Fred Brisbois, Sikorsky Aircraft Corp. and Larry Buehler, FAA ... - IHST

IHST MODELBased On Proven CAST ProcessIHST (CAST)Charters ActivityJHSAT (JSAT)Analyzes Accident DataProposes mosteffective interventionsJHSIT (JSIT)Assesses feasibility ofinterventionsworks implementationContinued data analysis,measure interventioneffectiveness (JIMDAT)IHSS – September, 2009IHST.org3

CHALLENGESNot the same for helicopters as for airplanesIncreased versatility of helicoptersrequires diverse actions toaddress challengesvs.IHSS – September, 2009IHST.org4

U.S. JHSIT PROCESS MODELReview JHSATRecommendations& Assign NumberJHSAT OverallEffectivenessValue (OE)√Initiate Top Level Safety Intervention Actions(e.g. promoting IHST, SMS, Infrastructure changes)√ √ √Assign JHSITAverageFeasibility Value√PrioritizeRecommendations(OE x F)√GroupRecommendationsBy CommonTheme√PreparePreliminarySafetyEnhancementPlanIHST ApprovalPrepare DetailedSafetyImplementationPlanIHST ApprovalExecute andMonitor ProgressOf SafetyImplementationPlanIHSS – September, 2009IHST.org6

Technical Feasibility: The ability of the project to take advantage of the current state of technology inpursuing further development.3 - Off-the-shelf technology, no development required2 - Some development required, not currently in public use1 - Major technology development effort requiredFinancial Feasibility: Should consider the total cost of the implementation, including the planningprocess. Financial feasibility also involves the capability of the participating organizations (FAA,Manufacturers, and Airlines and Operators) to provide the appropriate funding needed to implement theproject.3 - Relatively low cost to implement2 - Relatively medium cost to implement1 - Relatively high cost to implementOperational Feasibility: Involves the “practicality” of the project within the context of the operatingenvironment, including NAS, ground operations, maintenance, inspection, etc. Considers whichorganizations within the aviation system are impacted.3 - Minimal change to entities within the operating environment2 - Modest change to operating environment1 - Major change to operating environmentSchedule Feasibility: Can the project to contribute to achieving the goal in a selected timeframe? Mustconsider implementation schedule by project.3 - Less than 2 years to full implementation2 - Full implementation in 2-5 years1 - Longer than 5 years to full implementationRegulatory Feasibility: Should be evaluated against current rules and certificationprocess. Could be a deterrent due to a long approval process.3 - No policy change2 - Guidance change only (orders, handbooks, policy)1 - Rule changeIHSS – September, 2009IHST.org7

JHSIT EVALUATION MATRIXExampleJHSATEffectivenessJHSITFeasibilityFINALRANKINGJHSAT FLEET RECOMMENDATION3 2.95 8.86 SM4 Make proactive use of safety information to createawareness of known hazards and reduce the risk of accidents3 2.82 8.46 TN4 Expand training in aeronautical decision making (ADM) andrisk management3 2.79 8.36 SM14 Provide for non-punitive safety event reporting.3 2.78 8.34 TN5Provide comprehensive training on aircraft performance3 2.69 8.08 SM19 Ensure that training policies and SOPs enhance training forcrew awareness of critical flight systems, operational riskmanagement and appropriate Aeronautical Decision Making(ADM) training.IHSS – September, 2009IHST.org8

MANAGING BUSINESS = MANAGING SAFETYFinancial Management SystemSafety Management SystemFinance PlanSafety PlanTargets & ObjectivesTargets & ObjectivesBudgetBudgetAccountabilitiesLevels of AuthorityProceduresAccountabilitiesLine ManagementAuthoritiesProceduresChecks and BalancesMonitoring/Line ChecksAuditPlanAccountantsAudit PlanSafetyCommitteeAuditsBalanceSheetsAuditsSafetyAchievementIHSS – September, 2009IHST.org9

U.S. JHSIT CORE MEMBERSHIPLarry BuehlerCo-ChairFred BrisboisCo-ChairNameLindsay CunninghamDenise UhlinMike HurstChris EastleeBJ RaysorKeith JohnsonHarold SummersTom JudgeTerry PalmerMarty RinconOrganizationFAA, 135 Air Carrier Operations BranchSikorsky Aircraft Corporation, Director, Aviation & Product SafetyAmerican Eurocopter, Accident InvestigatorBristow Western Hemisphere Helicopter Services, Director Quality & SafetyPHI, Chief PilotAssociation of Air Medical Services, Government Relations ManagerArkansas Children's Hospital, Director of OperationsAirborne Law Enforcement Association, Safety ManagerHAI, Director Flight Operations & Technical ServicesExecutive Director, Life Flight of MaineFlightSafety International, Manager, Rotorcraft Special ProgramsAirsure Limited, Aviation Claims SpecialistIHSS – September, 2009IHST.org10

