Federal Aviation Administration Helicopter Safety Update

Federal Aviation
Administration
Airbus Helicopters
Safety Seminar
By: Matt Rigsby
Office of Accident Investigation and
Prevention, AVP-100
Federal Aviation
Administration
•1
Helicopters We Just aren’t “Normal”!!
•If you need one of these, are you a real pilot?????
Federal Aviation
Administration
2
FY 2014 Accident Summary
for
U.S. Registered Rotorcraft
October thru April
Federal Aviation
Administration
FY 14 – U.S. Registered Rotorcraft Accidents
Cumulative Counts – 48 Accidents, 8 Fatal Accidents, 15 Fatalities
Same time period, previous FY: 82 Accidents, 23 Fatal Accidents, 46 Fatalities)
Accidents:
Fatal:
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Total
12
3
5
11
6
4
7
48
3
0
1
1
1
1
1
8
5
0
1
3
2
2
2
15
Fatalities:
Data Source: FAA, NTSB Databases. Includes only events classified as accidents and does not include incidents. The accident numbers for each
month of the Fiscal Year may vary from the previous monthly briefing based on analysis between FAA and NTSB databases for the specified
month. The NTSB database may include accidents that were not reported to this office resulting in slightly different numbers.
Federal Aviation
Administration
FY 14 – U.S. Registered Rotorcraft Accidents
Accident Operations Summary (Cumulative)
Acronyms:
EMS = Emergency Medical Services, ENG = Electronic News Gathering, GA = General Aviation,
GOM = Gulf of Mexico
Accidents:
Fatal:
Fatalities:
+ Includes 2 Part 91 Aerial Application Flights: 1 Positioning, 1 Crop Warming
Federal Aviation
Administration
FY 14 – Total Accidents by Industry (Oct 2013 - Apr 2014)
Due to rounding each
Industry percentage, the
overall total may not equal
100%.
Totals include 4
Public Aircraft (3
Law Enforcement, 1
Aerial Observation).
Federal Aviation
Administration
FY 14 – Total FATAL Accidents by Industry (Oct 2013 - Apr 2014)
Due to rounding each
Industry percentage, the
overall total may not
equal 100%.
None of the fatal
accidents involved a
Public Aircraft.
Federal Aviation
Administration
FY 14 – Total FATAL Accidents (Oct 2013 - Apr 2014)
Preliminary Analysis: 8 total Oct-Apr 2014
4 – Wire/Object Strikes
1 - IIMC
1 – Unknown
2 – Power Loss / autorotation
Federal Aviation
Administration
FY 2013 Accident Summary
for
U.S. Registered Rotorcraft
Federal Aviation
Administration
FY 13 – U.S. Registered Rotorcraft Accidents
Cumulative Rotorcraft Accidents – 162 (37 Fatal Accidents, 74 Fatalities)
Same period FY 2012: 139 Total Helicopter Accidents (19 Fatal Accidents, 39 Fatalities)
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Total
Accidents:
16
11
11
12
10
11
11
14
21
20
15
10
162
Fatal:
4
5
2
3
3
4
2
1
4
4
2
3
37
Fatalities:
7
7
4
11
6
8
3
2
9
8
5
4
74
Data Source: FAA, NTSB Databases
Includes only events classified as accidents and does not include incidents. The accident numbers for each month of the
fiscal year may vary from the previous monthly briefing based on analysis between FAA and NTSB databases for the
specified month. The NTSB database may include accidents that were not reported to this office resulting in slightly
different numbers.
Federal Aviation
Administration
FY 13 – U.S. Registered Rotorcraft Accidents (cont.)
Accident Operations Summary (Cumulative)
Acronyms:
EMS = Emergency Medical Services, ENG = Electronic News Gathering, GA = General Aviation,
GOM = Gulf of Mexico
EMS
91/
135
GOM
91/
135
Part
135
Other
Air
Tour
135/136
Accidents:
12
5
13
3
Fatal:
5
2
3
Fatalities:
12
4
4
Part
133*
Part
137
ENG
91/
135
GA
91+
N Reg
Outside
U.S.
1
17
0
108
3
0
0
1
0
23
3
0
0
1
0
41
12
*Includes 2 fatal Utilities Patrol accidents with human external load
+Includes 3 Aerial Application flights not conducted under Part 137:
1 fatal Part 91 frost control flight,
1 fatal Public Operation grass seeding flight,
1 nonfatal Part 91 cherry drying flight.
