1. Accident Data & Statistics
U.S. Rotorcraft
Accident Data & Statistics
Lee Roskop, FAA
Rotorcraft Standards Staff
International Helicopter
Safety Team
Scott Tyrrell, FAA
Rotorcraft Standards Staff
U.S. JHIMDAT Government Co-Chair
January 23, 2013

2. Overview
Accident Data and Trends
Industry Sector Analysis
Analysis by NTSB Finding Code
Recent Concerns
IHST Review
SPSs, IRs, Occurrences
U.S. JHIMDAT Current Actions
Questions and Answers

3. U.S. Rotorcraft Accident and Fatal Accident Counts
16% decrease 152 accidents in 2009 to 129 accidents in 2011 but lost nearly all of that improvement with a 15% increase from 129 accidents in 2011 to 148 in 2012

4. U.S. Rotorcraft Accident & Fatal Accident Rates
Estimated 11% increase in accident rate, 25% in fatal accident rate from 2011 to 2012
*Rates estimated using flight hours from the FAA’s GA & Part 135 Activity Survey

5. Current Accident Rates vs. IHST Goal
IHST’s U.S. Goal by 2016: 1.8 accidents per 100,000 flight hours

6. Measuring Significance of Improvements
5 Year Snapshots by Month
Plotted average accidents by month
Superimposed lines for 2 x standard deviation
Observed progress based on 5 year increments
Plotted
Plotted

7. Average Accidents/Month: 2001-2005

8. Average Accidents/Month: 2001-2005 with 2 x Standard Deviation
The dashed blue lines represent 2 standard deviations above and below the red line.

9. Average Accidents/Month: Comparing 2001-2005 with 2006-2010
The lower the green line plots below the red, the better. Ideally we’d like to see the green line plot closer to the bottom dashed blue line.

10. Average Accidents/Month: Comparing 2001-2005 with 2011-2015
The time period currently is only populated by 2 years, 2011 and Some nice reduction during the summer months, but stagnancy in many Spring and Fall months.

11. Industry Sector Analysis

12. IHST Industry Analysis: 2000, 2001, 2006: 523 Accidents
46.4% attributable to Personal/Private, Instructional/Training, and Aerial Application

13. FAA Follow Up On Industry Analysis: 2010-2012: 411 Accidents
61.3% attributable to Personal/Private, Instructional/Training, and Aerial Application

14. IHST Industry Analysis 2000, 2001, 2006: 84 Fatal Accidents
Note that while Instructional/Training is still 3rd highest in the chart, the fatal accident percentage is much lower than the accident percentage from the previous chart. Not so for personal/private. Note also the location of Aerial Application in this pie chart for comparison on the next slide.

15. FAA Follow Up On Industry Analysis: 2010-2012: 69 Fatal Accidents

16. Accident Rate Estimates (per 100,000 flight hours)
2000, 2001, 2006
Personal/Private
31.99
Instructional/Training
7.84
Aerial Application
11.35
Helicopter EMS
3.70
Personal/Private
25.71
Instructional/Training
4.96
Aerial Application
16.99
Helicopter EMS
1.87
1. Flight hours from CYs 2000, 2001, 2006, 2010 extracted from FAA’s GA & Part 135 Activity Survey.
2. Flight hours from CYs 2011 and 2012 estimated using historical flight hour increase of 3% per year over CY 2010 hours.
High number of accidents compared to low amount of exposure (flight hours) means high accident rates for personal/private, instructional/training, and aerial/application. Note the increase in aerial application rate in estimates.

17. Fatal Accident Rate Estimates (per 100,000 flight hours)
2000, 2001, 2006
Personal/Private
6.27
Instructional/Training
0.60
Aerial Application
0.84
Helicopter EMS
0.93
Personal/Private
5.60
Instructional/Training
0.31
Aerial Application
1.46
Helicopter EMS
0.55
1. Flight hours from CYs 2000, 2001, 2006, 2010 extracted from FAA’s GA & Part 135 Activity Survey.
2. Flight hours from CYs 2011 and 2012 estimated using historical flight hour increase of 3% per year over CY 2010 hours.

