The Reality of Aeronautical Knowledge

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International Helicopter Safety Team (IHST) workshop presentation from HeliExpo 2013

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  • Most of you have seen this course description on the Heli Expo website, and should be familiar with it I’m going to attempts to go a little bit beyond where we left off after flight training, not to get in the weeds with specific aeronautical knowledge but to give that knowledge a bit of critical thinking.
  • Hopefully by the end of the session we will all take a little bit different View as to what we really consider before during and after we go out on a flight question to ask yourself right now is when I’m flying, do I actually consider the consequences of not tying my aeronautical knowledge to what is happening, when it happens?
  • We all have a story that defines us in aviation.Years ago, I left Fort Rucker, ending up in Camp Stanley Korea on my first tour. Just after I arrived I had learned of a new process the Army had adopted where we had to assess the risk prior to our flight at the time we just mocked that we had a ton of paperwork for a one half hour flight just to strap a cobra on our back and scream around the countryside we often talked about complacency and how that would affect what we did in the cockpit we talked about crew management and how important it was to mix the experience levels we conducted frequent pilot briefings where instructors would put you on the spot in public, requiring you to spout off an emergency procedure from memory it seemed at the time like aeronautical knowledge was consistently a part of our everyday life and one of the most interesting things I can recall, is when we would get the additional flight facts and open discussions on the various incidents and accidents pertaining to our airframes. We had great discussions with some amazing old pilots who we just thought farted dust but these guys challenged us, and made us a whole lot better, even if that was embarrassing at timesThey gave us perspective
  • As a young infantryman at Fort Benning Georgia they put us in a standard classroom to view a movie the goal was to provide some perspective to what our life would be like in the event we ever went to combatCold Warfootage was Vietnam the subject was blood and gorealso keep in mind that this was in the days before special effects, so this was 100% real blood, goo, and every cut off on this you could imagine some guys fainted, some guys got up and left, and some guys just turn their heads in places but we left with some perspective
  • THIS ACCIDENT WAS AN ONBOARD VESSEL 28 SOME ODD PHOTOS GORE AND GOO REMOVED….. BUT PERSPECTIVE FOR NEW PILOTS IS THAT THEY GET MUCH MORE FROM THIS. IT HITS HOME.
  • WHEN YOU CAN APPLY THE PHOTOS TO PROCEDURES AND ACCIDENT REPORTS, IT WILL MAKE A DIFFERENCE
  • THIS IS WHAT NEEDS TO BE ADDRESSED IN THE INDUSTRY WE HEAR, READ AND DISCUSS THAT ACCIDENTS ARE HAPPENING MORE IN THE SMALL OPERATIONS THANIN LARGER ENTITIES LARGE COMPANIES ARE APPLYING ROBUST SMS PROGRAMS GETTING THE MESSAGE IS HARD FOR SMALL PART 91 TYPE OPERATIONS WHERE WE ALL CAN BE A PART OF THE CHANGE IS TO ENSURE WE DO THE BEST WE CAN TO GET THES FRINGE ELEMENTS (SMALL COMPANIES AND OWNER/OPERATORS) THAT WE CONNECT WITH AND HELP THEM IN THE PROCESS RESEARCH IS STARTING TO OCCUR AND MORE WILL HAPPEN. THOUGHT: CAN WE FORCE A CHANGE BY SHEAR FORCE OF INFORMATION SATURATION?
  • ONE OF THE IMPORTANT PARTS OF OUR JOBS AS PILOTS IS CRITICAL THINKINGI THINK THAT C-T IS VITAL TO PERSPECTIVEREAD THRU THIS SLIDEWE ALL USE CRITICAL THINKING SKILLSALL OF THESE THINGS ARE HAPPENING AT THE BOTTOM OF PAGEHOW WE APPLY THESE TO AERONAUTICAL KNOWLEDGE IS ESSENTIAL
  • At the ERAU Prescott campus in Arizona, we collaborated in the College of Aviation to produce an aviation safety text and I volunteered to write the helicopter safety chapter A few months later we abandon the project but not after some of us had completed a good amount of work which I kept a couple of years ago I offered the text for review to the IHST to see if it could be useful about a year later we came out with the Reality Of Aeronautical Knowledge: The Analysis Of Accident Reports Against What Aircrews Are Supposed To Know Are the concept was to approach what we know and a little bit beyond that, and combine it with detailed accident study from the IHST so this practically illustrates and lends perspective as a side note, I really wanted to add blood and gore to the documentation but for obvious reasons it probably wasn’t the smartest way to go I encourage you to download the document from the IHST website
  • We are putting a lot of effort in the industry to promotion of safetyHow far does that get though?While @ Heli-Expo, see how many things you experience that are overtly safety related.Now what has your aviation culture or upbringing lent you regarding perspectiveLets take a quick survey; - How are you getting perspective into your operations?
