ALEA Safety First Program Newsletters

October 2005

Keith Johnson
Safety Program Manager

INTERNATIONAL HELICOPTER SAFETY SYMPOSIUM

I recently attended the first “International Helicopter Safety Symposium” in Montreal, Canada. AHS International, HAI, the FAA, Transport Canada and several original equipment manufacturers sponsored the event. The primary objective of the conference was to develop a strategy to reduce accidents by 80% over the next 10 years. This is a lofty goal, but it is achievable. I believe we can do even better. Our objective should be to eliminate accidents.

As part of this effort we need to gather information on aviation “incidents.” Incidents are defined in the FAR’s as, “Those occurrences other than an accident, associated with the operation of an aircraft, which affects, or could affect the safety of operations.” Investigating incidents helps us to identify issues, including trends that will enable us to take preventive measures and avoid an accident. It is a proactive measure. Only through taking proactive steps can we eliminate accidents.

Beginning in 2006, we will be initiating an incident reporting program. To be fully effective, it will require every organization and individual to participate. By collecting and sharing this vital information we can eliminate accidents.

ACCIDENT UPDATE

The ALEA Law Enforcement Accident Database has just been updated for 2005. We have had 9 accidents so far this year. Loss of control and mechanical failure continue to be our nemesis. If you have not taken the opportunity to read this section of the website, you should. It is a very telling story.

Supervisors need to be looking at the causes of accidents and taking proactive measures to prevent these accidents. The presence or lack of accidents is a function of leadership. That’s where it all starts. We need to have achievable standards, train to the standards, comply with the standards, supervise, assess results, and give feedback. And, let’s not forget about the importance of accountability. We all need to step up to the plate and be accountable.

One of the best methods to get people to perform in accordance with organization standards is to acknowledge and reward good work that complies with the standards. It does not need to be an especially noteworthy effort. Just doing the job we get paid to do. Performance is a function of consequences. What is rewarded today gets done tomorrow.

RISK MANAGEMENT

Risk management can be defined as the reduction or elimination of risk to the extent that the level of risk is acceptable compared to the benefits of completing the mission. Safe does not mean risk free. Safety is not what we do, it’s the result of how we do it. The most important thing we do is managing risk. Contrary to the beliefs of some, risk management does not keep us from accomplishing the mission. It enables us to accomplish the mission safely, effectively and efficiently. No one that has had an accident ever completed the mission.

Each and every member of the organization has a responsibility to operate in the safest manner possible. Never take unnecessary risks. If they are unnecessary, why would you take them? Too often, familiarity and prolonged exposure without a mishap leads to loss of appreciation of risk.

I wish to share an accident story forwarded to me by Bill Quistorf, Chief Pilot, Snohomish County Sheriffs Office. The accident was reported in the U.S. Army safety publication, FLIGHT FAX. It reads as follows, reported by LTC W. Rae McInnis, Retired:

In the first accident I investigated, the pilot in command was a highly experienced Department of the Army Civilian Aviator who made a mistake. How highly experienced? He had twenty thousand rotary-wing flight hours. That’s right; 20,000 rotary-wing flight hours, and in broad daylight he hit a set of wires that had been in the local flying area for over 20 years. Wires he knew were there. Wires he had crossed thousands of times. The wires were marked on the map.

How did he let it happen? First, he was navigating from memory. When you fly in the same area for 20 years you figure you can do that. When the student pilot asked where they were, he came inside the cockpit, found a point on the map and showed it to him. This brought both sets of eyes inside the cockpit at a critical point when a set of high-tension wires appeared from behind the trees. By the time he realized they were there, it was too late. He took the controls and tried to fly under the wires but was unable to do so. Fortunately, his 20,000 hours of experience enabled him to execute a controlled crash that caused no significant injuries. However, the aircraft was destroyed.

There were standards in place to prevent this accident. The brigade SOP required no less that 50 feet above the highest obstacle while in terrain flight. It also forbade dipping into open areas surrounded by the obstacles. The student pilot on the controls not only was flying below the 50- foot limit, but also dipped into an open field that had the wires on the far end. Had the crew been operating in compliance with the standard, there would not have been an accident. THE END.

Does this sound familiar? Highly experienced pilot, operating in a familiar setting, still made a mistake. Just being a few feet too low would seem to be a minor mistake. In aviation, even small mistakes can have catastrophic consequences.

Remember, standards are for everybody. Comply with your standards. It just may save your life.

If you have an experience you would like share, send it to: safety@alea.org. It’s always confidential if that’s your wish.

Remember – Safety First!

Keith Johnson