Canadian Helicopter Conference Safety & Quality Summit—March 18-20, 2013
Improving Helicopter Safety
Member, Transportation Safety Board of Canada
18 March, 2013
[Check against delivery]
Slide 1 – Title page
Slide 2 - Outline
Slide 3 – A challenging job …
Helicopter pilots have a very challenging job. They operate at low levels, near obstacles, and over challenging terrain. They deal with dynamic weather, and they work in conditions such as VFR and, often, in MVFR. And the type of work you do, and the helicopters' design, often place your aircraft near its power-and-performance limits.
Slide 4 — … In a growing industry
As one American aviation consultant noted recently, when it comes to manufacturing, the combined military and civil value of helicopters is just as big as business jets. According to the General Aviation Manufacturers Association, manufacturers delivered over 1000 helicopters in 2012—up 21 percent from 2011. Business jet makers, by comparison, delivered 3 percent fewer in 2012 than they did in 2011.
Slide 5 – Demographics/experience
Helicopter pilots who earn their commercial license graduate with a relatively low amount of experience. Many of them are operating in:
- remote bases
- austere situations
- self-dispatch regimes
- high-tempo operations
- non-routine / dynamic roles/tasks
There are also many low-time pilots with a narrow operational experience:
- VFR only, or
- very limited exposure to IFR or IMC.
Slide 6 – Canadian JHSAT
According to a report by the Canadian JHSAT, single-engine piston helicopters represent just 11 percent of the fleet, but a disproportionate 25 percent of accidents.
Slide 7 – EHEST
According to the European Helicopter Safety Team, in most accidents, pilots had limited flight experience on type—less than 1000 hours in a third of the cases.
And in just over a quarter of accidents, the pilot had less than 100 hours experience on the type involved in the accident.
Slide 8 – EHEST (continued)
When you break it down further, by type of operation, you can see that general aviation really stands out.
Slide 9 – Transportation Safety Board of Canada statistics
Now let's look at some statistics from the TSB, specifically, accidents involving aircraft governed by the Canadian Aviation Regulations, subparts 702, 703 and 704. Those are the parts governing aerial work, air taxis, and commuters, respectively.
"commercial aircraft" is a broad category, and no, it's not only helicopters. There are a lot of small turboprop or piston airplanes in there. Nonetheless, 702 and 703 covers most commercial helicopters in this country, so we can't ignore that fact. Medevacs, forestry work, law enforcement, and—as we here in the West are well aware—the oil and gas industry. Helicopters are crucial to these operations.
Slide 10 – Transportation Safety Board of Canada Watchlist
In 2012, the TSB released an updated version of its safety Watchlist, a document that identifies the issues posing the greatest risk to Canadians and Canada's transportation system. Four of the nine issues on the Watchlist are in aviation, and two of them correlate highly to 702s and 703s.
Slide 11 – CFIT (Controlled flight into terrain)
This is what happens when an otherwise sound aircraft, under pilot control, is unintentionally flown into the ground, a mountain, water, or an obstacle. Often pilots aren't aware that something's gone wrong until it's too late.
The key factors:
- Darkness, fog, snow and rain (can affect visibility).
- Fatigue or inexperience (can impair judgment).
- Checklists or conversations (may be distracting).
Slide 12 – Safety management and SMS
Good safety management is all about looking at what you do, looking at your practices, and looking for risks—in other words, hazard identification. And then it's about taking steps to deal with those hazards, proactively. Put another way, it's about finding trouble before trouble finds you.
But not everyone is required to have one.
Slide 13 – International Helicopter Safety Team
"Top 10" list
Another way to help reduce accidents can be found in the International Helicopter Safety Team's (IHST) very commendable
"Top 10" list of recommendations.
This list covers areas such as equipment, training, safety management and maintenance.
Slide 14 – The Way Ahead (Short to Medium Term)
Operators shouldn't wait for the regulators to say what the best practice is. Instead, operators need to get out ahead of regulation. Be proactive, and focus on the areas that are within operator control.
That's why the IHST's Top 10 list is an excellent idea, and today I'd like to look at four potentially high-return areas in particular.
Slide 15 – Install cockpit recording devices
Recorders are of tremendous value. Cost, however, has always been an issue—but today there are smaller, lighter, lower-cost options. Once you've got a recorder, you have access to objective, quantitative data—information that can provide a true picture of normal operations.
