INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads...

34
INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF FRENCH STATE AIRCRAFTS INCIDENTS AND ACCIDENTS Tuesday, March 27 March 27, 2018 – STAMP Workshop 2018 Armed Forces Biomedical Research InsKtute BréKgny sur Orge (France) Anthony Vacher, Anne-Emmanuelle Priot, Léonore Bourgeon

Transcript of INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads...

Page 1: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

INTRODUCINGCASTMETHODINTOTHESAFETYINVESTIGATIONSOFFRENCHSTATE

AIRCRAFTSINCIDENTSANDACCIDENTS

Tuesday,March27March27,2018–STAMPWorkshop2018

ArmedForcesBiomedicalResearchInsKtuteBréKgnysurOrge(France)

AnthonyVacher,Anne-EmmanuellePriot,LéonoreBourgeon

Page 2: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

ACTION&COGNITIONINOPERATIONALSITUATIONDEPARTMENT

PERCEPTIONUNIT COGNITIVEERGONOMICSUNIT

ResearchandexperKseacKviKes

Howmilitaryenvironmentconstraintsimpacthumanpercep4onandadapta4on?

Studyofthecogni4ve&socialdeterminantsofdecision-making

inriskyenvironments

Page 3: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

StateAircraYFleet

MINISTRYFORTHEARMEDFORCES MINISTRYOFINTERIOROTHERMINISTRIES

KEYFIGURES2017≈1,600aircraYs:837airplanes,604helicopters,103UAVs,66gliders5accidentsand8seriousincidents|≈360,000flighthours3.7events(including1.4accident)per105flighthours

FROMMAAIBANNUALREPORT,2017

≈80%ofallstateaviaKonacKvity

Page 4: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

q  Independentbodycreatedin2003,agachedtotheMinistryofArmedForces,disKnctbudget

q ResponsibleforthesafetyinvesKgaKonsofincidentsandaccidentsinvolvingstateaircraYs

q  Legalcontext:ICAOAnnex13,EuropeanandFrenchlegisla4on,Armedforcespolicies

q  10permanentsafetyinvesKgators‒  9withtechnicalandopera4onalexper4ses‒  1ergonomist(>2014)

q Publicfinalsafetyreport(mostofthem)

StateAircraYAccidentInvesKgaKonBoardBureauenquêtesaccidentsdéfense-air

Page 5: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

AccidentAnalysisModelsandMethodsUsed2003

CAUSAL-TREEMETHOD

2014

HUMANFACTORSANALYSISANDCLASSIFICATIONSYSTEM

2008

Toovercomethetradi4onallimitsoftradi4onalaccidentanalysismethods=>CASTmethod

StateAircraYAccidentInvesKgaKonBoardBureauenquêtesaccidentsdéfense-air

Page 6: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

IntroducKonofCASTmethodintoSAAIB’ssafetyinvesKgaKons

q  Analysisbasedon:‒  InformaKongatheredbytheinvesKgaKonteam(FDR,CVR,documents,interviews,finalreport,…)

‒ OtheravailablepublicinformaKon(Parliamentreports,MinistryofArmedForcesdocuments)

q  ForarecurrenttypeofaccidentsinmilitaryaviaKon:“Brownout”or“suddendegrada4oninvisibilityduetothedustcloudgeneratedbythehelicopter’srotor”

Approachfollowedq  ForanaccidentforwhichaHFexperKsewascommissionedby

theSAAIB,asasupplementtootherusualmethods

Page 7: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Helicopterdustlanding–DayKme

h]ps://www.youtube.com/watch?v=N6dCW1SFroA

Page 8: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

COURTESYDRA.E.PRIOT,NATORTOWORKINGGROUP,2012

Helicopterdustlanding–Night-Kme

Page 9: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

EventSummaryq  July17,2013–8:00PM

q  SaharaDesert(Africa)q  “Sabre”CounterterrorismTaskForce

q  AirbusHelicoptersH225MCaracal

q  4thSpecialForcesHelicopterRegiment”Nowherewithoutus!”