JHSIT WORKING GROUPSStrategic Areas of InterventionSafetyManagement(24)XXTrainingCommunications & Marketing(9) Systems,Equipment &Information(10)MaintenanceX (4)Regulatory(5)XInfrastructureX (5)X* Reason, 1990IHSS – September, 2009IHST.orgXAccident11

IMPROVING PERFORMANCEPROBABILITY⇒FREQUENT PROBABLE OCCASIONAL REMOTE IMPROBABLESEVERITY ⇓A B C D EI - CATASTROPHIC 1 2 4 8 12II - CRITICAL 3 5 6 10 15III - MARGINAL 7 9 11 14 17IV - NEGLIGIBLE 13 16 18 19 20PercentOccurrencePerfect Real Good Okay Not So Awful CatastrophicGoodBadOutcomesIHSS – September, 2009IHST.org12

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Call to Action• It’s time for the industry to recognize its maturity,and formalize its safety and training. The theme ofthe JHSIT products begins with implementation ofan SMS. Along with that, the use of Flight DataMonitoring (FDM) has come of age and is viablefor helicopter operators. Through FDM, you willsee flaws in standardization, operationalprocedures, and training. You can now use the"just culture" and, if needed, appropriate,identifiable training to improve your overalloperation.IHSS – September, 2009IHST.org17

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OPERATIONAL RISKSingle engine (Non-turbine)Single pilotNot IFR capableNo autopilotNo terrain avoidance systemNo de-ice capabilityRISKWHO IS INVOLVED INDECISION MAKING,RISK ACCEPTANCE,RISK MITIGATION?No CRM / Formal trainingIHSS – September, 2009IHST.orgDual engine turbine engineDual pilotIFR capableAutopilot, fully coupledTerrain Avoidance Warning SystemAll weather capableTraining / CRM19

U.S. JHSIT CORE MEMBERSHIPLarry BuehlerCo-ChairFred BrisboisCo-ChairIHSS – September, 2009IHST.orgNameLindsay CunninghamDenise UhlinMike HurstChris EastleeBJ RaysorKeith JohnsonHarold SummersTom JudgeTerry PalmerMarty RinconJames McKennaOrganizationFAA, 135 Air Carrier Operations BranchSikorsky Aircraft Corporation, Director, Aviation & Product SafetyAmerican Eurocopter, Accident InvestigatorBristow Western Hemisphere Helicopter Services, Director Quality & SafetyPHI, Chief PilotAssociation of Air Medical Services, Government Relations ManagerArkansas Children's Hospital, Director of OperationsAirborne Law Enforcement Association, Safety ManagerHAI, Director Flight Operations & Technical ServicesExecutive Director, Life Flight of MaineFlightSafety International, Manager, Rotorcraft Special ProgramsAirsure Limited, Aviation Claims SpecialistBell Helicopter20

WHAT THE HELL DO WE KNOW ABOUTFINANCE?Return on Investment (ROI): This is calculated by dividing the net present value by the presentvalue of the project costs. The net present value is calculated by subtracting the present value ofproject costs from the present value of project benefits. The model calculates ROI based oncosts, benefits, and the discount rate that are entered by the user.ROI =t∑i=1⎡⎢⎢⎣( B − C )( 1+n)t∑i=1ii( 1+r)i( 1+n)⎡Ci⎢i⎣⎢ ( 1+r)i⎤⎥⎦⎥i⎤⎥⎥⎦=t∑i( + ) ⎤ t1 n ⎡C( 1 n)⎡Bi⎢ ⎥⎣⎢ +⎦⎥ − +∑i⎢i( 1 r) i ⎣⎢ ( 1+r)t ⎡iC( + n)⎤∑i 1⎢ ⎥ii=1 ⎣⎢ ( 1+r)⎦⎥i= 1 = 1ii⎤⎥⎦⎥WE KNOW ROISHI !IHSS – September, 2009IHST.org22

ACTIVE vs. LATENT FAILURES*OrganizationalFactorsLatent Conditions•Procedures incomplete•Poor layout/configurationUnsafeSupervisionLatent Conditions•Poor task planning•Parts/tools improperly labeledPreconditionsforUnsafe ActsLatent Conditions•Inadequate lighting•Equipment inappropriate for taskFailed orAbsent Defenses* Reason, 1990IHSS – September, 2009IHST.orgUnsafeActsActive Conditions•Omitted procedural step•Distraction/Interruption•Inadequate task knowledge•Poor techniqueAccident & Injury• Maintenance problem• Aircraft crashed24

