European Helicopter Safety Team: Samen sterk voor helikopter veiligheid

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Irma Sasbrink
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1 European Helicopter Safety Team: Samen sterk voor helikopter veiligheid Nederlandse helikopter veiligheidsdag 10 september 2010, NLR, Amsterdam Marieke van Hijum, EASA Michel Masson, EASA John Vincent, EASA

veiligheidsdag 10 september 2010, NLR, Amsterdam

2 EASA organisatie structuur European Helicopter Safety Team 2

3 Inhoud Introductie Methodologie Resultaten En verder Photo AgustaWestland European Helicopter Safety Team 3

4 European Helicopter Safety Team 4

5 Goal: To reduce the helicopter accident rate by 80% in 2016 Internationaal initiatief voor verbeteren van helikopter veiligheid Samenwerkingsverbanden op regionaal niveau European Helicopter Safety Team 5

6 Safety Analysis Team - EHSAT Analysis Safety Implementation Team - EHSIT Develop Safety Action Plans Implement Safety Action Plans Monitoring European Helicopter Safety Team 6

7 ECAST COMMERCIAL AVIATION SAFETY TEAM EHEST HELICOPTER SAFETY TEAM EGAST GENERAL AVIATION SAFETY TEAM EHSAT Core Team EHSIT Core Team Sub-group on Communication Regional Teams EHSIT Specialist Teams European Helicopter Safety Team 7

Team EHSIT Core Team Sub-group on Communication Regional

8 IS Deelnemers EHEST NO SE FI IE DK EE LV LT UK NL PL FR BE LU CH DE SI CZ AT SK HU RO PT ES IT BG GR MT CY European Helicopter Safety Team 8

9 Introductie Methodologie Resultaten En verder Photo Eurocopter European Helicopter Safety Team 9

10 Methodologie Analyse van helicopter ongevallen aan de hand van gestandaardiseerde IHST methode Methode ook toegepast door helicopter teams in onder andere Verenigde Staten, Brazilie en Canada EHEST heeft HFACS analyse (door Wiegmann and Shappell) toegevoegd, om een beter beeld van human factors te krijgen European Helicopter Safety Team 10

Staten, Brazilie en Canada EHEST heeft HFACS analyse (door Wiegmann and Shappell)

11 Analyse Standard Problem Statements European Helicopter Safety Team 11

12 Analyse - HFACS Voor beide analyse methoden geldt dat de diepgang afhangt van de informatie in het ongevalsrapport European Helicopter Safety Team 12

13 Introductie Methodologie Resultaten En verder Photo Vasco Morao European Helicopter Safety Team 13

14 Scope Dataset Ongevallen (definitie ICAO Annex 13) Periode: Lokatie: EASA Member States Eindrapport van ongevallenonderzoeksraad aanwezig EHEST voorlopige resultaten gepresenteerd in oktober 2008 (186 ongevallen) EHEST eindrapport analyse in oktober 2008 verwacht (311 ongevallen) Volgende slides zijn gebaseerd op 303 ongevallen (goede indicatie voor eindrapport) Eindrapport Analyse Oktober 2010 European Helicopter Safety Team 14

eindrapport analyse 2000-2005 in oktober 2008 verwacht (311 ongevallen) Volgende slides zijn gebaseerd op 303

15 Distributie van ongevallen over type operatie EHSAT Dataset State Flight, 4% (bijv. Politie, Military) Aerial Work, 32% (bijv. Fire Fighting, Sling/External Load) General Aviation, 45% (Bijv Pleziervluchten, Training, Business vluchten) Commercial Air Transport, 19% (bijv. Passenger, HEMS, Offshore, CAT Training, CAT Positioning) European Helicopter Safety Team 15

Fire Fighting, Sling/External Load) General Aviation, 45% (Bijv Pleziervluchten, Training,

16 Distributie Accident Distribution van ongevallen over Phase over of vluchtfase Flight EHSAT EHSAT Dataset Dataset Fatal Non Fatal 35% 30% 25% % of Accidents 20% 15% 10% 5% 0% Standing Taxi Take-off En route Approach & Landing Manoeuvring European Helicopter Safety Team 16

30% 25% % of Accidents 20% 15% 10% 5% 0% Standing Taxi Take-off En

17 Standard Problem Statement analyse resultaten % of Accidents where SPS level 1 has been identified at least once EHSAT Dataset Pilot judgement & actions Safety Culture/Management Ground Duties (Planning&Preparation) Pilot situation awareness Data issues Mission Risk Part/system failure Regulatory Maintenance Post-crash survival Aircraft Design Infrastructure Communications Ground personnel 65% 51% 38% 35% 35% 27% 25% 25% 18% 17% 16% 9% 7% 1% 0% European 10% Helicopter 20% Safety Team 30% 40% 50% 60% 17 70%

Mission Risk Part/system failure Regulatory Maintenance Post-crash survival Aircraft Design Infrastructure Communications

18 Voorbeeld van Commercial Air Transport scenario During a HEMS mission after the patient had been loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. The decision to continue was taken because an ambulance was waiting to transfer the patient to hospital. During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. European Helicopter Safety Team 18

The decision to continue was taken because an ambulance was waiting to transfer the patient to hospital.

