1. Transportation Safety Board of Canada Bureau de la sécurité des transports du Canada Lessons Learned from TSB Investigations of Helicopter Accidents (1994-2003) Joel Morley and Brian MacDonald International Helicopter Safety Symposium Montreal, QC September 26-29, 2005

2. Introduction Average of 53 Canadian registered helicopters involved in accidents each year (range of 44 to 68) 9.3 accidents per 100 000 flight hours

5. Method Employed sample of occurrences investigated by TSB (N=103) Comparison sample of military occurrences investigated (N=37) Categorized by a team of TSB investigators (4 step process)

6. Step 1: Initial Occurrence Categorization Power Loss Structural Failure Loss of Visual Reference Struck Object Loss of Control Loss of Separation Training for Emergencies Other

8. Step 2: Examination of Proportion of Fatal to Non-Fatal Accidents To see where greatest human cost was occurring Determined: –Number of accidents in each category which were ‘fatal’ (1 or more fatality) –Number of lives lost in each category

11. Step 3: Further Break-down of Occurrence Categories Examined types of events contributing to occurrences Selected sub-categories which seemed to capture these factors Loss of separation’, ‘training for emergencies’ and ‘other’ not sub- categorized

12. 3(a) Power Loss

13. 3(b) Structural Failure

14. 3(c) Loss of Visual Reference

15. 3(d) Loss of Control

16. 3(e) Struck Object

17. Step 4: Conclusions from Analysis What does this mean to me??

18. Conclusions – Loss of Visual Reference Accidents #3 in frequency, #1 in human cost 80% fatal with a total of 31 lives lost Civil helicopter flying largely VFR Possible counter-measures: –Awareness –Capability –Technology

19. Conclusions – Power Loss and Structural Failure Accidents (1) Together account for 52% of sample Improper maintenance 2 nd most frequent sub-category in both Underscores importance of efforts to understand and mitigate the factors underlying maintenance error such as: –Improved maintenance procedures –Awareness training

20. Conclusions – Power Loss and Structural Failure Accidents (2) Power loss is most heavily populated category but produced the fewest fatal accidents –Training to handle power failures effective Multi-engine helicopters also represented in power loss accidents

21. Conclusions – Loss of Control Accidents Well recognized hazards –Loss of tail rotor effectiveness –Decayed rotor RPM –Dynamic roll-over –Vortex ring state –Environmental –Flight Control Obstruction Efforts to address these hazards need to be maintained

22. Conclusions – Struck Object Accidents All hazards represented well known Potential counter measures could include: –Raising awareness –Revising procedures –Training in risk management

24. Conclusion Snapshot of accidents investigated Hope it will help drive safety management practices We need to devote resources to…

25. Questions???