Now we're into the areas of quality management, and operational control and oversight. With data mining, the information can let operators know how close they're coming to the brink, as well as the severity of any problems, and whether those problems are internal or external. And the applications aren't limited solely to safety and efficiency. There is also the potential for improved aircraft maintenance, and for the training of personnel.
It's not mandatory, but it is a good idea—because the big payback to installing recording devices comes in assisting/improving oversight and operational risk assessment, and mitigation, within your organization.
But remember: if you're going to use it, your crews need to know that voice and video recordings in the cockpit will not be put to punitive use. Because under the act that governs the TSB, all voice and video recordings are sacred. They're protected by law and cannot be released or distributed outside the TSB—and definitely not to discipline or prosecute individuals, regardless of whether there was an accident.
Slide 16 – Training
There are two key types of training:
- critical-issues training
- performance and limitation training
Slide 17 – Drayton Valley (A11W0152)
In October 2011, the Bell 206B was on a VFR flight from Whitecourt, AB, to Drayton Valley Industrial Airport, AB. The flight encountered and continued into instrument meteorological conditions. While attempting to descend though cloud, the aircraft collided with terrain during daylight hours, fatally injuring the pilot.
Findings from the report:
"The pilot continued the visual flight rules flight into weather conditions that required descent through cloud to reach destination."
"The pilot did not arrest the rate of descent, resulting in a collision with terrain in which the impact forces were not survivable."
Since the accident: Company pilots have all received human-factors training and pilot decision-making training.
Slide 18 – Elk Lake, ON (A10O0145)
A Bell 206B departed North Bay for a VFR flight to Kapuskasing, ON. The pilot was repositioning the helicopter for sightseeing flights planned at a local festival the next day. Another company pilot was a passenger. During the flight, poor weather conditions were encountered and the helicopter collided with an unmarked 79-foot tower. The helicopter then struck the ground and was destroyed, fatally injuring both occupants.
Findings from the report:
"The pilot did not adequately review the weather for the intended route prior to departure from North Bay. In addition, the flight service specialist did not offer a weather briefing as per the Manual of Operations. As a result, the pilot was not aware that poor or deteriorating weather conditions existed."
"Due to the deteriorating weather conditions, the pilot flew the helicopter at a low altitude. Reduced visibility likely obscured the tower and reduced the available reaction time the pilot had to avoid the tower."
"Because the tower was not depicted on the VNC or GPS, the pilot was not likely aware that it existed."
Since the accident:
In 2011, NAV CANADA published an Aeronautical Information Circular telling pilots to provide a margin for ground and obstacle clearance and for altimeter error.
Slide 19 – Slave Lake (A11W0070)
A Bell 212 was conducting water-bucketing operations in support of forest fire suppression services in the vicinity of Slave Lake, AB. In mid-afternoon, during an approach to pick up water, the helicopter crashed into the lake, sustaining major damage and fatally injuring the pilot.
Findings from the report:
"The pilot likely overestimated the helicopter's altitude while on final approach, due to glassy water conditions and a lack of visual references … ."
"Inconsistencies in recorded flight hours were noted in the pilot's external load experience."
Slide 20 – Safety management
Slide 21 — Lillooet (A09P0249)
Summary: A Bell 212 was engaged in firefighting just south of Lillooet, British Columbia. Approaching the Fraser River to pick up water, the helicopter descended unexpectedly, and its water bucket touched down in a fast flowing section of the river. The helicopter continued forward, dragging the water bucket, and then pitched nose-down, striking the surface. The pilot escaped the wreckage but drowned in the fast-flowing water.
Experience was not an issue: The pilot had roughly 10 000 flight hours total time on helicopters—1200 hours on type. He had 3300 hours carrying out forest fire water-bucketing. He also wore a helmet and was a good swimmer. But some risks still went unidentified, and the pilot was not wearing a personal flotation device.
- Risk: The helicopter's manual emergency release for an external load requires the pilot to remove one foot from the anti-torque control pedals. As a result, there is an increased risk of loss of anti-torque control at a critical time of flight.
- Risk: Operations in deep canyons may be subject to turbulent airflow and winds that rapidly flip from one direction to the opposite. Without adequate warning, helicopter pilots may be placed at risk.
Since the accident: Immediately afterward, the helicopter operator instituted policies requiring pilots to fly with the belly hook armed and to wear personal flotation devices (PFDs) when water bucketing.
This is a good case of an SMS in action. The initial risks—drowning and working the manual release during a critical time—were not identified in advance. However, after the accident, they were acknowledged and corrective action was taken to prevent them from happening again.
Slide 22 — Conclusions
Slide 23: Canada wordmark
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