  • HERE ARE SOME STATS FROM THE IHST COMPENDIUM (www.ihst.org)http://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdfAre we looking deep enough?What are we going to find?
  • In the JHSAT analysis, it was important to identify that each accident occurrence comprised many other issues that had to be accounted for in order to identify an intervention strategyhttp://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdfhttp://www.ihst.org/portals/54/Reality_Aeronautical_Knowledge_21MAY12.pdf
  • These points emphasize what was happening when the accident occurred.How many of you were truly familiar with these levels?How many of you find yourselves in this environment in your operation?http://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdfhttp://www.ihst.org/portals/54/Reality_Aeronautical_Knowledge_21MAY12.pdf
  • ALSO IMPORTANT TO THE EQUATION IS WHAT TYPES OF OPERATIONS ARE INCURRING THE MOST RISKNOT A LOT OF SURPRISES HEREhttp://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdfhttp://www.ihst.org/portals/54/Reality_Aeronautical_Knowledge_21MAY12.pdf
  • SOME DEMOGRAPHICS ARE ALSO REVEALINGhttp://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdfhttp://www.ihst.org/portals/54/Reality_Aeronautical_Knowledge_21MAY12.pdf
  • COMPARED TO A FEW YEARS AGO, THE AMOUNT OF SAFETY RELATED MATERIAL FOR HELICOPTER INDSUSRTY IS QUITE DIFFERENT AND GOOD. THE IHST IS BECOMING A GREAT HELICOPTER SAFETY RESOURCE SMART PHONE AND TABLET APPS ARE ON THEIR WAY POTENTIALLY
  • I want to take the discussion a different route and now use the NTSB reports and the Reality Text to provide some perspective.The Reality text is a synthesis of aircrews and operations and knowledgeThe idea is to take the text and apply it to your environment To generate further discussionsIn extending the HFH, the text offers a transition from an aeronautical knowledge topics, to relevant accident narratives to further the understanding and perspective.
  • REVIEW THE REALITY TEXT, PART 2 FOR A LOOK AT ALL OF THE AREAS WHERE ACCIDENTS ARE MORE FREQUENT AND THE ASSOCIATED INFORMATION.
  • THE FORMAT ABOVE IS A COMBINATION OF ACCIDENT REPORTS, AND IHST COMPENDIUM ANALYSIS.
  • BASICALLY, THIS SHOWS THE ACCIDENT OCCURANCE OF LOC. THIS FLOWS WELL WITH THE INTENT OF THE DOCUMENT
  • The first two questions are sort of open ended.Time will tell, but in my experience, perspective helps us apply knowledge to a higher levelJeff cooper was an exceptional mind. (a little about Col Cooper)He often understood perspective and his amazing words showed this.He wrote an amazing essay on principles of personal defenseI believe these translate well to the application of perspectiveOf course the last two (NEXT SLIDE)
  • ASK YOURSELVES THESE QUESTIONS
  • WHAT IF: COULD RESEARCH LEND PERSPECTIVE WHERE WE AS AN INDUSTRY AND SPECIFICALLY, SMALL OPERATORS NEED TO GO TO IMPROVE SAFETY
  • - Don’t say a plane - Don’t say because it stays here - Perspective? To see things from a different point of view? To enhance your point of view? To expand your concepts, knowledge and understanding? - Where do you take it? - I always leave the expo energized with a sense of purpose. Besides seeing some amazing things I wish I could experience.Where in the industry are the accidents happening? - Who/what is the “problem child”?Can association of Aeronautical Knowledge to Accident Data change anything?Can SMS be the answer to the questions above?We all surmise this as true, but the theory must be tested.
