1. US Army Aviation Safety Investment Strategy Team (ASIST) Russell Peusch System Safety Engineer US Army Aviation and Missile Command 2005 International Helicopter Safety Symposium 6/24/05

4. Analysis Team Army Aviation CenterArmy Aviation Center –Aviation Safety –Combat Developments –Training Developments & Simulation –Aviation Training Brigade –Evaluation & Standardization Aeromedical Research LaboratoryAeromedical Research Laboratory –Aircrew Protection –Aircrew Health & Performance Army Research LaboratoryArmy Research Laboratory –Human Engineering Program Executive Officer - AviationProgram Executive Officer - Aviation Aviation & Missile CommandAviation & Missile Command –DSA/Program Management –Aviation Research Development & Engineering –Systems Engineering –System Safety Army Safety Center (Now CRC)Army Safety Center (Now CRC) –Aviation Systems & Investigations –Risk Management Integration –Operations Research & Analysis Air Force Institute of TechnologyAir Force Institute of Technology –Operations Research

6. “Cause Factors” vs “Hazards” Individual issues Mistake-based Privileged data Blame focus Unit level interventions Systemic issues Risk-based Non-sensitive Prevention focus Army-wide investments

7. Environment (Leadership) - OPTEMPO -Culture -Experience Machine (Aircraft) - Complexity - Failures - Uncertain causes Environment (Mission) - Multi-ship - Over water - NVG Crew - Proficiency - Coordination - System Under- standing - - Structure for hazard statements: (human conditions)+(machine conditions)+(environmental conditions) during (mission tasks) resulting in (articulation of effects on the system) articulate hazards from the perspective of the operator applying conditions to “Source-Mechanism-Outcome” model Identifying Hazards

8. “Cause: Human Error” Pilot failed to follow proper procedures due to complacency & over-confidence. Pilot improperly diagnosed emergency due to high anxiety. Hazard(s) 1. Task saturation during a simulated engine failure (SEF) may result wrong throttle position at termination 2. Crew’s ability to perform successful maneuver is limited by inherent aircraft handling characteristics. 3. During the accident sequence dynamic forces may exceed injury threshold. Risk Management of Simulated Engine Failure (SEF) Training

9. ASIST Database Structure Accident Experience Table (all aircraft) Hazard Assignment Table (one for each a/c system) Hazard Assignment Table Book of Hazards (all aircraft) Hazard Assignment Table (one for each a/c system) Control Assignment Table Book of Controls (all aircraft) 1 ∞ 11 1 ∞ ∞ ∞

10. Hazard(s) 1. Task saturation during a simulated engine failure (SEF) may result wrong throttle position at termination 2. Crew’s ability to perform successful maneuver is limited by inherent aircraft handling characteristics. 3. During the accident sequence dynamic forces may exceed injury threshold. Potential Controls Doctrine - Increase minimum entry altitude for SEF training Organization - Increase flying hour program Training - Enhanced Crew Coordination Training - Emergency procedures simulator Materiel - Autorotational characteristics - Crashworthy seats Leadership - Integrate RM into institutional training & Edu Personnel - Facilities - Risk Management of Simulated Engine Failure (SEF) Training

11. Control Effectiveness Guidelines & Control Values Controls 1. ~~ 2. ~~ 3. ~~.. Prioritized Controls Priority Value 1. ~~ x% 2. ~~ y% 3. ~~ z%.. Cost Assessment High Medium Low Effectiveness Assessment Design Safety Devices Warning Devices Procedures & Training

12. KW Example Results

13. Common Hazards Across Timeframes* for US Army Rotary Wing Aircraft *Three timeframes: FY94-98, FY99-03 (non OEF/OIF), and OEF/OIF

14. Airframe Influence on Common Hazards US Army Rotary Wing Aircraft At any level of command, not using established controls is selective enforcement of standards and may result in aircraft damage or personnel injuries. A/C System Rank H-60 1 H-47 1 AH-64 5 OH-58D 9 Unit personnel may lack experience, wisdom, or seasoned leadership to apply risk management to the unit's mission resulting in uncontrolled hazards. A/C System Rank H-60 4 AH-64 6 OH-58D 10 H-47 32 Lack of factual and timely information, or lack of understanding of the available range of controls to manage high risk behavior, at any level of command, may result in damage to aircraft or personnel injuries. A/C System Rank OH-58D 4 AH-64 4 H-60 7 H-47 12

15. Timeframe Breakout of Common Hazards Across US Army Rotary Wing Aircraft Note: FY99+ analysis does not include OEF/OIF cases

16. Timeframe Breakout of Common Hazards Across US Army Rotary Wing Aircraft Rotary wing operations in close proximity to unimproved surfaces may result in degraded visual environment (brownout or whiteout) leading to loss of situational awareness (LOSA) and control loss with aircraft damage or personnel injury. A/C System Rank OEF/OIF H-60 2 1 AH-64 8 1 OH-58D 7 2 H-47 NR Maneuvering among obstacles while landing to unimproved or unfamiliar terrain under degraded visual environment (NVG, low illumination) increases workload may result in loss of situational awareness (LOSA) and undetected obstacle strike. A/C System Rank OEF/OIF H-47 2 1 H-60 15 20 AH-64 23 28 OH-58D NR

