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When is Training for Safety Not Enough?

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Old 12th Mar 2006, 02:44
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When is Training for Safety Not Enough?

In the interest of following up on some points made in the S-76 CFIT thread, here is a presentation given at the latest OGP Safety Committee meeting at Heli-Expo:

http://webpages.charter.net/nlappos/...gyofSafety.pdf

Comments, discussions and disagreements are cheerfully solicited!
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Old 12th Mar 2006, 03:24
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Where is the resistance?

Nick,

What are the major reasons no one goes forward with your recommendations? It seems they address many issues that the NTSB has highlighted with helicopter accidents in the last 10 years.

Correct me if I am wrong, but I dont think there is a collective corporate voice (entity) to move change forward. Inpart why change the way things have been operating (acceptable loss).

Pilots are too disorganized to force change (despite unions), common bond is we are not fixed wing drivers and sadly it seems to end there. Imagine a "brown flu" day in the GOM where the pilots did not show.

Manufactures do not seem to take the lead, Bell 206,407,427,430. Break the mold! I do like Bells over ECs (personal opinion). Do you think it could be return on investment?

Government RED TAPE....can't imagine this being an issue, run it through Haliburton and it will done ASAP.
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Old 12th Mar 2006, 11:20
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Nick,

From your accident data two things jumped out at me....the number of Mid-Air collisions and the single engine vice multi-engine accidents caused by engine problems (failures).

An observation on the CFIT numbers....how many of those were 206's that caught in IIMC events and were not "controlled" flight crashes but were loss of control accidents?

The usual accident noted as impacting man-made structures are tail rotors being stuck into things or striking the deck edge on landing or takeoff.

If you think the Bob Suggs/Beaudreaux concept of offshore operations is going to change in our life times....you need to change your brand of morning tea. Cheap is good....and they have been doing it that way forever. As long as oil field workers and pilots are content to jump into a Jetranger and ride all over the Gulf of Mexico then nothing will change.

When your brothers in the FAA start cracking down on safety issues and the oil companies get over the "cost of doing business" attitude they have towards the loss of lives in helicopter crashes, all this might change but not before then.

The American Helicopter industry is giving the customer exactly what they want as it is.

Think about being the CEO of one of the Big Two helicopter operators in the Gulf of Mexico and know that each year you will lose at least one pilot if not more due to crashes. I don't care to consider being a CEO of a major EMS operator with their accident rate of the past few years.
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Old 12th Mar 2006, 12:45
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North Sea vs. GOM Safety

How does the North Sea and GOM safety stats compare.
Are there somes numbers, say accidents per flight hour we can use or accident per legs? I know the equipment varies, case in point several years ago a R-44 went down at night!
Off course with stats we can set the confidence intervals and prove both areas of operations are just as safe.
If there is a diffrence in accident rates perhaps we can uncover the root causes.
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Old 12th Mar 2006, 13:20
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ATPMBA asked a great question:
"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.
See page 26 of:
http://www.ogp.org.uk/pubs/300.pdf#search='ogp%20aviation%20safety%20statistics'
But, you seem to have missed the point almost entirely, I think. Lappos seems to be asking that we stop focussing purely on training and fix the operational and equipment things to get good safety.
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Old 12th Mar 2006, 14:06
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rjs,
Maybe you're the one missing the point; your xenophobic reply mentions one page of a 76 page report which is 10 years out of date and has nothing to do with licensing, training, operational equipment or instructors. Even if you look at pages 50 and 51 of the same report and take a more representative average over 5 years you'll see that the accident rates per 100K hours for the 2 are the same. The report makes no reference to training or licensing, nor to pilot experience. Let's just forget the overall accident rate including EMS and now show us some statistics if that's your bag, where better equipment results in less accidents. Let's have a meaningful discussion about the benefits of moving map GPS giving better spatial awareness, TCAS giving better awareness to other aircraft, getting a proper common worldwide EGPWS obstacle database and training pilots to use all of these relatively new, expensive aids, but not lose their basic skills when these fail or give false results.
The repoprt from which you quote serves only to highlight that there are lies, damn lies and statistics

Last edited by Mama Mangrove; 12th Mar 2006 at 14:18.
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Old 12th Mar 2006, 15:22
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In some parts of the world aircraft are already fairly well equipped but "pilot error" accidents still happen.
Flight Data Monitoring is widely seen as a potent tool for improving the safety record.
http://www.caa.co.uk/docs/100/G%20en...esentation.pdf
Question is: will operators and customers fork out the cash? At times it seems their learning curve could be steeper.
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Old 12th Mar 2006, 16:11
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Mama,
If you think safety "has nothing to do with licensing, training, operational equipment or instructors" you are a bit away from the mainstream, where most of us think it has a LOT to do with this. If you think that OGP data has "nothing to do with licensing, training, operational equipment or instructors" you are also wrong, because it is an excellent source of comparative data that shows that the silly government restrictions that add cost and burden to piloting in the UK adds NOTHING to the safety record.

