European Helicopter Safety Team: Samen sterk voor helikopter veiligheid

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

EASA organisatie structuur

European Helicopter Safety Team

2

Inhoud Introductie Methodologie Resultaten En verder…

Photo AgustaWestland


3


4

Goal: To reduce the helicopter accident rate by 80% in 2016

• Internationaal initiatief voor verbeteren van helikopter veiligheid • Samenwerkingsverbanden op regionaal niveau European Helicopter Safety Team

5

Safety Analysis Team - EHSAT Safety Implementation Team - EHSIT

Analysis Develop Safety Action Plans

Implement Safety Action Plans Monitoring


6

ECAST COMMERCIAL AVIATION SAFETY TEAM

EHEST HELICOPTER SAFETY TEAM

EHSAT Core Team

EHSIT Core Team

EGAST GENERAL AVIATION SAFETY TEAM

Sub-group on Communication

Regional Teams EHSIT Specialist Teams


7

IS

Deelnemers EHEST

FI SE

NO

EE LV DK LT IE UK PL

NL BE DE

CZ

LU

SK FR

AT CH

HU RO

SI

BG PT

IT ES GR

MT


CY

8

Introductie Methodologie Resultaten En verder…

Photo Eurocopter


9

Methodologie • Analyse van helicopter ongevallen aan de hand van gestandaardiseerde IHST methode – Methode ook toegepast door helicopter teams in onder andere Verenigde Staten, Brazilie en Canada

• EHEST heeft HFACS analyse (door Wiegmann and Shappell) toegevoegd, om een beter beeld van human factors te krijgen


10

Analyse – Standard Problem Statements


11

Analyse - HFACS

• Voor beide analyse methoden geldt dat de diepgang afhangt van de informatie in het ongevalsrapport European Helicopter Safety Team

12


Photo Vasco Morao


13

Scope • Dataset –

Ongevallen (definitie ICAO Annex 13)

–

Periode: 2000 - 2005

–

Lokatie: EASA Member States

–

Eindrapport van ongevallenonderzoeksraad aanwezig

• EHEST voorlopige resultaten gepresenteerd in oktober 2008 (186 ongevallen) • EHEST eindrapport analyse 2000-2005 in oktober 2008 verwacht (311 ongevallen) • Volgende slides zijn gebaseerd op 303 ongevallen (goede indicatie voor eindrapport) European Helicopter Safety Team

Eindrapport 2000-2005 Analyse Oktober 2010 14

Distributie van ongevallen over type operatie EHSAT Dataset Aerial Work, 32%

State Flight, 4%

(bijv. Fire Fighting,

(bijv. Politie, Military)

Sling/External Load)

General Aviation, 45% (Bijv Pleziervluchten, Training,

Commercial Air Transport, 19%

Business vluchten)

(bijv. Passenger, HEMS, Offshore, CAT Training, CAT Positioning)


15

Distributie van ongevallen overofvluchtfase Accident Distribution over Phase Flight EHSAT Dataset EHSAT Dataset Fatal

Non Fatal

35% 30%

% of Accidents

25% 20% 15% 10% 5% 0% Standing

Taxi

Take-off

En route


Approach & Landing

Manoeuvring

16

Standard Problem Statement analyse resultaten % of Accidents where SPS level 1 has been identified at least once EHSAT Dataset Pilot judgement & actions

65%

Safety Culture/Management

51%

Ground Duties (Planning&Preparation)

38%

Pilot situation awareness

35%

Data issues

35%

Mission Risk

27%

Part/system failure

25% 25%

Regulatory Maintenance

18%

Post-crash survival

17%

Aircraft Design

16% 9%

Infrastructure Communications Ground personnel

7% 1%

European10% Helicopter Safety Team 0% 20% 30%

40%

50%

60%

17 70%

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

18

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

19

Voorbeeld van Commercial Air Transport scenario SPS

HFACS

Pilot decision making

Decision Making - Operation

Self induced pressure

Risk assessment – Operation

Failed to follow procedures

Skill-based errors

Flight profile unsafe

Whiteout/Vision restricted Channelized attention

Inadequate oversight Reduced visibility

Communication critical information/Planning

Selection of inappropriate landing site

Pressing

Management – Failure to enforce company SOPs

Procedural Guidelines


20

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

21

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

22

Voorbeeld van General Aviation scenario SPS

HFACS

Pilot inexperienced

Risk assessment – Operation

Mission planning

Overcontrol/Undercontrol

Pilot decision making

Procedural error

Inadequate standards and regulations Violation – Lack of discipline Wilful disregard for rules and SOPs Mission planning Inadvertent entry into IMC

Overconfidence

Failed to recognise cues to terminate course of action

Vision restricted by meteorological conditions Limited total experience


23

Aantal of EHEST aanbevelingen voor interventies Total number Intervention Recommendations (Level 1) Operations Operations

497

Training_Instructional Training/Instructional

472

Regulatory Regulatory

214

Data_or_Information_Issues Data or Information Issues

175

Maintenance Maintenance

77

Aircraft_System_Equipment_Design Aircraft System Equipment Design

56

Aircraft_Design Aircraft Design

52

Research Research

19

Manufacturing Manufacturing

14

Infrastructure Infrastructure

14

Search and Rescue Search_and_Rescue

1

0

100

200

300


400

500

600

24


Photo Agusta Westland


25

Volgende stap is implementatie • EHEST Communication Sub-Group Bereiken van all Europese stakeholders met een extra focus op General Aviation

• EHSIT Specialist Teams – Operations/SMS – Training – Regulation/Standards EAB 12 March 2010

European Helicopter SafetySafety Team European Helicopter Team

26

26

Huidige en geplande activiteiten (1) • Veiligheidspromotie – Video – Folders

• Best practice materiaal – Ontwikkelen van een pre-flight risk assessment checklist – Voorbeeldlijst van hazards – Handleiding instructeur – Maintenance toolkit European Helicopter Safety Team

27

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


28

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


29

Evenementen • International Helicopter Safety Symposium – 3 en 4 oktober 2010 in Cascais, Portugal. – Georganiseerd door IHST-US en EHEST – Verder informatie en registratie op www.ihst.org

• EASA Rotorcraft Symposium – 8 en 9 december 2010 in Köln, Duitsland – Verdere informatie en registratie op www.easa.europa.eu


30

Bedankt voor uw aandacht Deelnemen of meer informatie? [email protected] www.easa.europa.eu/essi/ehestEN.html


31

European Helicopter Safety Team: Samen sterk voor helikopter veiligheid

Recommend Documents