1. Safety Enhancement in Helicopter Operations
IHST Regional Conference
Delhi, India
Hosted by DGCA, COSCAP SA & RWSI
Somen Chowdhury
Executive Committee Member, IHST
VP Internationl, AHS

2. Contents Why IHST : Background Objectives, Goals & Implementation
Montreal Conference IHSS 2005
IHST Regional Cooperation
Safety : Every Step of the Way
IHSS 2007
Conclusions

3. Background: Current State of Affairs
Too many
Accidents /year worldwide
Lives lost Poor Public image
Business loss
Injuries Too expensive
UNACCEPTABLE

6. 24,294 Worldwide Civil Helicopters

7. Worldwide Helicopter Accidents/ year 1980-2005
Source : Roy Fox Bell Helicopter

8. Accident rates in India
Source: RWSI : AVM Sridharan

9. Need to bring down helicopter accident rates
Accidents rates per 100,000 hr
As per AUA ( Mike Kriebel):
2,225,000 total helicopter hours in USA in 2004
Accident rate per 100,000 flight hours : 8.09
Fatal rate 1.48
Turbine civil accident rate : 5.11
By contrast : U.S. Air carrier rate : 0.159
Data shows no change in rate over 24 years
India rate: distributed 400 hrs/yr
8.9 per 100,000 hrs for 2004
AUA : American Underwriter’s association
Need to bring down helicopter accident rates

10. Comparative Accidents Data

11. The Real Challenge Iceberg Theory1
Accidents 10
Serious Incidents
300
Incidents
1200
Near Misses
Heinrich Ratio
The BIG Picture
Hidden or Unseen
Conditions are Below The Surface

12. The Danger… - is all around us!!!
Helicopters operate in a high-risk environment!
The aircraft is more complex than any other transportation method.
Coupled with a changing and unprepared environment.
Often performing demanding, high-risk missions….

13. IHSS 2005 was held in Montreal to kick- off the process
Need to Act
Can the industry do better ?
How ?
Need a mitigation Strategy
IHSS 2005 was held in Montreal to kick- off the process

14. IHSS 2005 Montreal Conference
Four day program
Training Sessions
Management
Military
Maintenance
Invited Speakers
Paper sessions
Military & Civil missions
Human Performance & Training
Design & Maintenance
Accidents & Regulation
Management & Economics
Discussion panels
Plenary session
Results
Attendance ~250
International
13 countries
5 continents
Industry wide
Government
Regulatory
Accident Investigators
OEMs
Mission groups
Operators
Pilots
Maintainers
Aviation Press
IHST set up

15. To reduce helicopter accidents by 80%
IHST
Mission
To provide government, industry and operator leadership to develop and focus implementation of an integrated, data-driven strategy to improve helicopter aviation safety worldwide, both military and civil.
Vision
To achieve the highest levels of safety in the international helicopter communities by focusing on appropriate initiatives prioritized to result in the greatest improvement in helicopter aviation safety.
IHST has been created to provide solutions to the industry to reduce accidents. The mitigations strategies recommended will be data based and justifiable. The IHST will develop a consensus based approach to implement its recommendations. The implementation will be carried out by all within the industry.
Goal
To reduce helicopter accidents by 80%
by 2016

16. CAST (commercial aviation safety team) was considered
IHST Organisation
Executive Committee
IHST
JHSAT
JHSIT
Subcommittees
Secretariat
JHSAT - Joint Helicopter Safety Analysis Team
JHSIT - Joint Helicopter Safety Implementation Team
CAST (commercial aviation safety team) was considered
a good model to follow

17. Implementation Process
Influence Safety Enhancements - Worldwide
Data
Analysis
Set Safety
Priorities
Achieve consensus on
priorities
Integrate into existing work and distribute
Implement Safety Enhancements - U.S.
Agree on
problems and interventions

18. IHST Regional Cooperation
International Cooperation is essential
Regulators
Operators
OEMS
In all regions of the world.
We start with S Asia
We are all in it together

23. Safety: Every Step of the Way
Continuing Airworthiness
Safety
Failure Prevention
technologies
Reliability
anti corrosion
- reduce vibration
Survivability
ext. airbag
Crash worthy seats
& fuel tanks
- floatation gear
- egress
Operational regulations
Maintenance
Human Factors
Training of all parties
-Pilot aids
Mission comprehension
Quality Assurance
- No Flaw
Airworthy
Product
Short term
Action
S M S
3 years
20-30 years

