Speech to the 3rd International Helicopter Safety Symposium
by Wendy A. Tadros
Transportation Safety Board of Canada
29 September 2009
Thank you for the kind introduction and thank you to the International Helicopter Safety Team for inviting me to your symposium. For those of you who are from away - bienvenue à Montréal.
Reducing the number of helicopter accidents by 80 percent in ten years - that's a big job! But I am truly impressed by the work you are doing to reach that goal.
I can tell you - The Transportation Safety Board of Canada will stand shoulder to shoulder with the IHST. Since 2005, the TSB has provided occurrence data to the Canadian Joint Helicopter Safety Analysis team. But we all know that data is only the beginning. We also need to put our shoulders to the wheel - to comb through the data, to test our assumptions, to root out the safety risks. And most importantly, to translate what we learn into concrete solutions to make flying helicopters safer.
The IHST and the TSB share common ground. In a sense we have the same objective - to reduce the risk of death and injury when flying helicopters. Along with others in the safety community, we can leverage our resources and our knowledge to find those concrete solutions.
I am here today to give you some insight into the challenges the TSB faces in investigating helicopter accidents. I want to tell you about some of the things we have found over the years. I also want to suggest some key areas where we could all focus our work in the future.
Before I do that, let me tell you a little bit about The Transportation Safety Board of Canada - what it is we do and why.
We investigate transportation accidents. We identify safety risks. AND we tell Canadians about these risks as soon as possible. Our sole aim is advancing transportation safety. We do not assign blame or assess liability -that is the job of the courts.
For almost 20 years, our skilled and dedicated investigators have painstakingly sifted through wreckage, combed through company records, interviewed witnesses and liaised closely with manufacturers and regulators - in search of concrete solutions. The work of Mother Nature and the absence of survivors often makes this job challenging.
As we all know, helicopters are used worldwide to get to terrain that is otherwise unreachable. In Canada, pilots weave through mountain passes and brave turbulent weather. Often they face low visibility over waters and the extreme cold of Canada's northern frontiers.
They fly people and supplies to offshore oil platforms and fly over sparsely populated and remote areas to support the mining, logging and other natural resource industries.
They fight fires and provide critical emergency medical evacuations. While a number of other countries face similar challenges, Canada's vast territory, diverse geography and climate, provides for almost all types of operating environments.
In turn, our helicopter investigations uncover a great deal of useful information -applicable to operations worldwide. I am happy to share what the TSB has learned over the last decade - in the hopes it will bring you closer to the concrete solutions you seek.
While we continue to learn from our investigations, the good news is - helicopter accidents have decreased in recent years in Canada. In the last decade they averaged about 11 accidents per 100,000 flight hours. In 2007, there was a significant decrease. In 2008, the number decreased again to a little over 8 accidents per 100,000 flight hours - That's a 28 per cent decrease over the 10-year average.
It is my hope this trend will continue. However, I cannot be deaf to the news. Over the summer- some new helicopter accident was being reported almost daily.
And I cannot be blind to what I see when I visit our regional offices, especially our Vancouver office, where there is always a steady stream of helicopter wreckage being examined.
Let's put this in perspective...
In the past 10 years, helicopter accidents have accounted for close to a quarter or 25% of TSB's air investigations. In the Western provinces of Alberta and British Columbia, these accidents account for close to a third or 32 per cent of our aviation investigations.
While each investigation involves a thorough and painstaking process, the TSB shares information about the safety risks it finds as soon as possible. We do not wait for the final report to be published. This allows you and other change agents to take corrective action in a timely manner.
For example, very early in our investigation of the crash of a Sikorsky S-92 off the coast of Newfoundland and Labrador, we informed Sikorsky about the broken studs. This resulted almost immediately in a Service Bulletin from the manufacturer. Fast on the heels came an FAA Emergency Airworthiness Directive aimed at reducing the risk of a similar failure.
Sikorsky also made changes to the flight manual instructing pilots to land immediately when main gearbox oil pressure drops to a certain level. These actions will lead to reduced risks for S-92 operators... while the investigation continues.
The TSB flags safety deficiencies as soon as we uncover them so that we can all learn from them and prompt timely action to advance transportation safety.
With the goal of making helicopters safer, over the past 10 years, the TSB has issued 16 safety information letters, 32 safety advisories and made 4 recommendations. In looking through these safety communications we found no one common theme. Rather, there were a number of broad themes - from loss of power, to loss of control, to striking an object. I think this may be a microcosm of what you are finding.
And the reasons these things happened were even more wide-ranging. What this tells me, is there will be no easy answers.
Let me give you an example of a difficult issue. In a number of investigations we looked at parts that failed before they were due to be replaced based on the number of hours flown. These are not premature failures.
Rather the cycling is much higher than the manufacturer predicted because of the nature of the helicopter operations. Additional strain is placed on the components, causing them to fail before their usual replacement intervals. Manufacturers can and have taken action by redesigning components, adjusting maintenance intervals or introducing cycle counts for maintenance to reduce early component failures.
Another area where the TSB alerted industry is occupant safety. We highlighted the need for survival equipment when operating over water. We pointed out deficiencies in the installation of both survival equipment and locator beacons. And we flagged problems with the design and use of safety harnesses ----particularly in operations like heli-logging.
I must tell you we receive positive responses to most of our communications. The result has been - essential safety information reached operators and regulators early. So they can effect change.
And let me assure you -- we don't stop there. We assess the responses provided by the regulator to our recommendations and post the results of assessments on our website.
We continuously review and re-assess the progress made until we are fully satisfied with the action taken.
