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Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services.

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Presentation on theme: "Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services."— Presentation transcript:

1 Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services

2 Overview Statistics IHST / EHEST Data Accident Examples Decision Making Theory Pre Departure Risk Assessment SMS and Decision Making Summary

3 Objectives Know that… Decision Making is part of the accident chain There are two types of Decision Making theories with different characteristics Pre-flight RAs are excellent DM tool Mission critical decisions can be pre-planned Use RAs as long term metric Know that the RW community is different when it comes to RAs

4 IHST / EHEST Activities Goal (by 2016): Reduce accidents worldwide by 80% Method Analyze accidents for common causesJHSAT Implement strategies to eliminate sameJHSI T Products Toolkits provided free of charge SMS, Training, Risk Assessment, HFDM, Mx D-V-E DVD Pilot Leaflet (DVE, LTE, Rollover, Vortex Ring State) (www.ihst.org) (

5 IHST Data Study analyzed 523 accidents in 2000, 2001 & 2006 Contributing Factors Pilot Judgment & Actions…………….84% Data Issues.……………73% Safety Management.…………… 43% Ground Duties.…………… 37% Pilot Situation Awareness.…………… 31% Part / System Failure.…………… 28% Maintenance.…………… 20% Mission Risk.…………… 19%

6 EHEST Study Study analyzed 311 accidents in 2000 ~ 2005IHST Pilot Judgment & Actions68%84% Safety Management52%43% Ground Duties40% 37% Data Issues37%73% Pilot Situation Awareness34% 31% Mission Risk28% 19% Part / System Failure22% 28% Maintenance14% 20%

7 Accident # 1 The Aircraft Single pilot, twin engine NVG capable The Pilot Ratings & hours unknown NVG trained The Environment Day VMC then Night IMC

8 Accident #1 The Flight Pick up hiker from mountain VFR flight plan The Accident Controlled flight into terrain Pilot, hiker killed Spotter survived

9 Accident #2 The Aircraft Single pilot, twin engine IFR equipped w/ autopilot NVG status unknown The Pilot Commercial, Instrument Helicopter 15+ years in area 8100 hours TPT The Environment Night VFR then Night (2100L) IMC Light Rain, Mist, Fog

10 Accident #2 The Flight Already offloaded patient Repositioning to base Radar track at 800’ agl The Accident Controlled flight into water Debris path 70’ long by 160’ wide (at 525’ deep) All major components accounted for at site Aircraft broke up Pilot, two flight nurses killed

11 Accident #3 The Aircraft Single pilot, twin engine IFR equipped w/ autopilot and coupled approach mode NVG capable but not in use, no TAWS The Pilot Commercial, Instrument Helicopter IFR qualified but not proficient 5200 hours TPT The Environment Night VFR then Night (2400L) IMC Fog

12 Accident #3 The Flight Diverting for weather to offload patient Called Approach for radar vectors to ILS On CL, GS, RoD increased from 500 fpm to No level off at either MDA (LOC or ILS) The Accident On centerline 3 nm north of runway Impact 80’ tree, debris path 164’ long (50m) All major components accounted for at site Aircraft broke up Pilot, two medics, one patient killed One survivor (patient)

13 Accidents Summary Common elements (in no particular order) Single pilot Instrument rated Aircraft in good working order Weather started out OK, but went down quickly Decision to continue A/C capability not fully used (autopilot) Controlled flight into surface Nearly all killed

14 Decision Making Theory Analytical Decision Making Ideal for the following conditions clear goal or outcome plenty of time all conditions, factors are known From this, the decision maker can develop wide range of options evaluate and compare options choose the optimal path

15 Decision Making Theory Analytical Methods Example Ddetectthe change E estimateneed to react C choosedesirable outcome I identifyactions to manage change D dotake action Eevaluateeffect on correcting situation Other aviation related analytical methods include IMSAFE, CARE, SADIE, TEAM, PAVE, 5Ps, 3Ss… Do you use these? When? Which one(s)?

