2. Safety Enhancement in Helicopter Operations IHST Latin American Regional Conference Sao Paulo, Brazil Somen Chowdhury Executive Committee Member, IHST VP Internationl, AHS

3. Contents Why IHST : Background Objectives, Goals & Implementation Safety : in Design, manufacturing & operations - Every Step of the Way IHSS 2005 Montreal Conference IHST Regional Cooperation IHSS 2007 Conclusions

4. Background: Current State of Affairs  Too many  Accidents ~ 565/year worldwide  Lives lost Poor Public image  Business loss  InjuriesToo expensive UNACCEPTABLE

6. 24,294 Worldwide Civil Helicopters

7. Six Years Data 2000- 2005 Civil & Military uses –3049 accidents –2643 fatalities –1027 serious injuries –5439 minor/ no injuries

8. Worldwide Helicopter Accidents/ year 1980-2005 Source : Roy Fox Bell Helicopter

9. Accidents rates per 100,000 hr As per AUA ( Mike Kriebel): –2,225,000 total helicopter hours in USA in 2004 –Accident rate per 100,000 flight hours : 8.09 –Fatal rate 1.48 –Turbine civil accident rate : 5.11 –By contrast : U.S. Air carrier rate : 0.159 US data shows no change in rate over 24 years Need to bring down helicopter accident rates

10. Bell civil turbine accident causes worldwide (1994-2003) Source : Roy Fox, Bell Helicopter Textron

11. Causes of Accidents Bell Civil turbine accident causes world wide (Pie chart) –Non Air worthiness ( Human) 74% –Unknown 12% –Airworthiness 14%

12. Accident status in SAM countries SAM: covers South, Central and Carribean countries Reference ICAO report 297- AN/171presented in ICAO conference RAAC/9, Santiago Chile 2005 Data primarily discusses large transport aircraft accidents Conclusions of report generally valid for helicopter operations

13. SAM countries ( contd) 1992 – 2001 ( 10 year period) Transport A/c accident data Asia-Australia 26.8% of all accidents Europe 21% of accdnts 29% of oprns N.America 20.5% of accdnts 42% of opns Central &S. America 16.8 % vs 9% Africa 14.5% ICAO Conclusion : accidents 3.8 times more likely in Latin American countries than in USA & Canada

14. SAM countries (contd) ICAO statistics (297 AN/171 ADREP) mentions hull losses in the region is 2 to 3 times world average (from 1993 to 2002) Flight Safety Foundation suggests a risk multiplier of 5 be considered for CFIT for Central & S American airspace compared to Australia /N Zland /US & Canada

15. ICAO report conclusions Air cargo operations hull losses have tripled from 1993 to 2002 world wide : accidents 22 times more frequent than passenger operations Cause : Less attention paid; operational hours are different; older fleet Helicopter accidents are frequent ( do not have separate numbers) Main causes: Human Factors, maintenance, operational issues, situational awareness, training Helicopter accidents globally about 50 times more than passenger transport aircraft Less attention and lack of enforcement of safety practices seem to be the primary cause of increased accidents

16. The Real Challenge Iceberg Theory Hidden or Unseen Conditions are Below The Surface The BIG Picture 1 300 1200 10 Heinrich Ratio Serious Incidents Accidents Incidents Near Misses

17. The ‘Swiss Cheese’ Model Some holes due to active failures (present in use) Other holes due to latent conditions (present, not visible) Successive layers of defenses, barriers, & safeguards Hazards ACCIDENT Barriers are Safety Nets When barriers fail

18. The Danger… - is all around us!!!

19. Goals & Implementation Need to Act Can the industry do better ? How ? Need a mitigation Strategy

20. Need to Act Helicopter operations are essential There is a need to have a comprehensive hard look as to how we operate and do business There is an absence of any concerted plan so far IHSS 2005 was held in Montreal to kick – off the accident reduction process CAST (commercial aviation safety team) was considered a good model to follow