RECOGNIZING RISKIHSS – September, 2009IHST.org25

WHO APPROVES CONFIGURATION?4 Point Upper Restraint Cabin Seats406 Enabled ELT / Auto Deployed ELTFwd / Aft Cabin Push Out windowAft Orientation BarAuto Float Deployment (AFDS)Cyclic Warning SystemEGPWSExternal Life RaftFDR / CVRGPSHEELSFlight Following SystemSingle Action Door ReleaseSkywatch / TCASWeather RadarS-76C+ (2000)YesNoYesYesNoYesNoYesYesYesNoYes (C ustomer)YesYesYesS-76A++ (1984)NoNoNoNoNoNoNoNoCVR onlyYes (Customer)NoNoNoNoYesHUMSNoNoContractor Changed – Impacting Level Of SafetyWas Risk Assessment At Appropriate Level?IHSS – September, 2009IHST.org26

SPACE SHUTTLECHALLENGERJanuary 28, 1986COLUMBIAFebruary 1, 2003IHSS – September, 2009IHST.org27

CHALLENGER ACCIDENT INVESTIGATION•Lesson Learned: Well-intentioned people and high-risk organizationscan become desensitized to deviations from the norm– Vaughan's book, The Challenger Launch Decision, called this“Normalization of Deviance”– Board identified this as a major factor in Columbia mishap, much likeChallenger disaster– "Unexpected becomes the expected which becomes theaccepted"– In both Challenger, Columbia: "The machine was talking to us, butnobody was listening"– Small anomalies may be symptomatic of larger problems -failure toaddress could be disastrous– System effects take years to develop and cause failuresDiane Vaughan, risk specialist and sociology professor Boston CollegeIHSS – September, 2009IHST.org28

RAISE THE BAR VIA PUSH –PULL STRATEGYClientsExecutiveLevelDemandsACCEPTABLE STANDARDSOperatorsWE NEED TO CREATE THE ‘PULL’ FROM CLIENTSTOMAKE THE ‘PUSH’ TO OPERATORS EASIERIHSS – September, 2009IHST.org29

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CULTURAL CHANGEDrinkingThen - Otis Campbell / the Andy Griffith ShowNow - MADD / Drinking and DrivingNow – Enabling is out…SmokingThen - “Dive Bomber” starring Errol Flynn and FredMacMurryNow – Second hand smoke / restaurants and barsNow - AdvertisingSeat belt use in automobilesThen – “Sissy”Now – Unacceptable not to use themIHSS – September, 2009IHST.org31

CULTURAL CHANGENearly every states/province already had laws against:drinking to excessdriving drunkselling liquor to minorsThe changes were not driven by laws. The basicprohibitions were already in placeEnforcement policy change.Tobacco, fewer prohibitions existed, but more havedeveloped as a result of the cultural change.Seat Belts – Manufacturing, use by example, userequirements led to a cultural change; phase-in byattritionIHSS – September, 2009IHST.org32

CULTURAL BEHAVIORAL NORMS & SAFETY– Acceptable Risk• Peacetime vs. combat environment– Acceptable Behavior• “Do you think we can get through?”– Management/Stockholder/Customer Expectations• The cost of cancellations/late flights vs. theprimary and secondary costs of accidents• Braniff “On Time Clock”–Peer Pressure• Competitive vs. Supportive– Non-punitive or “Just Culture”IHSS – September, 2009IHST.org33

SAFETY MANAGEMENT SYSTEMFramework For Cultural Change• Framework for Cultural Change - Safety ManagementSystem– Scalable– Adaptable–Integrated– Compliant• Cultural Change Timeline– Generational– Significant Emotional EventIHSS – September, 2009IHST.org34

REDUCING RISKChanging the StandardSTRATFORD, Conn., May 28, 2004 -- --SikorskyAircraft established another rotorcraft industryfirst by standardizing its new S-76 and S-92helicopter safety baseline to to include EnhancedGround Proximity Warning Systems (EGPWS) in inall civil aircraft configurations.IHSS – September, 2009IHST.org35

SAFETYResponsibility & AccountabilityAnd It Begins With US!!IHSS – September, 2009IHST.org36

Questions??Larry BuehlerFAACO-CHAIR US JHSITlarry.buehler@faa.gov202-267-3370Fred BrisboisSikorsky AircraftCorporationCO-CHAIR US JHSITfbrisbois@Sikorsky.com203-386-3559IHSS – September, 2009IHST.org37

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SAFETY MANAGEMENT SYSTEM (SMS) IWGChairman:Keith Johnson, Safety Program Manager, Airborne Law Enforcement AssociationMembers:Denise Uhlin, Bristow GroupFred Brisbois, Sikorsky Aircraft, Director Aviation & Product SafetyDr. Peter Gardiner, President and CEO of the Southern California Safety InstituteJ. Heffernan, HAI Director of SafetyEric Lugger, Director of Safety Air MethodsRichard Komarniski, Grey Owl Aviation Consultants Inc.Susan Brisbois, Education Resources, LLCIHSS – September, 2009IHST.org39

