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1JHSAT - March 2007
US Joint Helicopter Safety Analysis Team (JHSAT) Status
March 2007AIAC12 – Melbourne, Australia
Mark Liptak FAA ANE-110JHSAT Co-Chairperson
2JHSAT - March 2007
JHSAT Goal:
Provide intervention strategies to the IHST and Joint Helicopter Safety Implementation Team (JHSIT) that maximize the likelihood of reducing worldwide helicopter accident rates by 80 percent by 2016.
3JHSAT - March 2007
Basic CAST ProcessCAST (IHST)Charters Activity
JSAT (JHSAT)Analyzes DataProposes most
effective interventions
JSIT (JHSIT)Assesses feasibility of
interventions works implementation
Continued data analysis,measure intervention
effectiveness
4JHSAT - March 2007
US JHSAT Team Membership:
FAA ANE co-chair HAI co-chair
Turbomeca Schweizer Helicopters
Bell Helicopter Silver State Helicopters
Sikorsky Bristow Group
NASA Rolls Royce
AHS/NASA Airmethods
FAA ASW US Eurocopter
5JHSAT - March 2007
JHSAT Status
Data Analysis
Engaging with the international community
Near term safety recommendations
6JHSAT - March 2007
Data Analysis
7JHSAT - March 2007
JHSAT currently working process areas highlighted in yellow
CharterDevelopment
EstablishTeam
Select Data Set
ReviewNTSB
Docket Data
DevelopEvent
Sequence
IdentifyProblems
(what/why)
Assign StdProblem
Statements
ScoreProblem
Validity &Importance
Identify InterventionStrategies
ScoreInterventionAbility/Usage
Categorize and Prioritize Data
TechnicalReview
&Expert
Validation
Conflicts? ReportResults
No
Yes
IHST
JHSITCurrent task
8JHSAT - March 2007
Data Analysis:
All year 2000 accident data has been downloaded from the NTSB (~4000 files)
The US JHSAT team has completed initial analysis of all 197 accidents from the NTSB year 2000 dataset
For each accident the US JHSAT performs the following:reconstruct the sequence of eventsidentify what went wrong and why it went wrongassign an appropriate problem statementidentify appropriate corrective action(s)score findings based on validity, importance, ability
and usage
9JHSAT - March 2007
Primary Ops SecondaryAerial Application External Load Aerial Observation/patrol TrainingAir Tour Positioning/RTBSightseeing FerryBusiness - company owns a/c Air Taxi - Cargo (135)Corp/Exec - dedicated pilot Air Taxi - Passenger (135)EMS Cargo (91)ENG Public UseFirefighting Maintenance/Test flightInstructional/Training Evaluation flightLaw EnforcementLoggingCommercial OperatorExternal Load OffshoreOther Aerial Work Personal/PrivateUtilities - Patrol & Construction
JHSAT Mission Categories
10JHSAT - March 2007
US Rotorcraft Accident Trends1986-2006
1715
10
1311
20
17
23
20 20
14
17
-5
0
5
10
15
20
25
30
35
40
45
Oct
ober
Nov
embe
r
Dec
embe
r
Janu
ary
Feb
ruar
y
Mar
ch
Apr
il
May
June
July
Aug
ust
Sep
tem
ber
Month
Fre
qu
ency
Monthly Avg1986 - 2006
2000 Monthly Accident Count
Source: NTSB N-registered accidents, excluding amateur built
+2σ 1986 -
-2σ 1986 -
+3σ 1986 -
-3σ 1986 -
11JHSAT - March 2007
SPS No
Popping noise Engine power loss Exhaust valve failure - root cause not determined
24010 engine component failure
Mandate Textron Lycoming SB388B to reduce liklihood of exhaust valve failure
4 4 3 3
Overflew wires, then crashed onto street in nose low, left skid low attitude. Nosed downward and turned CCW
Improper autorotation or loss of control?
