This document provides an overview of loss of control accidents, which accounted for 41% of the 523 accidents studied. It examines specific loss of control occurrence categories like performance management, dynamic rollover, exceeding operating limits, emergency procedures, and loss of tail rotor effectiveness. Standard problem statements are given for the most common loss of control issues as well as intervention recommendations focused on training and safety management. Accident narratives are then presented to illustrate different loss of control scenarios. The goal is to use this analysis of real accidents to provide pilots with perspective on aeronautical knowledge and decision making beyond what is covered in typical flight manuals.
Helicopters: My Type A is Better Than YoursIHSTFAA
This document outlines topics that were discussed in a meeting about safety issues in the helicopter industry. The meeting used a debate format to discuss controversial topics related to following rules and regulations. Some of the topics covered included the use of personal electronic devices in the cockpit, conducting flight risk assessments, implementing safety management systems, managing fatigue risk for maintenance workers, and adhering to standard operating procedures. Both sides of each issue were presented over a 4 minute time limit to generate discussion.
IHST Safety Resources for Helicopter Pilots and OperatorsIHSTFAA
The International Helicopter Safety Team (IHST) was created in 2006 with the goal of reducing worldwide civil helicopter accidents by 80% by 2016. With over 500 volunteers from 28 countries, IHST analyzes accident data to determine causes and develops safety tools like toolkits, bulletins, fact sheets and leaflets focused on improving safety culture and reducing accidents related to loss of control, visibility issues, and other frequent causes. IHST has helped reduce the average number of accidents per year since its inception and provides various products on its website and social media to promote safer helicopter operations worldwide.
Safety Management Systems (SMS) and Decision MakingIHSTFAA
The document summarizes some key limitations of traditional safety programs:
1. Traditional safety programs are limited in their understanding of exactly what risks and threats create accidents, relying instead on "educated guesses" based on personal experiences.
2. They have no method of tracking safety implementations to measure return on investment and effectiveness.
3. They take a reactive approach rather than conducting analysis of the nature and prioritization of risks to proactively address safety issues.
This document discusses implementing safety management systems (SMS) for small fleet and private operators. It addresses some of the key challenges in doing so, such as scaling traditional SMS systems down to an administratively manage level and determining which elements to prioritize with limited resources. The biggest challenge identified is getting operators to see the need for an SMS in the first place. The presentation provides an overview of SMS and how it differs from traditional safety programs by taking a more proactive, data-driven approach. It offers practical advice on developing SMS policies for small operators, including establishing personal flight limits and duty time policies. Fatigue management is discussed as an important area requiring policy. A just culture policy example is also presented.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
This 50 minute webinar presented by Prof. David Thirtyacre of Embry-Riddle Aeronautical University Worldwide, looks at UASs--Unmanned Aerial Systems, sometimes called drones, and provides an overview of the emerging field.
This presentation was given on the 14th of April 2016 during the EASA/OPTICS Conference in Cologne, Germany. It is almost the same presentation given previously at the CHC Safety & Quality Summit but includes a few additional slides about the initial results of the data collected.
The presentation was prepared for the Indonesian DGCA's SAG members from the Directorates of Airports and Air Navigation. The objective of the workshop was to increase the members knowledge of the theory and practical application of aviation safety management systems.
Helicopters: My Type A is Better Than YoursIHSTFAA
This document outlines topics that were discussed in a meeting about safety issues in the helicopter industry. The meeting used a debate format to discuss controversial topics related to following rules and regulations. Some of the topics covered included the use of personal electronic devices in the cockpit, conducting flight risk assessments, implementing safety management systems, managing fatigue risk for maintenance workers, and adhering to standard operating procedures. Both sides of each issue were presented over a 4 minute time limit to generate discussion.
IHST Safety Resources for Helicopter Pilots and OperatorsIHSTFAA
The International Helicopter Safety Team (IHST) was created in 2006 with the goal of reducing worldwide civil helicopter accidents by 80% by 2016. With over 500 volunteers from 28 countries, IHST analyzes accident data to determine causes and develops safety tools like toolkits, bulletins, fact sheets and leaflets focused on improving safety culture and reducing accidents related to loss of control, visibility issues, and other frequent causes. IHST has helped reduce the average number of accidents per year since its inception and provides various products on its website and social media to promote safer helicopter operations worldwide.
Safety Management Systems (SMS) and Decision MakingIHSTFAA
The document summarizes some key limitations of traditional safety programs:
1. Traditional safety programs are limited in their understanding of exactly what risks and threats create accidents, relying instead on "educated guesses" based on personal experiences.
2. They have no method of tracking safety implementations to measure return on investment and effectiveness.
3. They take a reactive approach rather than conducting analysis of the nature and prioritization of risks to proactively address safety issues.
This document discusses implementing safety management systems (SMS) for small fleet and private operators. It addresses some of the key challenges in doing so, such as scaling traditional SMS systems down to an administratively manage level and determining which elements to prioritize with limited resources. The biggest challenge identified is getting operators to see the need for an SMS in the first place. The presentation provides an overview of SMS and how it differs from traditional safety programs by taking a more proactive, data-driven approach. It offers practical advice on developing SMS policies for small operators, including establishing personal flight limits and duty time policies. Fatigue management is discussed as an important area requiring policy. A just culture policy example is also presented.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
This 50 minute webinar presented by Prof. David Thirtyacre of Embry-Riddle Aeronautical University Worldwide, looks at UASs--Unmanned Aerial Systems, sometimes called drones, and provides an overview of the emerging field.
This presentation was given on the 14th of April 2016 during the EASA/OPTICS Conference in Cologne, Germany. It is almost the same presentation given previously at the CHC Safety & Quality Summit but includes a few additional slides about the initial results of the data collected.
The presentation was prepared for the Indonesian DGCA's SAG members from the Directorates of Airports and Air Navigation. The objective of the workshop was to increase the members knowledge of the theory and practical application of aviation safety management systems.
The document discusses how the Royal Air Force (RAF) optimizes pilot performance through continuous feedback and self-improvement programs. It describes how RAF training incorporates lessons from fields like psychology and behavioral science to help pilots understand factors influencing performance like stress, arousal, and decision-making. The RAF aims to capture sources of error and underperformance to improve safety. Similarly, the document suggests financial firms could learn from the RAF's approach to better optimize investment decision-makers' performance.