The data is 10 years old because it is available, you go on to spout newer data that supports my basic contention that UK rules do NOT add one bit to safety, they just cause pain for UK pilots.

If you wish to compare EMS, go ahead. The US HAS an EMS system, that is perhaps why it has EMS accidents.
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Old 13th Mar 2006, 05:07
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RJS,

The OGP report you mentioned refers to a midair involving a BK117 and a 365N in Campeche.
Can you or anyone point me to the final report?
Where is TCAS when we need it?
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Old 13th Mar 2006, 06:51
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As a relative newcomer, it strikes me that on this and other forums, after accidents, some pilots will groan and comment on the negative publicity it will bring to the helicopter industry, notably with regards to EMS in the States.

Why not view the negative publicity as a benefit and take advantage of it? For example, wouldn't it make an appealing documentary to some eager producer, looking into the "filthy rich" oil companies, making billions of dollars per year who aren't prepared to spend a small amount of money to make flying so much safer and reduce fatalities and accidents by x%?

I would have thought a carefully crafted "scandal" would add impetus to the cause. Just a thought...
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Old 13th Mar 2006, 10:19
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141Q

you've been looking at the same 60 minutes program i see. yes mr richard could probably come up with the goods, just buy him a ticket to the land of the white long cloud or drop into his hand some sterling footage from the southern parts of that cloud with scenes showing R22's pulling 180 hp and more and skiting about it. yessir you're onto it.

seriously.

nick i enjoyed that presentation,
what are the accidents rates comparisons between the different main jurisdictions. we hear all about how up them selves these JAA regs are, does it mean anything in lawnspace? don't worry about NZ they have enough bad debt cred to blast us all out of the sky.
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Old 13th Mar 2006, 10:57
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safety comparison

well i'll be, might have answered half my own question. switched off enroute for the land of nod and checked the ABC news site rural report to find a report (below) from guru dude called rob rich???? mustering drivers must be worse than kiwis.
there you go!!!


Call for new remote chopper pilots to get more training

Monday, 13/03/2006

A helicopter safety expert has called for more training and education programs to help ensure new chopper pilots are well-equipped to work in remote areas.

Rob Rich from Aviation Safety in Brisbane says a booming beef industry has helped fuel a big rise in the number of choppers used on stations.

More than 1,300 civil helicopters now operate in Australia but Mr Rich says many experienced pilots have left the industry.

"Our accident rate unfortunately would be probably almost double the world average only because we graduate a brand new pilot who goes out into the bush to operate in a remote area in very, very difficult flying conditions, when in fact he is a long way from his supervisor in many cases," he said.

[It also] tends to be a problem in those areas where guys operate unsupervised for a long, long period of time."

The shortage of experienced pilots and engineers is also being felt in New South Wales.

Armidale pilot Lachie Onslow recently advertised a pilot's job and had six replies but all from New Zealand.

He says one of the major problems driving people away from the industry are high fees and taxes charged by the Civil Aviation Safety Authority.

"A lot of our experienced pilots are leaving the industry to go overseas to Canada or PNG to chase more work and more money," he said.

"We've got the Vietnam vets are now at retiring age and the industry is growing as there are more opportunities for people."
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Old 13th Mar 2006, 11:14
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topendtorque,

The rates around the world are relatively constant, as RJSquirrel has posted - his reference to the OGP presentation from 8 years ago is still the best single source (later years of the OGP data support the original conclusions, in less thorough format). This tends to say that there is little benefit to the vast difference between regulatory philosophies of US and Europe. Maybe most of the extra cost/work that pilots are put through in Europe is a way to keep the aeronautical system elitist - only those with enough money can fly. The US rate of flight and ownership is double that of the UK, which might prove that (inflammatory) point.