18. NTSB Findings from 2008-2012 NTSB Methodology 0303403582
Assigns multiple “Findings” to each accident
Since 2008, each “Finding” uses a 10 digit “Finding Code”
Each 2 digits in the code drills down to a more specific factor
For example:
Analyzed most frequently used “Finding Codes”
Codes in place for 479 of the rotorcraft accidents from
May show best opportunities for improving safety
Environmental
issues
Physical
environment
Terrain
Snowy/icy
Effect on
operation
Only about half the 2008 accidents were assigned a finding code. For the other years, particularly 2012, there are accidents were the investigation is still open so a code has not yet been assigned.

19. Top 2 digit “Finding Codes”
Personnel Issues:
Cited in 77% of accidents
Aircraft:
Cited in 71% of accidents
Environmental Issues:
Cited in 40% of accidents

20. Top 10: 4 digit “Finding Codes”

21. Top 10: 6 digit “Finding Codes”

22. Recent Trends: 2012 closes poorly
Oct-Dec 2012
Accidents
60% higher than same period in 2011
Highest Oct – Dec total in 5 years
Tied, 2nd highest Oct – Dec total last 10 years
Fatal Accidents
57% higher than same period in 2011
Tied, highest Oct – Dec total last 10 years
Mitigation efforts by FAA, HAI, AOPA, and IHST
Mass media effort in mid October after 4 fatal accidents in 8 days

23. Recent Trends: 2013 starts poorly
January 2013
Record setting accident pace during first 9 days
7 accidents, 3 fatal accidents, 11 fatalities
If sustained, pace was for 24 accidents, 9 fatal accidents, 38 fatalities
Projection would have far exceeded highest total for any January the last 30 years
Accident pace slowed during mid month
Still projected to have a high total, but not record setting

24. What has changed? 5 years of steady progress
Consistent improvement, despite lagging the IHST’s desired 80% accident rate reduction
4 consecutive months of regression
Especially concerning since we are in the traditionally “lower accident” months

25. Recent FAA Safety Alert for Operators (SAFO)
Increased manual handling errors for Air Carrier pilots
Effects of modern aircraft technology
Pro: Enables precision, improves workload management
Con: Continuous use can lead to degraded pilot ability to quickly recover the a/c from an undesired state
Recommendations:
More training on when to use automated systems
More exercise of manual flying skills
Lesson:
Technology and Training must compliment each other
Cockpit advances should facilitate (not replace) basic pilot skills/decisions

26. IHST Review

27. US-JHSAT: Past Efforts
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
CY accidents (Report issued IHSS 2007)
CY accidents (Report issued IHSS 2009)
CY accidents (Report issued IHSS 2010)
Compendium Report – 3 year roll up/summary (Report issued 2011)
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.

28. US Accidents by SPS Lvl 1 - Compendium

29. US Accidents by IR Lvl 1 - Compendium

30. US Accidents by Occurrence Types - Compendium

31. Loss of Control Details - Compendium

32. Intervention Recommendations - IR3 Top 10 from “Compendium” Report
Install cockpit recording devices
Improve quality and depth of NTSB investigation and reporting
Autorotation Training Program
Follow ICA procedures with confirmation of compliance
Simulator Training - Advanced Maneuvers
Personal Risk Management Program (IMSAFE)
Training emphasis for maintaining awareness of cues critical to safe flight
Better Mx QA oversight to ensure adherence to the ICA/Manual
Mission Specific Risk Management Program
Enhanced Aircraft Performance & Limitations Training

33. Current JHSIT Toolkits “Addresses” 8 of the Top 10 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
Fred Brisbois will talk in more detail about the JHSIT’s toolkits, but this chart shows how their toolkits address the JHSAT’s recommendations. Of the Top 10 we just looked at, their Toolkits cover 8 of them already.

34. From JHSAT to JHIMDAT Goals of analysis evolved in 2011
JHSAT complete: Identified problems and recommended interventions
JHIMDAT initiated: Measure progress of implementation actions
Economic realities = more resource constrained effort
Economic downturn resulted in reduced industry participation
Original meetings of once/month reduced to 3-4 times annually
Detailed analysis on every accident not performed
Time consuming process not feasible with more limited meeting times
More strategic effort toward specific targeted areas
Industry may need to lead in areas where deeper study is desired