24. Design Failure Prevention Technologies Reliability Survivability
Fail safe design vs safe life design/ CPR for evolutionary design
Composite structures : prevents catastrophic failures
HUMS : DPHM; embedded sensors
Pilot situational awareness technolgies for operational risks
Reliability
Corrosion control
No single point failure for critical components : 10-9 probability
FMEA
Survivability
Energy absorbing seats
Crash worthy fuel tanks
Energy absorbing structures
Egress capability
RETURN

25. Probability and Severity Relationships

26. Failure risk mitigation strategy
HAZARD SEVERITY
HAZARD
PROBABILITY
Catastrophic
Level 1
Critical
Level 2
Significant
Level 3
Negligible
Level 4
Frequent – Level A
1A = EXTREMELY HIGH
2A = EXTREMELY HIGH
3A = HIGH
4A = MEDIUM
Probable – Level B
1B = EXTREMELY HIGH
2B = HIGH
3B = MEDIUM
4B = LOW
Occasional – Level C
1C = HIGH
2C = HIGH
3C = MEDIUM
4C = LOW
Remote/Seldom - Level D
1D = MEDIUM
2D = MEDIUM
3D = MEDIUM
4D = LOW
Improbable/Unlikely - Level E
1E = LOW
2E = LOW
3E = LOW
4E = LOW

27. Manufacturing Flawless manufacturing Reduce MDRs
Improved inspection technologies
Reduced variability
RETURN

28. Field Operations Maintenance
Definition:
A periodic maintenance
task established during the certification of the aircraft as an operating limitation of the type design certificate.
RETURN

29. Continuing Airworthiness Function
Airworthy:
In respect of an aeronautical product, in a fit and safe state of flight and in conformity with the type design
RETURN

30. Field Operations Continuing Airworthiness :
fielded aircraft must meet regulatory compliance to retain certificate of AW : specified through ICAS
Compliance with service bulletins and directives
Develop a SDR system : electronic data base (ICAO Annex 8 Part II chapter 4, paras & 4.3.6)
Develop common data base; FAA, TCCA, Australia are already engaged in the process
Reliable data base is key to mitigation strategies
Country of registry needs to develop a strong engineering group overseeing CAW activities
coordinate with OEM and certificating state
Must share incident data and failed components with OEM immediately
Develop trust: Safety is everyone’s responsibility ; OEMs know their aircraft best

31. Field & Flight Operations Human Factors
Human Factors is cause of 75% accidents
It is critical to enhanced safety
Need to integrate HF in maintenance
Provide smarter maintenance aids
Need to Provide increased situational awareness aids to pilots
The door opened in flight!
RETURN

32. IHSS 2007 Montreal Dates –September 17 to 20, 2007
Action Plans from JHSAT, JHSIT will be discussed
Report on worldwide participation

33. Conclusions
Safety is a way of life : Safety is to be practised at every step: all the time
Need to develop safety management systems
We need to reduce helicopter accidents : meet the 80% reduction goal
Short term focus : operations and human factors
Continuing airworthiness is critical to the process
Need reliable data; accident investigations must be done by an independent body
Support the IHST initiative

34. Build on trust; we are in it all together
Recommendations
Create independent safety boards in each country; reporting to parliament. Need to ensure accident findings are unbiased
Develop continuing AW organisation with strong understanding of the engineering of the product.
Develop a worldwide common SDR data base
Increased training in maintenance and flight operations
Implement SMS
Achieve ownership by increased delegation of regulatory responsibility : essential to develop a matured process
Gradually move away from “authorising” and “mandating” to consensus. : Replace “control” to “manage”
Manage compliance via strong audit process
Share failed components and accident investigations easily with OEMs
Build on trust; we are in it all together

35. Please check out the IHST website: www.ihst.org
Questions?
Please check out the IHST website:

38. Civil Helicopter Breakdown Percentage of Accidents, India
Causes
Numbers
Breakdown
Percentage
Power Loss
2 / 41
Airworthiness
13 / 41 (32%)
Structural/
Component Failure
11 / 41
Loss of Visual Reference
8 / 41
Non-AW (human, etc.)
26 / 41 (63 %)
Loss of Control
Struck Object
9 / 41
Training for Emergencies
1 / 41
All other occurences
Other
2 / 41 (5 %)
Total
41 / 41
2 / 41 (100 %)
Source : AVM, Sridhran, RWSI

39. The ‘Swiss Cheese’ Model
Successive layers of defenses, barriers, & safeguards
Barriers are
Safety Nets
Some holes due
to active failures
(present in use)
Hazards
When barriers
fail
Other holes due to
latent conditions
(present, not visible)
ACCIDENT