Lost of control when making emerg/auto to street
21074 pilot control/handling, inadequate autorotation
Autorotation training aids, simulators etc
3 4 3 2
Pilot had 3.2 hours in R22 last 90 days; marginal autorotations on Com-helicopter check 3.5 mos before acdt.
Lack of recent experience in M/M and with autorotations
13071 Transition to aircraft make/model
Develop company policy and training rqts for pilots transitioning between m/m
4 3 3 3
Pilot had 67 hours in helicopters.
Lack of total helicopter experience
13070 Pilot transition training model specific simulator training
4 3 2 3
Pilot intentions and actions unknown. Flight/systems information unkown.
Lack of information - flight and systems information
41020 information unavailable to investigators
cockpit recording devices
4 4 4 3
Event/Conditions Problem (what) Contributing Factor (why)
Standard Problem Statement
Intervention Recommendation UV I A
Sample of event processing
12JHSAT - March 2007
Validity - How valid do we think the Problem Statement is in this accident based on the available accident information?
Range:Guess = 0 Absolutely Sure = 4
Importance - How important is this particular Problem Statement in the causal chain in this accident?
Range:No importance = 0Cause of accident = 4
Ability - How well can this particular Intervention mitigate the cause or contributing factors of this accident scenario?
Range:No effect on Problem Statement = 0 Would Prevent Problem Statement = 4
Usage – Given this accident scenario, how confident are we that this Intervention will be utilized and will perform as expected in the real world?
Range:No Utilization = 0100% Utilization = 4
JHSAT Scoring Criteria
13JHSAT - March 2007
Results of full year 2000 dataset
Standard Problems & Accident Count by Primary Mission
210
170
145
101
92
74 68
53 51 48 47 44
32 30 24 17
37
27 28
12 16
13
9 8 9 6 10
6 4 4 5 3
0
50
100
150
200
250In
stru
ctio
nal /
Tra
inin
g
Per
sona
l / P
rivat
e
Aer
ial A
pplic
atio
n
Em
erge
ncy
Med
ical
Ser
vice
Com
mer
cial
Ope
rato
r
Law
Enf
orce
men
t
Offs
hore
Ext
erna
l Loa
d
Bus
ines
s -
Com
pany
ow
ns A
/C
Fire
fight
ing
Aer
ial O
bser
vatio
n / P
atro
l
Air
Tou
r
Sig
htse
eing
Ele
ctro
nic
New
s G
athe
ring
Logg
ing
Util
ities
Pat
rol a
nd C
onst
ruct
ion
Fre
qu
en
cy
SPSCount
AccidentCount
14JHSAT - March 2007
Results of full year 2000 dataset
Standard Problem Primary Category Frequency
40
1
17
3
15
4
11
2
98
87
66
26
24
24
23
20
10
1
0
50
100
150
200
250
300
350
400
450P
ilot j
ud
gm
en
t &a
ctio
ns
Sa
fety
Cu
lture
Da
ta is
sue
s
Ma
inte
na
nce
Gro
un
d D
utie
s
Pilo
t situ
atio
na
wa
ren
ess
Pa
rt/s
yste
mfa
ilure
Po
st-c
rash
surv
iva
l
Co
mm
un
ica
tion
s
Mis
sio
n R
isk
Re
gu
lato
ry
Air
cra
ft D
esi
gn
Infr
ast
ruct
ure
Gro
un
dp
ers
on
ne
l
Fre
qu
en
cy
15JHSAT - March 2007
Results of full year 2000 dataset
US JHSAT Intervention Categories
367
275
173143
119
43 33 28
050
100150200250300350400450
Tra
inin
g
Saf
ety
Man
agem
ent
Info
rmat
ion
Mai
nten
ance
Airc
raft
Des
ign
Reg
ulat
ory
Inst
ruct
iona
l
Infr
astr
uctu
re
Fre
qu
ency
16JHSAT - March 2007
Results of full year 2000 dataset
Top 15 JHSAT Intervention Sub Categories156
100
68
49 4637 37 36
31 30 29 28 2620 20
0
20
40
60
80
100
120
140
160R
ecor
der
Ris
kas
sess
men
t
QA
Ris
km
anag
emen
t
Aut
orot
atio
n
CF
I
Mis
sion
spec
ific
Inve
stig
atio
n
Sim
ulat
ors
LTE
Pre
fligh
t
Coc
kpit
indi
catio
n
SO
P -
Wx
Airc
raft
perf
orm
ance
SO
P -
Pre
fligh
t
Fre
qu
ency
17JHSAT - March 2007
Data Analysis Status:
To date the accidents analyzed have covered a wide spectrum of helicopter types and operations.
