The Reality of Aeronautical Knowledge: The Analysis of Accident Reports Against What Aircrews are Supposed to Know Acknowledgements We wish to acknowledge the group of professional helicopter safety experts that make up the International Helicopter Safety Team and the Training Industry Working Group that make this supplement possible. Author Scott Burgess, Assistant Professor Embry-Riddle Aeronautical University - Worldwide Helicopter Operations and Safety Discipline Chair Peer reviewed with input by U.S. Joint Helicopter Implementation Measurement Data Analysis Team (JHIMDAT) U.S. Joint Helicopter Safety Implementation Team (JHSIT) International Helicopter Safety Team Comments or suggestions on the content of this document are welcome and should be sent to: IHST Secretariat c/o the American Helicopter Society 217 N. Washington Street, Alexandria, VA 22314-2538 Email [email protected] If providing editorial comments, please note the specific page and/or paragraph pertaining to your suggestion and your contact information. 2 Table of Contents Part I Overview Executive Summary 5 Chapter 1 Introduction 6 Part II Beyond the Helicopter Flying Handbook 14 Part III Accidents by Occurrence Category Chapter 2 Loss of Control 26 Chapter 3 Autorotation – Forced 38 Chapter 4 Autorotation – Practice 43 Chapter 5 System Component Failure 48 Chapter 6 Strike 56 Chapter 7 Visibility 62 Chapter 8 Abnormal Runway Contact 69 Chapter 9 Fuel 74 Chapter 10 Landing Zone 78 Chapter 11 Fire 82 Chapter 12 External Load 86 Chapter 13 Abrupt Maneuvers 89 Chapter 14 Controlled Flight Into Terrain 92 Chapter 15 Ditching 96 Chapter 16 Aerodrome 100 Chapter 17 Unknown 103 Chapter 18 Conclusion 106 Annex A Acronyms 107 Annex B Definitions 109 References 111 3 PART I OVERVIEW 4 Executive Summary The intent of this product is to supplement FAA-H-8083-21, the Helicopter Flying Handbook (HFH). The Reality of Aeronautical Knowledge as it pertains to flight operation is simple; the pilot, aircrew, maintainer, operations, support personnel, and passengers all play a part in ensuring safe flight operations. When this is not done as set forth in aeronautical knowledge documentation, and previous training then risk elevates, aircraft are destroyed, and potential exists for people to die. This document will use this perspective to stimulate thought beyond the level in which pilots are currently trained. In this document, the reader will see the combination of practical knowledge beyond the level presented in the HFH, with both results of detailed study from the Joint Helicopter Safety Analysis Team (JHSAT), of the International Helicopter Safety Team (IHST) analysis, and finally, with language from actual accident report data (all part of the JHSAT dataset) from the archives of the National Safety Transportation Board. This document was originally initiated as a chapter to a safety text at Embry-Riddle Aeronautical University that remained undeveloped. The original goal of this document was to practically illustrate the cause and effect of adherence (or not) to published aeronautical knowledge for the helicopter pilot. This document utilizes recent research by the JHSAT, and it is applicable at any level and through all other components of the helicopter industry. The organization of discussion on topics is driven by the order of occurrence of accident analysis from the JHSAT. The JHSAT reviewed all U.S. - NTSB categorized accidents for the calendar years 2000, 2001, and 2006 for a total of 523 events. Information in Part II is presented to briefly explain the standard aeronautical knowledge items from a practical perspective by taking the HFH discussion further, then in Part III, adding JHSAT accident analysis information with redacted accident descriptions to proffer a deeper understanding and clear association of cause and effect. Inclusion of actual NTSB accident reports offer a realistic viewpoint and association to the environment in which we operate the helicopter. These are real events, which happened to real people. All information leading to identification of personal or sensitive information is redacted. The result is a bright spotlight on where pilots and aircrews should focus their attention in regards to safety of flight operations, situational awareness, and prevention of complacency. Ideally, flight operations at companies large and small, owner-operators, and particularly the CFI, will approach the ‘reality’, which this document intends to impart to their daily activity as helicopter operators. 