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November 2011 Archives

VIDEO: How not to do risk assessment for a helicopter job

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This video demonstrates why helicopters have a high accident rate relative to fixed wing.

 

The pilot clearly didn't anticipate this outcome. Fortunately he survived it, and so did the people nearby, who could also have been killed by high velocity debris.

Let's examine the decisionmaking processes that preceded this event.

Look at the space in which the helicopter was operating. Making a sound decision about whether or not to operate there entails understanding the principles of risk management, but most pilots are not trained in it.

Neither, by and large, are the decisionmakers who run small helicopter operations.

Relatively recently, some fixed wing pilots on MPL (multi-crew pilot licence) courses have begun to be taught threat-and-error-management as a part of their training, but that is not widespread.

A mission risk level can be calculated by multiplying the level of risk (on a 1 to 5 scale) by the seriousness of the potential outcome if the worst happens.

In this case the risk of hitting an obstacle was at least 4 but probably 5, and the outcome from hitting it (total loss of helicopter, high risk of death or injury to pilot and people on the scene) is definitely 5.

25 is a big number on this scale, so don't do it. The job can be achieved by some other means.

I have just come back from the International Helicopter Safety Seminar at Fort Worth, and I reported as follows in Flight International: "The top global industry problems, according to International Helicopter Safety Team data analysis, are the lack of a risk management culture at operator level, and poor pilot judgement when an accident situation develops."

So what we have just witnessed is not a one-off, it's endemic.

The Flight International report continues: "Analysis reveals that the top solution to poor helicopter operator safety performance is the adoption of low-cost flight data monitoring (FDM) systems, coupled with training tailored to correct the problems revealed by the FDM." So when pilots make bad decisions but get away with it, you know, and can do something about it.

"Having developed this analysis, the IHST's top problem, according to FAA IHST representative Sue Gardner, is how to get these messages out to the small operators which represent more than 80% of the industry."

The poisoned chalice presented to Cranfield University

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Back in 2008, in a Comment article in Flight International, we discussed a research task that Cranfield University had been given. I quote:

"Commissioned by the UK Department for Transport, Cranfield University is carrying out scientific tests to establish what contaminants are occasionally released into airline cabins in the engine bleed air feed to the air conditioning system.

"The purpose is to establish...what the contaminants are. It is not Cranfield's job to test what effects these have on crew and passengers. That is being done elsewhere.

"The DfT has a duty beyond that of Cranfield's very able scientists. It has to look at all the other evidence that has been gathered from multiple sources over decades, and it has manifestly not been doing this.

"Cranfield's resources are limited. They have five aeroplanes on which to carry out tests, and only 20 trips each. If they get no contamination events, or only low intensity ones, what then? Will they be able to project credible conclusions on this evidence alone?"

End of quote.

That job Cranfield took on was the figurative poisoned chalice. I used those words to the late Dr Helen Muir when I heard she had been tasked with leading the Cranfield team who were to carry out the tests. We were at a Flight Safety Foundation seminar where she was being presented with an award for her groundbreaking cabin safety research.

Muir was a Cranfield academic for whom I have huge respect, and I am among thousands in the aerospace world who share admiration for her work. She died well before publication of these test results. 

The report's conclusions were uncharacteristically weasel-worded. In fact they were not conclusions at all. Not according to the dictionary definition of that word anyway. You will see in a moment what I mean.

Now a Cranfield University professor, head of the University's nanotechnology department, has taken up the baton.

On 11 September, on Cranfield's campus, Prof Jeremy Ramsden chaired an international, multidisciplinary workshop backed by Swiss independent research organisation Collegium Basilea. The subject was Inhalable Toxic Chemicals in Aircraft Cabin Air.

This is what he had to say about Cranfield's work for the DfT: "This report actually found significant concentrations of organophosphate neurotoxins and other noxious substances in cabin air even under normal flying conditions.

"Unfortunately," said Ramsden, "the final conclusion of the report is the statement: 'With respect to the conditions of flight that were experienced during the study, there was no evidence for target pollutants occurring in the cabin at levels exceeding available health and safety standards and guidelines.'

"The first phrase underlines the fact that the study failed to achieve measurement of a 'fume event', even though that was one of its principal objectives. Even for 'normal flying conditions' the purported conclusion is irrelevant because no standards are available for some of the most problematical substances. Nevertheless, despite the fact that this 'conclusion' is neither sound nor justified by the actual work carried out, it has been carelessly and uncritically quoted, including by the UK Minister for Transport Theresa Villiers, and widely used to infer that there is no safety and health problem."

Ramsden also said what he thought should be done about this situation. He added:

"The mandatory inclusion of a health warning on air tickets, as on cigarette packets, would seem to be the alternative in the face of technical inaction."

If you want to find out more, enter the word "toxic" or "cabin air contamination" in the search box for this blog and you will find plenty more material.