USA Human Factor Helicopter Mishap Findings and Recommendations

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USA Human Factor Helicopter Mishap Findings and Recommendations

帅哥

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

4

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

5

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

6

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

11

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

13

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

14

HF White/Brownout (& V-I) Prone

Conditions

Day-Brownout

Day

Night-Brownout

Night

NIGHT

DAY

N = 117

15

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

16

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

17

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

19

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

20

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

21

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)

22

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

23

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

24

Mishaps By Phase Of Flight

25

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+

26

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

29

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

33

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

34

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!

37

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

38

Mishaps By Airframe

39

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

40

Recommendations

41

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

42

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.

43

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

44

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

45

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)

46

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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