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.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Aeronautical Decision Making And Risk Management For PilotsMySkyMom
This presentation relies heavily on the FAA\'s Risk Management Handbook, which can be found at http://www.faa.gov It covers factors related to ADM, statistics, best practices, and related case studies.
The influence of adverse weather conditions on pilots’ behavior and decision ...Berend Roosendaal
This paper presents a summary of the international literature regarding pilots’ behavior under adverse weather conditions. The literature also covers the influences on the decision-making process of the pilot. The focus of this study is on pilots who fly solely in general aviation.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Aeronautical Decision Making And Risk Management For PilotsMySkyMom
This presentation relies heavily on the FAA\'s Risk Management Handbook, which can be found at http://www.faa.gov It covers factors related to ADM, statistics, best practices, and related case studies.
The influence of adverse weather conditions on pilots’ behavior and decision ...Berend Roosendaal
This paper presents a summary of the international literature regarding pilots’ behavior under adverse weather conditions. The literature also covers the influences on the decision-making process of the pilot. The focus of this study is on pilots who fly solely in general aviation.
FAA Advanced Qualification Program (AQP) and CRM for Military & .docxlmelaine
FAA Advanced Qualification Program (AQP) and CRM for Military & Single Seat Pilots: Applications in CRM
ASCI 516 Applications in CRM
Module 8 Presentation
Military History of CRM
Military interest in CRM to prevent errors increased when training suggested an enhancement of mission effectiveness was also shown
In the Air Force, CRM was first considered as a way to take advantage of developments in training to update existing training for aircrew coordination
1980’s training programs in the Air Force, Army and Navy were generally referred to as Aircrew Coordination Training (ACT)
2
CRM in the Military
In 1970, civil aviation took the lead in CRM, and the military began implementing this type of training in the early 1980’s
3
Air Carrier and Military Aviation
Commonalities
Navigation
Weather
Controlling aircraft in flight
4
Differences
Purpose of organization
Qualifications of crews
Rank distinctions
Responsibilities of the crews
Labor relations
Miscellaneous factors (ie. Training)
5
Differences - Task
Task environment
Mission tasks
Decision goals
Time elements
Mission Alterations
Equipment
6
Differences - People
Entry level experience of military vs. civilian pilots
Promotion in military often means accepting jobs not related to flying
Motivation
Study of pilots who were both commercial airline and military reserve pilots showed military offers more of the “fun flying” and camaraderie
7
Differences - Organization
Rank and position
Officer/enlisted relations possible inhibitor of assertiveness
Rank reversals considered likely to add tension to cockpit relations
Formality that exits in military cockpit (based on recognition of rank differences) may act as barrier to effective communications
8
Military aircrew are often given duties that may interfere with their flying
safety officer
logistics officer
legal officer
maintenance officer
EEO program oversight
Scheduling
ordering A/C parts
train
investigate accidents
lecture
hold inspections
sit on promotion boards
fill out fitness reports
keep records
counsel subordinates
report to superiors
9
Training
Airlines are in business of transporting people safely – training is make that possible
Military trains for accomplishment of mission
virtually all peacetime flying is training activity
10
Military ACT/CRM Programs
By 1989 the Air Force/Navy/Army had at least one CRM-type program
Most programs are generally stand-alone lecture/discussion sessions, lasting 1-3 days
Videotapes developed for the airlines are often incorporated directly into programs
11
CRM For General Aviation
The Single Pilot
CRM For General Aviation
“No man is an island” and no pilot flies in a protective bubble.
How we interact with every person we come into contact with before and during a flight can significantly affect the outcome of that flight
Learning how to handle yourself and those around you is one of the keys to being a safer pilot
Crew Resourc ...
