1. Objectives of Safety Investigations Current Investigation Process
ACCIDENT/INCIDENT INVESTIGATION PANEL
Objectives of Safety Investigations
Current Investigation Process
Adequacy of Investigation Resources
Data Collection and Archiving
Advocating for Change
Investigation Tools
General Welcome to the Accident/Incident Investigation Panel
Objective of the International Helicopter Safety Seminar
To reduce the number of helicopter accidents by 80% in 10 years
Objective of the Accident/Incident Investigation Panel
How can we, the members of the Accident/Investigation investigation community, contribute to the IHSS Goal
Specifically, what are the Action Items that we can undertake to contribute to this goal.
How can we generate ownership within our investigation areas
Present suggested solutions to the rest of the members of this IHSS and the helicopter community.
To focus our work for this morning,
I will present some background information on the points depicted on this slide.
Self introductions from the attendees.

2. Advance Transportation Safety Conduct Safety Investigations
OBJECTIVES OF SAFETY INVESTIGATIONS
Advance Transportation Safety
Conduct Safety Investigations
Safety Significant Events
Unsafe Acts & Unsafe Conditions
Underlying Factors
Validating Safety Deficiencies
OBJECTIVES OF SAFETY INVESTIGATIONS
The basic objective of safety investigations is:
To advance flight safety through
The conduct of independent safety investigations by:
Determining the safety significant events that lead to the accident or incident
Defining the unsafe acts and conditions involved in these events
Uncovering the underlying factors that contributed to each safety significant event
Validating the safety deficiencies by doing
A Risk Assessment
A Defence analysis
A Control Options Analysis

3. Issue Safety Communications Distribute Investigation Reports Briefings
OBJECTIVES OF SAFETY INVESTIGATIONS
Advocate for Change
Issue Safety Communications
Distribute Investigation Reports
Briefings
Seminars
Working Groups
ADVOCATING FOR CHANGE
Issuing safety communications
Investigation teams issue:
Recommendations
Advisories
Safety Bulletins, and etc
Directed at those who are in the best position to implement corrective actions
Containing compelling arguments for changes that will mitigate the risks and recurrence
Distributing Investigation Reports
That contain compelling safety information
To educate the helicopter community
Holding briefings and conducting seminars
To motivate the helicopter community
Participating in Working Groups
To review investigation data and reports
To deepen research of the issues
To develop more risk control options
To make further recommendations for change

4. What should we investigate? To what extent do we investigate?
CURRENT INVESTIGATION PROCESS
What should we investigate?
To what extent do we investigate?
Should we look beyond this
specific accident?
DECIDING WHAT TO INVESTIGATE
Driven by the level of resources available
The investigation community has to make tough decisions
Which occurrences do we investigate, We can’t do them all
Do we only investigate accidents?
Should we also investigate serious incidents?
How deeply and thoroughly should we investigate
Do we investigate more than just
Finding out what happened
Finding the one who was responsible for the unsafe acts and unsafe conditions?
Determining the technical cause
Finding a quick local fix to the problem
Do we restrict investigation to only one occurrence:
Should the investigation consider at other occurrences
Should the investigation conduct research in its efforts to look for
Trends, other risk control options

5. Independent Safety Investigations Dedicated, Trained Human Resources
ADEQUACY OF INVESTIGATION RESOURCES
Safety Culture
Independent Safety Investigations
Dedicated, Trained Human Resources
Investigation Tools
ADEQUACY OF INVESTIGATION RESOURCES
Although I briefly mentioned resources when I talked about the decision as to what and how deeply we should investigate
The issue of resources goes beyond the simple money issue
We also have to look at:
Does the industry as a whole or the involved companies have:
The safety culture necessary for the conduct of independent safety investigations
The number of personnel required to conduct investigations
Trained personnel
The tools required

6. Data Storage & Retrieval System Data Accessibility
DATA COLLECTION AND ARCHIVING
Correct & Quality Data
Data Storage & Retrieval System
Data Accessibility
DATA COLLECTION AND ARCHIVING
Do our investigations collect and record the correct and enough safety data
Do we have adequate systems to store and retrieve investigation data
What are the appropriate levels of control for an investigation data system:
To much control makes the data useless
To little control could compromise the integrity and independence of the investigation process
Could restrict openness and willingness of persons to provide the investigation with accurate and complete information

