TSB Transportation Safety Summit

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A business case for data recording technology

Paul Spring
President, Phoenix Heli-Flight
Ottawa, Ontario, 21 April, 2016

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Slide 1: Cover Page

“When you know better… you do better.”

A Business Case For Data Recording Technology

Presented to: TSB Transportation Safety Summit

Presented by: Paul Spring, President, Phoenix Heli-Flight

Slide 2: Phoenix Heli-Flight

Photo of an helicopter approaching water

Slide 3: Phoenix Heli-Flight

Photo of an helicopter very close to a road full of police cars

Slide 4: Advocacy

I am not endorsing a particular product or manufacturer.

I am promoting the use of modern technology to enhance safety.

Slide 5: Not knowing can be fatal!

Tech solutions can provide knowledge that aids employees and managers with;

• DECISION MAKING
• TROUBLESHOOTING (Operational & Mechanical)
• PROACTIVE RISK REDUCTION
• ACCIDENT or INCIDENT ANALYSIS

Slide 6: Use of knowledge can prevent:

• Loss of Life
• Loss of Assets
• Loss of Reputation
• Unjustified Prosecution

All = Emotional or Financial Stress

Slide 7: The Rogue

Photo of five dogs in the woods

Slide 8: Comfort Logic Before Data Recorders

“Our pilots wouldn't do anything stupid or illegal because”

• Our pilots respect our clients and our helicopters
• We don't allow aggressive flying
• We only hire experienced crew
• We give them proper training
• We have a safety policy

Slide 9: Shocking Discoveries

I thought my company had it covered.

I was DEAD wrong!!

Slide 10: Helicopter flying

Photo of a forest as seen from an helicopter flying

“I'm sure the helicopter is being flown properly?”

Slide 11: Helicopter flying

Photo of one of the world's first models of helicopters flying with seven mens on board

Slide 12: Helicopter flying

Photo of a helicopter hovering low to the ground with two men hanging from the helicopter skids.

Slide 14: Helicopter flying

Photo of a helicopter hovering low to the ground with two men hanging from the helicopter skids.

Slide 15: Helicopter flying

Photo of a helicopter hovering low to the ground with two men hanging from the helicopter skids.

Slide 16: The Cost of Not Knowing

The pilot with his crew of 4 woodland firefighters onboard had been in level cruise at 1000 feet AGL for 20 minutes when the helicopter descended abruptly.

Slide 17: Helicopter

Photo of a crashed helicopter in the middle of a forest

Slide 18: Helicopter

Close up on the cabin of an helicopter crashed in the middle of a forest

Slide 19: The Aftermath

• 1 person dead, his family & friends devastated
• 4 persons injured
• 1 helicopter destroyed
• The company's reputation threatened

Slide 20: The TSB of Canada final report stated:

• “the pilot had previously flown in a similar manner “
• “however, no complaints were submitted” to the management.
• The helicopter involved had no HFDM.
• *many reports now include this observation*

Slide 21: Unintentional Non-Compliance

• Shortcuts
• Work arounds
• Procedural drift
• Bad norms
• Lack of training (initial or recurrent)
• Lack of supervision

Slide 22: Light/Affordable HFDM Is Available

• HFDM provides Operational Oversight.
• HFDM is both Reactive and Proactive.
• Phoenix's HFDM initiative made a profit the first year.
• HFDM recorders work on any aircraft.

Slide 23: HFDM

Image of a software analysing the flight of an helicopter

Slide 24: HFDM

Graph detailing the flight of an helicopter

Slide 25: Low Level High Speed Events

Graph illustrating the amount of low level high speed events per 1000 flight hours in 2009, 2010, 2011 et 2012.

Slide 26: Integrated HFDM Control Image

Illustration of an HFDM.

Slide 27: HFDM

Graph analysing the flight of an helicopter

Slide 28: Cameras

Illustration of cameras

Slide 29: Cameras

Photo of the interior of the cabin of an helicopter showing clearly the actions of the pilotes

Slide 30: Post Maintenance Run-up Incident

Following routine maintenance including a turbine gas path wash the engines of Phoenix's AS355N required a ground run. During the acceleration of one engine the helicopter began an uncontrolled rotation that ended in a collision with a ground power unit.

Slide 31: The Resulting Damage

• Photos of an helicopter on the ground.
• An uncontrolled 95 degree ground twist to the right.
• Damaging contact with a ground power unit resulting in a broken window and bent mirror bracket.

Slide 32: Cabin

Photo of the inside of the cabin of an helicopter clearly showing the actions of the pilot.

Slide 33: Cabin

Photo of the inside of the cabin of an helicopter clearly showing the actions of the pilot.

 Slide 34: Cabin

Photo of the inside of the cabin of an helicopter clearly showing the actions of the pilot.

Slide 35: Recollections & Recordings

• The pilot's recollection of the incident supported an assertion that he had no control over the incident and that the engine must have a mechanical problem.
• The Cockpit Voice Video Reorder (CVVR) showed how the pilot's situational non-compliance introduced the factors that caused the incident.

Slide 36: Post Investigation Knowledge / Results

• 5 SOPS were not followed.
• Fatigue may have been a factor.
• Personal distraction was a factor.
• The pilot learned how he caused the incident.

Slide 37: Discipline

Decision tree on the disciplinary action to take.

Slide 38: Post Investigation Actions

• No punitive action was taken.
• The pilot was given time off to settle personal affairs.
• Fatigue awareness was improved.
• A post-maintenance ‘speed bump' was put in place.

Slide 39: Spent vs. Saved

Slide 40: Pilot's Actions

Photo showing a pilot inside the cabin of his helicopter reading and pointing at a piece of paper.

Slide 41: Learnings In Action

16 months later the same helicopter had a post maintenance failure of a newly installed $600K engine.

The CVVR clearly showed the crew followed all company procedures as well as the instrument readings at the point of failure. The engine OEM provided full cooperation and warranty.

Slide 42: Financial Advantage$

• Recognition as proactive in quality assurance monitoring.
• Builds trust and a productive relationship with OEMs.
• Attractive to quality employees, WHEN USED RESPONSIBLY!

Slide 43: RFP Accountability Requirement

• 4.0 Safety
  1. How does your company measure and record its safety history?
  2. Are you enrolled in a Service by Hour or a Power by Hour program for any of your aircraft? If so, please describe by aircraft.
  3. Are your aircraft equipped with satellite tracking capabilities? Do you monitor and use this?
  4. Are your aircraft equipped with a Cockpit Voice Video Recorder? If so, what operational benefits do you realize?
  5. Do you utilize a Helicopter Flight Data Monitor? If so, how often is the data downloaded and/or reviewed? What do you do with previously downloaded, historical data?
  6. Are your aircraft equipped with Multi-Function Digital Acquisition Units? If so, what specific data collected are you currently tracking and why?
  7. What communication equipment is in place for your pilot should he require direction or have an issue in flight?
  8. Do all aircraft have a Traffic Avoidance System? Do you have a system in place to ensure it's turned on? Please describe.
  9. Do all aircraft have Helicopter Terrain Awareness System? If not, which aircraft have this capability? Do you have a system in place to ensure it's turned on? Please describe.
  10. Do you have Synthetic Vision installed in all aircraft? If so, please describe how this is used.

Slide 44: The Biggest Pay-Offs

1. For R/W aviation: reduction of injuries, fatalities and financial losses. Increased consumer confidence.
2. For crash investigations: a reduction in “No Cause Determined' findings.”
3. For Owners & Accountable Executives: Peace of Mind.

Slide 45: HFDM.ORG

Without Data - You Don't Know What You Don't Know