21. IHSS 2005 Montreal Conference Four day program –Training Sessions Management Military Maintenance –Invited Speakers –Paper sessions Military & Civil missions Human Performance & Training Design & Maintenance Accidents & Regulation Management & Economics –Discussion panels –Plenary session Results –Attendance ~250 –International 13 countries 5 continents –Industry wide Government Regulatory Accident Investigators OEMs Mission groups Operators Pilots Maintainers Aviation Press IHST set up

22. IHST Mission To provide government, industry and operator leadership to develop and focus implementation of an integrated, data-driven strategy to improve helicopter aviation safety worldwide, both military and civil. Vision To achieve the highest levels of safety in the international helicopter communities by focusing on appropriate initiatives prioritized to result in the greatest improvement in helicopter aviation safety. Goal To reduce helicopter accidents by 80% By 2016

23. Executive Committee IHST JHSATJHSIT Subcommittees Secretariat IHST Organisation JHSAT - Joint Helicopter Safety Advisory Team JHSIT - Joint Helicopter Safety Implementation Team

24. Implementation: Process Influence Safety Enhancements - Worldwide Data Analysis Set Safety Priorities Achieve consensus on priorities Integrate into existing work and distribute Implement Safety Enhancements - U.S. Agree on problems and interventions

25. Charters  Joint Helicopter Safety Analysis Team (JHSAT) Charter:  Conduct, review and analyse accident report and identify causal factors;  Investigate and recommend improvements and develop mitigation strategies to meet 80% goal ; periodic status measurements;  Draft action plans to determine intervention strategies and milestones for IHST approval.  Joint Helicopter Safety Implementation Team (JHSIT) Charter:  Develop and prioritize implementation plan;  Carry out rigorous cost-benefit analysis for implementation strategies to achieve IHST goals;  Develop action plans;  Coordinate implementation of IHST-approved strategies;  Develop and track performance;  Determine progress in meeting major milestones and effectiveness of interventions.

26. Buy-in Worldwide: Government, Military & Civil Groups, OEMs USA –AHS - American Helicopter Society International –AAMS - Association of Air Medical Services –FAA - Federal Aviation Administration –FSF - Flight Safety Foundation Inc. –HAI - Helicopter Association International –NAVAIR - U.S. Navy - Naval Safety Center –NTSB - National Transportation Safety Board –U.S. Army Combat Readiness Center Europe –BEA - Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile –EHA - European Helicopter Association Canada –TCCA - Transport Canada Civil Aviation –TSB - Transportation Safety Board of Canada India, Australia & now Brazil & Latin America (ABRAPHE, CENIPA) USA Bell Boeing Sikorsky RR Pratt & Whitney Honeywell Europe Eurocopter Augusta-Westand Turbomeca Canada CHC Helicopters Brazil : Petrobras,Lider Need all operators to buy-in

27. D (OEM) Original Equipment Manufacturer

28. OEM

31. Approach How do we achieve the best decisions? Regulatory obligations Voluntary Actions

32. Regulation Regulation = An enforced rule of conduct Tells industry: What to do / What not to do Outlines legal Obligations & authorities Assumes the industry will by default not comply Directed towards meeting public expectations Elements of posturing New Approach : sharing of responsibilities

33. Voluntary Compliance In the interest of one’s business, lives and efficiency of operations Develop a voluntary code of conduct : reflects maturity of the industry The Safety management system Need to Outline a plan Will be a proactive system Will be documented Will have a safety oversight system Training Quality Assurance Emergency preparedness A closed loop corrective system

34. Product Life Cycle Design Manufacture Operations Maintenance Modifications & Repairs Continuing Airworthiness

35. Airworthy Product S M S 3 years20-30 years Safety Failure Prevention technologies Reliability -anti corrosion -- reduce vibration Survivability technology -ext. airbag -Crash worthy seats & fuel tanks -- floatation gear -- egress Quality Assurance - No Flaw Operational regulations Maintenance Human Factors -Training of all parties --Pilot aids -Mission comprehension Safety: Every Step of the Way IHST Strategy Continuing Airworthiness Short term Action

