RISK AWARENESS: IMPROVING AIRCREW KNOWLEDGE

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RISK AWARENESSIMPROVING AIRCREW KNOWLEDGE
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Heard at ISASI 2005

• Risk for helicopters 10 x risk for airlines
• Proposed strategies
• Flight simulators
• CVRs

• EGPWS
• Crash-resistance standards
• NVG
• HUMS
• IS THIS ENOUGH ?
• IS THIS REALISTIC ?

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IMPEDIMENTS

• Cost
• Age of design
• Size of companies
• Variety of operations
• New risks
• Change in behavior (eg use of GPS)

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IMPEDIMENTS (cont)

• Lessons learnt but not assimilated

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What if
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What if
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Jan. 2000 Jun. 2005
354 Accidents
BEA

• 67 fatalities
• 133 hull losses
• Exposure difficult to assess
• No significant trends

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51 accidents with casualties
(4 undetermined)
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Avoidable
55 of fatalities
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New causes?

• Unsafe acts / behavior
• Abrupt maneuvers
• Low flight
• Negligent flight preparation
• Load securing
• Fuel
• WB
• Continuation of flight in marginal conditions
• Failure to appropriately react to malfunction
• Lower the collective
• Reaction after hyd. loss

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Specific helicopter factor

• I can land anywhere if
• I can better adjust to limits (weather)
• Overconfidence
• Accident ? It wont happen to me
• VIP factor

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Safety strategies

• Safety devices
• Hazard identification
• Procedures
• Improved training
•  Closing the loop 
• Tightening the loop

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TRAINING HISTORY
H SLE L

• Knowledge of Hardware
• Knowledge of Software
• Knowledge of Environment
• Knowledge of Liveware
• Knowledge of interactions
• Knowledge of failure modes

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WHO IS IMMUNE TO ACCIDENTS?

• There are two sorts of pilots
• Those who have landed gear up
• Those who will
• Bias in risk assessment experience
• Extremely remote vs frequent

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Investigation reports

• Standardized
• Based on facts
• Non-punitive approach
• All aspects reviewed (19 chapters)
• Participation of several partners
• Intended for prevention purposes
• Many details
• Lessons learnt

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Ground lessons case study

• Detailed study of circumstances and causes
• Questions
• Have we experienced anything similar?
• Have we been close to experiencing anything
  similar?
• What are the similarities?
• What are the differences?
• Are we immune to being involved in such a
  scenario?

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Questions (cont)

• What are our defenses? How could we improve them?
  
• How robust are they in an ever-changing
  environment?
• Can we precisely identify our defenses, the
  procedures?
• Do we perceive any gap between our planned and
  actual practices?
• Are we prone to defeating identified defenses?
• What are the root causes that we can map in our
  organization / in my personality ?

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Challenges

• Selection of cases to study
• Education of moderator / instructor
• Adherence of personnel confidence-based
  environment
• Address ALL actors, incl. Management
• Create a culture
• Time cost obvious, savings hidden

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Conclusion

• Close the loop proactive implementation
• Teaches about strengths and weaknesses
• A mindset
• Can be implemented in ANY organization, with no
  delay
• Investigating bodies are ready to help
• initiate the process

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Enhanced partnership