1200+ scored problem statements/intervention findings have been developed
JHSAT currently working further categorization and prioritization of the results
Expect to offer recommendations for all major operational groups in the US helicopter community by June ‘07
Currently working to form recommendations from the data
18JHSAT - March 2007
Engaging with the international community
19JHSAT - March 2007
Worldwide Helicopter Accidents/Year
1980 - 2005
0
100
200
300
400
500
600
700
800A
cc
ide
nts
/ye
ar
US Civil Registry Non-US Civil & Military US Military & USCG (ABC)
20JHSAT - March 2007
Engaging with the international community
The preceding slide shows worldwide accident trends for the last 26 years. The criticality of working with the international community to reduce worldwide rates is readily apparent since the US accounts for only 35 to 40% of accidents on an annual basis.
On-going efforts to identify other partners from Asia, South America, Oceania, etc. The US JHSAT team is currently developing contacts and coordinating this activity.
Any entity that possess large helicopter accident datasets that could be processed by a JHSAT method is being considered.
EASA, Canada, Brazil, and India now moving toward joining in this initiative.
21JHSAT - March 2007
Engaging with the international community
A structured approach will be used to manage the analytical and implementation work sponsored by the IHST.
Key attributes:
All recommendations will be data driven
Regional ownership - Data is owned and analyzed by those most familiar with it. Safety recommendations will be implemented by teams most familiar with local needs.
US JHSAT and US JHSIT teams will be assist in training/coaching regional teams, measuring the results of the safety recommendations and implementation effectiveness.
22JHSAT - March 2007
JHSAT/JHSIT
cross-talk
IHST Safety InitiativeAnalysis, Implementation and Metrics Management Structure
IHSTExecutive Committee
JHSATLead Group
JHSITLead Group
Canada JHSAT
EASA JHSAT
Canada JHSIT
EASA JHSIT
Region X, Y, Z JHSIT
US/CAN/EASA Consolidated
Recommendations
JHSAT sends recommendations to JHSIT
US/CAN/EASA/X,Y,Z Implementation
Results
Need to maintain a strongcommunication/feedback loopbetween IHST – JHSAT - JHSIT
Process development usingUS NTSB datarepresents 48% ofworldwide fleet
Measure Accident Reductions
Effectiveness
Measure Implementation
Effectiveness
Regions X, Y, Z defined as those pockets of operation not ableto staff a full JHSAT team and are willing to work implementation of US/CAN/EASA findings to benefit their fleets
Others?
ALEA groupEMS group
Military
US JHSAT
US JHSIT
23JHSAT - March 2007
JHSAT Lead Group Analysis of
International Data
Mark Liptak is JHSAT POC Seeking data rich partners Preliminary discussions with: Canada EASA (CAA-UK, France BEA) Brazil NZ, Australia Chile Canadian Military USN
Interim Goal: have Canada/EASA present status at the 2007 IHSS Symposium in Montreal Demonstrate that this is an international effort, and it has momentum
JHSIT will also have international partnermanagement responsibilities: custom tailored regional solutions coordinated with JHSAT coordinated with IHST
IHSTOutreach/Marketing
Emerging Fleets
Somen is the IHST POCIdentify emerging/high growth marketsDevelop strategy to: Foster participation Benefit from IHST knowledge baseCandidates: China India CIS?