  • IS IT SAFE TO SAY THAT AN SMS PROGRAM WILL DEFINITELY HAVE A POSITIVE INFLUENCE ON AN ENTITY’S BUSINESS? HOW LARGE DOES THE PROGRAM NEED TO BE?
  • This may be the start of a drive to get the answersIn the mean time, instructors are the keyPerspective must live in each small operation
  • WHAT DOES IT TAKE FOR OUR OPERATORS TO CHANGE AND ADOPT SOME KIND OF SAFETY PROGRAM?
  • THIS WILL OF COURSE TAKE TIME WE MAY NEVER KNOW THE ACTUAL LEVEL TO WHICH THE IHST CAN BE ATTRIBUTED TO THE SUCCESS OR FAILURE OF THE SAFETY MOVEMENT
  • EARLIER I SPOKE OF RESEARCHMORE IS COMING, BUT IF WE CAN PROVE BEYOND A DOUBT THAT THE APPLICATION OF ALL THIS SAFETY STUFF WILL NOT ONLY SAVE LIVES, BUT THAT IT WILL ALSO ENHANCE OPERATIONS AND MAKE YOU MORE PROFITABLE….ISN’T IT WORTH ANOTHER LOOK?
  • RESEARCH WILL OFFER PERSPECTIVE NEXT WE AS AN INDUSTRY MIGHT HAVE SUCCESS WITH THE RESSEARCH IN REDUCING RATES FOR APPLICATION OF SMS IN THE COMPANY.
  • The Reality of Aeronautical Knowledge

    1. 1. Heli-Expo 2013 Safety ChallengeThe Reality of Aeronautical Knowledge:The Analysis of Accident Reports Against What Aircrews are Supposed to Know
    2. 2. IntroductionFaculty with Embry-Riddle Aeronautical UniversityDiscipline Chair, Helicopter Operations and SafetyAssociate Program Chair, TransportationIHST Affiliations IHST, JHIMDAT IHST, JHSIT, Training Committee IHST, JHSIT, SMS Committee
    3. 3. Course DescriptionBest suited to accident prevention, thispresentation is a combination of practicalknowledge beyond the Helicopter Flying Handbookand research of the IHST’s Analysis Team. This in-depth look at aeronautical knowledge, decision-making, and understanding limitations is ideal forall experience levels. This presentation evolvedfrom extensive research into the industrypublication
    4. 4. ObjectivesPerspective Gain a higher level of operational/safety awareness as related to their functions within a company. Review accident information through the eyes of aeronautical knowledge Develop an acute awareness of perspective and how to use it
    5. 5. ReferencesBurgess, S. (2012). The reality of aeronautical knowledge: The analysis of accident reports against what aircrews are supposed to know. Joint Helicopter Measurement and Data Analysis Team, International Helicopter Safety Team. Retrieved from http:// www.ihst.orgCompendiums I & IIInternational Helicopter Safety Team, (2011). IHST reports: US JHSAT compendium report – Volume I. Retrieved from http:// www.ihst.orgInternational Helicopter Safety Team, (2011). IHST reports: US JHSAT compendium report – Volume II. Retrieved from http://
    6. 6. AgendaIntroduction and discussion of researchBeyond the Helicopter Flying HandbookDiscussion of Accidents by Occurrence CategoryConclusionDiscussion and Collaboration
    7. 7. Where do we come from? What is our cultural background?
    8. 8. What Provides Perspective?Training usually follows a set standardWe learn the minimums or just beyond We discuss an Auto We are demonstrated an Auto Then we practice an AutoDo we add value to the training?(Not thru abrupt maneuvers though)Do we take perspective far enough?
    9. 9. Perspective
    10. 10. Perspective
    11. 11. Perspective
    12. 12. Why Do This?Accidents happening in our industry seem to be occurringmore in specific areas Small companies (<3 ships) Single Owner OperatorsYoung/new Instructors in schools may end up in thispopulationThe population is hard to communicate withResearch is coming
    13. 13. Adjunct to PerspectiveCritical Thinking. Apply knowledge at the synthesis level to define and solve problems within professional and personal environments. As an integral component of problem solving and decision- making, this combination of skills allows one to form contentions, conclusions and recommendations. This skill combines all of the following tasks; analysis, evaluation, conceptualizing, application, solutions, recommendation, synthesis, researching, observation, exper ience, reflection, reasoning, communication.