I have outlined some of the things we learned in our investigations but I wanted to go further today. So, I asked our investigators - those who make their living (on the ground) investigating helicopter accidents - what trends they saw and where they thought our joint efforts should go in the future.
Almost all of them focused on the same three things. We do not have the data you have and so compared with what you are doing, these 3 things are very much the view from 30,000 feet.
To reduce helicopter accidents, the first thing investigators flagged for me was Safety Management Systems or SMS. Companies have all kinds of systems to manage their businesses. They have financial systems to manage revenues and expenditures.
They have Human Resource systems to manage their hiring and obligations to their employees. To name just a few... It only makes sense for aviation companies to have a system to manage safety. It makes sense for operators, for maintenance companies and for manufacturers...
The International Civil Aviation Organization fully supports Safety Management Systems for its member states. Canada leads the way as the first country in the world to require air carriers to implement safety management systems. Transport Canada took a staged approach to its introduction and the helicopter industry is on deck next.
There is always a greater sense of commitment when change comes from within. A few in the helicopter industry are implementing SMS in advance of regulatory requirements and they serve as champions. Some are just beginning the transition to SMS and many others will follow in 2010.
It is expected that SMS will benefit the bottom line in the long term. On the front end though, implementing SMS involves a significant investment of time and resources. Many large air carriers are on their way to having a robust SMS but I fear it may prove more difficult for smaller operators.
In the helicopter industry, it will also require a major change in how this industry deals with risk - and I am betting this will mean a major shift in culture.
This culture shift will take two forms and they are both key elements of SMS. The first is risk assessment and the second is non-punitive reporting.
The main objective in the helicopter industry has always been to "get the job done". The goal of SMS is to look at how you can get the job done safely. SMS gives full consideration to what could go wrong, to finding the risks and taking action to remove them before they lead to an accident.
These systems integrate safety into a company's day to day operations. And the benefits are obvious - reducing downtime and equipment repairs, and avoiding the consequences of a major accident.
But you can't fix a problem unless you know what it is and that leads me to the second shift in culture - a non-punitive reporting system. This is a culture where people feel free to report everything - even their own mistakes. After all, it is the people on the front lines who best understand the risks faced everyday. Through this reporting, operators gather information about safety hazards and come up with the best solutions to mitigate the risks. Brick by brick, one company at a time, this will improve the safety of individual companies.
Now if you really want to radically improve the safety of the whole helicopter industry, think about sharing these lessons - industry wide - for the benefit of all.
The second thing TSB investigators told me was...we will never figure out all of the causes of many, many helicopter accidents because we do not have the data we need to go beyond the obvious. I think you have found the same thing in reviewing your data. Accident investigations have benefitted from cockpit voice and flight data recorders for over forty years. As we know, recorders are an essential tool for understanding the sequence of events leading to an accident. While these systems have been installed in large aircraft for many years, and the data they store has become more detailed, small aircraft rarely carry them.
Accident investigators will tell you that the lack of objective information from voice and data recorders makes their job difficult. This is especially so with small aircraft crashes where often there are no witnesses and the damage is severe. I would argue that some form of recorded data qualifies as a first principle in this day and age.
As part of the Swissair investigation, the TSB went beyond first principles and recommended aircraft be fitted with image recorders. The NTSB has made similar recommendations, including one specifically aimed at smaller commercial aircraft. Image recorders are on the NTSB's Most Wanted List.
Given the technological advances we've seen in recent years, I am confident that installing recorders will become less expensive. And while they are not yet required, some helicopter manufacturers are developing flight data monitoring systems and some operators are voluntarily installing them. The Board is pleased with these developments and while we encourage any new means of improving data gathering, preservation and analysis, I must attach a caution.
In Canada, where there is an accident under investigation, on-board recordings including video recordings can only be used to further the safety investigation. These recordings are privileged and cannot be used in any legal, disciplinary or other proceedings.
However, other states treat recorded data differently. This is why the TSB called for internationally harmonized rules to protect the confidentiality of image recordings. I think this is an important principle to keep in mind - no matter the type of aircraft.
Lastly, TSB investigators told me we need to share information more freely - worldwide. Validating safety deficiencies through careful investigation will always be central to what we do. Be that as it may, investigators said we should not always wait for an accident on our own soil before acting.
They said we can and should look at each other's accidents in search of effective and timely solutions - to reduce safety risks at home.
To this end, there is the European Coordination Centre for Accident and Incident Reporting Systems, or ECC-AIRS. As similar accidents may occur all over the world, its purpose is the sharing and analyzing of occurrence data amongst member countries.
By joining ECCAIRS, the TSB hopes to draw upon this wealth of information and likewise, share the data we gather with other countries.
We encourage regulators and investigative bodies to explore initiatives such as ECCAIRS and to tap into its large knowledge base to advance transportation safety worldwide.
Sharing information is all well and good, but we must have the right information to share.
At the TSB we know we need to take a hard look at the quality and scope of the data we gather on minor incidents and find better ways to mine this data.
Often these incidents serve as precursors. If we can improve our ongoing knowledge base for minor incidents we may be able to prevent more serious accidents.
In closing, since its inception, the IHST has generated tremendous momentum. You now understand a great deal more about where the risks lie in the helicopter industry. And I look forward to watching where you will take this initiative.
I have talked about the work of the TSB, what we have learned from our investigations, and where we think we need to go to better address risks in the helicopter industry. Two of our TSB Senior Air Investigators is here with me today. I would like to introduce Brian MacDonald and André Turenne. I would invite you - the world's experts- to take this opportunity to speak with them. Perhaps in some small measure, their ideas will help you reach your goal of reducing the number of helicopter accidents by 80 percent -by 2016.
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