FAA Advanced Qualification Program (AQP) and CRM for Military & .docxnealwaters20034
FAA Advanced Qualification Program (AQP) and CRM for Military & Single Seat Pilots: Applications in CRM
ASCI 516 Applications in CRM
Module 8 Presentation
Military History of CRM
Military interest in CRM to prevent errors increased when training suggested an enhancement of mission effectiveness was also shown
In the Air Force, CRM was first considered as a way to take advantage of developments in training to update existing training for aircrew coordination
1980’s training programs in the Air Force, Army and Navy were generally referred to as Aircrew Coordination Training (ACT)
2
CRM in the Military
In 1970, civil aviation took the lead in CRM, and the military began implementing this type of training in the early 1980’s
3
Air Carrier and Military Aviation
Commonalities
Navigation
Weather
Controlling aircraft in flight
4
Differences
Purpose of organization
Qualifications of crews
Rank distinctions
Responsibilities of the crews
Labor relations
Miscellaneous factors (ie. Training)
5
Differences - Task
Task environment
Mission tasks
Decision goals
Time elements
Mission Alterations
Equipment
6
Differences - People
Entry level experience of military vs. civilian pilots
Promotion in military often means accepting jobs not related to flying
Motivation
Study of pilots who were both commercial airline and military reserve pilots showed military offers more of the “fun flying” and camaraderie
7
Differences - Organization
Rank and position
Officer/enlisted relations possible inhibitor of assertiveness
Rank reversals considered likely to add tension to cockpit relations
Formality that exits in military cockpit (based on recognition of rank differences) may act as barrier to effective communications
8
Military aircrew are often given duties that may interfere with their flying
safety officer
logistics officer
legal officer
maintenance officer
EEO program oversight
Scheduling
ordering A/C parts
train
investigate accidents
lecture
hold inspections
sit on promotion boards
fill out fitness reports
keep records
counsel subordinates
report to superiors
9
Training
Airlines are in business of transporting people safely – training is make that possible
Military trains for accomplishment of mission
virtually all peacetime flying is training activity
10
Military ACT/CRM Programs
By 1989 the Air Force/Navy/Army had at least one CRM-type program
Most programs are generally stand-alone lecture/discussion sessions, lasting 1-3 days
Videotapes developed for the airlines are often incorporated directly into programs
11
CRM For General Aviation
The Single Pilot
CRM For General Aviation
“No man is an island” and no pilot flies in a protective bubble.
How we interact with every person we come into contact with before and during a flight can significantly affect the outcome of that flight
Learning how to handle yourself and those around you is one of the keys to being a safer pilot
Crew Resourc.
Session no 1 basic contemporary safety conceptssameh shalash
Define and explain the terms “accident, incident, occurrence.
• Describe what the costs of an accidents and incidents are.
• Define and explain the term of safety.
• Emphasizing the need for hazard identification processes (Reactive; proactive; predictive).
• Describe the james reason accident causation model.
• Give an overview about the ABC Performance-Based Safety.
This reviews the strengths and weaknesses of long-established approaches to safety, and proposes new perspectives and concepts underlying a contemporary approach to safety.
This includes the following topics:
a) The concept of safety;
b) The evolution of safety thinking;
c) Accident causation — The Reason model;
d) The organizational accident;
e) People, operational contexts and safety — The SHEL model; and
f) Errors and violations;
Review of the National Culture Influence on Pilot’s DecisionMaking during fli...IOSRJBM
Thisreview paperstudies the influence of the national culture onflying safety in the cockpit. Likewise, the study aims toevaluate the pilot behaviour and response to risk during flight in terms of pilot decisionmaking. According to Helmreich (2000), ―cultural values are so deeply ingrained; it is unlikely that exhortation, edict, or generic training programs can modify them. The challenge is to develop organizational initiatives that congruent with the culture‖. Thus,evaluating the technology-culture interference impact on a pilot’s decision-making performance, within a specific region gives deep understanding of the pilot’s behaviour under the effect of this region national culture. In addition,this appraises the risk tolerance, error management and factors that affect pilot decision-making in regarding to national culture within the region.The expected contribution of this research is to enhance the pilot decision-making performance within the region of North Africa. Moreover, this study will enhances the implementation of Crew Resource Management training program (CRM), in which will support the culture calibration of the CRM tofit the pilot’sneeds within this region. Ultimately, a safe operation of the aircrafts and improvethe aviation marketwithin the region
Crew Resource Management and
Situational Awareness
ASCI 516
Module 5 Presentation
Overview of Situational Awareness (SA)
Definitions
Components of SA
CRM skills that aid in situational awareness
Threats to SA
Prevention methods to enhance SA
Theory of the Situation
A set of beliefs about what is happening and what action an individual should take.
Based on the interpretation of available information.