7. Compelling Arguments for Change Effectiveness of Communications
ADVOCATING FOR CHANGE
Compelling Arguments for Change
Effectiveness of Communications
Tracking Actions Taken
Degree of Risk Mitigation
ADVOCATING FOR CHANGE
Compelling Arguments for Change
The success of our investigations, safety communications and reports will hinge on our ability to present compelling arguments for change that are based on accurate data, and flawless assessments and clear conclusions.
The recommendations must also be based on thorough consideration of the risks, defences and control options.
Effectiveness of Communications
The effectiveness of our communications can be judged by:
The level of acceptance of our recommendations; and
The quality of the actions taken by stakeholders
Tracking Actions Taken
To evaluate the effectiveness of our recommendations investigators have to:
Track the actions taken
Degree of Risk Mitigation
To complete the quality assurance cycle, investigators must:
Assess the degree to which the risk have been mitigated by actions taken:
Fully satisfactory, satisfactory intent, satisfactory in part, and unsatisfactory
Determine the necessary follow-up or next steps:
Case closed, monitor progress, take additional action

8. Investigation Methodology
INVESTIGATION TOOLS
Historical Data
Trend Analyses
Volunteer Reporting
On-Board Recordings
Investigation Methodology
INVESTIGATION TOOLS
The quality of an investigation relies on a number of factors
In addition to the adequacy of resources and properly trained and equipped investigators,
The quality of investigations rely on a number of other factors
Historical Data
The amount, quality and accessibility of data on past accidents, incidents and investigations
Trend Analyses
The availability of trend analyses and other safety study information
Volunteer Reporting
Although it may seem to be a stretch to consider voluntary reporting as an investigation tool, the existence of a volunteer reporting system is not only indicative of the presence of a safety management system, but also and indicator of a good safety culture that will ensure reporting.
On-Board Recordings
The lack of information regarding the accident pre-conditions and the accident sequence, significantly reduce the capability of an investigation to find the true underlying factors to a safety significant event.
More and better on-board recorders would go a long way in filling this information void.
Investigation Methodology
The investigation methodology must include the search for the underlying factors and
The production of meaningful and effective safety communications.

9. Single-pilot, VFR & Difficult Conditions
CHARACTERISTICS OF HELICOPTER OPERATION
Single-pilot, VFR & Difficult Conditions
Remote Operations, Minimal Oversight
Long Hour, Minimal Rest
Minimal reporting, Few Investigations
Limited Scope & Depth Investigations
Discipline as a Corrective Measure
Band-aid Solutions
CHARACTERISTICS OF HELICOPTER OPERATION
My Final slide
Helicopter operations are unique in many ways:
A significant proportion of operations are
Single pilot
VFR
Remote operations
Difficult conditions
Long hours of work & minimal rest
Difficult and minimal oversight
Culture tends to result in:
Minimal volunteer reporting
Minimal interest in investigating incidents
Almost total reliance on the pilots self-monitoring the safety of operations
Tendency to limit the scope investigations to determine who or what failed.
Tendency to use discipline to deal with unsafe acts.
Tendency to use Band-Aid solutions for technical unsafe conditions

10. Current Investigation Process Adequacy of Investigation Resources
ACCIDENT/INCIDENT INVESTIGATION PANEL
Current Investigation Process
Adequacy of Investigation Resources
Data Collection and Archiving
Advocating for Change
Investigation Tools
Objective of the Accident/Incident Investigation Panel
How can we, the members of the Accident/Investigation investigation community, contribute to the IHSS Goal
Specifically, what are the Action Items that we can undertake to contribute to this goal.
How can we generate ownership within our investigation areas
Present suggested solutions to the rest of the members of this IHSS and the helicopter community.
The questions that we should consider are in the areas depicted on this slide
My proposal is to handle them in the sequence shown
Results in 30 minutes per topic, coffee break and a wrap-up
Comments and suggestions before we start?
You all should have a copy of the suggested questions for each topic