1
USA Human Factor Helicopter Mishap
Findings and Recommendations
USA Human Factor Helicopter Mishap
Findings and Recommendations
By
Colonel Pete Mapes, USAF, MC, CFS
2
Statement of Accountability
This brief represents the position of the
researcher. It does not represent the position of
any other organization including the United
States Air Force or the Department of Defense.
Cleared for public release by ASC Public Affairs.
Disposition Date: 29 March 2007
Document Number: AFRL-WS 07-0731
3
Background
• This study describes all 251 U.S. Army Class A-B
Rotary Wing Mishaps ascribed to ‘Human Factors’
from FY 85 to 05
• This data is based on a study of data archived in the
mishap files of the USA Combat Readiness Center at
Fort Rucker, Alabama
• This data is the second part of a study that will
include all rotary wing aircraft in the DoD
• The first part ‘USAF Helicopter Mishap Data’ was
publicly released on 18 Sep 2006
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Method
• Obtained all U.S. Army Rotary Wing Aircraft Class A &
B Mishaps ascribed to ‘Human Factors’ from FY 85 to
FY 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 or
more of lost duty time
• Minor injuries resulted in approximately less than four
weeks of lost duty time
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Outline
•Characterize the force
•Identify major areas of lethality,
injury and airframe loss
•Identify injury patterns
•Categorize mishaps by phase of
flight
•Summarize mishaps by airframe
•Formulate recommendations
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Force Categorization
7
Current Active Inventory or
Average Active Inventory for FY 85 – 05
0
200
400
600
800
1000
1200
1400
1600
1800
# TAI
UH-1*
AH-1*
H-6*
H-47
OH-58
H-60
AH-64
TH-67
*
*
*
* Mean/year
8
Utilization Rates,
Hours per Aircraft-Year, FY 85 – 05
0
50
100
150
200
250
300
350
400
450
500
Hours per Aircraft-Year
UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
TH-67
9
Major Areas Of Mishaps, Loss
Of Life & Injury
10
% of Inventory, FY 85 – 05, Involved in
Class A or B HF Mishaps
0
1
2
3
4
5
6
7
8
9
% Involved
UH-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 = 278
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HF Mishaps by MDS
UH-1 (28)
AH-1 (14)
H-6 (8)
H-47 (20)
OH-58 (61)
H-60 (65)
AH-64 (53)
TH-67 (2)
N = 251
12
HF Mishap Rates/100KHrs by MDS
0
0.5
1
1.5
2
2.5
3
UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
TH-67
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HF Mishaps by Type & Phase
T/O
Cruise
Hover
Landing
Balked
Taxi
T/O-M
Cruise-M
Hover-M
Landing-M
Taxi-M
Parked-M
Landing-O
CFIT
84.46%
MIDAIRS
12.75%
OTHER LANDING 2.8%
N = 251
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HF White/Brownout (& V-I) Prone
Conditions
Day-Brownout
Day
Night-Brownout
Night
NIGHT
DAY
N = 117
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HF WHITEOUT/BROWNOUT RATES
(/100K Hours) BY SYSTEM
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
TH-67
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Relative Risk of HF Mishaps at Night vs.
Day, FY 85 – 05
0
2
4
6
8
10
12
Relative Risk
UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
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Fatality & Injury Patterns
18
HF Fatality Rates/100K Hours BY
MDS
0
0.5
1
1.5
2
2.5
UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
TH-67
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HF Injury Rates/100K Hours By
System
0
0.5
1
1.5
2
2.5
3
3.5
4
UH-1 AH-1 H-6 H-47 OH-58 H-60 AH-64 TH-67
Total
Major
Minor
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HF Mishap Protection Factor
0
10
20
30
40
50
60
70 UH-1
AH-1
H-6
H-47
OH-58
H-60
AH-64
TH-67
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U.S. Army Rotary Wing Human
Factor Mishap Fatalities & Injuries
0 20 40 60 80 100 120 140 160 180 200 0 10 20 30 40 50
Multitrauma
Abdomen
Chest
LE
UE
Burns
Pelvis
T-L Spine
N eck
Head
Not Spec.
FATAL (N=230)
MAJOR INJURY
(N=140)
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Paired Pilot VS. Passenger & Crew
U.S. Army Rotary Wing Human Factor
Mishap Fatalities & Injuries
+ 1.4
(.699)
25.1 108 23.7 55 DEAD
+ 6.7
(.016)
16.2 70 9.5 22
MAJOR
INJURY
-2.6
(.462)
26.2 113 28.9 67
MINOR
INJURY
- 5.4
(.159)
32.5 140 37.9 88
NOT
INJURED
Δ%
(p value)
PAX & CREW
N = 431
# %
PILOTS
N = 232
# %
MISHAP
N = 112
p(X2 trend) = .27
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Pilot vs. Passenger & Crew
USA Non-HF Injuries & Fatalities
+13.3
RR = 1.75
(P<.00006)
30.2 95 16.9 69 FATAL
+1.04
RR = 1.2
(P<.538)
6.7 21 5.6 23
MAJOR
INJURY
-2.9
RR = .89
(p<.388)
21.3 67 24.2 99
MINOR
INJURY
-11.4
RR = .77
(p<.0011)
41.9 132 53.3 218
NOT
INJURED
Δ%
PAX & CREW
N = 315
# %
PILOTS
N = 409
# %
MISHAPS
N = 207
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Mishaps By Phase Of Flight
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HF Fatalities & Injuries by Phase OF
Flight - Overview
0 100 200 300 400 500
Cruise
T/O &
G/A
Hover &
Taxi
Landing
Minor
Uninjured
Major
Fatal
N = 740
of 974+
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HF Landing Mishaps
Day
Day - Low Vis.
