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When is Training for Safety Not Enough?

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When is Training for Safety Not Enough?

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Old 14th Mar 2006, 06:03
  #21 (permalink)  
 
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Last month's rotor and wing had an interesting article on this topic, written by Shell Aircraft.

Web version without the pictures/diagrams is here: http://www.aviationtoday.com/cgi/rw/...6&file=771.htm
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Old 14th Mar 2006, 08:32
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RJS you said - "How does the North Sea and GOM safety stats compare."
In spite of the attitude of North Sea pilots and crews for GOM'ers, and ignoring the fact that only 50 separate exams prevent Superman from getting a British pilot's license, and also understanding that cheap American operators employ poor instructors who can't even momorize Morse Code, the dolts!
The GOM has HALF the accident rate of the North Sea.


The truth is that statistics can be made to suit any purpose. The hours flown by offshore helos are statistically small and ANY accident can skew figures disproportionately. They are also highly reliant on the accident data collection being based on the same criteria worldwide - which they aren't.... an "accident" in one area may not even be considered an "incident" elsewhere. OGP (and Bob Williams in particular) do a great job in tracking accident rates and collectively trying to improve safety levels but it has to be remembered that the data gathering is not exactly like for like. To respond to your particular quote regarding the UK; the UK is not specifically covered by the OGP report, it is included as part of the "North Sea, thus an accident in the UK, Dutch, Danish or Norwegian sectors will be reflected in the N sea as a whole and not necessarily reflect the rate of an individual country. For the record, the ONLY (touch wood as ever) fatal offshore accident in the UK sector since 1992 was the one caused by an in-flight rotor blade failure on anS76 in July 2002.

I do not see any benefit in a X-Atlantic peeing contest when it comes to discussing safety but believe the impression your post gives should be put into better perspective.
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Old 14th Mar 2006, 11:20
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Get a file damaged message when trying to access Nick's presentation.

Is this just me ?
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Old 14th Mar 2006, 13:56
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RJS,

We may have half the accident rate but by gum we kill a lot more than they do. Are we just that more effiecient at what we do?

This link will take you to a very good discussion of issues germane to this thread.

RJS will find it interesting reading as it notes the UK leading role in promoting offshore safety improvements to aircraft, training, and procedures.

http://www.rigzone.com/news/insight/...opter_risk.pdf

Acutally, Superman would have to use a taxi in the UK considering his known medical deficiency regard Kryptonite.

Last edited by SASless; 14th Mar 2006 at 14:06.
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Old 14th Mar 2006, 16:00
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delta 3
Get a file damaged message when trying to access Nick's presentation.

Is this just me ?
yes, it's just you
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Old 15th Mar 2006, 01:48
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SASless,
According to the data, the GOM flys more hours than the rest of the earth combined, and more than twice as much as the North Sea.
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Old 15th Mar 2006, 02:01
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Nick,