40. Safety Management Systems - Transport Canada, FAA
Training Sessions
Safety Management Systems - Transport Canada, FAA
A systematic, explicit and comprehensive process for the management of safety risks that integrates operations and technical systems with financial and human resource management for all activities
Benefits -
a) Financial Benefit
b) Legal Compliance & Protection
c) Improved Business Management
d) Ethical Obligation
• Policy must address compliance, non- punitive reporting, continuous improvement and prevention
• SMS will not be effective in the absence of senior management commitment
• Roles and responsibilities within the organization must be clearly understood
• Communication and employee involvement are both crucial.
• Require safety objectives and goals
• Measures must be set up to track performance
• A formal review is conducted to assure that the SMS is working
SMS will be implemented in all regulated Canadian civil aviation orgs by 2007
Key Components
1) Safety management plan
2) Document management
3) Safety oversight
4) Training
5) Quality Assurance
6) Emergency Preparedness

41. Training Sessions Military Navy Army
Leadership, Training, Equipment, Culture
Kaki Risk Management (KRM)
Human Factors Analysis & Classification System
Skill based errors & Decision errors
Crew Resource Management (CRM)
Hard (letter of the law) & soft (spirit of the law) processes
Human factors - understanding people!
Army
Cumulative Risk Model
Risk Management Process - hazard identification, - severity & probability
Military Flight Operations Quality Assurance (MFOQA)
Proactive and systematic collection and analysis of operational data from aircraft for use in the continuous improvement of flight operations and readiness, specifically in the areas of Operations, Training, Maintenance and Safety
Aviation Safety Investment Strategy Team
Risk management - identify hazards & determine prevention & mitigation strategies
Shift focus from blame to prevention, from individual to system
Hazard Tracking Data Base
Web-based, provide customizable or standard briefing charts

42. Maintenance - Grey Owl & HAI
Training Sessions
Maintenance - Grey Owl & HAI
Human Factors!!!
The Dirty Dozen
1. Lack of Communication
2. Complacency
3. Lack of Knowledge
4. Distraction
5. Lack of Teamwork
6. Fatigue
7. Lack of Resources
8. Pressure
9. Lack of Assertiveness
10. Stress
11. Lack of Awareness
12. Norms
Maintenance Resource Management (MRM)
improving communication skills
decision making
effectiveness and safety in aircraft maintenance operations
Non-technical training
Operational Integrity
Situational Awareness
Error Chain Recognition
Communication Skills
Briefings
Synergy / Team Concepts
Leadership
Conflict Resolution
Decision Making
Stress Management

43. Invited Speakers Dr. Forster - HAI Mr. Resavage - President, HAI
Reflecting on the ICAO and its success, we determined that the issue of rotorcraft safety requires the initiation of a similar community-wide and international, military and civil collaborative effort to reduce the accident rate in the vertical flight community – both military and civil.
Mr. Resavage - President, HAI
There have been many safety initiatives but few of them have been coordinated and that identifying safety interventions, alone, is not enough, “they must be implemented.” “there is more than one path to safety. We must explore the potential for improvement through R&D and technological improvements but recognize that these are long term approaches and must be accompanied with interventions that can improve safety immediately through leadership, cultural change, improved internal systems and behavioral approaches for short term gains.”
Marinus Heijl, Deputy Director, Air Navigation Bureau, ICAO
xxx
BG Joseph Smith, US Army, Director of Army Safety/ Commanding General, U.S. Army Combat Readiness Center

44. Invited Speakers
Paul Arslanian, Bureau d’Enquetes et d’Analyses pour la securite de l’aviation civile (BEA)
xxx
Steve Finger, President, Sikorsky Aircraft Corp.
Mike Blake, Executive Vice President and Chief Operating Officer, Commercial Products, Bell Helicopter Textron, Inc.
Richard Healing, Former Member of the National Transportation Safety Board (NTSB)

45. Invited Speakers
Bob Sheffield, Managing Director, Shell Aircraft International
xxx
Sylvain Allard, President and CEO, CHC Helicopter Corp.
Tom Judge, President, AAMS - USA
different issues than rest of helicopter industry - business model, medical & aviation issues, reviewed Flight Operations database for AMS
Werner Marty, Flight Safety Officer and Pilot, Swiss Air Ambulance (REGA)
large operator (Safety program - management driven, reporting system, anti-collision, remove unused cables, review & revise SOPs, training, regulations, design,

46. IHST Executive Committee
Government Co-Chair Dave Downey, FAA
Industry/Operator Co-Chair Matt Zucarro, HAI
Secretariat Rhett Flater, AHS
Member Bob Sheffield, Shell Aircraft
Member Somen Chowdhury, IHSS Chair
Member Don Sherritt, Transport Canada