Risk management involves weighing the costs and benefits of risks. Hazard recognition is critical to risk management. A hazard is a present condition that could lead to an unplanned event, like an accident. Four common aviation hazards are a nick in a propeller blade, improper refueling, pilot fatigue, and use of unapproved parts. Personality, education, experience, and regulations all influence a pilot's ability to recognize hazards. Experience provides knowledge over time but can also provide a false sense of security that causes pilots to ignore or fail to recognize potential hazards.
This document outlines the objectives and content of an aviation security course taught by Dr. Paul Mears. The 5-day course aims to teach participants how to ensure passenger and crew safety, identify and manage security threats, and work as a team to maintain security. It covers topics such as security mindsets, passenger profiling, restraint techniques, and how to handle various inflight incidents. Participants conduct workshops where they must apply their skills to mock aircraft scenarios and respond appropriately to security issues while minimizing flight disruption.
This document discusses aeronautical decision making (ADM) and provides an example of how poor decision making can lead to an accident. It begins by explaining that ADM is a systematic approach that helps pilots determine the best course of action given the circumstances through recognizing hazards. The document then provides more details on the history of ADM training and the steps involved in good decision making. It also discusses analytical decision making using the DECIDE model. Finally, it gives an example of how a pilot rushing to make a Thanksgiving dinner ignored weather hazards and crashed while attempting a landing with 100 foot ceilings and 1/4 mile visibility, illustrating how failing to follow proper decision making can have tragic consequences.
This document outlines 12 common causes of human error in aircraft maintenance, called "The Dirty Dozen". It describes each of the 12 factors, including lack of communication, complacency, lack of knowledge, distraction, lack of teamwork, fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness, and norms. For each factor, examples of accidents are presented and recommendations are provided for how to reduce errors by improving safety nets like checklists, inspections, and communication between maintenance technicians. The goal is to raise awareness of the types of human errors that can occur and how following best practices in maintenance can help prevent accidents.
This document discusses cockpit automation and its effects on pilot skills. It summarizes a seminal 1995 study by Veillette and Decker that found pilots flying aircraft with early electronic flight displays (EFIS) showed some erosion of manual flying skills compared to pilots of conventional aircraft, especially during abnormal maneuvers or when the autopilot was disengaged. While automation has safety benefits, pilots must understand its limitations and not rely solely on automation to avoid errors during emergencies or abnormal situations when manual flying skills are needed. Maintaining basic flying skills is important when using automated aircraft.
This is from a webinar presented by Embry-Riddle Aeronautical University-Worldwide called “General Aviation Security.” The presenter is Dr. Daniel Benny.
JUST CULTURE IN AVIATION SAFETY MANAGEMENT (ASM)DigitalPower
The document discusses the concept of a "just culture" in aviation safety management. It argues that a non-punitive, confidential reporting system is essential for improving safety by allowing errors to be reported and addressed systemically without fear of blame or prosecution. Currently, many legal systems still approach errors as criminal matters, which discourages reporting and hinders safety improvements. A just culture aims to distinguish between honest mistakes and reckless actions, holding individuals accountable only in clear cases of negligence while still prioritizing systemic learning from errors.
Three out of four aviation accidents result from human error. Studies of human behavior examine both innate and learned factors that influence human performance. The Federal Aviation Administration utilizes such studies to understand why pilots make mistakes and reduce human errors. Research has identified several traits common in pilots prone to accidents, including disdain for rules, impulsiveness, and disregard for outside information. In contrast, successful pilots demonstrate concentration, workload management, and the ability to perform multiple tasks simultaneously.
This document summarizes key aspects of winter operations for airports, air traffic control, and pilots. It discusses how changing weather conditions increase risks of runway excursions and the importance of collaboration and communication between stakeholders. Specifically, it emphasizes the importance of disseminating timely information on field conditions to pilots, avoiding unstable approaches, understanding operational limitations during winter, and evaluating winter plans before the season begins to enhance safety. It also discusses challenges with complacency around standard phraseology and procedures over time.
System safety flight training occurs in three phases: 1) traditional stick-and-rudder skills are developed to a high degree of confidence, 2) risk management concepts are introduced through scenarios, and 3) more complex scenarios requiring focus on multiple safety issues are used. A traditional maneuver, like a short-field landing, can illustrate this by first focusing on skills, then introducing various risk factors without increasing training time, and finally incorporating risks into a complex scenario. System safety also applies to important lessons, like controlled flight into terrain, by discussing contributing factors during ground school and cross-country flights.
The document discusses methods for pilots to assess risk, including using a risk matrix to determine the likelihood and severity of potential hazards. It provides examples of assessing risks, such as the risk posed by deteriorating weather conditions for a VFR pilot. The document also discusses how pilots can mitigate identified risks, such as waiting for better weather or taking a more experienced pilot. A comprehensive risk assessment program is presented that considers additional factors like fatigue, weather, and flight planning. Determining the level of risk allows pilots to decide if flights require caution, exercise caution, or should be avoided or modified to reduce dangers.
This handbook provides tools and guidance for pilots to recognize and manage risk through all phases of flight. It discusses how approximately 85% of aviation accidents are caused by "pilot error" due to a lack of risk management training. The handbook teaches pilots to identify potential risks, determine if risks are justified, and establish standards and procedures to successfully manage risks. Checklists and scenarios in the appendices aim to help pilots incorporate risk management into flight planning and training to improve safety.
This document discusses single-pilot resource management (SRM) and how its principles can be applied to single-pilot aircraft operations. It then describes an accident involving an experimental aircraft where the pilot had installed a six-way powered automobile seat without properly assessing the risks. This led to hazards like overheating the circuit breaker due to an incorrect amperage rating. The installation of the non-aviation seat ultimately contributed to an in-flight fire and crash that killed both pilots. The document uses this accident as an example of how failure to recognize hazards and properly evaluate risks can lead to fatal consequences.
Frederick Rowson Bebington has over 50 years of experience in aviation, including glider piloting since 1966 with over 2,200 launches and 500 flight hours. He has held several safety officer roles and is currently the Safety Officer for the Drakensberg Soaring Club. He has extensive training in safety management systems, quality assurance, accident investigation, and aviation security. He has worked as an airline Safety and Quality Assurance manager and currently serves as Manager of Safety and Security for Skywise Airline.
1. The document discusses a Garmin G1000 avionics system training provided by Cessna for pilots. It details some of the training programs and focuses on transitioning to a FITS (FAA Industry Training Standards) approach.
2. It notes that FITS training principles like risk assessment, learner-centered grading, and problem-based learning could be introduced to maximize training effectiveness. FITS has also been proven to improve decision making and is applicable to primary, advanced, transition, and recurrent training.