19 Voorbeeld van Commercial Air Transport scenario During a HEMS mission after the patient had been Loss of Visual Reference loaded the helicopter crew decided to continue the mission in deteriorating weather conditions. The decision to continue was taken because an Inadequate ambulance was decisions waiting to transfer the patient to hospital. Pilot felt pressure During the take-off in poor visibility and falling snow the right front skid of the helicopter struck the surface and as a result it nosed over uncontrollably and impacted the ground. European Helicopter Safety Team 19

The decision to continue was taken because an Inadequate ambulance was decisions waiting to transfer the patient to hospital.

20 SPS Voorbeeld van Commercial Air Transport scenario HFACS Pilot decision making Self induced pressure Failed to follow procedures Flight profile unsafe Inadequate oversight Reduced visibility Selection of inappropriate landing site Management Failure to enforce company SOPs Decision Making - Operation Risk assessment Operation Skill-based errors Whiteout/Vision restricted Channelized attention Communication critical information/planning Pressing Procedural Guidelines European Helicopter Safety Team 20

Failure to enforce company SOPs Decision Making - Operation Risk assessment Operation Skill-based errors Whiteout/Vision

21 Voorbeeld van General Aviation scenario The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud base. Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. Shortly after the loss of radar contact the helicopter suffered an in-flight collision with terrain. European Helicopter Safety Team 21

22 Voorbeeld van General Aviation scenario No weather forecast obtained The helicopter was on a Visual Flight Rules flight. En route, it entered an area of rising terrain and low cloud No base. flight plan filed Radar tracking indicates that the helicopter slowed down, and then made a sharp turn before disappearing off the screen. No contact established with ATC Inadvertent IMC Shortly after the loss of radar contact the helicopter suffered an in-flight collision with terrain. Limited experience European Helicopter Safety Team 22

23 SPS Voorbeeld van General Aviation scenario HFACS Pilot inexperienced Mission planning Pilot decision making Inadequate standards and regulations Wilful disregard for rules and SOPs Inadvertent entry into IMC Failed to recognise cues to terminate course of action Risk assessment Operation Overcontrol/Undercontrol Procedural error Violation Lack of discipline Mission planning Overconfidence Vision restricted by meteorological conditions Limited total experience European Helicopter Safety Team 23

24 Total number Aantalof EHEST Intervention aanbevelingen Recommendations voor interventies (Level 1) Operations 497 Training_Instructional Training/Instructional 472 Regulatory 214 Data_or_Information_Issues Issues 175 Maintenance 77 Aircraft_System_Equipment_Design Aircraft_Design Research Manufacturing Infrastructure Search_and_Rescue and European Helicopter Safety Team 24

25 Introductie Methodologie Resultaten En verder Photo Agusta Westland European Helicopter Safety Team 25

26 Volgende stap is implementatie EHEST Communication Sub-Group Bereiken van all Europese stakeholders met een extra focus op General Aviation EHSIT Specialist Teams Operations/SMS Training Regulation/Standards European Helicopter Safety Team 26 EAB 12 March 2010 European Helicopter Safety Team 26

27 Huidige en geplande activiteiten (1) Veiligheidspromotie Video Folders Best practice materiaal Ontwikkelen van een pre-flight risk assessment checklist Voorbeeldlijst van hazards Handleiding instructeur Maintenance toolkit European Helicopter Safety Team 27

28 Huidige en geplande activiteiten (2) Actieplannen voor organisaties Eventueel voorstellen ontwikkelen voor regelgeving of standards richting autoriteiten Toolkits door IHST (SMS, Training, Flight Data Monitoring) Bijdragen aan ontwikkelen van een helicopter versie van IS-BAO (standaard en accreditatie voor business aircraft operations) European Helicopter Safety Team 28

29 Tot slot Al veel gedaan om ongevallen en veiligheidsissues beter te begrijpen De uitdaging ligt nu in het ontwikkelen, implementeren en monitoren van effectieve maatregelen om reductie van ongevallen te bereiken en het betrekken van de kleine operators en GA piloten bij EHEST en IHST. European Helicopter Safety Team 29

30 Evenementen International Helicopter Safety Symposium 3 en 4 oktober 2010 in Cascais, Portugal. Georganiseerd door IHST-US en EHEST Verder informatie en registratie op EASA Rotorcraft Symposium 8 en 9 december 2010 in Köln, Duitsland Verdere informatie en registratie op European Helicopter Safety Team 30

31 Bedankt voor uw aandacht Deelnemen of meer informatie? European Helicopter Safety Team 31

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