Based on individual’s perception of reality
Reality of the Situation
What is actual reality, without human perception
Theory of Practice
An individual’s concepts and skills developed over time, used to build and respond to Theories of the Situation
The sum of experience
Theory of the Situation
You are MOST likely to change your theory of the situation when:
Operating under low stress
Have access to and accept feedback
Develop inquiry skills into your Theory of Practice. Guard against interpreting information to support your Theory of the Situation
Theory of the Situation
You are LEAST likely to change your theory of the situation when:
Your Theory of Practice is over-learned
You have a complacent attitude
It is a crisis situation
The theory of the situation is central to your self-esteem/ego.
Got SA???
Situation Awareness is an accurate perception of the factors and conditions currently affecting the safe operation of the aircraft and crew.
(ICAO & Industry CFIT Task Force).
8
Defining SA
Situational assessment is defined as the process of achieving situation awareness. It is the process of information acquisition and interpretation that leads to the product defined as situation awareness
Adams, Tenney and Pew, 1995
Awareness Is the Result of
Multiple Situational Assessment
Observation of Situation
Comparing observation with:
Other Observations
Expectations
Plans
Seeking More Information
Situational Assessment on Three Levels
Perception: Failure to correctly perceive the situation
Integration of Information:
Failure to integrate or comprehend the information
Projection: Failure to project situation into the future
Pilot Elements of Situational Awareness
Experience and Training
Physical Flying Skills
CRM Skills (Teamwork)
Spatial Orientation
Health and Attitude
12
Operational Clues to Loss of Situational Awareness
Terrible Eleven
Incomplete Communications
Ambiguity
Unresolved Discrepancies
Use of Undocumented Procedures
13
Operational Clues to Loss of Situational Awareness
Terrible Eleven
Preoccupation or Fixation
No One Flying
No One Looking
Confusion
14
Operational Clues to Loss of Situational Awareness
Terrible Eleven
Deviations from SOP’s
Violations of Limits and Regulations
Failure to Meet Targets
15
Confused?
Maintain Control - Fly the aircraft.
Create Time & Space - minimize the impact of any errors or threats by avoiding critical flight segments until ready.
16
REVERT TO BASICS:
Maintain Control - Fly the Aircraft. Or delegate someone to with specifi.
Depending on the nature of the task, the level of safety management training required will vary from general safety familiarization to expert level for safety specialists, for example:
a) Corporate safety training for all staff,
b) Training aimed at management’s safety responsibilities,
c) Training for operational personnel (such as pilots, maintenance engineers, dispatchers / FOO’s and personnel with apron or ramp duties), and
d) Training for aviation safety specialists (such as the Safety Management System and Flight Data Analysts).
The scope of SMS training must be appropriate to each individual’s roles and responsibilities within the operation. Training should follow a building-block approach. As part of the ICAO requirements, an operator must provide training to its operational personnel (including cabin crew), managers and supervisors, senior managers, and the accountable executive for the SMS.
Training should address the specific role that cabin crew members play in the operation. This includes, but is not limited to training with regards to:
a) Unit 1 SMS fundamentals and overview of the operator’s SMS;
b) Unit 2 Safety policy;
c) Unit 3 Hazard identification and reporting; and
d) Unit 4 Safety Communication.
e) Unit 5 Review of Company Safety Management
f) Unit 6 Review of Safety Reporting
The base content comes from many sources but all aligned to the ICAO syllabus requirements, and created for an international operational airline.
If you are a startup airline, or looking to align courses with your specific operational standards, please take a look and check out
pghclearningsolutions@gmail.com leave a message and I will contact you where we can discuss your requirements, send you examples and if required, download my editable masters which you can customize to meet your own specific operational training requirements.