36. Design Failure Prevention Technologies –Fail safe design vs safe life design/ CPR for evolutionary design –Composite structures : prevents catastrophic failures –HUMS : DPHM; embedded sensors Reliability –Corrosion control –No single point failure for critical components : 10-9 probability –FMEA Survivability –Energy absorbing seats –Crash worthy fuel tanks –Energy absorbing structures –egress RETURN

37. DESIGN ENGINEERINGMAINTENANCE SYSTEMS STRUCTURESSYSTEMSSTRUCTURES STRUCTURAL MAINTENANCE REQUIREMENTS - Damage Tolerance Insp. - Safe Life Component Retirements SYSTEMS/ POWERPLANTS MAINTENANCE REQUIREMENTS - Maintenance Significant Items (MSIs) STRUCTURAL MAINTENANCE REQUIREMENTS - Structure Significant Items (SSIs) MANUFACTURER - Servicing - Maintenance Tasks - Repair Instructions - Components Manuals - Inspection Techniques - Troubleshooting - Tooling - Etc. ICAs MAINTENANCE REVIEW BOARD REPORT Functional Hazards Analysis (FHA) Systems Safety Analysis (SSA) - Candidate Certification Maintenance Requirements (CCMRs) - Major Futur Consequences Certification Maintenance Requirements (CMRs) AIRWORTHINESS LIMITATIONS

38. Probability and Severity Relationships

39. Failure risk mitigation strategy HAZARD SEVERITY HAZARD PROBABILITY Catastrophic Level 1 Critical Level 2 Significant Level 3 Negligible Level 4 Frequent – Level A1A = EXTREMELY HIGH 2A = EXTREMELY HIGH 3A = HIGH4A = MEDIUM Probable – Level B1B = EXTREMELY HIGH 2B = HIGH3B = MEDIUM 4B = LOW Occasional – Level C 1C = HIGH2C = HIGH3C = MEDIUM 4C = LOW Remote/Seldom - Level D 1D = MEDIUM2D = MEDIUM3D = MEDIUM 4D = LOW Improbable/Unlikely - Level E 1E = LOW2E = LOW3E = LOW4E = LOW

40. Manufacturing Flawless manufacturing –Reduce MDRs –Improved inspection technologies –Reduced variability RETURN

41. Monitoring of Fielded Systems Service Difficulty Reporting System (SDRS) Computerized Airworthiness Information System (CAIS) Civil Aviation Daily Occurrence Reporting Systems (CADORS)

42. Murphy’s Law No. 3 If anything can possibly go wrong, it will! MAMA MIA !

43. Murphy’s Law No. 8 By making something perfectly clear, someonewill be totally confused! ? ? ?

44. Field & Flight Operations Human Factors RETURN The door opened in flight! Human Factors is cause of 75% accidents It is critical to enhanced safety Need to integrate HF in maintenance Provide smarter maintenance aids Provide increased situational awareness inputs to pilots

45. IHST Regional Cooperation International Cooperation is essential –Regulators – Operators –OEMS In all regions of the world. We started with S Asia, Australia then Brazil Go to: S.Africa, Middle East, Japan Russia We are all in it together

46. IHSS 2007 Montreal Dates –September 19 to 21, 2007 Action Plan from JHSAT, JHSIT Report on worldwide participation Pictures from www.tourisme-montreal.org

47. Conclusions Need to act urgently in improving the safety of helicopter operations Important area of focus is human factors and situational awareness Get involved in the IHST process Accidents can be avoided : need to set up the right process The present accident rates in the helicopter industry are unacceptable

48. Questions? Please check out the IHST website: www.ihst.org

49. Thank you