Night
Night - Low Vis.
N = 52
26
7
9
10
27
HF Landing Mishaps
0 5 10 15 20
Drift - R/O
Slope - R/O
Lat - MRB
TR
Under
Excess Sink
Tailwind Day
Day - Low Vis
Night
Night - Low Vis
N = 52
28
HF Landing Fatalities & Injuries
Minor
Uninjured
Major
Dead
N = 280
8
20
149
103
All Fatalities and all major
injuries except one occurred
in B/O or IFR Visibility
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HF Hover/Taxi Mishaps
Day
Day - Low Vis.
Night
Night - Low Vis.
N = 46
87% occur at night & 33%
occur in low visibility
28
3
3
12
30
HF Hover/Taxi Mishaps
0 5 10 15
Not Spec.
Drift - R/O
Hit A/C
Excess Sink
Aero - Power
TR
Lateral (MRB) Day
Day - Low Vis
Night
Night - Low Vis
N = 46
31
HF Hover/Taxi Fatalities & Injuries
Minor
Uninjured
Major
Dead
N = 189
All Fatalities (10)
and 42 Major
Injuries (of 44 – 2
undet.) occurred at
night & 16.7% (9)
occurred in low
visibility
Of those uninjured
or with minor
injuries, 6 were
day (3 low vis) and
129 were night (3
low vis)
44
63
72
10
32
HF T/O & G/A Mishaps
Day
Day - Low Vis.
Night
Night - Low Vis.
N = 26
Whiteout, brownout
and night are the
largest HF risks for
takeoff and go-around
6
3
1
16
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HF T/O & G/A Mishaps
0 2 4 6 8 10
Wire
Drift - R/O
Lat - MRB
Lat - A/C
Aero - PWR
Day
Day - Low Vis
Night
Night - Low Vis
N = 26
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HF T/O & G/A Injuries
(NO HF FATALITIES OCCURRED DURING T/O & G/A)
Minor
Uninjured
Major
N = 110
10
71
29
35
HF Cruise Mishaps
Day
Day - Low Vis.
Night
Night - Low Vis.
N = 88
19
12
8
50
36
HF Cruise Mishaps
0 10 20 30 40 50
Aero -
Bank
Midair
Wire
Terrain
Day
Day - Low Vis
Night
Night - Low Vis
N = 88
Continued VMC into
IMC flight accounted
for 19/48 Terrain
CFITs, 3/30 Wire
CFITs and 70/162
fatalities. All but 3
were night events!
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HF Cruise Fatalities & Injuries
Minor
Uninjured
Major
Dead
N = 458
Cruise Fatalities
and Major Injuries
were the largest
groups in any
phase of flight
65
114
63
216
Wire strikes accounted for
42/216 cruise fatalities and
22/63 major injuries
Midair collisions
accounted for 50/216
cruise fatalities and 10/63
major injuries
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Mishaps By Airframe
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Comparison of Army Helicopters by
Threats & Type
X X X X
AH-64
XX X X X
H-60
XXX X X X
OH-58
A-C = D
X X X
H-47
X X
H-6
XXX X X X
AH-1
X X X
UH-1
Night TR B/O
MIDAIR
CFIT MDS
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Recommendations
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Technology Recommendations
(Life Saving)
• US Army Helicopters would benefit from a system similar to
TAWS
– 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 crashworthy
seat below ETL
• All helicopter occupants should be carried in crashworthy
seats capable of Gz mitigation with 4-point restraint
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Technology Recommendations
(Aircraft Saving)
• All helicopters need technology permitting safe flight and
the maintenance of situational awareness in
brownout/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 rotor
strikes:
– Warning systems that notify the pilot when an object
is in the proximity of the tail rotor.
– Automated systems permitting hover in a fixed
position without drift.
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Policy Recommendations
• No person should be allowed aboard an operating
helicopter without wearing a helmet at all times
• All occupants should remain strapped in position when
the vehicle is operated below ETL until it has landed or
achieved 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 the
landing of any assets airborne on VFR missions if
weather is forecast to fall below VMC or does
– Capable aircraft/pilots should use IFR clearances
• Emphasis should be placed on IMC proficiency
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Initiatives
• 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-Service
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Needed
• Radar Wire Detection
• Tail Warning and/or automated hover for OH & AH
aircraft (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)
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The material in this presentation represents the opinion of the
author and should not be construed to represent the position of
the United States Air Force, the Department of Defense or any
other organization.
Questions?
Colonel Pete Mapes
DUSDR/PR&A
(703)604-0482
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