I guess there is two more deaths to add to the tally if the reports out of Patterson are correct.
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Old 15th Mar 2006, 02:28
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Hello from Albuquerque:
Mr. Lappos, while I agree with your presentation about technology solving a number of our problems offshore, I do not think it will work in the EMS game. This is mainly due to most oil platforms don’t move. As an EMS pilot, I have never been to the same road intersection twice when responding to a wreck.
The very first thing is what the aircraft and crew is asked to do. Generally, we give a patient a fast ride to a hospital. Very little real medicine is practiced while in flight. A medical crew doesn’t want to do a number of procedures in flight. They try to stabilize the patient prior to transport unless there’s nothing left to do at their skill level but go.
So if the crew isn’t doing much beyond administering drugs, providing oxygen, monitoring vital signs and so forth, why do we need a large, twin engined helicopter? Three days ago, I flew to a multi casualty scene in our Astar. Another flight program responded as well in their Agusta 109E. Both aircraft and crew did the same thing – fast ride to the hospital. Both programs are VFR along with most EMS programs in the U.S. I have seen the cockpit of this aircraft - fully equipped for single pilot IFR. I’m guessing, but the Agusta probably cost a couple million more than the Astar – to do the same flight. This is why there are a lot of single engined EMS aircraft in the market.
What I see as the downside to single engined machines is the reduced potential for adding things like a simple auto-pilot. I’d like to think that everything that goes into a smaller machine is scaled down, but that’s not the case. To my knowledge, the Eurocopter auto-pilot for an Astar weighs maybe 70-80 pounds. Sure it could be installed, but then we’d be down to an hours worth of fuel and have the ability to carry a 180 lb patient. That won’t work here in New Mexico.
So what we need on the aircraft end is a cheap to buy and operate, single engined machine, with enough useful load for us to be able to do a reasonable distance, large patient, cabin with a little elbow room and still have the ability to add those things which are near and dear to us – auto-pilot, EGPW, enhanced vision equipment, etc.
This brings me to your IFR low level routes and point in space approaches. If I leave ABQ (5230’) headed east, before I get 10 miles, I need about a 12-14K MSA to clear the mountains. Presently, when we get over there, there’s no approach to shoot. So we take the time and money to have our own built and in the process buy the big twin with all the equipment needed to shoot a point in space approach to auto-hover. Say we have a certified (how much does this cost?) approach to every 10 mile square box over there, well, that’s a lot of approaches and a lot of money. We do it anyway. So far so good.
Here’s the bottom line, the part that kills the most of us. Sooner or later a crew will go IFR over there, shoot the approach, break out at 200’ and when they do, they get a radio call that goes something like this: “Heroflight 1, what’s your ETE. The patient is still being extricated.”(And a bunch of medical stuff which prompts you and the med crew to believe you need to be there instead of where you are) So there you are at the end of your point in space approach and the wreck is 7 miles up some gravel road surrounded by forest. Are you going to wait at your breakout point, which in all probability will alienate the local EMS provider (because you do fly a helicopter which can land anywhere, right?), or you going to go up the road VFR?
You don’t know what the obstacles are along this road because you only half way trust the database installed with all the other fancy equipment, so you have to do this part visually, unlike the surveyed approach you just shot. If you re-enter the clouds, you’re not doing the patient much good because now you have to climb up and re-shoot the original approach. You do this a few times with some of these local EMS providers and they’ll soon realize it’s just as quick to go by ground than to delay the transport waiting for you.
So what do you do? If you go up the road like the A109 crew did in northern California a few years ago after an IFR approach to the nearest airport, you drive it into the side of a hill and die. No, they didn’t have all the additional equipment you refer to, but they went over there IFR and decided to continue VFR into IMC conditions. This is the decision whereby we kill ourselves.
The point here is if a helicopter goes to an airport for anything other than fuel, you might as well send an airplane. Same goes for sending a helicopter to someplace far away from where it needs to be. Unless you can make up these approaches to literally any point in space, on the fly, with guaranteed obstacle clearance and aircraft performance margins, it won’t work doing EMS scene responses. Would the FAA sign off on this even if it were possible? I don’t think so considering how long it took them to let us use NVGs. EMS flight programs are already doing point in space approaches to hospitals and the like with technology present today. What would be the incentive for an operator to buy into all this new stuff?
As an aside, the regulations are also far behind even today’s technology. I can MEL our radar altimeter and launch out on the darkest night, WITHOUT NVGs, but I have to have it if I fly aided, even though I can now see the terrain. Make any sense to you?
I’m all for embracing technology that will make my job safer and easier, but until there’s a piece of equipment I can strap on my head or a turreted ball under the nose that allows me to see at night and in clouds like I was flying VFR in some semblance of VMC, we need to raise our weather minimums, get the medical crews more involved in the decision to go or stay home and just say no more often to requests for service.
Ron Powell
PHI Air Medical Services
Albuquerque NM
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Old 15th Mar 2006, 11:47
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ron-powell

Had a look at your epistle and thought, well could I describe to you in fifteen thousand words how to muster a mob of recalcitrant cattle all operating in diametric opposition. Just in time I saw your own answer which was -- say no --- every now and then.

