Helicopter Safety Study 3 (HSS-3)
SHORT: Lessons learned
4th International Helicopter Safety Symposium, Portugal, October 2010 More info:
[email protected]
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Acknowledgements We thank Norwegian technical, operative and administrative personnel from helicopter operators, air navigation providers, helicopter deck personnel and emergency preparedness organizations, as well as petroleum and civil aviation (Norway and UK) authorities for their constructive comments and openness in the best interest to improve helicopter safety HSS-3 has also benefit from information from the European Helicopter Safety Team.
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Outline Why What Main findings Conclusions
Report : http://www.sintef.no/Teknologi-og-samfunn/Sikkerhet/Rapporter--Reports/Helikoptersikkerhetsstudie-3-HSS-3/ Committee for Helicopter Safety : www.helikoptersikkerhet.no Technology and Society
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The project “owner group”
A/S Norske Shell BP Norway (BP) ConocoPhillips Norge (CoP) Eni Norge GDF SUEZ E&P Norge AS CAA-N Marathon Nexen Exploration Norge AS Statoil Total E&P Norge AS.
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Helicopter activities on the norwegian shelf Hammerfest
Overall, about
45 heavy helicopters
21 S-92 9 EC225 8 Super Puma L2 7 Super Puma L1 1 Super Puma L 1 EC155
HD
•S-92 Bristow
Brønnøysund
•S-92 CHC HS •EC225 CHC HS •EC225 Bristow
Kristiansund
•AWSAR Helicopter •Puma L1/L2 (CHC)
Florø
45 000 flight
OS
ST
Bergen
hours and about 750 000 passengers
Back up/Ad Hoc CHC HS
Sola
BR Sola Bristow Bergen Sola
EK
Ref: STATOIL
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2,3
} -5 % HU MS
1966
1990
O R G AN IZ C AT H AN IO N G AL ES
C O N D IT IO N S
L NA O TI A R RN E PE O TT A P
4,1
W EA TH ER
RISK; NUMBER OF FATALITIES PER MILLION PERSON FLIGHT HOURS
Problem to be addressed
RA DA R
1999
? NE W
AIR CR A
AC AS /
FT
2009
HSS-1
? ?
TC AS
2019 YEAR
HSS-2 HSS-3
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What - Approach – lessons learned Combine perspectives to provide a broader information about the system under evaluation Risk
influence modelling
Storytelling
Resilience
Engineering
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General risk influencing model
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Assumptions, limitations and uncertainties by the risk estimations Results shall be comparable to HSS-2 Risk for regular passenger transport offshore Risk estimates have to rely on expert judgments Quantifying trends (1990-1998 and 1999-2009) Dependencies between RIFs frequency and consequence are neglected
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Results: Contribution to accident frequency from Level 1 (11 operational RIFs for frequency) (Figure 6.2)
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Results: The risk influence from organizations (Figure 6.10)
Heli manufacturers Heli operators & Maintenance org. & Design org.
Heliport/ Helidekk
ATS/ANS services
SAR services
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Some results Norwegian sector: 1990-1998: 2.3 fatalities per million person flight hours 1999-2009: One accident, no fatalities 1990-2009 (20 years): 5 accidents, 12 fatalities, i.e. 0.9 fatalities per million person flight hours 0.4 accidents per million person flight hours British sector: 1999-2009: 5.6 fatalities per million person flight hours
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Risk reduction in three periods; Norwegian sector
Risk level
45 % reduction
16 % reduction 23 % reduction
HSS-1
1966
HSS-2
1990
HSS-3
1999
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2019
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The 16 % risk reduction is due to: New helicopter types, the latest generation helicopter technology Improved use of HUMS / Vibration Health Monitoring (VHM) Increased pilot skill Improved flight operational procedures Improved helideck design and helideck operations (new regulations, OLF’s Helideck Manual, OLF’s Recommended Guidelines) Improved emergency preparedness Two Norwegian Public Reports; NOU 2001: 21 and NOU 2002: 17 Committee for Helicopter Safety on the Norwegian Continental Shelf ICAO’s introduction of Safety Management System (SMS)
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Risk reduction in three periods; Norwegian sector
Risk level
45 % reduction
16 % reduction 23 % reduction
HSS-1
1966
HSS-2
1990
HSS-3
1999
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2019
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The 23 % estimated risk reduction in the next period (2010-2019) is due to: Continued introduction of new helicopter types Continued implementation of new generations helicopter technology Increased technical and operative experience with the new helicopter types (e.g. Sikorsky S-92 and Eurocopter EC 225) Further development, updates and increased use of HUMS / VHM Further development of Flight Data Monitoring (FDM) and SMS Introduction of Performance Class 2 enhanced (PC2e) Improved safety standard of helidecks (procedures, size, lighting, marking, monitoring of helideck motions, weather reports, turbulence knowledge) Improved meteorological services
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Storytelling and organizational change Use humour as a disarming tool or as a counter-power strategy: “An e-mail came from the management saying that if we could maintain over 90 per cent regularity for one week, they would buy cakes for all the bases. But then an employee answered in an e-mail saying that if the management could provide spare parts for the entire week, they would buy cakes for the entire management.”
