Today’s challenges Tomorrow’s opportunities

1. Today’s challengesTomorrow’s opportunities Solakonferansen Stavanger, 13-14 September 2011 David Learmount Operations & Safety Editor

2. Challenge & Opportunity • We have an opportunity to overcome safety challenges • If we overcome the challenges, new opportunities will open up.

3. The objective • Review where safety performance is today compared with recent years • Review what kind of accidents are still happening in the rotary wing and airline world • …and why they are still happening, according to EHEST/IHST/US JHSAT • Analysis of accident causes (EHEST/JHSAT)

4. IHST/EHEST: Who/what? • Set up in 2005 • Objective: reduce global helicopter accident rate by 80% by 1 January 2016 • Only four years to go, and no sign of a trend that would meet that objective by that date • Limitations of research programme so far: it has taken several years to dig out the data required to understand the problem

5. The global problem Trend? There isn’t one!

6. US civil helicopter accident trend compared with target US JHSIT: better, or coincidence?

7. Commercial helicopter accidents: Europe and rest of world • Commercial operators > 2250kg

8. Where we’re at (Airlines) • Fatal accidents only, simple numbers not rates • All types of airline operation including passenger, freight, positioning, ferry, training etc • Jet, turbo-prop and (occasionally) piston

9. Where we’re at (Airlines)(2) • IATA figures, western-built jets • Hull losses • The bars are IATA carrier figures, the line the global average

10. Can we get better? YES!Loss of/lack of control accidents • 2010 Afriqiya Airways, Tripoli, Libya • 2010 Ethiopian Airlines 737-800, Mediterranean Sea near Beirut • 2009 Turkish Airlines 737-800, Amsterdam • 2009 Colgan Air Dash 8 Q400, Buffalo • 2009 Yemenia Airbus A310-300, Indian Ocean near the Comoros Islands • 2009 Air France A330-200, South Atlantic • 2007 Adam Air 737-400, Java Sea near Sulawesi • 2006 Armavia A320, Black Sea near Sochi  • 2004 Flash Airlines 737-300, Red Sea near Sharm el-Sheikh • 2000 Gulf Air A320, Arabian Gulf near Bahrain  These ten accidents have killed a total of 1,137 people in ten years. Every single one was completely avoidable!

11. The message • Almost all the accidents that have happened in the last ten years, could have been prevented by the application of normal pilot skills. The problem is that those skills have been eroded by lack of practice. • Modern aeroplanes are highly reliable and beautifully built. They are also easy to fly, but very, very complex electronically. They can – and do – lull pilots – and airlines - into a false sense of security.

12. Can accidents be eliminated? • Most of today’s serious accidents could easily be eliminated • There will always be a few accidents that can’t be prevented because they will result from circumstances - or combinations of circumstances - that we have not yet encountered or predicted. But these will be rare.

13. Even a good airline can have a bad day (1) Accidents can still happen to really good airlines. But only the type of accident I just described, where the causal factors have not previously been encountered or predicted. Example: British Airways Boeing 777 (G-YMMM) on 17 January 2008 at London Heathrow. Hull loss, no fire, one passenger injury, no fatalities What happened? Forced landing 350m short of runway threshold when, one minute before landing, engine power was reduced by a sudden blockage of the fuel supply. Water ice crystals that had adhered to the fuel pipe walls during cruise were suddenly flushed into the fuel that was being delivered to the engines when the auto-throttle demanded power during final approach. Comment: This had never happened before in the history of aviation, and it had not been predicted either. The crew could not have done anything more than they did to save the aircraft. Moral of the story: even good airlines need insurance. Plus: a good example of the durability of modern airframes. This 777 hit the ground very hard, but didn’t break up and didn’t catch fire.

14. Even a good airline can have a bad day (2) Another example: 4 November 2010, Qantas Airbus A380 (VH-OQA) What happened? Uncontained failure of No 2 Rolls-Royce Trent 900 engine. High velocity metal fragments penetrated wing leading edge, cutting fuel and hydraulic lines and piercing forward wing spar. Multiple electrical and hydraulic systems failures. Crew had to deal with nearly 150 systems alerts on the electronic centralised aircraft monitor. The crew recovered the aircraft to Singapore where it landed safely. Major partial damage to engine and airframe, no injuries or fatalities. Comment: Stuff happens. Rolls didn’t know this was going to happen, so Qantas certainly didn’t. Investigation still proceeding. Moral of the story: 1. Train your crews, like Qantas does, to act as crews, and not to lose sight of the basics (airspeed, attitude, altitude, navigation) while dealing with multiple unforeseen technical problems. 2. Also a testament to the structural durability and systems redundancy in the latest generation of airliners

15. Even a good airline can have a bad day (3) “Sully” Sullenberger and the US Airways A320 that he ditched in the Hudson River near New York after a birdstrike had made his aircraft a glider. The aircraft’s flight envelope protection was not required: Sully flew the descent to ditching with respect for normal flight parameters Hull loss, but no injuries or fatalities Moral of the story: train your pilots for more than ordinary flying, because the day they have to take the autopilot out because things have gone wrong is the day they earn their money.