Re safety
To improve safety by upping the aircraft capability has got to be a sound idea and eventually driven by market forces as people digest the Jed Hart stories. There will be a cheap end of the market but economies of scale will pressure them and so will legislation if they get too reckless.

Hands on standards can always be good if the following logic is followed.

“Practised dexterity in areas of emergency probability should lead to accomplishment in the areas of improbability.”

That will be consolidated by routine hands on ops. If we train pilots to get them demonstrate acceptable recovery from a fair cross sample of “situations” in the way that they often get presented for your operation / aircraft, then by dent of his training he should give it a good shot if he has a problem just a bit different.

Ag and mapping operators already work the same sat nav systems that Nick refers to with very close tolerances, mostly with hands on, although their ground borne cousins in farm machinery do it now, hands off all day long and down to Millimetres tolerance.

Going further down the automated system, how do those that fly less hands-on keep their dexterity to a good standard to provide for emergencies when they might arise? Extra training costs heaps and limits duty hours.
This is the question or do we just assume fewer emergencies, better machinery.

I could illustrate the point by referring to the RPT pilot about 25 years ago who put down on a deserted glider field with total silence. Sure he was lucky he had local knowledge of the strip and, he had the practiced dexterity of a glider pilot.
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Old 15th Mar 2006, 12:53
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TopEnd,

How many "real" emergencies" does one experience in a flying career?

What is the difference between an "emergency" and a "abnormal situation"?

Do we spend way too much time training for what are not the emergencies that kill us.....and do not train for those emergencies that do kill us with great frequency?

Is the conventional wisdom of the current training mentality and Regulations demanding that training actually part of the problem?

I would suggest we place our emphasis upon the wrong topics and over emphaisize the wrong topics in most of our training today.
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Old 15th Mar 2006, 17:46
  #31 (permalink)  
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topendtorque,
To SASless' point, I suggest that a real emergency exists about 1 second before ground impact on a CFIT accident at about 10 times the frequency of the "emergencies" that you practice when you THINK you are preparing yourself for your job.

As pilots, we are all guilty of passing around the cups of bathwater when we practice all the emergencies that dont get us, while we prance around avoiding all those that do.

The same bathwater we sip when we ask for hard Cat A helicopters so that we can be more safe, while zero point zero percent of twin accidents are caused by inadequate Cat A performance! The same bathwater we drink when we practice stuck pedal "tail rotor emergencies" while 40% of all helo accidents occur when we take perfectly healthy, tip=top condition helos and hand fly them into the dirt.
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Old 15th Mar 2006, 19:45
  #32 (permalink)  
 
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Commercial system available

Here is a link that relates to the discussion. Several months ago I spoke to the customer rep and still awaiting a cost comparison between Garmin systems and this equipment.

http://www.cheltonflightsystems.com/...elicopter.html
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Old 15th Mar 2006, 20:00
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I can MEL our radar altimeter and launch out on the darkest night, WITHOUT NVGs, but I have to have it if I fly aided, even though I can now see the terrain. Make any sense to you?
So, get the MEL changed. If it's going to make things safer, whose going to object? No point in saying after the accident "I knew that would happen one day, if we flew without a radalt"
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Old 15th Mar 2006, 21:51
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>So, get the MEL changed. If it's going to make things safer, whose going to >object? No point in saying after the accident "I knew that would happen one >day, if we flew without a radalt"

We've had NVGs since 04/04 and this is one of the first things we found, regulatory-wise, that needed attention. No go.