5 Chapter 1 Introduction “The thing is helicopters are different from airplanes. An airplane by it's nature wants to fly, and if not interfered with too strongly by unusual events or incompetent piloting, it will fly. A helicopter does not want to fly. It is maintained in the air by a variety of forces and controls working in opposition to each other. And if there is any disturbance in this delicate balance the helicopter stops flying immediately and disastrously. There is no such thing as a gliding helicopter. That's why being a helicopter pilot is so different from being an airplane pilot, and why in generality airplane pilots are open, clear-eyed, buoyant, extroverts. And helicopter pilots are brooders, introspective anticipators of trouble. They know if something bad has not happened it is about to.” ABC NEWS COMMENTARY By Harry Reasoner During the Viet Nam War 16 February 1971 In fact, Harry Reasoner, though a very astute journalist, was misstating a well-known fact. Helicopters do glide. Some better than others, but none-the-less, they glide, and as such are well suited to smoothly landing in many areas that an airplane cannot. Unfortunately, the statistics do not bear that fact as well as they could. This chapter will prepare you to associate the complex knowledge from any level of training with accident analysis, and then illustrate the points further with accident narratives. We will discuss the rotorcraft specific details only. The primary thought of safe helicopter flight is to encourage pilots to conduct operations in a way that will mitigate risks and as such, drive down the danger to a level that will allow effective flight operation. Controlled Flight Into Terrain (CFIT) and/or Loss of Control (LOC) is a shared danger that both fixed and rotary-wing pilots are susceptible to, as an example, but we will discuss rotorcraft particular dangers. Ultimately, the reader will take away from this document an increased awareness of the potential dangers of helicopter flight combined with the multi-tasking required of the pilot, a sense of where attention must lie while in flight. The primary reasons that make some helicopter flights more dangerous are: The inherent operational proximity of obstacles to flight and the limited reaction time in the event of an emergency. Situational Awareness (SA) of operational area immediate to proximity to moving aircraft parts Cockpit workload and its effect on both of the above In this document, we will endeavor to elaborate on all facets of helicopter aviation. It is important to associate that many operational flight techniques evolved from former military pilots, it is prudent for the civil pilot to understand the background. Conversely, a number of civil technologies and procedures have influenced military operations. It is this sharing of technology, techniques and procedures that has greatly enhanced the rotorcraft industry in the last five decades. 6 As with any technologically evolutional field, there is also a discovery in efficiency and finding a better way to get the job done. If we study the history of Night Vision Devices (NVDs), then it is easy to understand this point. NVDs were fielded (practically) in the Vietnam era. NVDs were primarily developed as a use for detection in an offensive or defensive posture for the soldier on the ground. Through the late seventies, an evolution occurred that placed NVDs in the helicopter cockpit. Over the last 30+ years, the device has transitioned from large cumbersome and unsafe goggles protruding from the face to barely detectable ounces of weight locked securely off of the front of a helmet and a visual acuity change between 20/200 to 20/40 uncorrected, and they keep improving. NVD use in military helicopters was primarily incorporated for operational battlefield considerations and safety. This technology then found its way into the civil aviation industry and is now in use with the air ambulance helicopters, and airborne law enforcement, and rather than assisting in the detection of enemy forces, it allows for the detection of hazards to flight. This example echoes the growth and enhancement of the civil helicopter industry. Use of the helicopter in the general aviation, municipal and governmental market as discussed, has been prolific since the mid seventies. Nowhere was this shown better than recovery operations immediately following Hurricane Katrina in 2005. The integration of Civil, Military and Public Aircraft helicopters in that short frame of time is indicative of the versatility of not only the helicopter, but of those who use it, manage it, and maintain it. Since the origin of helicopter flight, the ability to hover and conduct vertical takeoff and landing operations has driven both design and use. Several factors have taken engineers to task in order for the craft to operate well in these environments; Design to lower weight, increase payload, lower mean time between failure (MTBF) factors, and reduce costs of operation, all while retaining effective safety capabilities. Helicopters have seen an evolution in use that has pushed their operations to land on the top of Mount Everest in 2005, or to low flight over ocean waters in the black of night in pursuit of drug running boats from Central and South America. There is no debate that versatility is the absolute strength of the helicopter. Chris Dancy states the industry, as identified by Helicopters Association International (HAI), accepts that there are 55 defined helicopter missions (Seimers, 2012). With this versatility, it is imperative that awareness to safety becomes the forethought.