USA Human Factor Helicopter Mishap Findings and Recommendations
USA Human Factor Helicopter Mishap Findings and Recommendations 1USA Human Factor Helicopter MishapFindings and RecommendationsUSA Human Factor Helicopter MishapFindings and RecommendationsByColonel Pete Mapes, USAF, MC, CFS2Statement of AccountabilityThis brief represents the position of theresearcher. It does not represent the position ofany other organization including the UnitedStates Air Force or the Department of Defense.Cleared for public release by ASC Public Affairs.Disposition Date: 29 March 2007Document Number: AFRL-WS 07-07313Background• This study describes all 251 U.S. Army Class A-BRotary Wing Mishaps ascribed to ‘Human Factors’from FY 85 to 05• This data is based on a study of data archived in themishap files of the USA Combat Readiness Center atFort Rucker, Alabama• This data is the second part of a study that willinclude all rotary wing aircraft in the DoD• The first part ‘USAF Helicopter Mishap Data’ waspublicly released on 18 Sep 20064Method• Obtained all U.S. Army Rotary Wing Aircraft Class A &B Mishaps ascribed to ‘Human Factors’ from FY 85 toFY 05 inclusive from the U.S. Army Readiness Center• Reviewed all 251 mishap reports on 278 helicopters• Created a data base for initial analysis• No monetary value is associated with fatalities• Major injuries resulted in approximately four weeks ormore of lost duty time• Minor injuries resulted in approximately less than fourweeks of lost duty time5Outline•Characterize the force•Identify major areas of lethality,injury and airframe loss•Identify injury patterns•Categorize mishaps by phase offlight•Summarize mishaps by airframe•Formulate recommendations6Force Categorization7Current Active Inventory orAverage Active Inventory for FY 85 – 05020040060080010001200140016001800# TAIUH-1*AH-1*H-6*H-47OH-58H-60AH-64TH-67**** Mean/year8Utilization Rates,Hours per Aircraft-Year, FY 85 – 05050100150200250300350400450500Hours per Aircraft-YearUH-1AH-1H-6H-47OH-58H-60AH-64TH-679Major Areas Of Mishaps, LossOf Life & Injury10% of Inventory, FY 85 – 05, Involved inClass A or B HF Mishaps0123456789% InvolvedUH-1* (32)AH-1* (18)H-6* (8)H-47 (22)OH-58 (65)H-60 (73)AH-64 (58)TH-67 (2)**** = Average/21 yrs N = 27811HF Mishaps by MDSUH-1 (28)AH-1 (14)H-6 (8)H-47 (20)OH-58 (61)H-60 (65)AH-64 (53)TH-67 (2)N = 25112HF Mishap Rates/100KHrs by MDS00.511.522.53UH-1AH-1H-6H-47OH-58H-60AH-64TH-6713HF Mishaps by Type & PhaseT/OCruiseHoverLandingBalkedTaxiT/O-MCruise-MHover-MLanding-MTaxi-MParked-MLanding-OCFIT84.46%MIDAIRS12.75%OTHER LANDING 2.8%N = 25114HF White/Brownout (& V-I) ProneConditionsDay-BrownoutDayNight-BrownoutNightNIGHTDAYN = 11715HF WHITEOUT/BROWNOUT RATES(/100K Hours) BY SYSTEM00.10.20.30.40.50.60.7UH-1AH-1H-6H-47OH-58H-60AH-64TH-6716Relative Risk of HF Mishaps at Night vs.Day, FY 85 – 05024681012Relative RiskUH-1AH-1H-6H-47OH-58H-60AH-6417Fatality & Injury Patterns18HF Fatality Rates/100K Hours BYMDS00.511.522.5UH-1AH-1H-6H-47OH-58H-60AH-64TH-6719HF Injury Rates/100K Hours BySystem00.511.522.533.54UH-1 AH-1 H-6 H-47 OH-58 H-60 AH-64 TH-67TotalMajorMinor20HF Mishap Protection Factor010203040506070 UH-1AH-1H-6H-47OH-58H-60AH-64TH-6721U.S. Army Rotary Wing HumanFactor Mishap Fatalities & Injuries0 20 40 60 80 100 120 140 160 180 200 0 10 20 30 40 50MultitraumaAbdomenChestLEUEBurnsPelvisT-L SpineN eckHeadNot Spec.FATAL (N=230)MAJOR INJURY(N=140)22Paired Pilot VS. Passenger & CrewU.S. Army Rotary Wing Human FactorMishap Fatalities & Injuries+ 1.4(.699)25.1 108 23.7 55 DEAD+ 6.7(.016)16.2 70 9.5 22MAJORINJURY-2.6(.462)26.2 113 28.9 67MINORINJURY- 5.4(.159)32.5 140 37.9 88NOTINJUREDΔ%(p value)PAX & CREWN = 431# %PILOTSN = 232# %MISHAPN = 112p(X2 trend) = .2723Pilot vs. Passenger & CrewUSA Non-HF Injuries & Fatalities+13.3RR = 1.75(P<.00006)30.2 95 16.9 69 FATAL+1.04RR = 1.2(P<.538)6.7 21 5.6 23MAJORINJURY-2.9RR = .89(p<.388)21.3 67 24.2 99MINORINJURY-11.4RR = .77(p<.0011)41.9 132 53.3 218NOTINJUREDΔ%PAX & CREWN = 315# %PILOTSN = 409# %MISHAPSN = 20724Mishaps By Phase Of Flight25HF Fatalities & Injuries by Phase OFFlight - Overview0 100 200 300 400 500CruiseT/O &G/AHover &TaxiLandingMinorUninjuredMajorFatalN = 740of 974+26HF Landing MishapsDayDay - Low Vis.NightNight - Low Vis.N = 5226791027HF Landing Mishaps0 5 10 15 20Drift - R/OSlope - R/OLat - MRBTRUnderExcess SinkTailwind DayDay - Low VisNightNight - Low VisN = 5228HF Landing Fatalities & InjuriesMinorUninjuredMajorDeadN = 280820149103All Fatalities and all majorinjuries except one occurredin B/O or IFR Visibility29HF Hover/Taxi MishapsDayDay - Low Vis.NightNight - Low Vis.N = 4687% occur at night & 