 Welcome everyone. My name is Fred Kaiser and I'd like to welcome you again to the FAA, the FAST Team National Resource Center, the production studios here at Sun & Fun, doing an exciting week here in Lakeland, Florida. Just a couple of housekeeping items before we get started. If you have any of these little items, make sure you turn them off, okay? Because if any of them go off during the presentation, we're going to have you come up here and give us a 10-minute presentation on helicopter aerodynamics. The other thing is if any time you hear something that says, easy victor, that means we have a problem inside the building and we need to evacuate. So what I'd like for you to do is just go ahead and exit out the same door that you came into, kind of hold out there for just a couple of minutes so that we'll be able to make my head count and make sure everybody's taken care of. Our next presenter started flying as a student in 1968. And I'm going to send you and read some of this because it is so fascinating. He retired as a state trooper, excuse me, with 28 years of service in both fixed wing and helicopter. He did 21 years in an airborne unit, fixed wing and helicopter. ATP, single engine, multi-engine, commercial, rotor crap, powered parachutes. My gosh, the list goes on and on. He's been with the FAA since September of 2001, five years as a FISDO inspector, three years with AFS-610 on light support aircraft, and the remainder of the FAS team as a program manager in Wichita, Kansas. And basically the presentation today is going to look at helicopter or rotor crap accidents, dealing principally with flight instructor issues, risk management strategies, mitigation strategies, et cetera, et cetera. Since that seems to be a very, very big thing going on today. And the FAS team is actively involved in that with mitigation strategies. Just real quickly, I just want to give a plug for the FAS team. If you want to know more about the FAS team, talk to the folks out there in the booth area today. And if you want to be a counselor, I'm sorry, forgive me, a FAS team rep or lead rep, let one of us know today. I would be more than happy to talk to you. And without any further delay, I'd like to introduce Mr. Jim Lamb, the presentator for the next... Good morning, good morning. Talk to you this morning about a project that was given to the FAA safety team, and that was the national helicopter accident training program. We were looking at reduction of accidents with a special focus on helicopter training accidents. Initially, when we looked at the program, we didn't realize exactly what our problems were going to be. And so we began our investigation using the NTSB reports. And I'm trying to get rid of something on my screen, I apologize. But trying to get NTSB reports to give us an idea of exactly what was occurring with the accident problems. Because we were hearing about them, we were seeing them, but we really didn't have a good grasp on what was actually occurring. When we began looking at the NTSB accident reports, we found that we were having quite a few of the training accidents occurring in the different makes and models of helicopters. So we wanted to decide why they were occurring and what areas we needed to look at. Why do we look at training accidents so closely? Well, it's because we tend to fly the way we train. And especially in helicopter emergency situations, we act off of our instincts, because most of the time we don't have the ability to assess our problem and figure out what our plan is going to be. It has to be an immediate situation. We react instinctively, and we will react the way we have trained. When we first started the project in 2008, we were discussing the accidents as we wanted to know what the causal factors were, and we needed to know what the highest frequency of training events that were ending up in accident situations. And then our next responsibility was to devise strategies that would eliminate or reduce the future training accidents. So our basis for this program was that we gathered information from 2006 and 2007 NTSB accident reports. In 2006, we saw that we had 155 total helicopter accidents. 28 of those, which was 18%, were related to training events. In 2007, the accidents increased, the total helicopter accidents to 221 accidents that year. And that particular year, we saw a decrease of down to 10.4%, but still, we had 28 training accidents. But as we pulled up our last statistics, we saw that in 2008, although our total helicopter accidents had reduced, we had 32 of those related directly to training events, and that raised our rate to 20.7%. We could immediately see that we appeared to have a trend. But the only way we can decide whether we indeed have a trend is if we look at a much greater picture. And so we used HAI Summary. They had an accident summary that they had compiled of NTSB reports, and that summary started with 1997 and ran through 2006. So we used our figures, adding the 2007 and 2008 to do a 10 year, excuse me, a 12 year summary. What we found was that during the very first six years of that summary, that the accidents total helicopter accidents were gradually increasing, yet the training accidents were holding steady. And then all together, when we looked at all helicopter accidents, we had 1144 accidents. So over 16% of those were directly related to training events. When we looked at the next six years, we saw a fluctuation in the number of helicopter accidents that were occurring. And 2003 through 2005 were the worst that we have seen in that 12 year area. And then they gradually reduced until we pulled up our 2008 numbers and we saw that our training accidents were increasing again. 