16 Decision Making Theory Analytical Method Characteristics Structured Time consuming Process breaks down with stress, limited time Analytical Methods Deliberate & thoughtful Better suited to Aircraft design Flight planning Aircraft purchasing

17 Decision Making Theory Intuitive Methods Fast Simple Memory based Work with limited information Option chosen probably OK, but not optimal Better suited to real time decision making (flying) and other dynamic, fast paced situations car driving, sports, combat

18 Decision Making Theory Naturalistic Decision Making (one intuitive DM process) Used in complex, fast paced situations Key features series of decisions interdependent (one affects the other) conditions constantly changing independently and as result of your action real time decision making (not planning) goals not well defined could be competing goals (safety vs …) decision maker is knowledgeable, experienced & professional (Peter Simpson)

19 Decision Making Theory Naturalistic Decision Making Not so much a method as the way we actually do things… Step 1:Situation Assessment(SA) Problem definition identify problem goal(s) information sources needed to succeed prioritize incoming information disregard (“park”) other stuff Risk assessment severity & probability Time available

20 Decision Making Theory Naturalistic Decision Making Step 2:Course of Action(CoA) Potential solutions considered (in order of use) rule basedone solution; procedure memory based; experience, sim, training choiceoptions; this or that will work maybe memory but not always creativenothing obvious consider similar situations for solution Simulation mental test of potential solutions and outcomes Act

21 Decision Making Types Comparison Factor Analytical Naturalistic Goalsdefinedvaried Pace (speed)slowfast Time availableplentylimited Stakeslowhigh Datacompleteincomplete Environmentknownchangeable Participantsmanyfew Decisionsas neededimmediate SolutionoptimalOK

22 Naturalistic DM Errors Two basic areas Situation Assessment errors poor understanding of situation poor risk assessment misjudge time available Course of Action errors right rule, wrong time right rule, poor application choose wrong procedure or option In general More information, experience helps recognize the situation & solutions

23 Naturalistic DM Errors Often competing goals Customer Financial Company Personal Peers Duty Contributing Factor: Motivations and Rationales Rationales Justify the decision Macho Invincible Impulsive Resignation Anti authority Management must eliminate competing goals educate against rationales => Safety is primary goal => Procedural compliance is key

24 Decision Making Errors People tend to.. Under estimate the situation Over estimate their ability

25 25

26 26 “Four Pillars of SMS” Safety Policy Safety Risk Management Safety Assurance Safety Promotion ICAO Doc 9859, 2 nd Edition, 2008 Ref: FAA AC A SMS Basics

27 Safety Management Systems Safety Risk Management Risk Assessment Hazard Identification Methods Mitigation

28 Safety Management Systems Safety Risk Management Hazard Identification methods Audits Hazard reports Safety surveys Pre Departure Risk Assessments

29 Pre Flight Risk Assessment Many to choose from FAA Vendors Operators Industry groups HAI web site Most have the same categories Environment / Wx, Crew / HF, Operation / Flight, Aircraft

30 30 SMS Environment Flight Ops Human Factors Helicopter Directions for use RISK ASSESSMENT Some of this can be done at start of shift SMS

31 31 SMS Run checklist for mission + return Tally scores and check risk value Risk value Risk range Major hazard Green = Go But major hazard needs mitigation SMS

32 32 © Eurocopter rights reserved SMS Mitigation: Obstacles Take credit on first page - 5 points Risk was 15 Now 10 SMS

33 33 © Eurocopter rights reserved SMS Mitigation codes Points deducted New risk value

34 34 © Eurocopter rights reserved Different conditions… Weather is worse… Pilot is less experienced Aircraft less capable Higher risk value Mitigation required What can we fix right now? SMS

35 35 © Eurocopter rights reserved SMS Mitigation: 1. Obstacles 2. Repair Take credit on first page - 7 points Risk was 30 Now 23 SMS

36 36 © Eurocopter rights reserved SMS Mitigation details from page 2 New risk score >20 with Mitigation. Waiver required ! SMS

37 37 © Eurocopter rights reserved SMS A chance to think it through in a no-threat environment Final step on RA Pre-approved If conditions get worse, then what?