Also includes 1 External Load logging flight not conducted under Part 133.
Federal Aviation
Administration
FY 13 – Total Accidents by Industry (Oct 2012 – Sep 2013)
Due to rounding each
Industry percentage, the
overall total may not equal
100%.
Chart includes 15 Public Aircraft accidents : Aerial Application
(1), Aerial Observation (1), Law Enforcement (13)
Federal Aviation
Administration
FY 13 – Total FATAL Accidents by Industry (Oct 2012 – Sep 2013)
Due to rounding each
Industry percentage, the
overall total may not
equal 100%.
Percentages include 4 Public Aircraft fatal accidents in the following sectors:
Aerial Application (1) and Law Enforcement (3)
Federal Aviation
Administration
FY13 Fatal Rotorcraft Accidents
•
37 Fatal Accidents
•
74 Fatalities (Cause of Death)
–
–
Blunt Force Trauma (79%)
Thermal Injuries (21%)
•
68% Day Light Conditions
•
79% VMC conditions
•
66% Turbine Single - Engine Type
(45% of U.S. Fleet – Single Turbine)
•
11% System Component Failure
• Main Rotor (2)
• Tail Rotor (1)
• Fuselage (1)
Federal Aviation
Administration
14
FY13 Fatal Rotorcraft Accidents
• Top Occurrence Codes (75%)
– Strike (32%)
• Object Strike
• Takeoff/ Landing
• Low Altitude Mission
– Visibility (24%)
• Fog/ Glare
• Inadvertent IMC
• Night/ Darkness
ADM
– Loss of Control (19%)
• Loss of Tail Rotor Effectiveness
• Exceeding Operating Limits
• Unknown
Federal Aviation
Administration
15
FY 2013 Abnormally High
• FY13 Totals:
– 162 Accidents, 37 Fatal Accidents, 74 Fatalities
• FY13 Comparison to FY12:
– Accidents:
– Fatal Accidents:
– Fatalities:
~17% increase
95% increase
~90% increase
• Estimated Rate Comparison of FY13 to FY12:
– Accident Rate:
– Fatal Accident Rate:
14% increase
83% increase
• Highest Percentage of Accidents by Make/Model:
–
–
–
–
1.
2.
3.
4.
Robinson R-44:
MDHI 369:
Robinson R-22:
Bell 206B:
15%
13%
10%
9%
Federal Aviation
Administration
16
Fatal U.S. Helicopter Accidents by State – 2008 - 2013
1.
2.
Texas
California
16
14
3.
4.
Arizona
Louisiana
9
6
5. Florida
6. Pennsylvania
5
5
7. Alaska
8. Missouri
5
5
Federal Aviation
Administration
Rotorcraft
Accidents
Maintenance Related
Accidents- Safety Starts
in the Hanger
Federal Aviation
Administration
Introduction
• In the past 5 years, we have identified
several significant spikes in rotorcraft
accidents caused by maintenance errors.
• These spikes represent an alarming upward
trend that must be addressed.
Federal Aviation
Administration
Data Parameters
• The following data includes only “workingtype” (turbine-powered) helicopters
regardless of what rule the helicopter was
operating under at the time of the accident.
– NO reports of “training-type” helicopters (reports
involving R-22, R-44, etc.) are included.
• The data sources included NTSB accident
reports and NPTRS record reviews for all
accidents, incidents and occurrences.
– NOTE: no VDRP reports were reviewed.
Federal Aviation
Administration
Trend Identified
•
•
•
•
•
2007 – 8 of 103 accidents = 7.7%
2008 – 10 of 83 accidents = 12%
2009 – 6 of 78 accidents = 7.6%
2010 – 13 of 68 accidents = 19.1%
2011 – 7 of 108 accidents = 6.4%
Federal Aviation
Administration
Summarized Data
• 2007 – 2011: 440 reported rotorcraft
accidents and incidents occurred in the US.
– Of the 440 reports, 10% (44 total) were caused by
maintenance errors.
• These accidents resulted in 13 fatalities, 10
serious injuries and 21 minor injuries.