1144 accidents in the first six years, the second six years was 1114 accidents. But we went from a little over 16% to over 19% of those accidents being training related. So for our total, for the whole 12 years, we found out that we had 2258 helicopter accidents that had occurred. This is all across the U.S. And over 17% of those were involved in simulated training events. We wanted to break those down to find out what were the causal factors that were occurring during that 12 year study. And were there certain training events that had a higher frequency of accidents than others? Our first report actually came from the FAA Analytical Services. And they broke down all the helicopter accidents that had occurred during the year of 2000. And their study indicated that training accidents, instructional accidents had the highest frequency of accidents over all of the others, which was really surprising when you think that when you compare those to all helicopter accidents and in the areas where we would expect to be most hazardous, such as aerial application or external loads, that simulated training events were actually having more accidents than the other areas. We started with our own 2006 study and we broke that down into four causal factors. NTSB reports showed us that in 2006 our primary causal factor was loss of control of the aircraft. They were losing control during their training events. And the second highest causal factor was low rotor RPM. So two things were happening right now. We're seeing that they're losing control of their helicopter during the training event. And the instructors are not recognizing when the rotor RPM begins to deteriorate, they're not recognizing it in time to salvage that training event. The one that I thought would be the highest would probably be LTE, loss of tail rotor effectiveness. But as you can see, that was fairly low. When we looked at the training events, we became aware that in actuality landing events were the highest frequency training event that was leading to an accident. But as we were putting the numbers together, we saw that in many of the NTSB reports they were talking about auto rotation training. And so we were curious because we had included auto rotation training into the landing events. And we were wondering how many of those landing events actually would have been an auto rotation event. And when we broke that down, we found that they were a large percentage of all the training accidents. In 2007, we increased our causal factors. So we would have a better breakdown. And yet, as you can see, loss of control was still the primary cause of the accidents. The difference in 2007 over 2006 was that we had more maintenance problems. But when we looked at pilot error, we saw that again in 2007 insufficient rotor RPM was the second main cause. So just like 2006, they were losing control of their aircraft and they weren't recognizing the deterioration of their rotor RPM in time. In 2007, we separated auto rotations from the other training events, separated them from landing. And when we did that, in 2007, auto rotations were 35% of the total accidents, total training accidents, followed by landing. And in 2007, cruise was the third highest frequency of events, auto rotation, landing, and cruise. That did change throughout the years. Another thing that we were seeing when we were working with the NTSB reports and doing the evaluations that numerous times they were mentioning that this accident was due to flight instructor error. And so in 2007, we took all of the accidents in which a flight instructor was on board giving instruction to see how many of those would be considered to be flight instructor error. And we found that 50% of all the accidents NTSB indicated that the instructor was an error. When we looked at all of the accidents, we looked at wire strikes, maintenance, weight and balance problems. When we looked in the entire spectrum for 2007, we found that loss of control was 18% of the time was leading to an accident and that 13% was inadequate supervision by the CFI. We increased the flight events in 2008. We added pinnacle approaches because we were seeing some of those on the accident reports. And in this graph right here, you're looking at all of the accidents involving all of the helicopter accidents. And we see that the highest frequency of accidents for the overall picture are occurring during crew's flight followed by landing. So this is, if we want to call it, the real world of helicopter flight. When we break it down to the training events, the simulated training events, it changes in that we were right back where we were in the previous two years that auto rotation training was still had the highest frequency of accidents followed by landing. We wanted to then look at the picture if we have this many accidents during training. Because we know that during training events, you can have solo flight, you may have some of those training events are by a certificated pilot who's just practicing or doing recurrency. But for the events that had a flight instructor on board, when we put the numbers together, we found that even if the flight instructor was on board, a time when we would expect that flight to be the safest, we were still finding a lot of the accidents occurring due to auto rotation training. We also wanted to find out how many of those accidents that were occurring with the flight instructor on board, how many of those NTSB considered to be flight instructor error. And then the NTSB reports in 2008, they showed that 100% of those accidents that occurred when the flight instructor on board, they found the flight instructor in error. We've developed different documents over the years to try to help us with our training programs. We've developed the practical test standards and the practical test standards is available for every category of aircraft that leads to a certification of a pilot, including the flight instructor. And the practical test standards gives us the ability to evaluate a instructor applicant both on their knowledge and their skills. But it also establishes the minimum standards that that pilot must meet to satisfactorily complete that practical test. And we also know that the flight instructor is one of our most essential parts of aviation safety. We have to assure that our flight instructors are adequately tested and that they are indeed prepared to go out and give flight instruction to a student and keep that student safe during that training event. Just as we update the practical test standards, we also have the rotorcraft flying handbook. And the rotorcraft flying handbook, although there are many, many fantastic documents for training out there produced by the industry, the