality assurance cycle, investigators must: Assess the degree to which the risk have been mitigated by actions taken: Fully satisfactory, satisfactory intent, satisfactory in part, and unsatisfactory Determine the necessary follow-up or next steps: Case closed, monitor progress, take additional action

Investigation Methodology INVESTIGATION TOOLS Historical Data Trend Analyses Volunteer Reporting On-Board Recordings Investigation Methodology INVESTIGATION TOOLS The quality of an investigation relies on a number of factors In addition to the adequacy of resources and properly trained and equipped investigators, The quality of investigations rely on a number of other factors Historical Data The amount, quality and accessibility of data on past accidents, incidents and investigations Trend Analyses The availability of trend analyses and other safety study information Volunteer Reporting Although it may seem to be a stretch to consider voluntary reporting as an investigation tool, the existence of a volunteer reporting system is not only indicative of the presence of a safety management system, but also and indicator of a good safety culture that will ensure reporting. On-Board Recordings The lack of information regarding the accident pre-conditions and the accident sequence, significantly reduce the capability of an investigation to find the true underlying factors to a safety significant event. More and better on-board recorders would go a long way in filling this information void. Investigation Methodology The investigation methodology must include the search for the underlying factors and The production of meaningful and effective safety communications.

Single-pilot, VFR & Difficult Conditions CHARACTERISTICS OF HELICOPTER OPERATION Single-pilot, VFR & Difficult Conditions Remote Operations, Minimal Oversight Long Hour, Minimal Rest Minimal reporting, Few Investigations Limited Scope & Depth Investigations Discipline as a Corrective Measure Band-aid Solutions CHARACTERISTICS OF HELICOPTER OPERATION My Final slide Helicopter operations are unique in many ways: A significant proportion of operations are Single pilot VFR Remote operations Difficult conditions Long hours of work & minimal rest Difficult and minimal oversight Culture tends to result in: Minimal volunteer reporting Minimal interest in investigating incidents Almost total reliance on the pilots self-monitoring the safety of operations Tendency to limit the scope investigations to determine who or what failed. Tendency to use discipline to deal with unsafe acts. Tendency to use Band-Aid solutions for technical unsafe conditions

Current Investigation Process Adequacy of Investigation Resources ACCIDENT/INCIDENT INVESTIGATION PANEL Current Investigation Process Adequacy of Investigation Resources Data Collection and Archiving Advocating for Change Investigation Tools Objective of the Accident/Incident Investigation Panel How can we, the members of the Accident/Investigation investigation community, contribute to the IHSS Goal Specifically, what are the Action Items that we can undertake to contribute to this goal. How can we generate ownership within our investigation areas Present suggested solutions to the rest of the members of this IHSS and the helicopter community. The questions that we should consider are in the areas depicted on this slide My proposal is to handle them in the sequence shown Results in 30 minutes per topic, coffee break and a wrap-up Comments and suggestions before we start? You all should have a copy of the suggested questions for each topic