1. RISK AWARENESS: IMPROVING AIRCREW KNOWLEDGE

2. Risk for helicopters = 10 x risk for airlines Proposed strategies : Flight simulators CVRs… Heard at ISASI 2005 EGPWS Crash-resistance standards NVG HUMS IS THIS ENOUGH ? IS THIS REALISTIC ?

3. Cost Age of design Size of companies Variety of operations New risks Change in behavior (eg : use of GPS) IMPEDIMENTS

4. Lessons learnt but not assimilated IMPEDIMENTS (cont)

5. What if…

7. Jan. 2000 – Jun. 2005 354 Accidents 67 fatalities 133 hull losses Exposure : difficult to assess No significant trends BEA

8. 51 accidents with casualties (+4 undetermined)

9. Avoidable 55% of fatalities

10. Unsafe acts / behavior Abrupt maneuvers Low flight Negligent flight preparation Load securing Fuel W&B Continuation of flight in marginal conditions Failure to appropriately react to malfunction Lower the collective Reaction after hyd. loss New causes?

11. I can land anywhere if… I can better adjust to limits (weather)  Overconfidence Accident ? It won’t happen to me VIP factor Specific helicopter factor

12. Safety strategies Safety devices Hazard identification Procedures Improved training « Closing the loop » Tightening the loop

13. Knowledge of Hardware Knowledge of Software Knowledge of Environment Knowledge of Liveware Knowledge of interactions Knowledge of failure modes TRAINING HISTORY H SLE L

14. WHO IS IMMUNE TO ACCIDENTS? There are two sorts of pilots : Those who have landed gear up Those who will Bias in risk assessment : experience Extremely remote vs frequent

15. Investigation reports Standardized Based on facts Non-punitive approach All aspects reviewed (19 chapters) Participation of several partners Intended for prevention purposes Many details Lessons learnt

16. Ground lessons : case study Detailed study of circumstances and causes Questions : Have we experienced anything similar? Have we been close to experiencing anything similar? What are the similarities? What are the differences? Are we immune to being involved in such a scenario?

17. Questions (cont) What are our defenses? How could we improve them? How robust are they in an ever-changing environment? Can we precisely identify our defenses, the procedures? Do we perceive any gap between our planned and actual practices? Are we prone to defeating identified defenses? What are the root causes that we can map in our organization / in my personality ?

18. Challenges Selection of cases to study Education of moderator / instructor Adherence of personnel : confidence-based environment Address ALL actors, incl. Management  Create a culture Time cost obvious, savings hidden

19. Conclusion Close the loop : proactive implementation Teaches about strengths and weaknesses A mindset Can be implemented in ANY organization, with no delay Investigating bodies are ready to help initiate the process

20. Enhanced partnership