Federal Aviation
Administration
Maintenance Actions
• The maintenance action that preceded most
of these accidents was engine changes.
– Over 25% (12 accidents) occurred following engine
changes
Federal Aviation
Administration
Specific Maintenance Errors
• 9 instances of failure to properly torque
lines/fittings.
– Causing 12 fatalities, 6 serious injuries and 7 minor
injuries
• 12 instances of failure to properly safety
component hardware
– Causing 9 minor injuries
• 12 instances of failure to accomplish a
proper inspection
Federal Aviation
Administration
Failure to properly secure/inspect
Federal Aviation
Administration
December 7, 2011
Inadequate maintenance of the helicopter, including (1) the
improper reuse of a degraded self-locking nut, (2) the improper or
lack of installation of a split pin, and (3) inadequate post
maintenance inspections
Contributing to the improper or lack of installation of the split pin
was the mechanic’s fatigue and the lack of clearly delineated
maintenance task steps to follow.
Contributing to the inadequate pos tmaintenance inspection was
the inspector’s fatigue and the lack of clearly delineated
inspection steps to follow.
Federal Aviation
Administration
26
Failure to Properly Torque
Federal Aviation
Administration
July 28, 2010
• The helicopter experienced a complete loss
of power and crashed. The accident flight
was the first full flight following an
abbreviated post maintenance check flight
after significant engine work. It was
determined the contract mechanic did not
properly install the fuel inlet union during
reassembly of the engine.
Federal Aviation
Administration
Failure to properly torque
Federal Aviation
Administration
November 1, 2009
• The pilot lost power and autorotated into
the water. 36.7 hours prior to the accident,
the turbine module had been replaced. The
cause was determined to be maintenance
personnel’s failure to correctly torque the
Pc line following that engine maintenance.
Federal Aviation
Administration
Failure to inspect and Torque, Reuse
of worn components
Federal Aviation
Administration
March 8, 2007
• The cause of the accident was maintenance
personnel failed to properly torque the flight
control servo lower attachment clevis and
reinstall a functioning lock washer. This
resulted in a flight control disconnect and
complete loss of control of the helicopter.
Federal Aviation
Administration
Failure to Properly Inspect
Federal Aviation
Administration
July 28, 2010
• Just prior to liftoff, the helicopter began to
shake violently and came apart.
Examination of the wreckage found a 2 ft.
outboard section of the MRB had separated.
The cause was determined to be inadequate
maintenance inspections of the MRB inertia
screw holes which resulted in failure due to
fatigue.
Federal Aviation
Administration
The Current State of Affairs
• Current regulations that pertained to most
of these accidents did not require RII
inspections following maintenance to
critical components.
• SHOULD THEY??
Federal Aviation
Administration
What can we do?
• Awareness is not only crucial for the maintenance
crews but also for the flight crews.
• Communicate: you are the front line of defense
• FAA Dr. Bob Johnson mx human factors
www.faa.gov/.../AMT_Handbook_Addendum_Human_Factor
s.pdf
• The Agency currently has a national goal to reduce the
number of GA accidents…
WHAT CAN WE DO NOW??
Federal Aviation
Administration
•Helicopter Safety Starts in the Hanger
•http://www.youtube.com/watch?v=CRhAivI69WE&feature=youtu.be
Federal Aviation
Administration
2014 NTSB Safety Alerts Focusing on Helicopter Safety
WWW.NTSB.GOV/VIDEOS
• Safety Through Helicopter Simulators
• Helicopter Safety Starts in the Hangar
• Safety and Security of Components
GA Maintenance Alert 121121
http://www.faasafety.gov/spans/noticeView.aspx?nid=4455
• www.rotor.com
Federal Aviation
Administration
38
2014 NTSB Most Wanted List
• Aviation: The FAA should:
– Address Unique Characteristics of Helicopter Operations
– Eliminate Distraction in Transportation
– Improve the Fire Safety in Transportation
– Strengthen Occupant Protection in Transportation
Federal Aviation
Administration
If its important for Corn Dogs it has to be important for us too!!!
Perhaps we need to placard this ??
Federal Aviation
Administration
Federal Aviation
Administration
41
Questions / Comments
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Administration
42
Questions / Comments
Matt Rigsby
Matthew.rigsby@faa.gov
or 817-222-5125
Federal Aviation
Administration