During the last seven years' painstaking study of helicopter accident reports by the relatively newly-formed International Helicopter Safety Team (IHST), it has become clear that one of the reasons for the rotary wing's consistently poor safety performance globally is that accident investigators have not taken the sector seriously.
The result of this lack of diligence is that, until the IHST was set up in 2005, relatively little detailed knowledge about the nature of helicopter accidents had been accumulated, and what little did exist had not been analysed or shared.
It was to address problems like these that the IHST was formed, with the aim of reducing global helicopter accident rates by 80% by 1 January 2016. According to figures so far, that level of performance improvement is far from guaranteed (see graphs), because although there appears to be a reduction in accident rates over the last few years, after decades of stasis improvement rates are slow - and are not guaranteed to be sustained.
On the optimistic side, however, it took the IHST some years to assemble and analyse the factual database from which they could determine effective "intervention strategies", and these have only been gradually released over the last four years or so. On that basis, the IHST may, by now, have built up a critical mass of knowledge-based "potential energy" which, as it is released, could cause an acceleration of the sector's safety performance improvement. That is, in fact, the objective of the exercise.
The US Joint Helicopter Safety Analysis Team (JHSAT) explains the situation in its recently published Compendium report, which states: "The JHSAT modified the original CAST [Commercial Aviation Safety Team] process to better account for helicopter accident data, which is considerably less detailed than commercial accident data.
"In helicopter accidents, there is often lack of recorded data from the helicopters and lack of in-depth government investigation of the accidents. The [JHSAT] report addresses these data deficits and makes recommendations to address them. IHST representatives have met with the US National Transportation Safety Board on multiple occasions to suggest methodologies for improving helicopter accident investigations."
The Compendium report, according to JHSAT, "Reprioritises and restates the findings of the three previous JHSAT reports by combining the data into a single data set. This combined data set establishes the baseline of US helicopter accidents for future IHST efforts."
More than 520 US helicopter accidents from 2000, 2001 and 2006 have been analysed so far, to derive recommendations and intervention strategies. When each individual year's conclusions have been extracted, the lessons have been remarkably consistent across all of them.
It is reasonable to suppose that, as accidents in more calendar years are analysed, existing strategies are more likely to be reinforced than significantly modified. One of the most emphatic revelations throughout the analyses is that helicopters don't usually cause crashes, people do. This is consistent globally.
When the IHST was seeking to ensure the common application of accident factor analysis, one of its agreed categories was the "standard problem statement" (SPS) - what went wrong?
The correlation between the conclusions in the JHSAT and EHSAT (European Helicopter Safety Analysis Team) studies is remarkable, but this had been predicted by analysts.
Both early studies found "pilot judgement and actions" was the top single causal factor in helicopter accidents, being present in 68% of the European events and 77% of those in the USA.
The JHSAT's latest figures, however, push the "pilot judgement and actions" SPS quota up to 84%, which certainly sends a message about training, safety management and mission risk assessment. Mechanical failure, unless as the result of inadequate maintenance, is well down the list of causal factors.
Training and instruction top the list of "level one intervention recommendations" (IR), insufficient training being a factor in 79% of all the accidents JHSAT studied. "Data/information" came second at 76%, and "safety management" third at 64%.
There is then a big drop to number four, "systems and equipment" (37%), followed by maintenance (23%), regulatory (18%) and finally infrastructure (9%).
At the "level two" IRs, each of those categories is analysed in much more detail, specifying exactly what kind of training, information or process was lacking in any given accident.
Particularly instructive is the JHSAT's top 20 intervention recommendations (see box). The top one is a call for the installation of cockpit recording devices - on the grounds that if they had them, data about incidents and accidents would be available immediately (see box).
One of the main problems the JHST faces is getting the message to the operators. Across the world, more than 80% of helicopter operators are small businesses, with four aircraft or fewer.
They are tightly resourced operations in a highly competitive, price-conscious marketplace that has been badly hit by the present economic climate. They do not go to safety conferences - they don't have the time. They don't run safety management systems, and without help would not know how to resource one, or run it.
They comply with regulations, but only to meet the legal minimums. Most work hard to be safe, but they do that by using - effectively - gut feeling, rather than data or analysis, and by using their existing knowledge, rather than acquiring new information.
The Netherlands-based Shell Aviation senior executive Bob Sheffield, who works with the IHST, says that to reach the small operators: "We'll need strong support from regulators and manufacturers. I'm not talking about new rules, I'm talking about the regulators and the manufacturers using their connections with license holders to promote the IHST's recommendations," he said. "The European Aviation Safety Agency's high-level commitment [part of the European Strategic Safety Initiative] is exemplary."
Above all else, the IHST wants to reach out to these small operators to provide them with the help they need, for free. If the team succeeds in reaching them it will transform rotary wing safety, because the target for accident rate reduction is 80% in just over four years' time - compared with 2005, and they represent 80% of the industry.
Finally, the International Helicopter Safety Seminar, this year being held in Fort Worth, Texas, is taking training as its theme.
Shell's Sheffield explains: "IHST will focus on the training sector, which has the highest accident rate and establishes the initial attitudes of all new pilots toward safety." US JHSAT RECOMMENDATIONS FOR HELICOPTER SAFETY IMPROVEMENT
The US Joint Helicopter Safety Analysis Team (JHSAT) has made a number of detailed recommendations to improve rotary wing management, engineering practice, operations management and crew training. There is room here for only a few, selected from the organisation's top twenty:
- Install cockpit recording devices. Develop and install flight data monitoring equipment to record the actions of the crew. Data can be used as immediate feedback to trainers, operators and flight crews and in the event of an accident investigation.
- Improve quality and depth of US National Transportation Safety Board (NTSB) investigation and reporting. Many accidents do not receive in-depth investigation by the NTSB. Investigations are being performed by telephone interview, or by personnel whose primary function is not accident investigation. Increase the degree of human factor investigations, to include detailed personnel information and an assessment of operator oversight.
- Autorotation training programme. Improve autorotation training in both primary and advanced flight training, and develop simulator programs to improve autorotation skills.
- Confirm engineering compliance. Ensure that maintainers and operators are aware of the importance of following the manufacturer's manuals.
- Simulator training for advanced manoeuvres. Incorporate simulator training in dynamic rollover, emergency procedures training, ground resonance, quick stop manoeuvres, targeting approach procedures and practice in pinnacle approaches and elevated platforms
- Personal risk management programme. Encourage the implementation and use of a personal pre-flight risk management programme.
- Training emphasis for maintaining awareness of cues critical to safe flight, such as the effects of impending weather concerns, the effects of density altitude, and wind and surface conditions.