At Heli-Expo 2014 NTSB Shares “Lessons Learned”
National Transportation Safety Board (NTSB) vice chairman Christopher Hart and a panel of industry and government experts shared “lessons learned from helicopter accidents” at a wide-ranging panel discussion at Heli-Expo yesterday. Topics discussed included maintenance, simulation and training and the advantages on-board video and data recorders provide in accident investigations.
“There are some bad [accident] numbers here,” Hart said. “They include [since 2004], 102 air medical flights, 54 air tours and 360 instructional flights. That’s why we’ve put helicopter safety on our ‘most wanted’ list and have issued more than 100 recommendations during that time that are helicopter-specific. That’s what we do. And we are happy to say our recommendations have resulted in a lot of improvements, including addition to the tour operators safety program and better inspection procedures being instituted by the manufacturers.”
Hart said improved safety requires the cooperation of all stakeholders. He also called for better human factors training for maintenance professionals, improved scenario-based training for pilots and an expanded use of flight and image recorders.
Don Lambert, senior director of technical safety for Air Methods, identified a “dirty dozen” causes of maintenance deficiencies including: distraction, pressure, complacency, lack of communication, lack of knowledge, stress, lack of teamwork, fatigue, lack of assertiveness, norms, lack of awareness, and lack of resources. “Distractions are very dangerous,” he said. “They will kill you.”
Lambert also decried the time-honored practice of “finger-tighting” parts during maintenance. “It’s amazing how many problems we’ve had due to finger-tighting over the years. Get out of that practice.”
Scott Tish, the chief pilot for Air Methods, counseled attendees on how to economically justify simulator training to their superiors and made an impassioned plea for improved rotorcraft simulation technology. “We’ve been the red-headed stepchild for too long,” Tish said, noting that, until recently, most simulator manufacturers focused on the needs of their Part 121 airline customers. Tish invited his audience to visit major simulator manufacturers on the Heli-Expo convention floor and ask them, “Where is our stuff?”
Tish said that for the advanced training his company pilots require, “only Level D” full-motion simulators are sufficient for realistic practice of maneuvers such as full autorotations to the ground.
Terry Palmer, training center director for Metro Aviation, pointed out that end users need to step up to the plate and increase their demand for simulator services if they expect training centers and simulator manufacturers to better serve their needs. Palmer noted that the 25 turbine helicopter simulators and 15 flight training devices based in the U.S. are far from busy all the time. She said scenario-based training in simulators is critical to teach and preserve “perishable skills needed to keep people safe.”
NTSB investigator Aaron Sauer showed how flight data and imagery recorders aided the Board in re-creating accident flights, using the 2013 fatal accident of an Alaska State Police AS350B2 as an example. That aircraft was equipped with an Appareo Systems Vision 1000 flight data and image recorder that was successfully downloaded after the accident. Based on recorder data from that crash, the NTSB was able to re-create the flight path and flight data from the aircraft into a simulation model. It shows the accident aircraft, flying at night in snow and low-visibility conditions, engaged in an erratic flight path, with multiple heading, altitude and speed changes and subject to wild pitch oscillations including tail slides, before crashing inverted and burning.