16. We can get better! The message from the airlines is: • We have already got much better than we were • …but we seem to have stopped getting better and are still having preventable accidents, but… • …some airlines don’t have accidents at all, or only have the ones that could not possibly have been avoided • So we can all be like them if we think and train like them! Now back to the safety stone-age: helicopters (with apologies to the North Sea oil-support sector which has made massive improvements over the last 20 years)

17. Helicopters: why get better? • High cost and poor safety (relatively) means that people only choose helicopter travel when there is no alternative • The market for helicopters and helicopter operations is being artificially restricted by a perception that helicopters are not safe. • Costs are difficult to reduce, so safety is the low-hanging fruit for those who wish to sell more helicopters or expand their operations in the long term.

18. EHSAT: top 3 problems/top 3 solutions Problems • Pilot judgement and actions • Safety culture/management • Ground duties Solutions (intervention strategies) • Flight operations and safety management culture • Training/instructional • Regulatory/standards/guidelines

19. Top Standard Problem Statements Pilot decision making Pilot-in-Command self induced pressure Inadequate oversight by the Authority Failed to follow procedures Selection of inappropriate landing site Reduced visibility – whiteout, brownout• Pilot’s flight profile unsafe for conditions Inadequate government/industry standards and regulations Disregarded cues that should have led to termination of current course of action or manoeuvre Aircraft position and hazards Pilot inexperienced with area and/or mission Mission involves operations at high density altitudes Management disregard of known safety risk Inadequate consideration of obstacles Top HFACS* issues Inattention Decision-making during operation Channelized attention Brownout/whiteout Risk assessment – during operation Overcontrol/Undercontrol Procedural Guidelines/Publications Communication Critical Information Mission Briefing Error due to misperception Technical/Procedural knowledge Pressing Cognitive task oversaturation Misperception of operational condition Distraction Excessive motivation to succeed * Human factors analysis and classification system Top worries: European Commercial helicopters

20. Top strategies (Europe) • SOPs: operators should be encouraged to establish and apply effective SOPs for all activities that they undertake • Safety culture: operators should develop an engagement/communication plan (videos, meetings, surveys, internet etc) to promote the development of a safety culture, risk assessment and rule compliance.

21. Top strategies 2 (Europe) • Run a closed-loop safety management system • Create a mission preparation and execution template against which every mission is checked before departure. Risk assessment will be central to this. • Risk assessment should be taught as a part of everyone’s job.

22. US accidents by operational sector JHSIT separates offshore from other commercial ops

23. US JHSAT: accidents by occurrence • Loss of control (41%) • Autorotation (32%) • System/component failure (28%) • Strike (16%) • Visibility (11%) • etc

24. Top US intervention recommendations (IR) • Improve training at all levels • Improve investigation and accident/incident reporting (lack of data is a serious impediment to improvement) • Improve safety management, with risk assessment and the application of SOPs high on the list (note that this pretty well harmonises with the EHEST recommendations)

25. How to intervene (US JHSAT) • Install cockpit recording devices - to record the actions of the flight crew. Data can be used as immediate feedback to trainers, operators and flight crews as well as accident investigation • Improve quality and depth of NTSB investigation. “Many accidents do not receive in-depth investigation. Investigations are being performed by telephone interview or by personnel who are not accident investigators. • Autorotation training programme. Improve autorotation training in both primary and advanced flight training and develop simulator programs to improve autorotation skills. • Confirm engineering compliance. Ensure that maintainers and operators are aware of the importance of following the manufacturer’s maintenance manuals and practices, and enforce this practise where required. • Simulator Training - advanced manoeuvres. Incorporate simulator training in dynamic rollover, emergency procedures training, ground resonance, quick stop manoeuvres, targeting approach procedures and practice in pinnacle approaches, unimproved landing areas, and elevated platforms .

26. US civil helicopter accident trend compared with target US JHSIT: better, or coincidence?

27. The message • Airlines have improved but can still easily do much better • Helicopters operators worldwide have not really started improving yet. It’s as if they didn’t even know the improvement option existed. But now the IHST is digging up the facts about helicopter accidents, so the backsliders’ arguments will be defeated. • All helicopter operations could be as safe as those achieved by North Sea oil support operators. They may not be perfect, but they are way ahead of the rest.

28. Thank you for your attention www.flightglobal.com/blogs/learmount