1. Preliminary Results EHEST Conference 13 October 2008 Cascais, Portugal

2. Preliminary Results2 Contents Data set description General data Identified factors data Standard Problem Statements HFACS Intervention Recommendations Concluding Remarks & Way forward

3. Preliminary Results3 Data set description Preliminary Results Picture Source AgustaWestland

4. Preliminary Results4 Scope of analysis Based on a data driven approach Focus on: Accidents (definition ICAO Annex 13) Date of occurrence year 2000 - 2005 State of occurrence located in Europe For this purpose Europe is defined as the EASA Member States (27 EU + plus Iceland, Liechtenstein, Norway and Switzerland) Only those accidents are being analysed where a final report from Accident Investigation Board is available

5. Preliminary Results5 Scope of preliminary dataset Total of 186 within timeframe 2000- 2005 have been analysed Covers work from 9 Regional Teams across Europe Does not cover all accidents within timeframe Preliminary results, not fully representative of European accidents in the reference period The following slides present preliminary results based on these 186 accidents

6. Preliminary Results6 Proportion of analysed accidents Estimated data for the 9 Regional Teams currently participating

7. Preliminary Results7 General Data Preliminary Results Picture Source Eurocopter

8. Preliminary Results8 General data Number of Accidents per Type of Operation

9. Preliminary Results9 General data

10. Preliminary Results10 General data Phase of Flight Distribution In hover Not in hover

11. Preliminary Results11 General data Injury level Distribution per Phase of Flight

12. Preliminary Results12 General data Pilot-in-Command Total Flight Experience in Hours All Helicopter Types

13. Preliminary Results13 General data Pilot-in-Command Total Flight Experience in Hours All Helicopter Types 0 – 1000 flight hours only

14. Preliminary Results14 General data Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type

15. Preliminary Results15 General data Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type 0 – 1000 flight hours only

16. Preliminary Results16 General data Pilot-in-Command Total Flight Experience in Hours All Helicopter Types Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.

17. Preliminary Results17 General data Pilot-in-Command Flight Experience on Type in Hours Accident Helicopter Type Note: Type of Operation at time of accident! Does not state the overall experience of the pilot for that ops type.

18. Preliminary Results18 Identified factors data Standard Problem Statements & HFACS Preliminary Results Picture Source AgustaWestland

19. Preliminary Results19 Identified factors data Two models used for identification of factors SPS HFACS Standard Problem Statements In total 1067 factors identified for all 186 accidents HFACS In total 445 factors identified for all 186 accidents

20. Preliminary Results20 SPS level 1 – All Accidents

21. Preliminary Results21 SPS level 1 compared with US JHSAT data Correlation is:.89

22. Preliminary Results22 SPS level 2 (top 10)– All Accidents (excluding Data Issues)

23. Preliminary Results23 Organisational Influences Unsafe Supervision Preconditions for Unsafe Acts HFACS model Merely symptoms Facilitate identification of the underlying causes

24. Preliminary Results24 Unsafe Acts ErrorsViolations 16% 84% 60% Skill-based Errors Perceptual Errors Judgement & Decision-Making Errors 12% 28% HFACS model – upper levels

25. Preliminary Results25 Preconditions Environmental Factors 17% Condition of Individuals 60% Personnel Factors 23% HFACS model – upper levels

26. Preliminary Results26 Supervision Failure to Correct Known Problem Planned Inappropriate Operations Inadequate Supervision 41% 59% Supervisory Violations 0% HFACS model – upper levels

27. Preliminary Results27 Organisational Influences Resource Management Organisational Climate Organisational Process 64% 24% 12% HFACS model – upper levels

28. Preliminary Results28 Going into more detail The following slides present the lowest level in the taxonomy: level 3 This provides a more detailed insight into the type of accidents occurring Results will be presented for the three main types of operation Commercial Air Transport Aerial Work General Aviation

29. Preliminary Results29 An example Commercial Air Transport scenario Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow.

30. Preliminary Results30 An example Commercial Air Transport scenario Once the patient was boarded the helicopter took off despite the degraded weather condition because an ambulance was waiting to bring the patient to the hospital. The helicopter hit the ground (snowed surface) with the right skid and nosed over just after take off in poor visibility due to falling and blowing snow. Loss of Visual Reference Inadequate decisions Pilot felt pressure

31. Preliminary Results31 SPS level 3 (top issues)– Commercial Air Transport

32. Preliminary Results32 HFACS level 3 (top issues)– Commercial Air Transport

33. Preliminary Results33 An example Aerial Work scenario During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. The helicopter lost altitude, contacted the surrounding trees and crashed.

34. Preliminary Results34 An example Aerial Work scenario During vertical take off with external cargo from a confined landing area in the forest, the helicopter started to rotate to the left after having cleared the tree tops. The helicopter lost altitude, contacted the surrounding trees and crashed. Operated near maximum take-off mass Loss of tail rotor effectiveness Tailwind Pilot intensive Obstacles Cargo not released

35. Preliminary Results35 SPS level 3 (top issues)– Aerial Work

36. Preliminary Results36 HFACS level 3 (top issues)– Aerial Work

37. Preliminary Results37 An example General Aviation scenario The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact.