33%occur in low visibility28331230HF Hover/Taxi Mishaps0 5 10 15Not Spec.Drift - R/OHit A/CExcess SinkAero - PowerTRLateral (MRB) DayDay - Low VisNightNight - Low VisN = 4631HF Hover/Taxi Fatalities & InjuriesMinorUninjuredMajorDeadN = 189All Fatalities (10)and 42 MajorInjuries (of 44 – 2undet.) occurred atnight & 16.7% (9)occurred in lowvisibilityOf those uninjuredor with minorinjuries, 6 wereday (3 low vis) and129 were night (3low vis)4463721032HF T/O & G/A MishapsDayDay - Low Vis.NightNight - Low Vis.N = 26Whiteout, brownoutand night are thelargest HF risks fortakeoff and go-around6311633HF T/O & G/A Mishaps0 2 4 6 8 10WireDrift - R/OLat - MRBLat - A/CAero - PWRDayDay - Low VisNightNight - Low VisN = 2634HF T/O & G/A Injuries(NO HF FATALITIES OCCURRED DURING T/O & G/A)MinorUninjuredMajorN = 11010712935HF Cruise MishapsDayDay - Low Vis.NightNight - Low Vis.N = 88191285036HF Cruise Mishaps0 10 20 30 40 50Aero -BankMidairWireTerrainDayDay - Low VisNightNight - Low VisN = 88Continued VMC intoIMC flight accountedfor 19/48 TerrainCFITs, 3/30 WireCFITs and 70/162fatalities. All but 3were night events!37HF Cruise Fatalities & InjuriesMinorUninjuredMajorDeadN = 458Cruise Fatalitiesand Major Injurieswere the largestgroups in anyphase of flight6511463216Wire strikes accounted for42/216 cruise fatalities and22/63 major injuriesMidair collisionsaccounted for 50/216cruise fatalities and 10/63major injuries38Mishaps By Airframe39Comparison of Army Helicopters byThreats & TypeX X X XAH-64XX X X XH-60XXX X X XOH-58A-C = DX X XH-47X XH-6XXX X X XAH-1X X XUH-1Night TR B/OMIDAIRCFIT MDS40Recommendations41Technology Recommendations(Life Saving)• US Army Helicopters would benefit from a system similar toTAWS– Militarize a COTS item to provide this for legacy aircraft– Use Navy TAWS when computer present• Bring datalink weather data into the cockpit• Provide COTS traffic warning technology to prevent midairs• All helicopters need wire detection technology• All occupants should use lap and shoulder restraints• Airbag use should be evaluated• Crew positions should be designed to eliminate (minimize)the need for any crewmember to be out of a crashworthyseat below ETL• All helicopter occupants should be carried in crashworthyseats capable of Gz mitigation with 4-point restraint42Technology Recommendations(Aircraft Saving)• All helicopters need technology permitting safe flight andthe maintenance of situational awareness inbrownout/whiteout conditions, particularly at night:– Automated hover with instant availability– Automated landing systems– Sensor based systems• All helicopters without rearward visibility (AH & OH)should be equipped with technology to prevent tail rotorstrikes:– Warning systems that notify the pilot when an objectis in the proximity of the tail rotor.– Automated systems permitting hover in a fixedposition without drift.43Policy Recommendations• No person should be allowed aboard an operatinghelicopter without wearing a helmet at all times• All occupants should remain strapped in position whenthe vehicle is operated below ETL until it has landed orachieved a stabilized hover• Combat operations may need exceptions to above• VFR training should cease in IMC for all pilots– High Risk Mission, approve at O-6 level– Supervisors should actively recall or direct thelanding of any assets airborne on VFR missions ifweather is forecast to fall below VMC or does– Capable aircraft/pilots should use IFR clearances• Emphasis should be placed on IMC proficiency44Initiatives• Occupant Protection– Navy SBIR on crashworthy passenger seating– ARMY Airbags in OH-58 (No stroking seat)•STWG white paper commissioned– Air Force•SBIR on localizing crew functions in back•SBIR on crashworthy crew seating•SBIR on crashworthy passenger seating• Terrain, weather & traffic awareness– DSOC Dem/Val program with GPS based data– Tri-Service45Needed• Radar Wire Detection• Tail Warning and/or automated hover for OH & AHaircraft (no rear visibility)• Wireless Intercom for aft compartment crew• Collection of adequate data for analysis by all services– Night hours by year and aircraft type– Instrument hours by year and aircraft type– Phase of flight exposure data (MFOQA)• Time in various altitudes & flight regimes• Man years of exposure– Mishap data (MFOQA)– Recommend Joint Analysis Center (USUHS)46The material in this presentation represents the opinion of theauthor and should not be construed to represent the position ofthe United States Air Force, the Department of Defense or anyother organization.Questions?Colonel Pete MapesDUSDR/PR&A(703)604-0482 人为因素？
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