3. Cessna aims to expand FITS training by developing online pre-course materials, support for regional instructors, and integrating flight training devices to provide more advanced G1000 instruction worldwide.
This document provides industry best practices for helicopter flight data monitoring (HFDM) programs. It discusses the key components of an HFDM program, including hardware and software, organizational structure, and processes. The hardware should be capable of reliably recording and transferring relevant flight data. The organizational structure should include a program manager, data analysts, and a review group. The core processes involve collecting, validating, analyzing and trending flight data to identify safety issues and improve performance. Maintaining a good relationship between the HFDM program and the operator's safety management system is also emphasized.
This document provides guidance on requesting and coordinating helicopter medical evacuation missions. It discusses typical scenarios, identifying the location, preparing the landing area, receiving the helicopter, and considerations from the pilot's perspective. The key aspects covered are:
1. Requesting crucial information such as accurate coordinates, visibility, clouds, wind conditions and nearby landing areas.
2. Preparing a clear, obstacle-free landing zone at least 25x25 meters and removing any hazards like power lines, loose objects or people.
3. Receiving the helicopter by making yourself visible with lights, flares or signals and protecting yourself from rotor wash.
4. Understanding what pilots see on approach to identify potential obstacles or unsafe conditions
An analysis of 97 personal/private pilot accidents from 2000, 2001, and 2006 found that the most common specific problems were related to pilot judgment and decision making (48%), issues with landing procedures (37%), problems implementing procedures (36%), and maintaining the proper flight profile (34%). Human/aircraft interface issues contributed to 11% of accidents.
The document discusses how the Royal Air Force (RAF) optimizes pilot performance through continuous feedback and self-improvement programs. It describes how RAF training incorporates lessons from fields like psychology and behavioral science to help pilots understand factors influencing performance like stress, arousal, and decision-making. The RAF aims to capture sources of error and underperformance to improve safety. Similarly, the document suggests financial firms could learn from the RAF's approach to better optimize investment decision-makers' performance.
Risk management involves weighing the costs and benefits of risks. Hazard recognition is critical to risk management. A hazard is a present condition that could lead to an unplanned event, like an accident. Four common aviation hazards are a nick in a propeller blade, improper refueling, pilot fatigue, and use of unapproved parts. Personality, education, experience, and regulations all influence a pilot's ability to recognize hazards. Experience provides knowledge over time but can also provide a false sense of security that causes pilots to ignore or fail to recognize potential hazards.
This document outlines the objectives and content of an aviation security course taught by Dr. Paul Mears. The 5-day course aims to teach participants how to ensure passenger and crew safety, identify and manage security threats, and work as a team to maintain security. It covers topics such as security mindsets, passenger profiling, restraint techniques, and how to handle various inflight incidents. Participants conduct workshops where they must apply their skills to mock aircraft scenarios and respond appropriately to security issues while minimizing flight disruption.
This document discusses aeronautical decision making (ADM) and provides an example of how poor decision making can lead to an accident. It begins by explaining that ADM is a systematic approach that helps pilots determine the best course of action given the circumstances through recognizing hazards. The document then provides more details on the history of ADM training and the steps involved in good decision making. It also discusses analytical decision making using the DECIDE model. Finally, it gives an example of how a pilot rushing to make a Thanksgiving dinner ignored weather hazards and crashed while attempting a landing with 100 foot ceilings and 1/4 mile visibility, illustrating how failing to follow proper decision making can have tragic consequences.
This document outlines 12 common causes of human error in aircraft maintenance, called "The Dirty Dozen". It describes each of the 12 factors, including lack of communication, complacency, lack of knowledge, distraction, lack of teamwork, fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness, and norms. For each factor, examples of accidents are presented and recommendations are provided for how to reduce errors by improving safety nets like checklists, inspections, and communication between maintenance technicians. The goal is to raise awareness of the types of human errors that can occur and how following best practices in maintenance can help prevent accidents.
This document discusses cockpit automation and its effects on pilot skills. It summarizes a seminal 1995 study by Veillette and Decker that found pilots flying aircraft with early electronic flight displays (EFIS) showed some erosion of manual flying skills compared to pilots of conventional aircraft, especially during abnormal maneuvers or when the autopilot was disengaged. While automation has safety benefits, pilots must understand its limitations and not rely solely on automation to avoid errors during emergencies or abnormal situations when manual flying skills are needed. Maintaining basic flying skills is important when using automated aircraft.
This is from a webinar presented by Embry-Riddle Aeronautical University-Worldwide called “General Aviation Security.” The presenter is Dr. Daniel Benny.
JUST CULTURE IN AVIATION SAFETY MANAGEMENT (ASM)DigitalPower
The document discusses the concept of a "just culture" in aviation safety management. It argues that a non-punitive, confidential reporting system is essential for improving safety by allowing errors to be reported and addressed systemically without fear of blame or prosecution. Currently, many legal systems still approach errors as criminal matters, which discourages reporting and hinders safety improvements. A just culture aims to distinguish between honest mistakes and reckless actions, holding individuals accountable only in clear cases of negligence while still prioritizing systemic learning from errors.
Three out of four aviation accidents result from human error. Studies of human behavior examine both innate and learned factors that influence human performance. The Federal Aviation Administration utilizes such studies to understand why pilots make mistakes and reduce human errors. Research has identified several traits common in pilots prone to accidents, including disdain for rules, impulsiveness, and disregard for outside information. In contrast, successful pilots demonstrate concentration, workload management, and the ability to perform multiple tasks simultaneously.
This document summarizes key aspects of winter operations for airports, air traffic control, and pilots. It discusses how changing weather conditions increase risks of runway excursions and the importance of collaboration and communication between stakeholders. Specifically, it emphasizes the importance of disseminating timely information on field conditions to pilots, avoiding unstable approaches, understanding operational limitations during winter, and evaluating winter plans before the season begins to enhance safety. It also discusses challenges with complacency around standard phraseology and procedures over time.
System safety flight training occurs in three phases: 1) traditional stick-and-rudder skills are developed to a high degree of confidence, 2) risk management concepts are introduced through scenarios, and 3) more complex scenarios requiring focus on multiple safety issues are used. A traditional maneuver, like a short-field landing, can illustrate this by first focusing on skills, then introducing various risk factors without increasing training time, and finally incorporating risks into a complex scenario. System safety also applies to important lessons, like controlled flight into terrain, by discussing contributing factors during ground school and cross-country flights.