    14. 14. Reality is PerspectiveThe Reality of Aeronautical Knowledge: The Analysis ofAccident Reports Against What Aircrews are Supposed toKnowSupplements to the HFH are necessaryDoctrine, techniques and procedures need perspectiveInclusion of actual NTSB accident reports offer a realisticviewpoint and association to the environment in which weoperate the helicopter. These are real events, whichhappened to real people.
    15. 15. Perspective is Safety(Answer these Questions Strictly from your Perspective And not your Companies perspective)Do you associate a flight operation with safety?How integral is safety TO your operational environment?How do you see the industry promoting safety?How overt is safety in your environment?Was safety perspective always present in your career?
    16. 16. Statistics as PerspectiveIn the U.S. JHSAT analysis, their three year assessment of523 accident events identify that 16% produced a fatality.Over half (51%) of these accidents did not produce an injury. What does this say about our industry? Where do these fatalities come from? What is our weakest link?
    17. 17. Statistics as PerspectiveAccident Occurrences like Loss of Control was identifiedwith 41% of the accidents.Loss of Control can occur at various times during a flight, soit was important to further express a category ‘Phases ofFlight’ with sub-categories such as; Landing (108 accidents/ 4 fatal accidents) Enroute (102 accidents/34 fatal accidents).
    18. 18. Statistics as PerspectiveHighest % of accidents came from the (personal/private)industry category 97 out of the 523 total accidents (18.5%).Instructional/Training (Dual) incurred the highestpercentage of accidents (14%, or 73 accidents) for “Activity”classification.Positioning/Return to Base had 69 accidents (13%).
    19. 19. Statistics as PerspectiveFAR Part 91 operations incurred 70% of the total accidents.FAR Part 91 operations account for just over half of therotorcraft flight hours each year (amount of exposure).FAR Part 91 ends up accounting for a higher percentage ofaccidents compared to amount of exposure partly becausethe Personal/Private and Instructional/Training industrieshave such a high percentage of the accidents and bothoperate Part 91.
    20. 20. Statistics as PerspectiveMost of the accidents occurred in good weather during thedayOver half of the pilots (246 of 523) totaled over 2,000 flighthoursPIC time was less than 500 hours (for almost the samepopulation).
    21. 21. What has the Industry/IHST/HAIrecently done with perspective? Flyers, Fact Sheets, Essays, Presentations Posting research Training worksheets IHST and HAI working groups and committees Training and education Publications etc
    22. 22. Applied RealityReality text : Part II Beyond the HFH
    23. 23. Applied PerspectiveReality text takes knowledge and compares to realaccidents.Accidents were reviewed to determine best examples ofcause and effectExtension of HFH discussion concurrent with IHST accidentoccurrence categories
    24. 24. Extending the DiscussionIntent to extend discussion on specific areas of the HFH toIHST accident data analysis18 topics are expanded Standard issues like mast bumping or SWP/VRS Multifaceted issues like Situational Awareness and ADM Complex issues like Low Level Flight dealing with WX/PWR/Visibility/Obstacles/Distractions
    25. 25. Applied Reality Reality text : Part III AccidentAnalysis teamed with NTSB Reports
    26. 26. SynthesisSnapshots of high volume accidents by occurrence category Explain Introduce Define Identify problemAccident NarrativesLets have a look ……..