Available online at httpdocs.lib.purdue.edujateJournal.docxcelenarouzie
Available online at http://docs.lib.purdue.edu/jate
Journal of Aviation Technology and Engineering 3:2 (2014) 2–13
Crew Resource Management Application in Commercial Aviation
Frank Wagener
Embry-Riddle Aeronautical University
David C. Ison
Embry-Riddle Aeronautical University–Worldwide
Abstract
The purpose of this study was to extend previous examinations of commercial multi-crew airplane accidents and incidents to evaluate
the Crew Resource Management (CRM) application as it relates to error management during the final approach and landing phase of
flight. With data obtained from the Federal Aviation Administration (FAA) and the National Transportation Safety Board (NTSB), a x2
test of independence was performed to examine if there would be a statistically significant relationship between airline management
practices and CRM-related causes of accidents/incidents. Between 2002 and 2012, 113 accidents and incidents occurred in the researched
segments of flight. In total, 57 (50 percent) accidents/incidents listed a CRM-related casual factor or included a similar commentary within
the analysis section of the investigation report. No statistically significant relationship existed between CRM-related accidents/incidents
About the Authors
Frank Wagener currently works for Aviation Performance
Solution
s LLC (APS), dba APS Emergency Maneuver Training, based at the Phoenix-Mesa
Gateway Airport in Mesa, Arizona. APS offers comprehensive LOC-I solutions via industry-leading, computer-based, on-aircraft, and advanced full-flight
simulator upset recovery and prevention training programs. Wagener spent over 20 years in the German Air Force flying fighter and fighter training aircraft
and retired in 2011. He flew and instructed in Germany, Canada, and the United States. He holds several international pilot certificates including ATP,
CPL, CFI, as well as a 737 type rating. He graduated with honors from the Master’s in Aeronautical Science Program at Embry-Riddle Aeronautical
University. Correspondence concerning this article should be sent to [email protected]
David C. Ison has been involved in the aviation industry for over 27 years, during which he has flown as a flight instructor and for both regional and
major airlines. He has experience in a wide variety of aircraft from general aviation types to heavy transport aircraft. While flying for a major airline, Ison
was assigned to fly missions all over the world in a Lockheed L-1011. Most recently, he flew Boeing 737–800 aircraft throughout North and Central
America. He worked as an associate professor of aviation for 7 years at a small college in Montana. He is currently Discipline Chair–Aeronautics and an
assistant professor of aeronautics for Embry-Riddle Aeronautical University–Worldwide. Ison has conducted extensive research concerning aviation
faculty, plagiarism in dissertations, statistics in aviation research, as well as the participation of women and minorities in aviation. His previo.
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India Orthopedic Devices Market: Unlocking Growth Secrets, Trends and Develop...Kumar Satyam
According to TechSci Research report, “India Orthopedic Devices Market -Industry Size, Share, Trends, Competition Forecast & Opportunities, 2030”, the India Orthopedic Devices Market stood at USD 1,280.54 Million in 2024 and is anticipated to grow with a CAGR of 7.84% in the forecast period, 2026-2030F. The India Orthopedic Devices Market is being driven by several factors. The most prominent ones include an increase in the elderly population, who are more prone to orthopedic conditions such as osteoporosis and arthritis. Moreover, the rise in sports injuries and road accidents are also contributing to the demand for orthopedic devices. Advances in technology and the introduction of innovative implants and prosthetics have further propelled the market growth. Additionally, government initiatives aimed at improving healthcare infrastructure and the increasing prevalence of lifestyle diseases have led to an upward trend in orthopedic surgeries, thereby fueling the market demand for these devices.
RMD24 | Retail media: hoe zet je dit in als je geen AH of Unilever bent? Heid...BBPMedia1
Grote partijen zijn al een tijdje onderweg met retail media. Ondertussen worden in dit domein ook de kansen zichtbaar voor andere spelers in de markt. Maar met die kansen ontstaan ook vragen: Zelf retail media worden of erop adverteren? In welke fase van de funnel past het en hoe integreer je het in een mediaplan? Wat is nu precies het verschil met marketplaces en Programmatic ads? In dit half uur beslechten we de dilemma's en krijg je antwoorden op wanneer het voor jou tijd is om de volgende stap te zetten.
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Cracking the Workplace Discipline Code Main.pptxWorkforce Group
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In this deck, you will learn the significance of workplace discipline for organisational success. You’ll also learn
• Four (4) workplace discipline methods you should consider
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1. Heli-Expo 2013
Safety Challenge
The Reality of Aeronautical Knowledge:
The Analysis of Accident Reports Against
What Aircrews are Supposed to Know
2. Introduction
Faculty with Embry-Riddle Aeronautical University
Discipline Chair, Helicopter Operations and Safety
Associate Program Chair, Transportation
IHST Affiliations
IHST, JHIMDAT
IHST, JHSIT, Training Committee
IHST, JHSIT, SMS Committee
3. Course Description
Best suited to accident prevention, this
presentation is a combination of practical
knowledge beyond the Helicopter Flying Handbook
and research of the IHST’s Analysis Team. This in-
depth look at aeronautical knowledge, decision-
making, and understanding limitations is ideal for
all experience levels. This presentation evolved
from extensive research into the industry
publication
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
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
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://
6. Agenda
Introduction and discussion of research
Beyond the Helicopter Flying Handbook
Discussion of Accidents by Occurrence Category
Conclusion
Discussion and Collaboration
7. Where do we come from?
What is our cultural
background?