q  Crew:Captain,Pilot,FlightEngineer,2CommandosinCargo

q Mission:Transportof10commandosfromarearopera4ngbasetothebivouacareaofamotorizedunitinthedesert

Page 10: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

EventSummary

q Patrolflight(withalighthelicopter)q TacKcalnightflight(toovercomepossiblethreats)withNVG

q Extremeenvironment:heat(41°C),dust,sand,hos4leterritory

q Duringthelanding,thehelicopterdriYedtotheleY,hittheground,androlledoverontoitsside

Page 11: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

HazardandLossIdenKficaKon

HazardsH-1:Abnormallandingzonecontact

LossesL-1:Slightphysicalinjuries(crew,soldiersinthecargo)L-2:Lossofmission(opera4onalmissiondisrupted)L-3:Damagetohelicopter(material&financiallosses)

Page 12: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

ProximateeventsleadingtotheaccidentBeforeflightCrewaskedforaSFsimplifiedmarkingoftheLZ(oneIRstrobelight)

T0–1HTake-offfromrearopera4onalbase

T0–40secDescentbegin

T0–28secCaptainandpilotdecidetolandina«manual»modeCorrectapproachslopeandspeedforadustlanding

T0–14secPFannounces“visualonthestrobelight”CaptainaskFlightEngineertoannouncetheheightregularlyNocommunicaKoninthecockpitduring11sec–Ver4calspeed:64n/min

ShortfinalSuddendegrada4oninvisibilityduetothedustcloudgeneratedbythehelicopter’srotor(Brownout).CaptainlosesvisualreferencesNoannouncement.Captainseektoregainit

T0–7secRadioalKmeteralarm:30Y.UnintendedacKonontheflightcommandsbyPF(Cyclingpitch)=>ThehelicopterskidstotheleY

T0–3to1secRadio-alKmeteralarm:15Y.Captainlooksatthe“Hoverscreen”andannounces:“WeskiddingontheleR,Goaround!”V.speed(-317Y/min)

T0PFannounces”Ilostvisualreferences”.Thelenskateofthehelicopterstrikestheground.Theuncontrollablehelicopteroverturns

Page 13: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Proximateeventsleadingtotheaccident

BeforeflightCrewaskedforaSFsimplifiedmarkingoftheLZ(oneIRstrobelight)

T0–1HTake-offfromrearopera4onalbase

T0–40secDescentbegin

T0–28secCaptainandpilotdecidetolandina«manual»modeCorrectapproachslopeandspeedforadustlanding

T0–14secPFannounces“visualonthestrobelight”CaptainaskFlightEngineertoannouncetheheightregularlyNocommunicaKoninthecockpitduring11sec–Ver4calspeed:64n/min

ShortfinalSuddendegrada4oninvisibility:“Brownout”.Captainlosesvisualreferences.Noannouncement.Captainseektoregainit

T0–7secRadioalKmeteralarm:30Y.UnintendedacKonontheflightcommandsbyPF(Cyclingpitch)=>ThehelicopterskidstotheleY

T0–3to1secRadio-alKmeteralarm:15Y.Captainlooksatthe“Hoverscreen”andannounces:“WeskiddingontheleR,Goaround!”V.speed(-317Y/min)

T0PFannounces”Ilostvisualreferences”.Thelenskateofthehelicopterstrikestheground.Theuncontrollablehelicopteroverturns

Page 14: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Safetycontrolstructuretoprotectagainstabnormallandingzonecontact

PhysicalH225MHelicopterProcesses

H225MHelicopterautomaKon

SensorsAutomatedflight

control

FlightCrew

Manualflight

control

ExternalvisualenvironmentthroughNVGOthersensoryinforma4on

HumanMachineInterface

Currentmode,targets,etc.

Setmode,targets,etc.

AdvancedAutoma4cFlightControlSystem

LandingZone

LZmarkers(groundcommandounit)

Presenceofanyeasilyiden4fiableobject(rocks,trees,etc.)