SMS IWG ACTIVITIES2007• Sep SMS Tool Kit Published• Oct Exxon Mobil announces IHST Toolkit SMS attributes will form part of all futurecontractual technical specifications.2008• May ALEA Adopts IHST SMS Toolkit• July SMS .PPT Workshop developed• 19 SMS Presentations and Workshops at 15 Different Conferences / Venues• 30 Articles promoting Safety and SMS in Air Beat Magazine2009• FEB Interactive Computerized SMS Training Tool (courtesy AvStar)• SEP Tool Kit Revision – expanded and aligned with FAA 120-92A• Mentoring Program – 5 operatorsIHSS – September, 2009IHST.org40

SYSTEMS, EQUIPMENT & INFORMATION IWGChairpersons:Lindsay Cunningham, JHSIT, American EurocopterBJ Raysor, JHSIT, Arkansas Children’s HospitalMembers:Dick Healing, R3 ConsultingMike Hurst, JHSIT Resource, PHIStuart Lau, CAPACGJim Morgan, BristowRobert Vandel, FSFWilliam Voss, FSFRobert Dodd, NTSBBob Whetsell, AerobytesThomas Longridge, Resource, FAA FOQADoug Farrow, Resource, FAA FOQAIHSS – September, 2009IHST.org41

SYSTEMS, EQUIPMENT & INFORMATION20072008JUL: Checklist for Helicopter Accident Investigation delivered to NTSBDEC: Project planning meeting with Flight Safety Foundation to implement HEMS FOQAProgram2009JAN: Follow-up face-to-face meeting with FSF on HEMS FOQA ProjectFEB: Presentation at NTSB EMS Hearing on recording equipmentFEB: Follow-up meeting with FSI on EMS FOQA projectFEB: Launch HEMS FOQA Project with Flight Safety Foundation at Heli-ExpoFEB: Flight Data Monitoring Workshop to take place at CHC Safety SummitSEP: Flight Data Monitoring ToolkitOCT; Flight Data Monitoring Workshop and HEMS FOQA Project Meeting to take place atAMTC2010Monitoring/recording systems standard equipment on major airframe OEMsIHSS – September, 2009IHST.org42

TRAINING IWGChairperson:Terry Palmer, FlightSafetyMembers:Marty Rincon, AirSureJack Hustwit, ERA MedTom Ramirez, AvStar MediaElden Mayo, ERA maintenancePaul Osterman, American EurocopterSue Brisbois, Education Resources LLCIHSS – September, 2009IHST.org43

TRAINING IWG ACTIVITIES2008Nov Educational meeting with insurance underwriter managementCompile resources for flight training and flight simulation training devices2009• APR: Exportable Educational Program for insurance underwriters• MAY: Follow-up meeting with insurance underwriters• APR – AUG: Regional insurance and Government educational sessions• MAY: Follow up educational meeting with insurance underwriter management• SEP: Training Toolkit including resource material• OCT: Rewrite best practices and resources for CAMTS• DEC: New simulator makes and models including single engine• Provide extensive initial and recurrent training in helicopter emergencies. Performance, flightplanning, aeronautical decision making (ADM), risk management, inadvertent IMC, make &model transition and specialized mission training• New training programs – OEMS, professional training organizations, associations andsimulator providers - ongoing 2008 - 2010IHSS – September, 2009IHST.org44

INFRASTRUCTUREChairperson:T. Judge, LifeFlight of MaineMembers:Eric Lugger: Air Methods CorporationRex Alexander: OmniflightRachael Miller, MS: ResearcherJeni OBryon: recently left position as lead Aviation Planner for Maine DOTGreg Thompson, National Center for Atmospheric ResearchRalph Petragnani: Belfort InstrumentsChris Eastlee: Air Medical Operators AssociationDan Norman: Satellite Technologies Incorporated.IHSS – September, 2009IHST.org45

INFRASTRUCTURE IWG ACTIVITIES2008:Completed work on Pilot Records and Improvement Act Recommendation2009:Identify what needs to happen and budget to move HEMS ADDS tool from experimental tooperationalAssess national grid of existing AWOS federal, stateAssess national grid of other weather sourcesAssess national grid of GPS approachesAssess mechanisms to tie other weather sources into FAA gridAssess what is needed to establish a low level IFR infrastructureIHSS – September, 2009IHST.org46

U.S. JHSIT WORKING GROUPSCo-ChairsSMSTrainingLarry Buehler Fred BrisboisKeith JohnsonDenise UhlinTerry Palmer Marty RinconeSystems,Equipment &InformationRegulatoryInfrastructureMaintenanceLindsayCunninghamEvansBJ RaysorMike HurstChris EastleeTom JudgeHarold SummersIHSS – September, 2009IHST.org47