35. Current US JHIMDAT Analysis Efforts
Assess Progress by Analyzing Recent Years
Data set from CY2009 – 2011
High level analysis has categorized:
Industry where a/c is used
Activity being performed when accident occurred
Occurrence/Sub-Occurrence Code defined “What Happened?”
Compare CY09-11 results to data in Compendium
So where does the JHSAT go from here. First, the 3 years of data is being compliled into a single dataset. As the analysis methodology changed slightly over the years, this is not a trivial task, but is nearing completion. A compendium report will be available for next year’s IHSS in Fort Worth TX.
The compendium will provide a more statistically relevant baseline of how helicopters were crashing pre-IHST. It will also provide the baseline that post-IHST safety enhancements have affected helicopter safety.
The JHSAT will also use the Compendium Report to generate Pocket reports for specific missions and common occurrence types.
We need to get the message out to all operators.

36. U.S. JHIMDAT Future Efforts
Targeted Industry Outreach
ALEA
Ag Ops
NTSB Finding Codes
Compare findings from recent accidents to Compendium
Improved tracking of System Component Failures
Classify system failures using established taxonomies
Air Transport (ATA)/Joint Aircraft System/Component (JASC)
Update to Compendium, compare recent accidents

37. IHST Upcoming Action Items
Launch Regional Teams
North America Helicopter Safety Team (NAHEST)

38. Questions?

39. Back-up IHST Slides

40. US Accidents by Operation
Most accidents occur in Part 91 operations. Not surprising, this is the FAR part most helicopters operate under.

41. US Accidents by Mission
Most accidents occur in Personal or Training flights. This is where operating hours would help us refine the picture. Rather than the raw number of accidents, where is the highest accident rate.
For instance, look at aerial application. In CY2000, Aerial Application represented 14% of all helicopter accidents in the US. By CY2006, it was only 4% of the total. Were they suddenly that much safer? Or were they flying less helicopters in that mission.
Helicopter EMS on the other hand got progressively worse as the time went on. Or did it? The HEMS industry was growing during this period.
Without flight-hour data, by mission, it is difficult to tell the whole story.

42. US Accidents by SPS Lvl 1
The US JHSAT started analyzing the CY2000 accident data. These NTSB had completed the investigations and had closed the dockets on most of these accidents. In addition, litigation on the accidents had been completed. This allowed the manufactures and operators the freedom to discuss the accidents in an open forum.
After CY2000 was complete the JHSAT started on CY2001 for the same reasons and then began the CY2002 data set. The story, as you can see by this chart, was relatively constant. Rather than complete CY2002, the JHSAT, with the approval of the IHST ExComm, went to the last year of accidents prior to IHST beginning; CY If CY2006 looked the same as 2000 and 2001, the intervening years could be assumed to follow the same pattern.
For the 523 accidents analyzed, Pilot Judgment and Actions, Data issues, and Safety Management Systems were the three most frequently cited issues.

43. US Accidents by IR Lvl 1
Likewise, Training, Data Information (including HFDM), and SMS were the 3 most frequently cited Intervention recommendations.

44. US Accidents by Occurrence Types
When the JHSAT first started analyzing accidents, we assumed that widely varying missions, would have their own unique sets of Problems and corresponding recommendations. The JHSAT was surprised at the end of the analysis to see that 80% of the recommendations were NOT specific to any mission.
This presented a problem to the Implementation team. The former Co-Chair of the US-JHSIT asked the JHSAT to tell him HOW the helicopters were crashing. This led to a new form of analysis. Instead of analyzing by mission, the JHSAT began analyzing by Occurrence Type. The JHSAT used a modified CAST-ICAO Common Taxonomy Term (CICTT) to identify what type of accident occurred.
In this type of analysis, an accident can have more than one occurrence type associated. For instance, if the T/R driveshaft fails, the pilot may attempt an autorotation. By virtue of being in the accident database, the autorotation was probably not successful. If the pilot lost control and crashed the helicopter, there would be three occurrence type associated.
Coincidently, the chart shows Loss of Control, Autorotation, and System Component Failure as the top three occurrence types in the US analysis.

45. Loss of Control Details
To assist the JHSIT in coming up with effective Safety Enhancements, the JHSAT subdivided many of the occurrence types.
There are many ways to ‘Lose Control’ and each may have a different way to prevent it in the future.
Performance Management, allowing the rotor RPM to fall off for example, was the leading cause of Loss of Control. But look at number 4 – Interference with Controls. These are vastly different.