38 SMS and Decision Making Review of DM process… Analytical methods… Ultimate goal in mind (safety) No threats at hand Time is not an issue Can think ahead Consult references, others Review multiple options Select optimum solutions Better suited to the planning process, so… Do it before flying…

39 39 © Eurocopter rights reserved Solutions may be the same on many flights Repeat is OK; it builds DM experience and consensus Experience is key element of good Naturalistic DM (SA & CoA) These serve as the limits or boundaries of what you can do Maybe not a lot of planning time but better than while flying

40 40 © Eurocopter rights reserved SMS Waiver Approved ! Use as briefing tool for crew Keep RA with other paperwork Time to go flying… Waiver Requested Back to our RA…

41 Decision Making Now you are flying... Patient is on board Condition is critical and getting worse Flight plan is changing… Weather is getting worse (300’ and 1nm)2 > 4 Destination hospital is now closed for weather2 > 4 Diverting to new hospital; unknown to you0 > 2 At 90 % limit for fuel burn0 > 1 Duty day extended to Back of the Clock 0 > 5 Previous total: = Risk matrix ORANGE band 20 ~ 39 goes RED at 40 Points shown here for discussion. We do NOT pull out the RA and recalculate

42 Decision Making Cascading changes things are backing up Conditions deteriorating but still manageable However, fatigue is setting in still have to land, refuel and return you are busy with radio, GPS, fuel planning… not the ideal time to make decisions… But this is exactly when a decision is needed (Situation Awareness) You reached your preset limits

43 Decision Making What to do? (Course of Action) You are now well into the ORANGE band One more item puts you in the RED… Land? Land and transfer patient? Keep going? Previous RA planning… a)weather below FOM minimumsLAND ! b)2 or more conditions changed for the worseLAND ! Coord with ground unit; guide them to you

44 Decision Making It is recognized you cannot pre-plan for everything However we know that Real time decisions are hard to get right As conditions get worse, risks increase Recognizing the change (SA) is key, then Execute the well known, pre-planned decision (CoA) Under SMS… We still “Plan the Flight, Fly the Plan” But, we also, under certain circumstances, “Plan to Land, Land to Plan”

45 Accident #1 NTSB Report Decision making Competing goals No Risk Assessment The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to take off from a remote, mountainous landing site in dark (moonless), night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the [operator’s] safety-related policies, including lack of a requirement for a risk assessment at any point during the mission…

46 Accidents Revisited Three fatal CFIT accidents discussed previously… VFR at beginning of flight Then deteriorated to IMC Decision made to continue Could use aircraft automation But, decided to continue visually Using this RA & DM briefing sheet Weather below FOM minimums: Land & Wait (Or, if IFR capable, go IFR)

47 47 © Eurocopter rights reserved Fables !

48 The camel, kneeling, waited patiently for his master to finish loading him. One sack, two sacks, three, four… “When is he going to stop?” the camel said to himself. Finally, the man clicked his tongue and the camel stood up. “Let us go,” said the master, pulling on the bridle. But the camel did not move. “Come on!” cried the man, jerking the rope. But the camel dug in his feet and stayed where he was. “I see,” said his master, and with a sigh he took two sacks down from the camel’s back. The Camel

49 “That, I think, is a fair weight,” murmured the camel to himself, and at once began to move. They walked all day at a good speed and the man thought they would be able to reach the village. But, at a certain point the camel stopped. “Courage,” said the master, “only a few more miles and we are there.” The camel’s only response was to lie down on the ground. “My legs tell me,” he said to himself, “that we have walked enough for today.” And the man was obliged to unload and to camp beside the camel in the desert. Fables of Leonardo Da Vinci, Hubbard Press, 1973.

50 Summary Decision making errors are real Well known part of accident causation Decision making is a dynamic activity Successful decision making is difficult “on the go” SMS activities can facilitate successful decision making The RA is a good tool for that Works as an excellent crew briefing tool We can modify the way we make decisions Try to make at least some of them in advance if this happens, then I will do that…

51 51 Fire Fighting Morning Consider Morning or Afternoon Different equipment Longline Bambi bucket (Inspected) Modify Fire base Dip pond No night ops No IFR ops (May need separate one for X-country) Modify Days ON (more days, more points)

52 Implementation Question How to get this to (past) the pilots? More than a box checking exercise… Builds situational assessment Good briefing tool Gives you an (honest) out Defends you if things go wrong Past management? Long term improvements System wide situational assessment 52

53 53 © Eurocopter rights reserved 53 Closing Comments What to do with all those Risk Assessments?

54 54 Pre - Departure Risk Assessment Review 30 days worth 80 in the green 15 in the yellow 05 in the red What caused risky scores? Are there systemic factors? Develop corrective, preventive actions SMS Tips: Safety Assurance

55 55 Risk Assessments Last 6 Months SMS Tips: Safety Assurance

56 Safety Assurance This metric shows you are looking ahead at hazards reviewing them for trends tracking efforts at continuous improvement This is a cornerstone of SMS

57 Thank You


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