Helicopter Safety Study 3

Helicopter Safety Study 3 Main report 2 2 3 PREFACE This report is the result of very good cooperation between the petroleum industry, the helicopter industry, labour unions, the authorities and research in a joint effort to improve the safety of helicopter transport on the Norwegian Continental Shelf. We hope our recommendations will be of use to the community, and that the industry and the aviation authorities follow up our suggestions for concrete measures. We thank all contributors for their openness and valuable input. Trondheim, March 2010 Ivonne Andrade Herrera 4 5 TABLE OF CONTENTS EXECUTIVE SUMMARY...........................................................................................................9 1. INTRODUCTION................................................................................................................17 1.1 Report structure.............................................................................................................17 1.2 Background, financing, and project organisation .........................................................18 1.3 Project goals..................................................................................................................21 1.4 Conditions and limitations ............................................................................................22 1.5 Definitions.....................................................................................................................22 1.6 Abbreviations................................................................................................................26 2. METHOLOGY FOR QUANTIFICATION OF RISK .....................................................29 2.1 Risk model and influence diagram ...............................................................................29 2.1.1 RIF frequency model ........................................................................................31 2.1.2 RIF consequence model....................................................................................32 2.2 Quantification of risk using the risk model...................................................................32 2.2.1 Data sources and use of statistics......................................................................33 2.2.2 Expert judgment and use of identified trends ...................................................33 2.2.3 Conditions, limitations and uncertainty in the estimation of risk .....................34 3. DEVELOPMENTS IN THE PERIOD 1999–2009............................................................37 3.1 Technical helicopter development ................................................................................37 3.2 Operational helicopter development.............................................................................39 3.3 Development of helideck design and helideck operations............................................41 3.4 Changes in Air Traffic Management ............................................................................41 3.5 Organisational development .........................................................................................42 3.6 Development in authority and customer relationships..................................................43 3.7 Development within emergency preparedness .............................................................46 3.8 Other changes................................................................................................................47 4. DEVELOPMENTS IN THE NEXT DECADE (2010–2019)............................................49 4.1 Trends in the next decade (2010–2019)........................................................................49 4.2 Changed framework conditions internally within the two largest Norwegian helicopter operators.......................................................................................................51 4.2.1 General..............................................................................................................51 4.2.2 Change of decision-making authority, management of resources and work practices ...................................................................................................52 4.2.3 Importance for maintenance routines................................................................53 4.2.4 Changes in competence and training ................................................................54 4.2.5 Changes in cooperation and communication ....................................................56 4.2.6 Penalties ............................................................................................................57 4.2.7 Conclusion regarding changed framework conditions ......................................58 4.2.8 Suggested measures ..........................................................................................58 4.3 Norwegian additional requirements to offshore helicopter traffic................................59 4.3.1. Conclusion regarding Norwegian additional requirements ..............................60 5. STATISTICS ........................................................................................................................63 5.1 Summary of incidents in the Norwegian sector 1999–2009.........................................63 5.2 Traffic volume ..............................................................................................................64 5.3 Accidents in the North Sea 1990–2009 ........................................................................66 6. QUANTIFICATION IN THE RISK MODEL ..................................................................71 6.1 Contribution to accident frequency from operational RIFs.............................................71 6 6.2 Risk contribution from operational RIFs for frequency ...............................................73 6.3 The importance of operational RIFs for consequence ..................................................75 6.4 The importance of organisational RIFs.........................................................................77 6.5 Changes in risk 1999–2009 and 2010–2019.................................................................79 7. ESTIMATED RISK LEVEL 1999–2009............................................................................83 7.1 An introductory estimate for the current risk level ........................................................83 7.1.1. Number of fatalities per accident ......................................................................83 7.1.2. Number of fatalities per million person flight hours.........................................84 7.2. Discussion of risk estimate ...........................................................................................84 7.2.1. Statistical significance.......................................................................................84 7.2.2. Sensitivity in relation to individual accidents ...................................................85 7.3. Accidents on the UK and Canadian Shelf in the period 1999–2009 ............................86 7.3.1. Overview of the accidents.................................................................................86 7.3.2. Accidents caused by lightning strike.................................................................92 7.3.3. Accidents during visual approach to offshore facility ......................................92 7.3.4. Analysis of the accidents...................................................................................93 7.3.5. Assessments of accidents and serious incidents in 2009 ..................................94 7.3.6. Norwegian and UK sector.................................................................................95 7.4. Conclusion as regards risk level on the Norwegian Shelf ............................................96 7.5. Fulfilment of goals in public report NOU 2002: 17 .....................................................98 7.5.1. The main goal....................................................................................................98 7.5.2. Secondary goals ................................................................................................98 8. PERCEIVED RISK............................................................................................................101 8.1 Introduction.................................................................................................................101 8.2 Understanding of perceived risk and contributions to safety improvement ...............102 8.2.1 Risk and safety influencing factors – significance of “small indicators” .......102 8.2.2 What can stories of incidents tell us about perceived risk? ............................104 8.2.3 Perceived risk varies and is context and situation dependent .........................106 8.2.4 Suggested measures ........................................................................................106 8.2.5 Suggestions for new questions about perceived risk ......................................107 8.3 Significant conditions for perceived risk ....................................................................108 8.4 Employees’ own stories ..............................................................................................112 8.4.1 Stories from a critical incident ........................................................................112 8.4.2 Incident or accident during take-off or landing on helicopter decks ..............114 8.4.3

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