flying handbook really is the basis for all the helicopter training programs. Because the helicopter training handbook is the document that's going to describe and evaluate the way each task in the practical test standards is going to be completed. Also, this is a document that we tried to revise and currently the next revision of the flying handbook is being completed because there have been changes. We have been working with AFS 630 keeping them informed on what we're finding so that they can update their books to cover the problems that we're finding in the training area. One of the places we see very few changes up to this point has been in the regulatory area. A flight instructor applicant has to hold at least a commercial or an ATP. And for a flight instructor, they have to have a minimum of 150 flight hours to be eligible to go after that certificate. And of course, after the required training, then they have to pass the required practical test. Now, when we do a comparison of this to say an airplane applicant who's seeking flight instructor certificates, they also have to have a commercial pilot certificate or an ATP. But a commercial pilot certificate for an airplane requires 250 hours. So one of the things we're looking at is the fact that we have a flight instructor for a helicopter who may have a more difficult training event to teach than an airplane, but yet we're starting them out with 100 hours less flying time than we do the airplane applicant. Now, we have made some changes such as SBAR 73, which applies to Robinson R-22s and R-44s. And the Robinson Company was instrumental in the team effort to develop this SBAR 73, which requires additional training errors for solo flight and for flight instructors. But when we do the studies, we have the SBAR for Robinson, but we're finding that accidents actually occur in all makes and models of helicopters, not just Robinson's. And so far, we haven't developed or changed anything in the requirements for the other helicopters or for the entire field of helicopter training. In our risk assessment, NTSB has indicated that the majority of the rotorcraft training accidents when a flight instructor was on board, NTSB has indicated the majority of those accidents were the instructor's failure to intercede quickly enough. What those reports are showing us is that the instructors appear not to be or don't appear to be recognizing a problem quickly enough. They're allowing the training event, whether it's low rotor RPM or whether they're losing control of the aircraft, they're allowing the event to go so far that it escalates to the point where they can't recover. And so an accident occurs. They don't appear to be recognizing that the problems are starting. Many times when we were looking at the reports, we were seeing that they were having split needles, low rotor RPM, and the instructor wasn't recognizing until the rotor RPM had deteriorated to the point where they couldn't regain the RPM and thus they ended up in an accident. The other thing that we found is that the training events, the highest frequency of training events that end up in an accident are a very narrow range and most of those involved auto rotation training. When we looked at this, we found out that this trend and indeed there is a trend has been occurring for at least 12 years because that's what our studies show. Our risk matrix as we have put it together right now indicates that a operator using helicopters has a likely probable likelihood that one or more of their aircraft will be involved in an event that ends up in substantial damage to that aircraft or injuries or death to the occupants. So where do we do? What do we do? What's our first step to change this trend? Well, we started that in Kansas City at the National Weather Training Center in March of this year. We started with what we called an ILC and that was an industry level committee meeting and in this industry we invited the manufacturers, training providers, operators, and the special use entities. We gave them the information that I've given to you and we asked them to help us interpret the causal factors using their expert knowledge to come in and give us some insight what isn't working and what do we need to change. This was a team effort and we consider this a team and as we continue through this we need all of our industry to come in and help us with this. This particular industry meeting, we had 37 industry members came in. We had 10 different agencies, 10 different agency personnel come in and our team was, although it was hosted by the FAA safety team, we had training and maintenance providers, we invited helicopter emergency services to come in and we had several of those. State aeronautical divisions were in because they're responsible for the activities going on in their states. Insurance, law enforcement, we had some of the major helicopter groups come in. International helicopter safety team, very, very strong advocate of the safety programs that we're working with, airborne law enforcement, CAMTS, and the NAACS were all there and with their help we identified some problems that we felt needed change. We talked about recurrency of training. We know that many of us are guilty of going out and we do our currency training twice a year for flight reviews. It's been an hour of flight training and that's all we get. We're going to try to change that. Our flight instructor training, with flight instructors they can renew their flight instructor certificate with an online course but does that truly prepare them for the problems that we're finding in our accidents. We want to work with them on intervention techniques. How do we change our program so that they have better training and how to recognize problems before they get out of hand? And experience, as we just talked about, the requirement for an initial flight instructor certificate for a helicopter instructor is less than an airplane instructor yet the requirements or the training events may be more difficult in the helicopter. We want to talk about crew training changes and night emergency procedures, especially with our helicopter EMS people. We talked a lot about simulator training and simulators are an