Selectanappropriate

landingareaforhelicoptersRealizeacomplete

markingofLZ

CommandoRegimentSpecialOperaKons

CommandinSahel

4thSpecialForcesHelicoptersRegiment

GroundMarkersTrainingUnit

CrewQualifica4on&TrainingCentre

MaintenanceUnit

2GunnersFlightEngineerCaptainFlying-Pilot

DevelopingandMaintainingskills&qualifica4ons

Reportskillsqualifica4onsissues

Training,Qualifica4on

check,DevelopS.O.P.

Qualifica4oncheckLocaltrainingReport

skillsandqualifica4onsissues

Reportissues

Helicoptertechnicalavailability

Page 15: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Safetycontrolstructuretoprotectagainstabnormallandingzonecontact

PhysicalH225MHelicopterProcesses

H225MHelicopterautomaKon

FlightCrew

Landingarea

LZmarkers

CommandoRegimentSpecialOperaKons

CommandinSahel

4thSpecialForcesHelicoptersRegiment

ArmySpecialforcesBrigadeArmyLightAviaKon

SpecialOperaKonsCommand

GeneralstaffheadquartersoftheArmies(État-Majordesarmées)

MinistryofArmedForces(Ministèredesarmées)

ArmyHeadquarter

GeneralDirectorateofArmaments

IntegratedMaintenanceStructure

Maintenancecompanies

Manufacturers

Qualifica4on,Training,SOP

Qualifica4on,Training,Staff

SFSOPdevelopment

DefineOpera4onalcontract

Page 16: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

H225MHelicopter”Caracal”

SomespecificaKonsq  Medium-classhelicopterq  Five-bladerotor,poweredbytwoenginesq  AdvancedAutoma4cFlightControlSystem

q  Gradualarrivalinunitsfromthemid-2000s

Mainmissionsq  CombatSearchandRescueq  Tac4caltransport/Specialopera4onq  Casualty/Medicalevacua4on

Technicalfailure:noneUnsafeinteracKons:Contactwiththelandingzonewhenthetrajectorywasunstable(5ktlaterallen-handdrin,−400feet/min)

Page 17: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

CrewcomposiKonandexperience

CAPTAIN

PILOTFLYING

FLIGHTENGINEER

RIGHTDOORCOMMANDO

33yearsoldPatrol&Squadronleader1,300flighthourstotal

600onH225M,250withNVG

31yearsold,Opera4onalPilot,1,400flighthourstotal800onH225M,>300withNVG

44yearsold,ChiefWarrantOfficer2,200flighthourstotal,58flighthoursandfirstoperaKonalmissiononH225M

Unit:4thSpecialForcesHelicopterRegiment-3rdsquadronOnthetheatersincetwomonths,previousdeploymentsontheater

36yearsold300flighthourson

H225M,including70bynight

35yearsold150flighthoursonH225M,including80bynight

LEFTDOORCOMMANDO

Page 18: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Pilot-PilotFlying

SafetyRequirementsandConstraints:q Operatethehelicopterinaccordancewith4thSFHRproceduresq Choosethelandingmodeduringthepre-flightbriefingq Managetheflightpathforasafelanding(speed,roll,…,drin)inmanualmodeq Performanalternatevisualsweepinsideandoutsidetocontrolthetrajectoryq Maintainexternalvisualreferencesun4lcontactq Ini4ateagoaroundifvisualreferencesarelost

UnsafeControlAcKons:q Chosethelandingmodetolateq Focusedonlyonexternalvisualcues.Didnotcheckinsidethecockpitq Madeanunintendedac4onofthecyclicpitchcontrolq Didnotdetecttheskidq Didnotini4ateagoaroundwhenthestrobelampdisappearfromitsvisualfield

