RISK AWARENESS: IMPROVING AIRCREW KNOWLEDGE

1. RISK AWARENESS:IMPROVING AIRCREW KNOWLEDGE

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

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

4. IMPEDIMENTS (cont) • Lessons learnt but notassimilated

5. What if…

6. 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. New causes? • 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

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

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

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

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