Here is the web site for that OGP data (provided above by squirrel), I looked at page 26 and it has comparative data from various regions:
http://www.ogp.org.uk/pubs/300.pdf#search='ogp%20aviation%20safety%20statisti cs'
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Old 13th Mar 2006, 14:10
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Why JARs beat FARs

There is a philosophical point worth making about the use of regulatory standards as the basis for your day-to-day flight ops. The average human performance will inevitably fluctuate on an hourly, daily, weekly or monthly basis. We are rarely consistent in anything we do. The problem with this is that if you fluctuate below the standard set by the regs the you are in the 'unacceptable zone'.

If you choose a higher standard as your reference then you will help to ensure that fluctuations in performance do not fall below the minimum (regulatory standard). Just so happens that JARs are a pre-existing and convenient set of standards for anyone disillusioned with FARs to use as a reference.

I honestly cannot believe that there are pilots out there who think that the GOM is a 'beacon of excellence'. You must be joking!!

In trying to find ways of reducing the accident rates we need a comprehensive armoury of tools. Regs are just one part but as Nick has highlighted, new equipment will help an lot.

In my recipe book for a better working environment for all helo ops I include:

1. Better Equipment
2. Higher reference standards
3. High quality sim training with LOFT (remember it's the people in the box, not the quality of the box that counts so when you go for a 'dry lease' of the sim be sure you are not just perpetuating the shortcomings you have already).
4. High standards of maintenance
5. CRM - and I don't just mean a troll through a library of old accidents but a real attempt to help us identify within ourselves those negative facets that reduce crew effectiveness. Same deal for maintainers.
6 Tie the whole thing together with a good Safety Management Systems. I know from practical experience that you cannot get an SMS past first base without having to get the senior (accountable) management to sign up to it. Not just lip service but really sign up to it. Get it past first base and the whole thing becomes a thing of beauty. Five years later you would not believe you were once back there, where you started - "were we really that bad? dumb? unsafe"? Try it - it works.
7. Get the infrastructure right. Whether it's radar, ADS-B or WAM - we need it. Whats good for the airlines is good for us - keep saying it.
8. With the industry demography pointing to a crisis in the years ahead we must see the younger generations receiving greater depth of training. Enough of this "10 hours IF will do" routine. If the guys don't have the experience then they must surely have a better foundation. Look at the military - they have young guys doing serious stuff with v. expensive equipment - the difference is they were not expected to do the job on the back of 150 hours gathered hither and thither doing VFR navexes.

Enough already

G
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Old 13th Mar 2006, 23:51
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We train for CFIT and accidents continue to happen; the pilots always get blamed.

A defintion of insanity could be :To repeatedly to the same task- over and over, again- and expect different results. That is what happens with CFIT, the aircraft are not improved and when a CFIT happens we are surprised.

I'm with Nick on this one I think the industry/governments have done all they can with the human side of the man machine interface. Its now time to improve the machine.

The Flight Safety Foundation website has tons of data showing how GPWS has improved airline safety. It's worth a visit.

P.S. : Excellent Presentation Nick
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Old 14th Mar 2006, 01:01
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isn't the military already working on most of those issues? fbw and rfid
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Old 14th Mar 2006, 02:28
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"To repeatedly to the same task- over and over, again- and expect different results"

I would have said we are expecting the same results, not different. The result is a safe take off and landing; anything else is not desired.

With the greatest of respect, Nick, I suspect that there is one key difference that may be skewing your perception of the problems. You have had a very diverse career with a range of demanding projects that have stretched your intellectual and cognitive skills. You have been part of a stimulating and interesting team working with cutting edge technology, and you have operated a/c up to and beyond their flight envelopes. In fact, you have defined their envelopes. No doubt, some aspects have been a little mundane (relatively) but probably not for protracted periods.

The average line pilot on offshore operations is carrying out a very repetative task with very little scope for stretching his brain. He may have little or no aspiration to extend himself beyond the minimum required to do the job and, indeed, there may be very little scope to achieve this even if he wanted. The same must be true of Airline Operations. Combine this with unsociable working hours and a potentially fatigueing roster, and there exists the potential for that classic condition caused by low arousal levels, TIBMIN: Thumb in bum, mind in neutral.

Whatever howls of protest that comment might provoke, it has to be acknowledged as a truth, and any offshore pilot who denies they have been in that condition at some point on a flight is probably being economical with the truth (or doesn't remember, because at the time they were TIBMIN!)

So, by all means introduce new technology; I'm a big fan of it as anyone who knows me can vouch. I want EGPWS, TCAS, 4 axis APs, EFIS, FMS. I want new IFR route structures and approach procedures. If you can warn me of wires or that my tail rotor is too close to the crane boom, that's great too. But,the overiding and dominant factor has to be the crew and the way they are trained and the way that training and assessment continues.