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Results: Organizational changes and safety CHC Norway and Bristow Norway have experienced comprehensive changes in their internal framework conditions 1999-2009 They have got access to more capital and a larger fleet The meeting between different management cultures has required demanding learning- and integration processes The current study has revealed a set of organizational development characteristics that may have contributed to reduced focus on the primary operational tasks In the long run such effects represent a safety threat if they are not properly managed Technology and Society
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Potential threats to helicopter safety on the NCS in the next period Abstraction of Norwegian additional requirements for offshore flights Exemption from offshore special requirements; deviation from recommended guidelines Inadequate management of change Reduced competence due to retirements Insufficient competence and resources in the CAA-N Too much focus on cost and revenues by the different players on the NCS
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The present Norwegian additional requirements Norwegian Air Operative Certificate (AOC) Special requirements (Norwegian CAA): Helicopter operators and helidecks Modified Automatic Dependence Surveillance Vibration Health Monitoring (VHM / HUMS) Weather reports and forecasts
OLF 066: Guidelines for offshore flights OLF 074: Guidelines for helideck personnel A number of safety measures recommended in the public report NOU 2002: 17 “Helicopter Safety on the NCS”
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Perceived risk – the significance of small tokens Perceived risk depends on the context and situation “Small tokens” are of great importance to the passengers The passengers’ own stories fulfill several functions: They are an important source for self control and sharing of
knowledge They give input to what can be done to reduce perceived risk and improve safety
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Resilience Engineering* Complements the focus on failures with a focus on the variability of normal performance Can be utilized to analyze successful operations (flights without incidents) Flight safety is considered a dynamic property and the result of an interaction between several actors and functions Helicopter safety has to be created; it is not a system to be “owned”. In the HSS-3 proactive safety indicators are suggested based on the resilience principles. *In cooperation with MINES ParisTech
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Results: HSS-3 proposed indicators Helicopter safety is a result of something that the system does and not a passive property of the system. Safety is a dynamic characteristic and the result of interaction between several organizations. This view guides the indicators that are identified in the study. It is recommended periodically to review the indicators to see if they are still relevant or whether new indicators should be considered. This study represents a step forward from mainly learning from failures to consider also normal operations without failures. The recommended set of indicators represents a combination of quantitative and qualitative data.
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Recommended safety measures (1) Improve safety regarding approach helideck operations Implement automatic flight approach procedures Improve pilot training, use of simulators etc. Minimize flights during night conditions and reduced visibility,
particularly flights to ships
Reduce the possibility of technical failures Complete thorough criticality analyses (FMECA) or similar Use of the latest generation proven helicopter technology Maintain the Norwegian additional requirements for offshore
flights, e.g. to the use of HUMS and M-ADS (or similar) Consistently apply the OLF recommended guidelines Improve the routines for reporting failures in critical safety equipment on helidecks.
