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Hazrep Program Review HHAZAZRREPEP PPROGRAMROGRAM Report: Second Quarter 2012 Summary of reports spanning April 2012– June 2012 Helicopter Services Division HazRep Program Review: Hazards are something each of us encounter every day simply due to the nature of op- erating in the aviation environment. PRISM has created a system (similar to NASA’s ASRS) designed to diminish the risks your organization and its’ employees face while performing their jobs. Our vision is to elevate every subscriber’s awareness of com- mon industry hazards, thereby mitigating the associated risks. But we need your help in order to identify these hazards. Please consider participating in this program by en- tering your hazard information into the Aviation Risk Management Online Resource (ARMOR) on the PRISM website (Professional subscribers only) [or emailing a soft copy if you prefer] to PRISM any hazard reports submitted to you via your reporting process. Your information will be completely sanitized to ensure anonymity, and your submission will then be destroyed to ensure confidentiality. We will compile the infor- mation and create a hazard knowledgebase for the sole purpose of safety analysis. This will allow us to provide you with the most current and applicable hazard identifica- tion and risk mitigation information available. There are currently over 180 PRISM sub- scribers; with adequate participation this hazard knowledge base will become a benefi- cial component of your Safety Management System. We want to dispel any misgivings and reassure you that the information will not be identifiably associated with any com- pany, and will be used for the stated safety purpose only. A Valuable SMS Component This report is created for inclusion into your Safety Management System to aid in iden- tifying hazard trends present in organizations with similar operating characteristics. Small flight departments face a scale deficiency regarding report submissions; this re- port is designed to mitigate that deficiency by increasing the swath of hazard data ac- cumulated for your use in comparison and trending analysis. PRISM Solutions 303.770.4276 HAZREP PROGRAM Hazard Data One hundred and thirty helicopter specific reports are contained in this quarter’s sum- mary. The reports are grouped into twelve basic hazard categories. Click on the sec- tion of the graph to view the corresponding, de-identified, reports. PRISM Solutions 303.770.4276 Hazard Details Continuous ImprovementCorrective Action Severity Hazard Details Completed Corrective Actions Catastrophic I was on standby all day as always. I received a call to fly at 12:30 am, This was brought up at the Safety Committee Meeting and it was 20 minutes after I feel asleep. I was told I had to be at the airport at agreed that we will give more notice for redeye flights. 2am for a 2 hr flight. Other factors caused the trip not to go, however with zero rest time and being ready standby all day, a redeye duty day is not at all safe. I know my body and to ask it to stay awake over 24 hrs and fly is very dangerous. There should be a minimum of 5 hrs notice prior to a redeye flight. Marginal It has come to my attention that the emergency assembly area is different than what is listed in the Emergency Procedures flip chart. The meeting point is actually pretty far from the point diagrammed in the chart. T his could cause much confusion in times of emergency. Negligible Jeppesen updates in base offices accumulate where 1 person updates It is the responsibility of the crewmember doing the preflight the charts. When they are busy or not in town no one updates them inspection to check and update the Jepp charts for the operating with the result being that flights are dispatched without current charts region, both paper and aircraft iPads, and make sure they are and that is a violation of our IS-BAO manual possibly FARs. compliant with our Air Transportation Operations Manual. If there is Suggestion: Each base have a designated person responsible to verify an anticipated revision, this crewmember will be expected to show that Jeppesen revisions to include iPads are available for revision. early as to comply with the revision sometime before the trip. This Each pilot prior to the trip should be made responsible to check to see Duty will be shared by all crew members as they see revisions come if there are revisions due and to post these to the aircraft manuals at due. We will strive to share these responsibilities among all flight some point during the trip. The iPads are required by SOP to be crewmembers. Best practices would be for all flight crewmembers to checked by the PIC prior to flight, but need to be amended to update be issued an iPad with chart subscriptions, and be responsible for the iPad at some point prior to completion of the trip. The designated preflight actions on the issued iPad. person in each base is still responsible to make sure this happens, but each pilot should be responsible to post revisions when available and not wait for the designated person to do so. Our manual should be augmented to reflect this policy. Negligible How about iPads for every aircraft? We could have every pilot get Idea passed on and will be evaluated this season. one? Negligible A year ago [company] was a smaller company that needed everyone to This issue was discussed at the safety committee meeting. It was step up and do everything it took no matter what is was to get the job agreed that this has become a problem in our organization. Everyone done. Commonly if you heard someone say "its not my job" it was agreed to take a more hands off approach instead of trying to get looked down on. While we still need everyone to step and do anything involved in every aspect of every problem. to get the job done, this needs to be more organized. I am starting to see that efforts are being duplicated to complete the same task. People are trying to take on tasks of other departments without any PRISM Solutions Hazard Details Continuous ImprovementCorrective Action Severity Hazard Details Completed Corrective Actions idea of the big picture consequences. Sometimes critical items are being communicated to the incorrect persons. The downside to this overlap/incorrect communication is that it does not follow the correct communication structure and is incorrectly addressed. The more people a piece of information goes through the farther from the correct it becomes. Everyone needs to understand their position and do 110% of their job. Negligible I have noticed an increase in use of cell phones for personal calls, texting and ear bud usage. It is my belief this hinders productivity and creates a safety hazard in some cases. Immediately stop the use of ear buds and blue tooth ear devices unless their use is for business purposes and limit the use of cell phones for personal calls. Negligible During a department meeting, it was discovered that many team members had not recently completed SMS training. Require team members to login to the PRISM website and complete the Safety Management Systems for Employees Computer Based Training (CBT) module. Document their completion and keep certificates on file. PRISM Solutions Hazard Details DeviationCorrective Action Severity Hazard Details Completed Corrective Actions Critical Flight Crews are not remaining current in their FAA instrument The main portion of hoisting has been completed and more hours for currency, namely in their execution of six approaches within the last training should be available. [Company] have been notified to monitor six months. In order to do this training it requires two pilots and an the status of their people and take proactive steps to ensure aircraft. Aircraft have had limited hours available due to maintenance compliance. issues and other training requirements namely hoisting. End results pilots are not completing their required instrument training for both the FAA and the 28 day cycle proficiency training. Marginal Maintenance personnel observed working on lift with out safety harness, improper work shoes, complete disregard for Safety Policy & Program. Negligible A recent analysis of MEL entries was conducted and it appears that a The D.O. has sent a personal letter, as well as addressing each pilot number of MEL log entries were being entered into the airplane flight individually, expressing the importance of writing MELs as they happen log on the final leg or upon the return to home base. en-route. We have developed a maintenance trend tracking system to monitor write ups. There has been a revision to our GOM addressing this issue and we are providing additional training on the topic to all flight crews. PRISM Solutions Hazard Details EquipmentCorrective Action Severity Hazard Details Completed Corrective Actions Catastrophic Recently a crack was found on one of the tail rotor blades. Due to the The Safety Committee convened to discuss the safety concerns. documented problem of defective blades on the Augusta AW139 Recommendations were agreed upon as specified. It was determined Helicopters, I am submitting this report to request that a daily to leave this issue open and revisit it on a weekly basis. inspection be completed by a qualified and trained mechanic on the tail rotor blades of all AW139 aircraft before the first flight of each day. This alarming discovery warrants extra safety precautions to eliminate a catastrophic failure of the tail rotor system and a possible loss of life. Catastrophic While departing from the elevated helipad, the left side rear passenger After speaking with crew,along with the Maintenance Personnel, I door slammed into the open position. This incident occurred while have three recommendations to mitigate the reported hazardous transitioning from the roof top into forward flight.
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