    27. 27. 3. Standard Problem Statement. The most common Loss of Control problem came from Performance management. Within this occurrence it is clear that the pilot decision-making was a problem. Additionally, there appears to be a significant amount of information missing to pinpoint specific performance management issues. Accident reporting vs. engine monitoring equipment contributed to this lack of solid causal factors and the industry is engaged in improving this situation. What the reader can take away from the following charts is how at each level, loss of control predominantly occurs from a human factors point of view. In most cases the underlying cause was the failure to perform specific procedures, execute a proper decision, communicate, or adequately plan. Performance Management (Loss of Control) (present in in 79 out of 523 accidents)SPS Level 1 SPS Level 2 SPS Level 3Pilot Judgment & Procedure Implementation Inappropriate Energy/power managementActionsPilot Judgment & Procedure Implementation Pilot control/handling deficienciesActionsPilot Judgment & Landing Procedures Autorotation – PracticeActionsPilot Judgment & Human Factors - Pilots Disregarded cues that should have led toActions Decision termination of current course of action or maneuverPilot Judgment & Crew Resource Management Inadequate and untimely CFI action to correctActions student action Dynamic Rollover (Loss of Control) (present in in 31 out of 523 accidents)SPS Level 1 SPS Level 2 SPS Level 3Pilot Judgment & Procedure Implementation Improper recognition and response to dynamicActions rolloverPilot Judgment & Procedure Implementation Pilot control/handling deficienciesActionsPilot Judgment & Crew Resource Management Inadequate and untimely CFI action to correctActions student actionPilot Judgment & Landing Procedures Selection of inappropriate landing siteActions 27
    28. 28. Exceeding Operating Limits (Loss of Control) (present in 27 out of 523 accidents) For Loss of Control in general, the Top 3 IRs for training were: Training emphasis for maintainingSPS Level 1 SPS Level 2 SPS Level 3 awareness of cues critical to safe flight, Enhanced Aircraft Performance & Limitations Training,Pilot Judgment & Human Factors - Pilots Disregarded cues that should have led toActions Decision termination of current course of action or and Inflight Power/Energy Management Training. maneuverGround Duties Mission/Flight Planning Inadequate consideration of aircraft For Loss of Control in general, the Top 3 IRs for Safety Management were: Personal Risk performance Management Program (IMSAFE), Use Operational Risk Management Program (Preflight),Ground Duties Mission/Flight Planning Inadequate consideration of aircraft operational Establish/Improve Company Risk Management Program. limitsPilot Judgment & Procedure Implementation Pilot control/handling deficiencies Often times young pilots are attuned to what their aircraft control requirements are in theActions cockpit and what directly relates to those tasks such as CRM. This mentality is sometimesPilot Situational External Environment Lack of knowledge of aircrafts aerodynamic carried forward as the pilot graduates to instructor, and perhaps more so in these smallAwareness Awareness state (envelope) companies. It is important to integrate pilot training and education with environment that includes a comprehensive management system for both operations and safety. This should occur early in a pilot training program. Emergency Procedures (Loss of Control) (present in 23 out of 523 accidents)SPS Level 1 SPS Level 2 SPS Level 3 5. Accident Narratives. Since we are reviewing several Loss of Control (LOC) areas, there will beMaintenance Performance of MX Duties Failure to perform proper maintenance several narratives for each of the loss of control discussions above. procedurePilot judgment & Procedure Implementation Pilot control/handling deficiencies National Transportation Safety Board NTSB ID: Aircraft Registration Number:actions Occurrence Date: Most Critical Injury: None FACTUAL REPORT AVIATIONGround Duties Aircraft Preflight Performance of Aircraft Preflight procedures Occurrence Type: Accident LOC - Performance Management inadequate Airport Proximity: Off Airport/Airstrip Distance From Landing Facility: Accident Information Summary- Loss Of Tail Rotor Effectiveness (Loss of Control) (present in 23 out of 523 accidents) A helicopter was destroyed following a loss of tailrotor effectiveness landing. The flight was conducted under the provisions of 14 CFR Part 135 and was on a visual flight rules flight plan. Visual meteorological conditions prevailed atSPS Level 1 SPS Level 2 SPS Level 3 the time of the accident. The pilot reported minor injuries to himself and one passenger. There were a total of fourPilot judgment & Procedure Implementation Inadequate response to Loss of tail rotor occupants including the pilot.actions effectiveness After losing tail rotor effectiveness, the pilot was able to land the helicopter in a field amongst pine trees. The mainPilot judgment & Human Factors - Pilots Disregarded cues that should have led to rotor stuck the trees and the helicopter rolled over on its right side. A fire erupted and the helicopter was consumed. The occupants had exited the aircraft prior to the fire.actions Decision termination of current course of action or In a written statement, the pilot