Strong SOPs, and crew discipline have to be in place combined with a company culture of expected standards. Do you have a crew that when the "minimums" EGPWS aural warning goes off responds with "200 ft, visual with the runway, landing" every time it goes off, even when its CAVOK and they have seen the runway miles away, or do you have a crew that selects a lower minimum setting, in contravention of SOPs, to avoid that irritating noise. Or that sets a radalt bug to zero to avoid that irritating orange light. Do the crew behave on the line in the same disciplined manner they do in a LOFT exercise, or is that all just for show and, hey, this is the real world. Do you have a crew that's happy to sit at 1850 ft rather than 2000 ft because the pilot can't be arsed to correct the error, and they are hot and tired and busy having a bitch and moan about the company management, or do you have a pilot who curses himself because he has lost 50 ft and corrects immediately? Standards, pride in personal standards and discipline are the corner stones of professional aviation.

However you wrap it up, if you lose 2000 ft and hit the ground/sea, without having noticed it, you are either incapacitated or TIBMIN. Full stop.
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Old 14th Mar 2006, 04:12
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212Man,

I think I know what you meant by your statement....

Strong SOPs, and crew discipline have to be in place combined with a company culture of expected standards. Do you have a crew that when the "minimums" EGPWS aural warning goes off responds with "200 ft, visual with the runway, landing" every time it goes off, even when its CAVOK and they have seen the runway miles away...
How Strong are the SOP's and how strict the crew discipline before you find yourself with a pair of Tibmin Robots at the helm?

At some point the expensive talking ballast up front may encounter something that does not fit nicely into the checklist and SOP's....then what?

What if the SOP or checklist does not work for all possiblities that might be encountered and thus set you up for a problem such as happened to the DC-10 at Chicago when one of the engines departed the wing on a CAVU day and the crew used the exact specified standard procedure for a single engine failure and Died. Or....like has happened in a 212 Sim at Forth Worth...when the Captain briefed the company procedure for a problem after LDP....carried it out and crashed because the procedure did not consider one of the failures that can occur that does not fit the SOP as written.

I guess the famous Eket Takeoff Brief of "We're outta here!" on takeoff number 63 that day would fall slightly outside those Strong SOP's and Crew Discipline concepts despite the fact both pilots knew exactly what was meant and what was going to happen?
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Old 14th Mar 2006, 04:15
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There are indications in my part of the world that a significant number of road accidents occur whilst people are driving modern, powerful vehicles with power steer/cruise control/air-conditioning/comfortable seats on straight four lane highways for long distances. They drift off, lose control and hit something - usually fatally.
I drive on the same roads over similar distances in a vehicle that has little or no mod cons - my driving requires that I pay attention.
When I was taught to fly, helicopters were fairly rudimentary and required significant effort to operate efficiently. There was heavy emphasis on the application of good airmanship.
I now fly one of the most swept up SPIFR machines with all the gear rather like a modern, expensive motor.
These machines make you lazy and reliant upon "the Systems" unless you have an acceptable level of self-discipline that keeps your mind on the job. Some pilots are safety conscious some are not - some should be flying some shouldn't be.
GAGS E86
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Old 14th Mar 2006, 05:04
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SASless,
funny you should say that: I nearly quoted that take off brief (we're outta here)!

I think you have to descriminate between SOPs as a form of automated response that has no thought behind it and a standard response that has been considered before carrying out. Also, you cannot criticise a crew for acting in accordance with SOPs based on the KNOWLEDGE THEY HAVE AVAILABLE TO THEM. So, if after rotation in a jet a crew get an engine out warning and maybe a fire warning, coupled with a sudden yaw, I hardly think you can complain if they carry out the company SOP for engine failure/fire. Unless they watch their CFM-56 fly past the port window, how the hell can they know any different?

I was thinking more along the line of normal operations, not abnormal ops where the checklist or QRH may not cater for every eventuality and the crew may have to improvise and use their knowledge and experience to deal with a problem.

For normal ops, there should be commonality of standards. If you don't like an SOP question it and discuss it on the ground with the relevant post holder, but don't invent your own procedures, or pass them on to others. "Well, what the book say is this, but what I like to do is this" etc.

Also, don't be lulled into thinking that automation is the key to it all. It will free up spare mental capacity and should broaden your situational awareness, but unless you know how to operate it (training) and what your company/manufacturer procedures are (SOPs) you can still get into trouble. If anything it demands stronger discipline to use.

SOPs do not mean losing individual airmanship or becoming a robot.
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