17. Timeframe Breakout of Common Hazards Across US Army Rotary Wing Aircraft Combining multiple stressors (fatigue, OPTEMPO, high winds, low contrast, lack of training, family situation) with mission operations (sling load) in high workload environment can cause LOSA (divided attention) resulting in aircraft or equipment damage. A/C System Rank OEF/OIF H-47 2 4 H-60 22 26 AH-64 NR OH-58D NR Aircraft operations in degraded visual environment (night aided over water) may result in loss of situational awareness (LOSA) resulting in the aircraft striking an object. A/C System Rank OEF/OIF H-47 3 3 H-60 75 77 AH-64 NR OH-58D NR

18. Other Significant Hazards by Aircraft System Hazard Value & (Ranking within System) Hazard IDHazard StatementRWOH-58DH-60H-47AH-64 22 Unknown accident cause involving aircraft flight into terrain with no survivors or witnesses. 4.4% (3) 0.8% (29) 7.6% (3) 0.10% (88) 6.8% (1) 11 Use of the Abbreviated Aviation Accident Report (AAAR) for aviation accidents does not provide adequate accident information to apply risk management to the accident investigation process. 3.5% (6) 3.1% (7) 7.0% (5) 1.5% (16) 0.9% (33) 5 Hovering in close proximity to terrain in a degraded visual cue environment and high workload may result in loss of situational awareness (LOSA) causing inadvertent hover drift and collision with terrain or obstacles. 2.8% (7) 16.2% (1) 1.8% (20) 2 Maneuvering among obstacles in a degraded visual environment causes an escalation of workload and increases fatigue which may result in a collision with terrain or obstacles. 2.3% (9) 1.5% (18) 0.6% (4) 6.7% (2) 195 Loss of situational awareness (LOSA) during formation flight may result in a midair collision. 2.3% (10) 6.7% (6) 58 Flight into known deteriorating weather may result in loss of situational awareness (LOSA) or spatial disorientation and loss of aircraft control. 2.3% (11) 1.2% (22) 2.3% (11) 3.4% (9) 218 During an accident sequence, the aircraft structure may transmit loads that exceed human tolerance resulting in injury or trauma, in an otherwise non-injurious environment. 1.6% (12) 11.4% (2)

19. DOTMLPF Control Analysis Doctrine Control IDControl RW Control Value 28 Standardize mission risk assessment and briefing process3.1% 20 Establish a new flying hour category for individual task flight training hours2.1% 304 Standardize doctrine and operational procedures for mulit-ship operations0.3% 574 Design and develop an interactive electronic technical manual0.3% Organization Control IDControl RW Control Value 26Increase and structure pilot flight hours7.1% 13 Evaluate and resource the maintenance force structure to match present aviation requirements0.9% Training Control IDControl RW Control Value 33 Develop, field, and sustain an enhanced crew coordination training program.7.2% 384 Establish and mandate risk management training program,.4.0% 537 Evaluate increasing the minimum requirements for attending the IPC/MOI course3.3% 536 Implement a Hazard Based Investigation Process, which includes an assessment of risk management application effecting the accident.3.1% Leadership & Education Control IDControl RW Control Value 416 Establish minimum operational experience and flight time requirements for selection as aviation commander3.8% 15 Modify Aviation Branch Officer Career Model AR 600-3 to develop experience, tactical & technical proficiency.3.2% 18 Provide commanders guidance and training for crew selection, mission tailoring, and balancing of resources to do the mission.2.8% 621 Evaluate unit crew rest and endurance policy with regards to unit duty day in a combat environment.2.1%

20. DOTMLPF Control Analysis (cont) Materiel Control IDControl RW Control Value 46 Install Digital Source Collector (DSC) to support accident investigation, aircrew training, maintenance, and accident prevention. (MFOQA)14.0% 8 Modernize flight control system to improve aircraft stability, control, and guidance throughout the flight envelope for all environments11.6% 7 Develop and install new Night Vision Systems with improved acuity and field of view (2 nd Gen FLIR).4.5% 1 Develop and issue new Night Vision Goggles with improved acuity and field of view.4.4% 622 Instrument Flight cueing to inform the pilot of movement over a given point in a DVE3.1% 1155 Develop a situational awareness technology to inform the pilot of movement over a given point in a DVE2.5% 369 Develop an automated approach landing system through improvements to the flight control system (FCS).2.1% 318 Establish a command information system which tracks all forms of high risk behavior and marginal performance. (MFOQA)1.9% Personnel Control IDControl 544 Modify the Army's screening process for flight school to identify individuals that are more compatible with modern aircraft and mission complexity (i.e., multitasking in glass cockpits). 70 Modify -10 to mandate 4th crew member for H-47 sling load operations. Note: Personnel controls shown as examples from aircraft analyses.

21. Conclusions Hazard identification is key to accident reduction Hazards experienced in OEF/OIF were not “new” to the RW community No single “silver bullet” to combat the hazards, but –Controls to reduce workload and bridge the experience gap through MFOQA - go a long way Need to close the loop on risk management

22. ASIST Process Improvements Data driven hazard “outcomes” Articulation of risk by hazard severity and probability Risk reduction estimates through system safety rules for control application

23. Questions? Russell Peusch Commercial (256) 842-8632 russell.peusch@redstone.army.mil