said that, as he approached the landing area, the helicopter was, "...about 250 pounds maneuver below maximum gross weight of 3,200 pounds." The pilot stated that, while on approach to land, he noticed a tree thatSafety Flight Procedure Training Inadequate avoidance, recognition and recovery he had not seen before and decided to abort the landing. He said he, "...began a power pull to 100 percent torque and aManagement training: Loss of Tail Rotor Effectiveness (LTE) transition to forward flight. The helicopter immediately began a rapidly accelerating yaw to the right. I applied maximum left pedal to halt the yaw, which was ineffectual." The pilot stated that, when he was clear of obstacles, he attempted to regain control. He said that, at that point, he, "...believed [he] still had a functioning tail rotor, but that it may have entered a loss of tail rotor effectiveness state and need only be regained." The pilot also stated that, "the 4. Intervention Recommendation. Training and Safety Management were the two primary low rotor RPM warning light and horn began to come on with each pull of the collective..." recommendations for intervention for loss of control accidents. This is followed by specifically The National Transportation Safety Board determines the probable cause(s) of this accident as follows. suggesting training it by topic of aeronautical knowledge relating to piloting skills, airframe The pilots failure to attain translational lift following an aborted landing and the loss of tail rotor effectiveness knowledge, and specific information regarding typical flight operations and missions. All encountered by the pilot. Factors to the accident were the low rotor rpm and the trees. recommendations center on the integration of safety and operations management. 28 29
    29. 29. National Transportation Safety Board NTSB ID: Aircraft Registration Number: National Transportation Safety Board NTSB ID: Aircraft Registration Number:FACTUAL REPORT AVIATION Occurrence Date: Most Critical Injury: None FACTUAL REPORT AVIATION Occurrence Date: Most Critical Injury: None Occurrence Type: Accident LOC - Dynamic Rollover Occurrence Type: Accident LOC - Emergency ProceduresAirport Proximity: Off Airport/Airstrip Distance From Landing Facility: Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:Accident Information Summary- Accident Information Summary-The pilot of the med-vac helicopter reported that, during liftoff at the remote site, he encountered a loss of visual Two commercial helicopter pilots, both certificated helicopter instructors, were in a turbine-powered helicopterreference due to a "brown out" condition created by blowing dust at 3 feet AGL. He then attempted to land the practicing autorotations with a power recovery prior to touchdown. The flying pilot inadvertently activated the flight stop augmented fuel flow switch during a power recovery, and overspeed the engine and main rotor. The other pilothelicopter without any visual reference; however, the right skid contacted the ground first. A rolling motion to the left joined him on the controls, and increased collective to reduce rotor rpm. The helicopter climbed abruptly towas created and, after the left skid contacted the ground, a dynamic rollover ensued. The helicopter came to rest on its about 60 feet above the ground, where the tail rotor drive shaft separated. The engine subsequently lost power, and anleft side. autorotation was accomplished. Investigation disclosed that the engine and main rotor system had been exposed to significant overspeed conditions, resulting in a catastrophic failure of the turbine engine, and the tail rotor drive shaftThe National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilots coupling. The flight stop switch on the collective has no protective guard, and can be readily engaged, allowingselection of an unsuitable landing site, which caused "brown-out" conditions during departure liftoff and resulted in loss the engine to enter the augmented fuel flow regime and, under certain conditions, causing the engine to overspeed.of control of the helicopter. The switch has a history of inadvertent activation, and resultant engine overspeed events. The National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilots inadvertent activation of the collective flight stop/emergency fuel augmentation switch, which resulted in engine and main rotor overspeeds, thereby precipitating failures of the tail rotor drive shaft coupling and power turbine blades. A factor associated with the accident was the manufacturers inadequate design of the flight stop switch, which hasNational Transportation Safety Board NTSB ID: Aircraft Registration Number: insufficient safeguards to preclude inadvertent activation.FACTUAL REPORT AVIATION Occurrence Date: Most Critical Injury: FATAL Occurrence Type: Accident LOC - Exceeding Operating Limits National Transportation Safety Board NTSB ID: Aircraft Registration Number:Airport Proximity: Off Airport/Airstrip Distance From Landing Facility: FACTUAL REPORT AVIATION Occurrence Date: Most Critical Injury: NoneAccident Information Summary- Occurrence Type: Accident LOC - Emergency ProceduresThe pilot was assigned to fly for a geophysical seismic team in rugged high desert conditions (elevation 5,366 feet). Onhis second day of flying, he was requested, by one of the team members, to "fly a little