US Army Aviation Safety Investment Strategy Team (ASIST)

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

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

7. Machine (Aircraft) - Complexity - Failures - Uncertain causes Crew - Proficiency - Coordination - System Under- standing Environment (Mission) - Multi-ship - Over water - NVG Identifying Hazards • Environment • (Leadership) • OPTEMPO • Culture • Experience • - 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

8. Risk Management of Simulated Engine Failure (SEF) Training 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. • “Cause: Human Error” • Pilot failed to follow proper • procedures due to complacency • & over-confidence. • Pilot improperly diagnosed • emergency due to high anxiety.

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

10. Risk Management of Simulated Engine Failure (SEF) Training 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 -

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

12. KW Example Results Demo

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 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 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 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

19. DOTMLPF Control Analysis

20. DOTMLPF Control Analysis (cont) 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