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Recommended safety measures (2) Improve the management of organizational changes and changes in the internal framework conditions; Active use of risk analyses prior to implementing changes, and utilize the
experience after changes have been implemented Improve CAA-N’s mandatory inspection and surveillance programmes Ensure that the Norwegian additional requirements are kept
Increase the use of proactive safety indicators; Improve safety management by extended use of leading indicators Develop indicators based on observations of successful normal
operations (landing on moving helidecks, base/heavy maintenance etc.) Further develop the PSA project on “Risk level in Norwegian petroleum industry” (RNNP) to also include:
reported incidents from the ATS/ANS and the helideck function a set of leading and lagging indicators as proposed monitor changes in risk levels through an update of the HSS-3 model
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Recommended safety measures (3) Improve interaction between the operators involved in offshore helicopter transport;
Increase the involvement of the ATS/ANS for offshore operations Improve the communication and exchange of information internally and between the relevant players Increase feedback from the CAA-N to the helicopter operators in order to improve organizational learning across organizations Improve the communication within and between the helicopter manufacturers and the helicopter operators. There is a special need to increase the availability of spare parts
Develop and maintain technical and operational competence
Change the training of the technical personnel, i.e. increase system comprehension and give more time to train on equipment that is specific for the operations on the NCS Extend and adapt the training of the pilots to realistic and critical situations Initiate a project to look at the possibilities and possible safety gain of the paperless cockpit (Electronic Flight Bag or similar).
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Recommended safety measures (4) Reduce the risk of lightning strikes and their possible consequences on helicopters; Initiate a research project taking weather conditions and
operations on the NCS into consideration
Minimize exemptions from regulations and the OLF recommended guidelines; Minimize exemptions in overturn evacuation training Exempt possibilities to interpret the regulations that may lead to
the lack of independent inspections of critical maintenance tasks offshore Minimize exemptions from the Norwegian additional requirements and the special practice established for helicopter transport on the NCS (e.g. regarding the use of HUMS and M-ADS)
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Recommended safety measures (5) Evaluate measures to reduce perceived risk; Make the safety videos less ‘serious’ (scaring) and stimulate the passengers to
support each other socially Consider choice of seat in relation to specific needs Consider a possible weight limit for offshore workers in order to facilitate evacuation in emergency situations Improve the communication equipment in the helicopters and train the pilots to give clear and evident Passenger Announcements Fasten loose equipment in the cockpit (pilot’s suitcase, manuals etc.) Increase awareness of the heliguards as to their behaviour; notably to pay specific attention to those travelling for the first time, plus assisting passengers embarking/disembarking in bad weather condition (wind, helideck movements) Minimize exemptions from recurrent training for helicopter ditching Improve communication of credible information after incidents Extend the project “Risk level in Norwegian petroleum industry” (RNNP) with new questions related to quantitative mapping Expand the next editions of the RNNP with a specific qualitative part on helicopters
Follow up and implement the recommendations presented in the HSS-3 report.
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Recommended basis for ranking priorities
Cost/benefit Estimated risk reduction Feasibility Time aspect Correlation with other safety measures
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The top ten recommended safety measures 1. 2. 3. 4. 5. 6.
Complete thorough technical criticality analyses (FMECA) Use of the latest generation proven helicopter technology Implementation of automated approach Improve the CAA-N’s inspection and surveillance programmes Consistently apply the OLF's recommended guidelines Minimize flights in night conditions and in reduced visibility
7. Extend and adapt the training of the pilots to realistic and critical situations, and stress simulator requirements 8. Extend the training of the technicians 9. Continuance/replacement of the M-ADS 10. Improve communication and interaction between the operators involved in offshore helicopter transport
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Conclusions Helicopters are vulnerable; the present positive picture may easily change. Thus, safety has to be created and recreated everyday. No final solution exists The estimated risk reduction in the next decade presupposes that the threats are controlled by means of continuous proactive and reactive safety efforts Perceived risk depends on the situation and may differ from the statistical or estimated risk Implementation of the recommended safety measures has to be well organized. Technology and Society
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Helicopter Safety Study 3 (HSS-3)
Thank you for your attention Questions?
Estoril, October 2010 Ivonne Herrera, SINTEF
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