easier; less aggressively." On his Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:third day of flying, he was assigned to pick up five team members and their equipment. Once airborne (density altitude Accident Information Summary-was 8,908 feet), he had been briefed that he would receive GPS team distribution coordinates; instead, he was After the patient was placed aboard the helicopter, the pilot started the engines and performed a hover check. He theninstructed to land and hold for a period of time. A witness observed the helicopter fly eastbound, and then make a 45 to moved the helicopter forward to gain airspeed and initiated a climb to cruise altitude. After reaching an altitude of60 degree bank turn [180 degrees] back to the west. The witness then saw the helicopter turn southbound, lower its about 100 feet, the main rotor rpm light and audio warning system activated, and the number 2 engine N1 rpm andnose down almost vertically, and then reduce its nose low pitch to approximately 45 degrees as it disappeared from torque began to decay. The pilot attempted to regain normal engine parameters, but was unable to regain engine rpm.sight. Post accident examination of the engine revealed that the manual throttle pointer on the fuel control was in the The pilot maneuvered to avoid several light poles as he attempted to land in a parking lot. By this time, main rotor rpmemergency position. The first and second stage turbine wheels were found with their blades 50 to 70 percent melted, had bled off sufficiently to prevent the hydraulic pumps from pressurizing the hydraulic system, and all flight controlsindicating an engine that functioned for a time at a temperature level well above its limits. locked is a slight right-banked attitude. This prevented the helicopter from reaching the parking lot. The helicopter impacted a construction area in a right bank, nose down attitude. An on-site and later follow-up investigation by FAAThe National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilots loss and Rolls-Royce investigators revealed a B-nut on the Pc line connecting the power turbine governor (PTGOV) to theof aircraft control due to abrupt flight maneuvering. Contributing factors were the high density altitude weather fuel control unit (FCU) had become loose at the T-fitting end. It was partially torqued and could be moved with thecondition, the total loss of engine power due to the pilot manually introducing excessive fuel into the engine and over fingers. The female end was threaded onto the male end three-quarters of a turn. There was no cross-threading. Thetemping the turbine section, and the lack of suitable terrain for the ensuing autorotation. torque stripe was broken. According to Rolls-Royce Allison, "This line serves a critical function to the engine control system and when leakage occurs will cause the engine to roll back to an idle or near idle condition." The NTSB determines the probable cause(s) of this accident as follows. A loose B-nut on the PC line connecting the power turbine governor (PTGOV) to the fuel control unit (FCU) that created a leak and caused the engine to roll back to an idle condition, causing a low hydraulic system pressure and subsequent control lock. A contributing factor was the unsuitable terrain (construction area) on which to make a forced landing. 32 34
    30. 30. ApplicationIs there validity to lending perspective between safety andaeronautical knowledge?Could such perspective help reduce accident rates?Cooper’s Essay on Principles Alertness Decisiveness Speed Coolness Ruthlessness Surprise
    31. 31. ApplicationIs there validity to lending perspective between safety andaeronautical knowledge?Could such perspective help reduce accident rates?Cooper’s Essay on Principles Alertness Decisiveness Speed Coolness Ruthlessness Surprise
    32. 32. Perspective, Application, and Analysis A New Angle of Attack! Research
    33. 33. Questions for ResearchWhat brought us here and what is the problem or issue?Where in the industry are the accidents happening?Who/what is the “problem child”?What is a solution?Safety Management
    34. 34. Tackle the ProblemsWhat is the influence of Safety Management on the smallhelicopter entity?
    35. 35. Need for ResearchThe Reality of Aeronautical Knowledge as it pertains toflight operation is simple; The pilot, aircrew, maintainer, operations, support personnel, and passengers all play a part in ensuring safe flight operations.When this is not done as set forth in aeronauticalknowledge documentation, and previous training then riskelevates, aircraft are destroyed, and potential exists forpeople to die.
    36. 36. TheoryIf we can prove the benefit of an SMS in a small helicopterentity, they will adopt some form of SMS and therebysignificantly reduce accident rates.
    37. 37. HypothesisIntegration of SMS in the small helicopter entity will show asignificant reduction of accident rates in the industry andthereby businesses are more productive and efficient.
    38. 38. Related ResearchChen, C-F., Chen, S-C (2012)Buckner (2013)McNeely, S. C. (2012)Soukeras, D. V. (2009)
    39. 39. GoalAdd to the body of knowledgeShow cause for application of safety measuresProve that action is profitable
    40. 40. QuestionsScott Burgessscott.burgess@erau.eduSkype: scott.burgess308940-232-1179

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