The document discusses methods for pilots to assess risk, including using a risk matrix to determine the likelihood and severity of potential hazards. It provides examples of assessing risks, such as the risk posed by deteriorating weather conditions for a VFR pilot. The document also discusses how pilots can mitigate identified risks, such as waiting for better weather or taking a more experienced pilot. A comprehensive risk assessment program is presented that considers additional factors like fatigue, weather, and flight planning. Determining the level of risk allows pilots to decide if flights require caution, exercise caution, or should be avoided or modified to reduce dangers.
This handbook provides tools and guidance for pilots to recognize and manage risk through all phases of flight. It discusses how approximately 85% of aviation accidents are caused by "pilot error" due to a lack of risk management training. The handbook teaches pilots to identify potential risks, determine if risks are justified, and establish standards and procedures to successfully manage risks. Checklists and scenarios in the appendices aim to help pilots incorporate risk management into flight planning and training to improve safety.
This document discusses single-pilot resource management (SRM) and how its principles can be applied to single-pilot aircraft operations. It then describes an accident involving an experimental aircraft where the pilot had installed a six-way powered automobile seat without properly assessing the risks. This led to hazards like overheating the circuit breaker due to an incorrect amperage rating. The installation of the non-aviation seat ultimately contributed to an in-flight fire and crash that killed both pilots. The document uses this accident as an example of how failure to recognize hazards and properly evaluate risks can lead to fatal consequences.
Frederick Rowson Bebington has over 50 years of experience in aviation, including glider piloting since 1966 with over 2,200 launches and 500 flight hours. He has held several safety officer roles and is currently the Safety Officer for the Drakensberg Soaring Club. He has extensive training in safety management systems, quality assurance, accident investigation, and aviation security. He has worked as an airline Safety and Quality Assurance manager and currently serves as Manager of Safety and Security for Skywise Airline.
1. The document discusses a Garmin G1000 avionics system training provided by Cessna for pilots. It details some of the training programs and focuses on transitioning to a FITS (FAA Industry Training Standards) approach.
2. It notes that FITS training principles like risk assessment, learner-centered grading, and problem-based learning could be introduced to maximize training effectiveness. FITS has also been proven to improve decision making and is applicable to primary, advanced, transition, and recurrent training.
3. Cessna aims to expand FITS training by developing online pre-course materials, support for regional instructors, and integrating flight training devices to provide more advanced G1000 instruction worldwide.
This document provides industry best practices for helicopter flight data monitoring (HFDM) programs. It discusses the key components of an HFDM program, including hardware and software, organizational structure, and processes. The hardware should be capable of reliably recording and transferring relevant flight data. The organizational structure should include a program manager, data analysts, and a review group. The core processes involve collecting, validating, analyzing and trending flight data to identify safety issues and improve performance. Maintaining a good relationship between the HFDM program and the operator's safety management system is also emphasized.
This document provides guidance on requesting and coordinating helicopter medical evacuation missions. It discusses typical scenarios, identifying the location, preparing the landing area, receiving the helicopter, and considerations from the pilot's perspective. The key aspects covered are:
1. Requesting crucial information such as accurate coordinates, visibility, clouds, wind conditions and nearby landing areas.
2. Preparing a clear, obstacle-free landing zone at least 25x25 meters and removing any hazards like power lines, loose objects or people.
3. Receiving the helicopter by making yourself visible with lights, flares or signals and protecting yourself from rotor wash.
4. Understanding what pilots see on approach to identify potential obstacles or unsafe conditions
An analysis of 97 personal/private pilot accidents from 2000, 2001, and 2006 found that the most common specific problems were related to pilot judgment and decision making (48%), issues with landing procedures (37%), problems implementing procedures (36%), and maintaining the proper flight profile (34%). Human/aircraft interface issues contributed to 11% of accidents.
This document provides an update from the US Training Working Group. It discusses their focus areas from JHSAT reports including autorotation training, HF/CRM/SMS, and advanced maneuver training. It outlines initiatives like developing an advisory circular on autorotation training and adding areas of HF/CRM to pilot testing standards. It also lists upcoming fact sheets and presentations on training safety topics. The group aims to move from reactive to proactive safety approaches and share best practices across the industry.
The document provides an executive summary and overview of the European Helicopter Safety Team (EHEST) and its analysis of 2000-2005 European helicopter accidents. Some key points:
- EHEST aims to reduce the civil helicopter accident rate in Europe by 80% by 2016 as part of the International Helicopter Safety Team.
- The European Helicopter Safety Analysis Team (EHSAT) analyzed 311 helicopter accidents from 2000-2005 and identified common factors and safety issues.
- The top three factors identified were pilot judgment & actions, safety culture/management, and ground duties.
- The European Helicopter Safety Implementation Team (EHSIT) will use the EHSAT's findings
Occurrance Categories for Helicopter AccidentsIHSTFAA
The top 5 occurrence categories for personal/private helicopter accidents from 2000-2001 and 2006 were: loss of control (41%), autorotation (emergency or practice) (27%), systems component failure (23%), strike to an object (21%), and fuel related (12%). The percentages were based on an analysis of 97 personal/private helicopter accidents by the Joint Helicopter Safety Analysis Team.
More information can be found here:
tiii.be/projects/drumduino
The Drum Duino is a novel device that makes music or rhythmical sounds using any object as percussive instrument.
The rhythmical sounds follow the drum patterns that are programmed using a tangible user interface. The main focus in this project was to design a tangible link combined with digital processing and physical output. This physical output is then transferred into audible sounds so it becomes a novel instrument. In addition it is a fun instrument to use because the user can experiment with different sounds using common objects found in his environment. Many of us may have grown up playing and learning music through beating and tapping on any object we could find in our vicinity. The more creative the user is, the more exciting the music gets. Both shape and material of the chosen objects will determine the sound that will be created by the tapping of the Drum Duino device.
Relatório Final - CENIPA - Acidente com a Aeronave - PR-OMO em 17/06/2011Jeferson Espindola
O relatório descreve um acidente com um helicóptero AS 350 B2 matrícula PR-OMO que ocorreu em 17 de junho de 2011. O helicóptero colidiu com o mar durante um voo de transporte de passageiros à noite em condições meteorológicas adversas, matando o piloto e seis passageiros. O relatório fornece detalhes sobre a aeronave, os tripulantes, as condições meteorológicas, a investigação e análise do acidente.