We have been able to change a few things and possibly the idea behind not changing this Radalt requirement is that we do have two sets of goggles per aircraft. If we send one set off for re-calibration, the pilot uses the remaining set. We can also fly from "known" point to known point, i.e. hospital to airport, etc. with a single set. No scene flights though, until the other set comes back.

As to the point of illustration, it's my belief regulations are lagging far behind new technology on the market today, not just a typical learning curve.

Ron Powell
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Old 16th Mar 2006, 01:25
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Yes, but surely you don't need a change in the regs to make the MEL more restrictive, if that's what you want for your organisation?
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Old 16th Mar 2006, 02:37
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Nick,
Where does the helo DGPS approach stand at the moment re commercial availability. Still hoops to jump through?
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Old 16th Mar 2006, 20:37
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"The British Airline Pilots Association (BALPA) recently and officially voiced concern that "Airline pilots increasingly lack 'basic flying skills' and may be unable to cope with an inflight emergency such as sudden mechanical failure." The union warns that pilots are becoming too reliant on automated systems and are not being encouraged or trained to fly manually"

Interesting article about Airline pilots becoming to reliant on automation.


Full article here: http://www.aviationnow.com/avnow/new...glass_0206.xml
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Old 17th Mar 2006, 04:07
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Nick, what a great presentation. The accident statistics you use support your arguement, and I find that both your arguement and the statistics are entirely consistent with modern error management theory:
Identify the problem.
Identify the systemic failures that led or contributed to the problem.
Engineer out the failure points identified. (Nick's arguement)
If you cannot engineer it out: provide significant warning or awareness signs for the impending hazard.
If you cannot adequately warn people, train them how to cope with the situation.
If training cannot adequately protect them, don't do it.

In otherwords, training around the problem is the poorest of the fixes available. I have had it related thus:
Problem: workers injured falling down slippery stairs on way to basement.
Most effective fix: identify and stop source of slippery-ness, coat in non-skid surface, and provide banister.
Less Effective: ensure stairs brightly lit. Paint top of each riser with yellow stripe, provide warning sign at top and bottom of stairs.
Least effective: give people practice at walking on slippery stairs, teach them how to effectively break a fall.
Remaining alternatives: relocate basement stores to same level, or build lifts (ie do not do task).

ron-powell: I am pleased that you have mentioned NVG. Why did you not feel that it was a CFIT defence Nick? Or was it just less significant than a 24 hour defence such as EGWPS?

Also ron, the reason you can fly unaided at night without the rad-alt, yet not with NVG is the rule V technology development conundrum. With the introduction of NVG into civil helicopter operations coming some 70 years after night flying was attempted, there was a much greater knowledge base to work off when dreaming up the rules. Rad-alts are also a CFIT defence device, albeit an early one that fits into the less effective warning area of failure management. Thus they were incorporated into the NVG requirement as a CFIT defensive aid. Had night unaided ops been dreamt of after the invent of the rad-alt you can bet your bottom dollar they would not be an optional item for night unaided. Though I think that in both unaided and NVG, they should be on the MEL.