excellent device that we can use however the problem is at this time that simulators are primarily available for larger helicopter operators using twin-engine helicopters with turbine engines. Not very many simulators or FTDs available for the small helicopter trainer. We were looking at training requirements, changes in the requirements for the helicopter operators and many of those changes that we're thinking about really would be something that they would take on on their own, not something that would be mandated for them. Changes in maintenance, night vision. Right now the FAA safety team has a responsibility to address every item that came from that committee. If that item is outside of the FAA safety team's area of responsibility we need to forward that information. If it's regulatory we need to send it up to AFS 800. If it has to do with changes in the practical test standards or the handbooks then we need we need to work with AFS 630 in Oklahoma City. And we need to develop new training programs based on the information that we received from this committee meeting. In our 2009 plan which started in October of 2009 or actually October 2008 we were given the responsibility to develop safety materials and we would provide those to our helicopter training providers to develop a risk assessment program for their own operation. A risk assessment program that would help them to identify their tasks, their training hazards and problems within their own training operation that would help them eliminate any future accidents. We're working with CFI workshop lesson plans right now. Currently there's a national helicopter CFI workshop program that is being put on throughout the country. We're going to incorporate our CFI workshop lesson plans into that national program and we'll use the information that we've been working with, the statistics that we're working with. We're going to discuss simulators, we're going to discuss recurrency training, inadvertent IFR situations. The trainers provide additional information for their students to understand what happens if they get an inadvertent IFR and if you've ever been in that situation and you're not IFR qualified in a helicopter it's very very frightening. Want to talk to the instructors about their experience and their abilities. They need to understand that they may have limitations especially in their initial years of training that until they get practice and get experience they may not be prepared to instruct auto rotations to a touchdown. Instruction, intervention. One of the problems that we're seeing accident after accident is that the instructors are not recognizing that a problem is occurring and they're waiting too long to do anything about it. We want the instructors to be prepared to train in the use of night vision goggles and night operations because especially with the EMS operators this is a primary event for them. Many of them are starting to use night vision goggles. One of the things that the committee wanted to put spatial emphasis on was CFI mentoring programs. We want to encourage the more experienced flight instructors to work with the younger instructors, the less experienced instructors. Give them insight into the areas that are going to cause them problems when they're providing training to a student. Help them to better understand those events and those problems that can quickly deteriorate and give them an understanding before it happens rather than the instructor learning on their own and maybe turning into an accident. We're also making changes to the FAA Safety.gov program. The website is an excellent source for information for all categories of aircraft but we know in the past that the FAA Safety.gov has been primarily targeting fixed wing pilots but they're working on it and they're changing that so that it is available and has training programs for all categories of aircraft, helicopters, light sport. We want to make it user-friendly for the helicopter people. They don't have to go digging through all the information to find the training programs that apply to helicopters, direct links to the helicopter training programs and also to the national industry groups because these groups are constantly providing updates on problems and accident information. In 2010 we plan on doing our second industry level committee meeting and at that point it will be the responsibility of the FAS team to talk to them about all of the agenda items that they brought up and how we've acted on those during the 2009 fiscal period and we'll also review the changes. We'll look at accident statistics in 2009 and then we're going to as a group as a team reevaluate our strategies for mitigation of future accidents again to discuss what works, what doesn't work and think out of the side of the box because what we've been doing for the past 12 years apparently isn't working. It's a teamwork goal and we're all working toward the same goal which is accident prevention but we can't do it as individuals we need to do it as a team we all need to get together work as a team and put our ideas together and then maybe we have a chance to diagnose our problem and correct it. The national helicopter accident reduction team we're scattered throughout the U.S., Hawaii, Alaska we're there to assist anybody in the helicopter aviation world we can help you but we really need the help from the industry to help us to help us understand where the problems are at and how we can go about changes making change excuse me customer service is a very important factor for the FAA safety team and if you don't remember this website which I can guarantee you I won't the easy way to find the website is to go to FAA.gov not safety.gov but FAA.gov click on about FAA go to offices and then aviation safety which will take you to the feedback area where you can make comments ask questions tell us what works doesn't work we want positive and negative information we need your feedback that's how we change how we make our changes and how we become a better organization I thank you for your time if there's any questions I'd be glad to entertain those at this time if not I appreciate your attention thank you my pleasure thank you everyone great go ahead