The document identifies 12 classic accident pitfalls for pilots: responding to peer pressure, mental expectancy, get-there-it-is, duck under syndrome, scud running, continuing VFR into IMC, getting behind the aircraft, loss of positional/situational awareness, operating without sufficient fuel reserves, descent below minimums en route, flying outside the envelope, and neglect of flight planning, checks, and pre-flights. Each pitfall is defined and an example accident scenario provided. The document aims to help pilots identify and avoid dangerous situations.
This is a short overview of various models of understanding behaviour and theories of change, which will be analysed in depth using case studies from the countries participating in IEA DSM Task 24 (www.ieadsm.org). The presentation was given at the NZ workshop for Task 24 on February 15, 2013 in Wellington.
This document summarizes the history and development of helicopters from Leonardo Da Vinci's early sketches in 1480 to the first practical helicopter in 1933. It describes key developments such as Forlanini using steam power in 1800 and Cornu's piloted flight in 1907. The document also explains the basic flying principles of helicopters, including how main and tail rotors provide lift and control directional movement, allowing helicopters to hover and fly in any direction.
A Safety Snapshot of the U.S. Civil Helicopter CommunityIHSTFAA
This document provides safety data and analysis on U.S. civil helicopter accidents from 2000-2012. It finds that while accidents have decreased from 159 in 2006 to 134 in 2012, more progress is needed. Personal/private flights accounted for 20% of accidents but only 4% of flight hours. The highest percentage of accidents occurred during instructional/training flights, positioning/return to base flights, and personal/private flights. Loss of control and visibility issues due to weather were the most common causes of fatal accidents. The International Helicopter Safety Team is working to analyze accident data and develop safety toolkits, leaflets, and fact sheets to reduce accidents by addressing issues like hazardous attitudes and operational pitfalls.
The document summarizes Captain Mike Pilgrim's presentation on Helicopter Flight Data Monitoring (HFDM) at the Helitech International 2013 workshop. It discusses the goals of improving helicopter safety through HFDM, how HFDM works to proactively identify and address operational risks, and provides examples of how HFDM data was used to identify and address issues related to approach deviations and expedited approaches.
This document discusses hazard identification and risk management. It begins with an overview of the International Civil Aviation Organization's (ICAO) Safety Management System framework, which includes hazard identification, risk assessment and mitigation. Several examples of hazards are provided, emphasizing the importance of clearly defining hazards rather than describing them by their potential consequences. The document then discusses methods for identifying hazards, including considering one's main fears and how events could occur. It introduces bow-tie diagrams as a tool for displaying hazards, potential causes, consequences and risk controls. The remainder of the document provides guidance on assessing risks and developing mitigation actions associated with identified hazards.
This document provides an overview of a safety management systems (SMS) meeting. It includes an agenda for the meeting that covers SMS overview, practical applications of SMS including policy and risk management, decision making within an SMS, and a lunch break. It also includes tips and examples for developing an SMS policy, identifying hazards, and evaluating risk. Speakers notes provide additional context and pose questions to attendees.
This document contains a presentation from the Federal Aviation Administration on using acronyms, checklists, and memory aids to improve safety during helicopter training maneuvers like autorotations. The presentation provides examples of acronyms like "PRE-AUTOS" for pre-flight autorotation briefings and "HASEL" for in-flight pre-autorotation setup briefings. It discusses how checklists are required by the Practical Test Standards and cites statistics on accident rates during instructional/training flights. The goal is to explore how these tools can help pilots prioritize tasks and mitigate risks.
- The document discusses developing a safety management system (SMS) that is actively used in operations rather than sitting on a shelf.
- It outlines a 4 step process to make the SMS live: 1) set goals; 2) identify and record hazards; 3) conduct risk analysis; 4) implement controls.
- Key aspects include brainstorming hazards, using a risk assessment matrix to prioritize hazards, developing barriers and controls proportional to risk, and engaging stakeholders from all levels of the organization.
Helicopter rescues involve several steps. The boat prepares by clearing loose items and briefing crew without firing flares. Communication is established with the helicopter via VHF radio. The helicopter approaches from the starboard side and a winchman is lowered. The winchman takes charge and injured people may be lifted via stretcher. Crew on the boat should follow the winchman's instructions regarding lines and maintain their course. On completion, the helicopter crew should be thanked.
2017 Heli-Expo - The Reality of Aeronautical KnowledgeIHSTFAA
This document summarizes a training course on helicopter safety perspectives using accident data analysis. It introduces the instructor and provides an overview of the course objectives, which are to help pilots gain operational safety awareness, review accidents from an aeronautical knowledge perspective, and develop an awareness of perspective. The document outlines topics that will be covered, including a discussion of loss of control accidents categorized by occurrence. It presents charts analyzing accident data by occurrence category and flight phase. Case studies of specific loss of control accidents are also summarized. The document recommends that training and safety management interventions are needed to address human factors causes commonly seen in loss of control accidents.
This document provides an analysis of 523 helicopter accident reports against what pilots are expected to know based on training manuals. It finds that the most common cause of accidents was loss of control, often due to failures in pilot decision-making, procedure implementation, or performance management. Accidents were most frequent during personal/private flights and flight instruction. The majority of accidents occurred in good weather and involved pilots with substantial experience. The analysis aims to provide pilots with perspective on accidents by highlighting recurring issues to improve safety.
1. The document discusses various human factors that can lead to accidents in aviation, such as distraction, time pressure, and misperceptions.
2. It analyzes data on 523 helicopter accidents between 2000 and 2006, finding that the majority occurred during the enroute phase of flight and most involved emergency medical services.
3. Maintaining situational awareness, effective crew resource management, and understanding human tendencies towards error are emphasized as important for safety.
Human Factors in Aviation discusses the importance of human factors training in the aviation industry. Some key points:
- Human error is the primary cause of about 70% of aviation accidents.
- CRM (Crew Resource Management) training focuses on effective teamwork and resource utilization to improve safety.
- The SHEL model examines the interactions between Liveware (humans), Software, Hardware, Environment and other Liveware.
- Factors like personality, culture, stress and decision-making can impact safety. Proactive approaches like FOQA (Flight Operations Quality Assurance) and voluntary incident reporting aim to prevent accidents before they occur.
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Analysis and Importance of Helicopter Accident Reports
1.