The question is then, given that we now have the knowledge of the rad-alt technology and it's defence against our industry's biggest killer (CFIT), why do we have to wait for our mama (FAA/CAA/CASA/etc) to tell us it is a smart requirement? Can we not make these reasoned restrictions without having to be told? Or more importantly, can we responsibly have items like that MEL unserviceable without stretching the intent of the MEL to get us home? Are we that responsible yet? Or must our mama make it black and white no-go to ensure we do not abuse her trust?
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Old 17th Mar 2006, 05:33
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Having had the good fortune to experience both sides of the public transport coin I can say with personal experience that the gulf between commercial fixed-wing and rotary is as wide as the one outside Mexico. The the major differences can be catagorised as:
Operational (SOP's as 212man says),
Enviromental (the chance of an Airbus 340 being dispatched to a remote location to pick up a RTA victim is small) and
Equipment (yet to see EGPWS in a helicopter - I wait to be corrected).
On the operational side, rotary tend to have challange and response checklists which are really cumbersome and frequently misused as a result to the low stimulus as suggested above many times. In the FW world the SOP is a script, you learn your 'role' in the crew and while it takes time to absorb, it is a wonderful thing to watch when the pilot-non-flying can anticipate the next move by the pilot-flying. As a result the airbourne checklist in the Airbus has about 10 items between two checks, and the Boeing has none, at the moment the longest leg flown commercially is SIA from SIN to EWR for approximately 18 hours, thats not many checks per hour. I know that there is still a large community of single pilots out there, but strong SOP's work even for that enviroment. SOP's are written for all aspects of NORMAL operations VFR/IFR, Precision Approaches, Non-Precision Approaches.
Enviromental differences are hinted in the intro, FW go into 3000 meters of tarmac with an approach aid at one end and the surrounding countryside has been surveyed to the nth degree, it still does not prevent FW's picking up trees or worse, but at least an approach into Nairobi in 2006 is very similar in geographical terms to one made in 1954. FW do however have much more dynamic situations to deal with, they cover huge territiory and can depart from a flat Sea Level field with an OAT of +40C and arrive at a 6800' elevation field where the IAS/TAS split on landing is 30kts. The rotary world will always have the problem of 'doing what a helicopter does' they are masters of the offshore shuttle and getting an injured soul into the hospital inside the 'golden hour'. There is however a lot more that can be done to improve the IFR and more critically the IFR/VFR transition phases. I believe it is this transition phase which causes the most near death experiences - reported or unreported. FW know what they will see on an approach, All Weather Operations (Cat II or less) are really set into the stimulus/response bracket. The pilots are sensitive to very specific actions on very specific stimuli (AP self disengage below 1000' - Go-Around, call "Go-Around Flap" PNF response - "Flap 3" etc, etc).
The equipment in modern Boeings and Airbus are something to behold. I have seen some of the attempts made by RW constructors to create meaningful EFIS and a FULLY intergrated flightdeck, truly they are 20 years behind. I really wonder how much true Human Factors research has been made into instrument presentation on RW flightdecks - rather than the personal foibles of a small group of people who design the layouts. There is a guy called Edward Tufte who writes some very insightful books on this very subject. In my opinion, the RW EFIS attempts are cluttered with superfluous ticks and dots, strange combinations of digital and analog (very good if done well) and a distinct lack of being able to give the best visual information in the most intuitive way. Having things like EGPWS and TCAS gives the FW world such a wonderful outlook onto the current aircraft situation and most importantly - what will happen in the next few minutes. The flightdeck is intergrated - no tuning of navaids, unless you really desperately want to, you only get the information you need and the result is being able to see the wood for the trees.
I am very pleased that I have been given the benefit of having experienced both operations, it has made me admire both strands of aviation that much more, but the RW world desperately needs to catchup.

edited for dire spelling as a result of nasty cold caught doing Ultra Longhaul!

Last edited by Thridle Op Des; 17th Mar 2006 at 10:00.
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Old 17th Mar 2006, 05:58
  #40 (permalink)  
 
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TOD,
very well said

One correction: EGPWS is standard on the S-92 and optional on the 76.

I fully agree with your comments on checklists and it really irks me the way many RW checklists have gone down the route of becoming a step by step guide to operating. The step by step guideshould be done on the ground in the expanded SOPs, and the checklist should just be used to confirm the most critical items ('killer items' as NASA have referred to them)

One area where the FW world operators have an advantage in that respect is the normally excellent FCOMs the manufacturers produce. Sadly the RW manuals are less well produced.

I agree about RW EFIS and integration of systems, but would say that ECF are on track, helped no doubt by their being part of EADs (owns Airbus too). To introduce a new a/c with an FMS that has an inactive fuel page, due to there being no fuel flo input, seems symptomatic of that lack of integration.
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