47. The way forward… JHSIT JHSAT Determine how to Analyze accidents
best implement the
solutions
recommended by
the JHSAT.
JHSAT
Analyze accidents
to determine what
solutions can
prevent & mitigate
the problems
Measure success via the diminishing accident rate!
JHSAT - Joint Helicopter Safety Advisory Team
JHSIT - Joint Helicopter Safety Implementation Team

48. Buy-in worldwide Italy Japan Netherlands Switzerland United Kingdom
Australia
Brazil
Canada
Columbia
France
Germany
India
Italy
Japan
Netherlands
Switzerland
United Kingdom
United States
Who’s Next??
There have been numerous safety efforts by different groups which have helped in dribs and drabs, but this sis the first effort on such a large scale which has gained international buy-in.

49. Training Panel Summary
Training Objectives:
Review present flight review requirement standards/minimum requirements
Review international regulations (JAA, TC, ICAO)
Review inadvertent IFR training requirements
Develop/explore distance learning instruction (HAI, Diamond endorsements) for Mx, Pilot, management
Increase use of synthetic (simulator-based) training
Synthetic auto-rotation training
Emphasis on IFR training
Review long term training objective
Current certification criteria for pilots and mechanics
CRM, MRM, safety culture

50. Training Panel Summary (cont.)
OEM develop training standards that should be verified by audit process
Training Recurrent and Initial schedules
Training for new technology
FITS training model as guideline
Better accident/incident statistics are necessary
Self disclosure program
HOW DO WE PROVIDE INCENTIVES FOR OPERATORS TO ADOPT SAFETY GUIDELINES ?!

51. Training Panel Summary (cont.)
OEM :
OEM develop training standards that should be verified by audit process
Training Recurrent and Initial schedules
Survey by OEMs on training issues for HeliExpo, other conventions and mailing
Heliprops-type program for maintainers
Review Medallion program or similar programs (HAI platinum) for roadmap
Encourage membership in similar programs

52. Last Six Years Data 2000- 2005 Civil & Military uses 3049 accidents
2643 fatalities
1027 serious injuries
5439 minor/ no injuries

53. Feedback to Manufacturer PRINCIPAL MAINTENANCE
ICAs
Feedback to Manufacturer
OPERATOR
OPERATOR
MAINTENANCE
PROGRAM
Regulatory
Approval
In-Service
Monitoring
Monitoring
PRINCIPAL MAINTENANCE
INSPECTOR
Operator Reliability
Program

55. Bell civil turbine accident causes worldwide (1994-2003)
Source : Roy Fox, Bell Helicopter Textron

56. CAST (commercial aviation safety team) was considered
Need to Act
Helicopter operations are essential
There is a need to have a comprehensive hard look as to how we operate and do business
Absence of any concerted plan so far
IHSS 2005 was held in Montreal to kick – off the process
CAST (commercial aviation safety team) was considered
a good model to follow

57. Charters Joint Helicopter Safety Analysis Team (JHSAT) Charter:
Conduct, review and approve detailed accident report analysis and identify causal factors;
Investigate and recommend improvements and develop mitigation strategies to allow goal achievement and periodic status measurements;
Draft action plans to determine intervention strategies and milestones for IHST approval.
Joint Helicopter Safety Implementation Team (JHSIT) Charter:
Develop and prioritize implementation strategies;
Carry out rigorous cost-benefit analysis for implementation strategies to achieve IHST goals;
Develop action plans;
Coordinate implementation of IHST-approved strategies;
Develop and track performance;
Determine progress in meeting major milestones and effectiveness of interventions.

58. Buy-in Worldwide: Government, Military & Civil Groups, OEMs
USA
Bell
Boeing
Sikorsky RR
Pratt & Whitney GE
Honeywell
Europe
Eurocopter
Augusta-Westand
Turbomeca
Canada
CHC Helicopters
USA
AHS - American Helicopter Society International
AAMS - Association of Air Medical Services
FAA - Federal Aviation Administration
FSF - Flight Safety Foundation Inc.
HAI - Helicopter Association International
NAVAIR - U.S. Navy - Naval Safety Center
NTSB - National Transportation Safety Board
U.S. Army Combat Readiness Center
Europe
BEA - Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile
EHA - European Helicopter Association
Canada
TCCA - Transport Canada Civil Aviation
TSB - Transportation Safety Board of Canada
India : DGCA : support from Jt.Sec Sanjay Kumar, DG & Jt.DG of DGCA
There have been numerous safety efforts by different groups which have helped in dribs and drabs, but this sis the first effort on such a large scale which has gained international buy-in.
Need all operators to buy-in