2. INTRODUCTION
Scott Burgess, Assistant Professor
• Faculty with Embry-Riddle Aeronautical University
• Program Chair, Bachelor of Science in
Aeronautics
• IHST Affiliations
§ USHST, Joint Helicopter Implementation Data Analysis
Team (JHIMDAT)
§ USHST, Joint Helicopter Safety Implementation Team
(JHSIT)
§ USHST, Training Working Group
3. COURSE DESCRIPTION
• Discussion of practical knowledge beyond the
Helicopter Flying Handbook combined with
research of the IHST’s Analysis Team.
• In-depth look at aeronautical knowledge,
decision-making, and understanding limitations
• Ideal for all experience levels; Best where
training occurs initial/recurrent
4. OBJECTIVES
Perspective
§ 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. REFERENCES
Compendiums I & II
International Helicopter Safety Team, (2011). IHST reports: US JHSAT compendium
report – Volume I. Retrieved from http:// www.ihst.org
International Helicopter Safety Team, (2011). IHST reports: US JHSAT compendium
report – Volume II. Retrieved from http://www.ihst.org
USJHIMDAT (2014). Comparative report. U.S.JHIMDAT data to U.S.JHSAT data.
Burgess, 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.org
6. AGENDA
Perspective of Aeronautical Knowledge
Beyond the Helicopter Flying Handbook
Discussion of Accidents by Occurrence Category
Conclusion
Discussion and Collaboration
7. What is our cultural
background?
Where do we come from?
8. • a particular attitude toward or way of regarding
something.
• the relationship of aspects of a subject to each
other and to a whole.
• subjective evaluation of relative significance.
• the ability to perceive things in their actual
interrelations or comparative importance.
• the state of one's ideas, the facts known to one,
etc., in having a meaningful interrelationship.
• Other elements of perspective
10. WHAT PROVIDES PERSPECTIVE?
• Training usually follows a set standard
• We learn the minimums or just beyond
§ We discuss an Auto
§ We are demonstrated an Auto
§ Then we practice an Auto
• Do we add value to the training?
§ (Not thru abrupt maneuvers though)
• Do we take perspective far enough?
11. • War stories
• NTSB reports
• Actual occurrences and the after action
reviews
• Open discussions (pilot briefings)
These give us the reality of knowledge!!!
WHAT ARE GOOD VEHICLES TO
PROMOTE PERSPECTIVE?
16. WHY SHOULD WE DO EXPLORE
REALITY OF KNOWLEDGE?
• Accidents happening in our industry seem to be
occurring more in specific areas
§ Small companies (<3 ships)
§ Single Owner Operators
• Young/new Instructors in schools may end up in
this population
• The population is hard to communicate with
• Research is needed and just now starting to
happen
17. TOOLS FOR PERSPECTIVE
Critical 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,
experience, reflection, reasoning, communication.
18. TOOLS FOR PERSPECTIVE
• Use of Exemplars
• The Reality of Aeronautical Knowledge: The Analysis of
Accident Reports Against What Aircrews are Supposed to
Know
• Supplements to the HFH are necessary
• Doctrine, techniques and procedures need perspective
• Inclusion of actual NTSB accident reports offer a realistic
viewpoint and association to the environment in which we
operate the helicopter. These are real events, which
happened to real people.
19. TOOLS FOR 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?
(Answer these Questions Strictly from your Perspective
And not your Companies perspective)
20. TOOLS FOR PERSPECTIVE
• Statistics
• IHST data can be used to lend perspective
• Associate the data to your setting
• Take the information to the next level
• Associate accident data into your training
22. STATISTICS AS PERSPECTIVE
• Accident Occurrences like Loss of Control was
identified with 41% of the accidents.
• Loss of Control can occur at various times
during a flight, so it was important to further
express a category ‘Phases of Flight’ with sub-
categories such as;
§ Landing (108 accidents/ 4 fatal accidents)
§ Enroute (102 accidents/34 fatal accidents).
23. STATISTICS AS PERSPECTIVE
• Highest % of accidents came from the
(personal/private) industry category
§ 97 out of the 523 total accidents (18.5%).
• Instructional/Training (Dual) incurred the
highest percentage of accidents (14%, or 73
accidents) for “Activity” classification.
• Positioning/Return to Base had 69 accidents
(13%).
24. STATISTICS AS PERSPECTIVE
• FAR Part 91 incurred 70% of the total accidents.
• FAR Part 91 accounts for just over half of the
rotorcraft hours each year (amount of exposure).
• FAR Part 91 accounts for a higher percentage of
accidents compared to amount of exposure partly
because
• Personal/Private and Instructional/Training industries
have such a high percentage of accidents and both
operate Part 91.
25. STATISTICS AS PERSPECTIVE
Most of the accidents occurred in good weather
during the day
Over half of the pilots (246 of 523) totaled over
2,000 flight hours
PIC time was less than 500 hours (for almost the
same population).
DO THESE STATS TELL US ANYTHING?
26. WHAT HAS THE INDUSTRY/IHST/
HAI RECENTLY DONE WITH
PERSPECTIVE?
• Flyers, Fact Sheets, Essays, Presentations
• Posting research
• Training worksheets
• IHST and HAI working groups and committees
• Training and education
• Publications
• etc
27. APPLIED PERSPECTIVE
• Reality text takes knowledge and compares to real
accidents.
• Accidents were reviewed to determine best
examples of cause and effect
• Extension of HFH discussion concurrent with IHST
accident occurrence categories
28. EXTENDING THE DISCUSSION
• Intent to extend discussion on specific areas of
the HFH to IHST accident data analysis
• 18 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
29. SYNTHESIS
• Snapshots of high volume accidents by
occurrence category
§ Explain
§ Introduce
§ Define
§ Identify problem
• Accident Narratives
Lets have a look ……..
30. 26
Chapter 2
Loss of Control
1. Short explanation and introduction. [HFH Ch. 9, 10, 11; AOM]
Loss of control accidents account for the largest group of accidents from the studies.
Additionally, as the chart below depicts, there are sub-occurrence categories within loss of control
accidents. In this document, we will review the top group which include performance management,
dynamic rollover, exceeding operating limits, emergency procedures, and loss of tail rotor
effectiveness.