Engaging with the International Community
JHSIT Lead Group Implementing
Regional Solutions
24JHSAT - March 2007
US CivilDataset
Selection (1/2 of
helicoptersWorldwide)
JSAT ProcessUnderstanding
Refining
JHSAT Analysis
IdentifyFCAA &MilitaryPartners
Train FCAA &
Military Partners in JHSATProcess
FCAA & Military Partners conductJHSAT
analyses on their
accident data
Expert Review/
Validation
MitigationRecs - Global
MitigationRecs
FCAA & Mil
Coordinating JHSAT US and International Efforts
First SetUS Mitigation
Recs
Mar/Apr 06May/June 06
May-Jan 07May 07
2Q 07
1Q 08
TBD 08
TBD 07/08TBD 06/07
Sept 06
TechReview
Feb 07
IHST
JHSAT is now working to bring EASA, CA, AU, SA, India into the process
Current task
Current task
25JHSAT - March 2007
Potential Barriers:
JHSAT:Variation in dataset quality, languages, definitions, etc, around the world may make use of a standardized JHSAT approach more difficult.
Military data may not be available.
Lack of fleet hours will complicate ability to measure results.
Regional teams may be difficult to staff with sufficient level of expertise representing manufacturers, operators and regulatory interests.
JHSIT:Regional operations and regulations may make some implementation actions difficult.
26JHSAT - March 2007
Offering near term safety recommendations
27JHSAT - March 2007
Interim recommendationsReports reviewed by the JHSAT:NASA - U.S. Civil Rotorcraft Accidents, 1963 Through 1997NASA - Analysis of US Civil Rotorcraft Accidents from 1990 to 1996 and Implications for a Safety Program NASA - ASRS Rotorcraft Incident Study - Draft Data Summary Aviation Safety Reporting SystemNASA - Helicopter Accident Analysis TeamAMPA - A Safety Review and Risk Assessment in Air Medical TransportCRS - Report for Congress - Military Aviation SafetyOGP - Safety Performance of Helicopter Operations in the Oil and Gas Industry - 2000 DataTSB Canada - Lessons Learned from TSB Investigation of Helicopter Accidents (1994 - 2003)Bell Textron - History of Helicopter SafetyOther NTSB and international reports may be considered.
The JHSAT has identified important recommendations from a series of existing helicopter safety reports.
These recommendations were submitted to the IHST in November so that the JHSIT would have several well founded general recommendations to work with.
The JHSAT plan to issue its full set of analytical results by 2Q07.
28JHSAT - March 2007
US JHSAT interim recommendations:
1. – Promote the adoption of Safety Management Systems in the helicopter community.
2. – More consistent and comprehensive NTSB involvement and investigation needed in helicopter accidents.
3. – Reestablish the collection of worldwide helicopter fleet hour data as previously performed by the FAA.
4. – Establish a helicopter safety website to disseminate important information
5. – Use proximity detection equipment in helicopters.
6. – Use flight recording devices and cockpit image recording systems in helicopters.
7. – Develop a strategy to improve pilot Aeronautical Decision Making.
(NB: this listing is not intended to indicate prioritization)
29JHSAT - March 2007
In Summary
The IHST’s 80% accident reduction cannot be met without active involvement of the worldwide helicopter community.
The US JHSAT has adapted the CAST accident analysis process for use in the helicopter community.
We are currently working with EASA, Canada, Brazil and India to establish participating regions.
The AU/NZ region is rich with useful helicopter data, joining the IHST’s initiative would have significant positive impact on helicopter flight safety going forward.
The IHST looks forward to working with experts from the region to meet its worldwide goals.
30JHSAT - March 2007
JHSAT Workshop
This briefing is one piece of an effort to seek new partners in the IHST’s worldwide initiative.
Anyone from the AU regional helicopter community interested in participating in an analytical team, analyzing data from the Australian region is invited to continue the discussion this Friday.
Members of the US JHSAT are available to offer perspectives on regional data, provide a more detailed look at the accidentanalysis process and answer questions about the worldwide initiative.
Please see me after the meeting.
31JHSAT - March 2007
Questions?