38. Preliminary Results38 An example General Aviation scenario The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. The helicopter then suffered an in-flight collision with terrain directly after the loss of radar contact. No weather forecast obtained No flight plan filed Limited experience Inadvertent IMC No contact established with ATC

39. Preliminary Results39 SPS level 3 (top issues)– General Aviation

40. Preliminary Results40 HFACS level 3 (top issues)– General Aviation

41. Preliminary Results41 Intervention Recommendations Preliminary Results Picture Source Jaume Bosch

42. Preliminary Results42 Intervention Recommendations In total 11 Intervention Recommendation categories identified The categories help identify areas for working groups of EHSIT Note: some categories do overlap but they do succeed in suggesting areas to focus

43. Preliminary Results43 Intervention Recommendations for All Accidents Intervention Recommendation Categories – All Accidents Flight Ops & Safety Management/Culture

44. Preliminary Results44 Overview of top categories Flight Ops & Safety Management/Culture Regulatory Training/Instructional

45. Preliminary Results45 Example IRs Within each IR type there are a wide range of different interventions that have already been identified so far The following are some un-prioritised examples from across all operational categories:

46. Preliminary Results46 IRs Examples: Training/Instruction Better training for specific missions & operating environments E.g.: Improve training for mountain operations specifically for landing on snow covered surfaces Better training for inadvertent entry in IMC condition Better training on type specific issues and operational limits. Special training supervision arrangements should be considered when dealing with slow learning students who are taking longer to complete the PPL(H) syllabus.

47. Preliminary Results47 IRs Examples: Training/Instruction Instructors/examiners be updated more regularly by TRTOs. Establish measures to avoid culture of non- compliance Include risk assessment training Encourage organising private helicopter pilots into flying clubs etc for mutual support and better exchange of experiences / safety information

48. Preliminary Results48 IRs Examples: Flight Ops & Safety Management/Culture Develop safety management system (SMS) Promoting a safety culture vs. getting the job done regardless Investigate the user-friendliness of checklists Manage human factors risk especially regarding routine violation Use a Flight Data Monitoring system to give feedback to pilots Increased oversight of new pilots During the mission preparation, the management should take into account the experience of each crew member and mix the different skills. Better planning especially for higher risk missions Increase awareness of obstacles & provision of Wire Strike Protection System

49. Preliminary Results49 IR Examples: Regulatory Require greater flight data recording usage to assist in future occurrence investigation Promote research inexpensive, lightweight, airborne flight data and voice recording equipment for smaller helicopters VFR flight criteria for helicopters and licence privileges for pilots should be reviewed to reduce the risk from flight in a Degraded Visual Environment Review the deck markings on ships involved in winching operations with the aim of including a requirement to clearly display the dimensions of the 'manoeuvring zone', such that it can be clearly seen by the helicopter crew. Establish specific training requirements for operational crew members other than flight crew required for aerial works operations.

50. Preliminary Results50 Other Selected IR Examples Improve crashworthiness & survivability Improve OEM manufacturing quality assurance Establish safe limits of helideck movement for helicopters operating offshore Validated, simplified weight and balance process should be made available Provide better information on aircraft fuel consumption for pilots to safely plan flights on the basis of verified fuel contents. Type specific airworthiness improvements Making specific safety enhancing equipment part of the build standard Making specific equipment available for operators to adapt aircraft for specific missions / environments

51. Preliminary Results51 Intervention Recommendations - Way forward It is expected the EHSIT will need to prioritise the Interventions Recommendations based on safety benefit and practicality Different types of EHSIT organisations can be envisaged: By type of operation By type of recommendation By type of activity Mix of the above Other Centralised or regional-based

52. Preliminary Results52 Concluding Remarks & Way forward Preliminary Results Picture Source Eurocopter

53. Preliminary Results53 Concluding remarks EHSAT analysis covers European wide helicopter accident data Preliminary results already provide indication of type of accidents Preliminary results will be used by EHSIT And shared with IHST

54. Preliminary Results54 Concluding remarks Main accident factors are operational. The top 3 are: Pilot judgment & actions Safety management /culture Pilot situation awareness High correlation with US results Different patterns for: Commercial Air Transport Aerial Work General Aviation

55. Preliminary Results55 Concluding remarks HFACS provided a complementary perspective on these factors and together with SPS, was used to produce recommendations The top 3 intervention recommendation categories are: Flight Operations and Safety Management/Culture Regulatory Training / Instructional

56. Preliminary Results56 Way forward EHSAT will continue analysis to complete 2000-2005 timeframe Intervention recommendations will be handed over to the implementation team, the EHSIT EHSIT will be launched after this Conference And we would like you to join

57. Preliminary Results57 Thank you for your attention Questions? European Helicopter Safety Team EHEST