Loss of Control
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Performance
Management
Dynamic
Rollover
Exceeding
Operating
Limits
Emergency
Procedures
LossofT/R
Effectiveness
Interference
withControls
Ground
Resonance
Tie-
downs/hoses
Settlingw/
power
%ofTotalAccidents
Figure 9. Loss of Control Occurrence Category
Note: Categories are a percentage of the total of 523 accidents
Accidents by Phase of Flight
Phase of Flight was determined as the flight profile the aircraft was in when the
accident sequence was initiated. Hover includes In Ground Effect (IGE) and Out of Ground
Effect (OGE) operations. For identification purposes Maneuvering was considered a Phase
of Flight which was NOT classified as Landing, Enroute, Hover, Take-off, Approach,
Standing and Taxi. In general, Maneuvering is considered to be a change of direction
whether in low speed or high speed flight. Figure 10 identifies Enroute as the Phase of
Flight where the majority of fatal accidents occurred. These fatalities can be attributed to
potentially higher velocity speeds at impact.
Phase of Flight
2
4
3
11
28
34
4
2
18
32
63
78
72
68
104
0 20 40 60 80 100 120
Taxi
Standing
Approach
Take-off
Hover
Maneuvering
Enroute
Landing
Accidents
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
Figure 10. Phase of Flight (523 Accidents)
Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow
9
Figure 2. Loss of Control. Adopted from U.S. JHSAT Compendium Volume I Figure 9. The sum of the percentages exceed
100% as each of the 523 accidents analyzed could be assigned to multiple occurrence categories. For example, if the
aircraft ran out of fuel, an autorotation ensued, followed by a loss of control, the accident is counted against three separate
occurrence categories: Fuel, Autorotation, and Loss of Control
2. Accident Occurrence. Loss of Control (LOC) occurred in 41% of the 523 accidents studied by the
U.S. JHSAT. LOC is defined as the pilot losing control of the aircraft for any of these reasons:
Performance Management - pilot maintaining insufficient power or rotor RPM for
conditions.
Dynamic Rollover – the tendency of the helicopter to continue rolling when the critical angle
is exceeded, if one gear is on the ground, and the helicopter is pivoting around that point.
Exceeding Operating Limits - helicopter is operated near the established limitations of the
model/type.
Emergency Procedures - improperly responding to an onboard emergency.
Interference with Controls - interference by pilots, passengers, loose baggage, or
factors related to maintenance.
Ground Resonance
Loss of Tail Rotor Effectiveness (LTE) or Unanticipated Yaw is an occurrence of an
uncommanded yaw, which, if not corrected, can result in loss of control
Tie-downs/Hoses
Settling with Power
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 3
Pilot Judgment &
Actions
Procedure Implementation Inappropriate Energy/power management
Pilot Judgment &
Actions
Procedure Implementation Pilot control/handling deficiencies
Pilot Judgment &
Actions
Landing Procedures Autorotation – Practice
Pilot Judgment &
Actions
Human Factors - Pilot's
Decision
Disregarded cues that should have led to
termination of current course of action or
maneuver
Pilot Judgment &
Actions
Crew Resource Management Inadequate and untimely CFI action to correct
student action
Dynamic Rollover (Loss of Control) (present in in 31 out of 523 accidents)
SPS Level 1 SPS Level 2 SPS Level 3
Pilot Judgment &
Actions
Procedure Implementation Improper recognition and response to dynamic
rollover
Pilot Judgment &
Actions
Procedure Implementation Pilot control/handling deficiencies
Pilot Judgment &
Actions
Crew Resource Management Inadequate and untimely CFI action to correct
student action
Pilot Judgment &
Actions
Landing Procedures Selection of inappropriate landing site
31. 28
Exceeding Operating Limits (Loss of Control) (present in 27 out of 523 accidents)
SPS Level 1 SPS Level 2 SPS Level 3
Pilot Judgment &
Actions
Human Factors - Pilot's
Decision
Disregarded cues that should have led to
termination of current course of action or
maneuver
Ground Duties Mission/Flight Planning Inadequate consideration of aircraft
performance
Ground Duties Mission/Flight Planning Inadequate consideration of aircraft operational
limits
Pilot Judgment &
Actions
Procedure Implementation Pilot control/handling deficiencies
Pilot Situational
Awareness
External Environment
Awareness
Lack of knowledge of aircraft's aerodynamic
state (envelope)
Emergency Procedures (Loss of Control) (present in 23 out of 523 accidents)
SPS Level 1 SPS Level 2 SPS Level 3
Maintenance Performance of MX Duties Failure to perform proper maintenance
procedure
Pilot judgment &
actions
Procedure Implementation Pilot control/handling deficiencies
Ground Duties Aircraft Preflight Performance of Aircraft Preflight procedures
inadequate
Loss Of Tail Rotor Effectiveness (Loss of Control) (present in 23 out of 523 accidents)
SPS Level 1 SPS Level 2 SPS Level 3
Pilot judgment &
actions
Procedure Implementation Inadequate response to Loss of tail rotor
effectiveness
Pilot judgment &
actions
Human Factors - Pilot's
Decision
Disregarded cues that should have led to
termination of current course of action or
maneuver
Safety
Management
Flight Procedure Training Inadequate avoidance, recognition and recovery
training: Loss of Tail Rotor Effectiveness (LTE)
4. Intervention Recommendation. Training and Safety Management were the two primary
recommendations for intervention for loss of control accidents. This is followed by specifically
suggesting training it by topic of aeronautical knowledge relating to piloting skills, airframe
knowledge, and specific information regarding typical flight operations and missions. All
recommendations center on the integration of safety and operations management.
29
For Loss of Control in general, the Top 3 IRs for training were: Training emphasis for maintaining
awareness of cues critical to safe flight, Enhanced Aircraft Performance & Limitations Training,
and Inflight Power/Energy Management Training.
For Loss of Control in general, the Top 3 IRs for Safety Management were: Personal Risk
Management Program (IMSAFE), Use Operational Risk Management Program (Preflight),
Establish/Improve Company Risk Management Program.
Often times young pilots are attuned to what their aircraft control requirements are in the
cockpit and what directly relates to those tasks such as CRM. This mentality is sometimes
carried forward as the pilot graduates to instructor, and perhaps more so in these small
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.
5. Accident Narratives. Since we are reviewing several Loss of Control (LOC) areas, there will be
several narratives for each of the loss of control discussions above.
National Transportation Safety Board
FACTUAL REPORT AVIATION
NTSB ID: Aircraft Registration Number:
Occurrence Date: Most Critical Injury: None
Occurrence Type: Accident LOC - Performance Management
Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:
Accident Information Summary-
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 at
the time of the accident. The pilot reported minor injuries to himself and one passenger. There were a total of four
occupants including the pilot.
After losing tail rotor effectiveness, the pilot was able to land the helicopter in a field amongst pine trees. The main
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.