8. 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?
12. Why Do This?
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 coming
13. Adjunct to 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, exper
ience, reflection, reasoning, communication.
14. Reality is Perspective
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.
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. Statistics as Perspective
In the U.S. JHSAT analysis, their three year assessment of
523 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. 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).
18. 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%).
19. Statistics as Perspective
FAR Part 91 operations incurred 70% of the total accidents.
FAR Part 91 operations account for just over half of the
rotorcraft flight hours each year (amount of exposure).
FAR Part 91 ends up accounting for a higher percentage of
accidents compared to amount of exposure partly because
the Personal/Private and Instructional/Training industries
have such a high percentage of the accidents and both
operate Part 91.
20. 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).
21. 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
23. 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
24. 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
25. Applied Reality
Reality text : Part III Accident
Analysis teamed with NTSB Reports
26. Synthesis
Snapshots of high volume accidents by occurrence category
Explain
Introduce
Define
Identify problem
Accident Narratives
Lets have a look ……..
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 & Procedure Implementation Inappropriate Energy/power management
Actions
Pilot Judgment & Procedure Implementation Pilot control/handling deficiencies
Actions
Pilot Judgment & Landing Procedures Autorotation – Practice
Actions
Pilot Judgment & Human Factors - Pilot's Disregarded cues that should have led to
Actions Decision termination of current course of action or
maneuver
Pilot Judgment & Crew Resource Management Inadequate and untimely CFI action to correct
Actions 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 & Procedure Implementation Improper recognition and response to dynamic
Actions rollover
Pilot Judgment & Procedure Implementation Pilot control/handling deficiencies
Actions
Pilot Judgment & Crew Resource Management Inadequate and untimely CFI action to correct
Actions student action
Pilot Judgment & Landing Procedures Selection of inappropriate landing site
Actions
27
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 maintaining
SPS Level 1 SPS Level 2 SPS Level 3
awareness of cues critical to safe flight, Enhanced Aircraft Performance & Limitations Training,
Pilot Judgment & Human Factors - Pilot's Disregarded cues that should have led to
Actions Decision termination of current course of action or and Inflight Power/Energy Management Training.
maneuver
Ground 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.
limits
Pilot Judgment & Procedure Implementation Pilot control/handling deficiencies Often times young pilots are attuned to what their aircraft control requirements are in the
Actions cockpit and what directly relates to those tasks such as CRM. This mentality is sometimes
Pilot Situational External Environment Lack of knowledge of aircraft's aerodynamic carried forward as the pilot graduates to instructor, and perhaps more so in these small
Awareness 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 be
Maintenance Performance of MX Duties Failure to perform proper maintenance several narratives for each of the loss of control discussions above.
procedure
Pilot 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 AVIATION
Ground 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 at
SPS 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 four
Pilot 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 main
Pilot judgment & Human Factors - Pilot's 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 that
Safety 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 a
Management 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 pilot's 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. 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 Procedures
Airport 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 helicopter
reference 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 pilot
helicopter 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 to
was 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 an
left 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 shaft
The National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilot's
coupling. The flight stop switch on the collective has no protective guard, and can be readily engaged, allowing
selection 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 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
National 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: None
Accident Information Summary- Occurrence Type: Accident LOC - Emergency Procedures
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 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 then
instructed 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 of
60 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 and
nose 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 rpm
emergency 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 controls
indicating 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 FAA
The National Transportation Safety Board determines the probable cause(s) of this accident as follows. The pilot's loss and Rolls-Royce investigators revealed a B-nut on the Pc line connecting the power turbine governor (PTGOV) to the
of 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 the
condition, 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. The
temping 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. 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
31. 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
33. Questions for Research
What 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
35. Need for Research
The Reality of Aeronautical Knowledge as it pertains to
flight 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 aeronautical
knowledge documentation, and previous training then risk
elevates, aircraft are destroyed, and potential exists for
people to die.
36. Theory
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.
37. 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.
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.