Lessons Learned from TSB Investigations of Helicopter Accidents (1994-2003)
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Transcript of Lessons Learned from TSB Investigations of Helicopter Accidents (1994-2003)
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Transportation Safety Boardof Canada
Bureau de la sécurité des transportsdu Canada
Lessons Learned from TSB Investigations of Helicopter
Accidents (1994-2003)
Joel Morley and Brian MacDonald
International Helicopter Safety SymposiumMontreal, QC
September 26-29, 2005
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Introduction
• Average of 53 Canadian registered helicopters involved in accidents each year (range of 44 to 68)
• 9.3 accidents per 100 000 flight hours
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Accident Rate for Canadian Registered Helicopters (1994-2003)
10.8
11.8
9.8
10.3
9.3
7.6
8.8
7.6
9.7
7.5
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Acc
iden
ts /
100
000
ho
urs
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Accident Rate by Aircraft Category (1994-2003)
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Acc
iden
ts p
er 1
00 0
00 h
ou
rs
Airliners
Commuter Aircraft
Air Taxi
Aerial Work
Corporate/Private/Other
State
Helicopters
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Method
• Employed sample of occurrences investigated by TSB (N=103)
• Comparison sample of military occurrences investigated (N=37)
• Categorized by a team of TSB investigators (4 step process)
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Step 1: Initial Occurrence Categorization
• Power Loss• Structural Failure• Loss of Visual Reference• Struck Object• Loss of Control• Loss of Separation• Training for Emergencies• Other
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Occurrences by Category
35%
17%15%
10%
8%
6%
4% 5%Loss of Power
Structual Failure
Loss of Visual Reference
Loss of Control
Struck Object
Training for Emergencies
Loss of Separation
Other
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Step 2: Examination of Proportion of Fatal to Non-Fatal Accidents
• To see where greatest human cost was occurring
• Determined:– Number of accidents in each category which
were ‘fatal’ (1 or more fatality)– Number of lives lost in each category
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Ratio of Accidents to Fatal Accidents by Category
37
19
15
108
46
4
86
12
4 5
1 02
05
10152025303540
Power L
oss
Struct
ural
Failur
e
Loss
of V
isual
Ref
eren
ce
Loss
of C
ontro
l
Struck
Obje
ct
Loss
of S
epar
atio
n
Traini
ng fo
r Em
erge
ncies
Oth
erNu
mb
er o
f O
ccu
rren
ces
Number of Accidents
Number of Fatal Accidents
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Number of Lives Lost by Category
Pow er Loss, 17
Structural Failure, 12
Loss of Visual Reference, 31
Loss of Control, 8
Struck Object, 8
Loss of Separation, 1
Training for Emergencies, 0
Other, 4
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Step 3: Further Break-down of Occurrence Categories
• Examined types of events contributing to occurrences
• Selected sub-categories which seemed to capture these factors
• Loss of separation’, ‘training for emergencies’ and ‘other’ not sub-categorized
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Sub-Categories for Power Loss
44%
3%8%
24%
5%
16% component failure
contaminated fuel
FOD
improper maintenance
other
undetermined
3(a) Power Loss
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3(b) Structural FailureSub-Categories for Structural Failure
56%33%
11%
component failure
improper maintenance
other
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3(c) Loss of Visual ReferenceSub-Categories for Loss of Visual Reference
13%
33%54%
snow ball
lack of contrast
VFR into IMC
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3(d) Loss of ControlSub-Categories for Loss of Control
10%
30%
10%
30%
10%
10%
dynamic roll-over
loss of tail rotoreffectiveness
flight controlobstruction
rotor decayed
vortex ring state
environmental
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3(e) Struck ObjectSub-Categories for Struck Object
13%
25%
25%
37%
trees
wires
terrain
slung object caughtobstacle
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Step 4: Conclusions from Analysis
What does this mean to me??
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Conclusions – Loss of Visual Reference Accidents
• #3 in frequency, #1 in human cost
• 80% fatal with a total of 31 lives lost
• Civil helicopter flying largely VFR
• Possible counter-measures:– Awareness– Capability– Technology
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Conclusions – Power Loss and Structural Failure Accidents (1)
• Together account for 52% of sample
• Improper maintenance 2nd most frequent sub-category in both
• Underscores importance of efforts to understand and mitigate the factors underlying maintenance error such as:– Improved maintenance procedures– Awareness training
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Conclusions – Power Loss and Structural Failure Accidents (2)
• Power loss is most heavily populated category but produced the fewest fatal accidents– Training to handle power failures effective
• Multi-engine helicopters also represented in power loss accidents
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Conclusions – Loss of Control Accidents
• Well recognized hazards– Loss of tail rotor effectiveness– Decayed rotor RPM– Dynamic roll-over– Vortex ring state– Environmental – Flight Control Obstruction
• Efforts to address these hazards need to be maintained
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Conclusions – Struck Object Accidents
• All hazards represented well known
• Potential counter measures could include:– Raising awareness– Revising procedures– Training in risk management
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Comparison of Civil to Military Accidents by Category
36
17 1510 8 6 4 5
13
25
9 6
16
28
0 3
05
10152025303540
Loss of Power
Structual Failure
Loss of Visual R
eference
Loss of Contro
l
Struck Object
Training for Emergencies
Loss of Separation
Other
Category
% o
f A
cc
ide
nts
Civil
Military
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Conclusion
• Snapshot of accidents investigated
• Hope it will help drive safety management practices
We need to devote
resources to…
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Questions???