In a written statement, the pilot said that, as he approached the landing area, the helicopter was, "...about 250 pounds
below maximum gross weight of 3,200 pounds." The pilot stated that, while on approach to land, he noticed a tree that
he had not seen before and decided to abort the landing. He said he, "...began a power pull to 100 percent torque and a
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
'low rotor RPM' warning light and horn began to come on with each pull of the collective..."
The National Transportation Safety Board determines the probable cause(s) of this accident as follows.
The pilot's failure to attain translational lift following an aborted landing and the loss of tail rotor effectiveness
encountered by the pilot. Factors to the accident were the low rotor rpm and the trees.
32. 32
National Transportation Safety Board
FACTUAL REPORT AVIATION
NTSB ID: Aircraft Registration Number:
Occurrence Date: Most Critical Injury: None
Occurrence Type: Accident LOC - Dynamic Rollover
Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:
Accident Information Summary-
The pilot of the med-vac helicopter reported that, during liftoff at the remote site, he encountered a loss of visual
reference due to a "brown out" condition created by blowing dust at 3 feet AGL. He then attempted to land the
helicopter without any visual reference; however, the right skid contacted the ground first. A rolling motion to the left
was created and, after the left skid contacted the ground, a dynamic rollover ensued. The helicopter came to rest on its
left side.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilot's
selection of an unsuitable landing site, which caused "brown-out" conditions during departure liftoff and resulted in loss
of control of the helicopter.
National Transportation Safety Board
FACTUAL REPORT AVIATION
NTSB ID: Aircraft Registration Number:
Occurrence Date: Most Critical Injury: FATAL
Occurrence Type: Accident LOC - Exceeding Operating Limits
Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:
Accident Information Summary-
The pilot was assigned to fly for a geophysical seismic team in rugged high desert conditions (elevation 5,366 feet). On
his second day of flying, he was requested, by one of the team members, to "fly a little easier; less aggressively." On his
third day of flying, he was assigned to pick up five team members and their equipment. Once airborne (density altitude
was 8,908 feet), he had been briefed that he would receive GPS team distribution coordinates; instead, he was
instructed to land and hold for a period of time. A witness observed the helicopter fly eastbound, and then make a 45 to
60 degree bank turn [180 degrees] back to the west. The witness then saw the helicopter turn southbound, lower its
nose down almost vertically, and then reduce its nose low pitch to approximately 45 degrees as it disappeared from
sight. Post accident examination of the engine revealed that the manual throttle pointer on the fuel control was in the
emergency position. The first and second stage turbine wheels were found with their blades 50 to 70 percent melted,
indicating an engine that functioned for a time at a temperature level well above its limits.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilot's loss
of aircraft control due to abrupt flight maneuvering. Contributing factors were the high density altitude weather
condition, the total loss of engine power due to the pilot manually introducing excessive fuel into the engine and over
temping the turbine section, and the lack of suitable terrain for the ensuing autorotation.
34
National Transportation Safety Board
FACTUAL REPORT AVIATION
NTSB ID: Aircraft Registration Number:
Occurrence Date: Most Critical Injury: None
Occurrence Type: Accident LOC - Emergency Procedures
Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:
Accident Information Summary-
Two commercial helicopter pilots, both certificated helicopter instructors, were in a turbine-powered helicopter
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 pilot
joined him on the controls, and increased collective to reduce rotor rpm. The helicopter climbed abruptly to
about 60 feet above the ground, where the tail rotor drive shaft separated. The engine subsequently lost power, and an
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 shaft
coupling. The flight stop switch on the collective has no protective guard, and can be readily engaged, allowing
the engine to enter the augmented fuel flow regime and, under certain conditions, causing the engine to overspeed.
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 pilot's
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 manufacturer's inadequate design of the flight stop switch, which has
insufficient safeguards to preclude inadvertent activation.
National Transportation Safety Board
FACTUAL REPORT AVIATION
NTSB ID: Aircraft Registration Number:
Occurrence Date: Most Critical Injury: None
Occurrence Type: Accident LOC - Emergency Procedures
Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:
Accident Information Summary-
After the patient was placed aboard the helicopter, the pilot started the engines and performed a hover check. He then
moved the helicopter forward to gain airspeed and initiated a climb to cruise altitude. After reaching an altitude of
about 100 feet, the main rotor rpm light and audio warning system activated, and the number 2 engine N1 rpm and
torque began to decay. The pilot attempted to regain normal engine parameters, but was unable to regain engine rpm.
The pilot maneuvered to avoid several light poles as he attempted to land in a parking lot. By this time, main rotor rpm
had bled off sufficiently to prevent the hydraulic pumps from pressurizing the hydraulic system, and all flight controls
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 FAA
and Rolls-Royce investigators revealed a B-nut on the Pc line connecting the power turbine governor (PTGOV) to the
fuel control unit (FCU) had become loose at the T-fitting end. It was partially torqued and could be moved with the
fingers. The female end was threaded onto the male end three-quarters of a turn. There was no cross-threading. The
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.
33. APPLICATION
Is there validity to lending perspective between
safety and aeronautical knowledge?
Could such perspective help reduce accident rates?
Cooper’s Essay on Principles
§ Alertness
§ Decisiveness
§ Speed
§ Coolness
§ Ruthlessness
§ Surprise
34. APPLICATION
• Is there validity to lending perspective between
safety and aeronautical knowledge?
• Could perspective help reduce accident rates?
• Cooper’s Essay on Principles
§ Alertness
§ Decisiveness
§ Speed
§ Coolness
§ Ruthlessness
§ Surprise
36. QUESTIONS FOR RESEARCH
• What caused the problem or issue?
• Where in the industry are the accidents
happening?
• Who/what is the “problem child”?
• What is a solution?
• Safety Management
37. SOLVE THE PROBLEM
What is the influence of Safety Management on
the small helicopter entity?
38. NEED FOR RESEARCH
• The Reality is only a perspective
• Big corporations get it.
• Limited research exists in SMS implementation
• When this is not done as set forth in aeronautical
knowledge documentation, and previous training
then risk elevates, aircraft are destroyed, and
potential exists for people to die.
39. THEORY
• Removing risk reduces error potential
• Applying a safety system If we can prove the
benefit of an SMS in a small helicopter entity,
they will adopt some form of SMS and thereby
significantly reduce accident rates.
40. HYPOTHESIS
• Integration of SMS in the small helicopter
entity will show a significant reduction of
accident rates in the industry and thereby
businesses are more productive and efficient.