Page 19: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Pilot-PilotFlyingFeedbacks:q  (Toofew)visualreferencesinaDVE:NVG,sandy,dustyandflatLZwithoutany

clearvisualcluesq  Innerearandsomesthesicfeedbacks(butnotaccurateandreliableenough,

especiallyinavibra4ngmachine)q  Informa4onfromtheelectronicflightinstrumentsystem(nutnotcheck)q  Informa4onfromtheothercrewmembers(butnoverbalcommunica4on)q  Novisualoraudiblealarmstowarnforaskid

EFIS–Hoverscreen

Page 20: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Pilot-PilotFlying

Mentalmodelflaws:q Thoughthatthemissionhadnounusualrisks=>Shortpreflightbriefing,missionusedfortraining(simplifiedLZmarkingprocedureandmanualmodelanding)

q Fearoflosingthefewexternalvisualreferencesincaseofinstrumentcheck=>PFdidnotperformalternatevisualscansinside/outside

q Believedthehelicopter’strajectorywascorrect.TheskiddingofthehelicopterwasperceivedasanIRstrobemovementduetotherotorblades

REALSITUATION

INPILOTMIND

Page 21: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Captain–Non-FlyingPilotSafetyRequirementsandConstraints:q Operatethehelicopterinaccordancewith4thSFHRproceduresq Request(complete)markingofthelandingzonebeforeflightq Choosethelandingmodeduringthepre-flightbriefingq Ensureeffec4veCrewResourcesManagement(collec4veSA)q Performanalternatevisualsweepinsideandoutsidethecockpittopreciselycontrolthehelicopter’strajectoryduringlandingiscorrectq Ensuresecurity(lookatpoten4althreatsoutsideandonIRcamerascreen)

UnsafecontrolAcKons:q Failedtorequestacompletemarkingofthelandingzoneq Chosetotraininmanualmodeduringanopera4onalmissionq Chosethelandingmodetolateq Failedtoestablishaneffec4veCRMduringflightq Didnotannouncethelossofvisualreferencesq Hasdetectedthelef-skidontheHoverscreentoolate

Page 22: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Captain–Non-FlyingPilot

Mentalmodelflaws:q  Thoughthatthemissionhadnounusualrisks=>Shortpreflightbriefing,

training(simplifiedLZmarkingprocedureandmanualmodelanding)

Feedbacks:q  (TooFew)visualreferencesinaDVEq  Innerearandsomesthesicfeedbacks(notreliable)q  Informa4onfromtheelectronicflightinstrumentsystemq  Informa4onfromtheothercrewmembers(butnocommunica4on)q  Novisualoraudiblealarmstowarnforaskid

Context:q  NodustlandingprocedurewasavailableforH225Mq  Training:only5flighthoursduringthe2monthbetweentwodeploymentsq  CaptainawareoftheabsenceofqualifiedmarkerforhelicopterLZmarkingq  Possiblepresenceofenemies

Page 23: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

FlightEngineerSafetyRequirementsandConstraints:q Operatethehelicopterinaccordancewith4thSFHRproceduresq Announcetheevolu4onofflightparameters(includingradio-al4meterheight,ver4calspeed,pitchangle,availablepower,…)q MonitortheIRcameraonboardq Ensuresecurity(lookatpoten4althreatsoutsideandonIRcamerascreen)

UnsafeControlAcKons:q Didnotannounceheightandver4calspeedq Failedtodetecttheexcessivever4calspeedandlateraldrin

Feedbacks:q Informa4onavailableonflightpanel

Mentalmodelflaws&Context:q Firstopera4onaldustlandingonH225M,nopriortraining...q A]en4onmobilizedontheIRcameramanagement:seekstoposi4onitonthelightoftheIRstrob

Page 24: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Allaircrewmembers

Contextofdecision-making:q NodustlandingprocedureforH225Mq Flyonbotholdandnewhelicoptergenera4onq Highpaceofdeployments:≈8monthaboardperyearq Minimalannualquotaofflighthoursnotreached(only150FH),veryli]leflightdevotedtotrainatlandingindustq TraininginFrance:only5hoursinthe2monthsprecedingtheirmissionq NolocaldustlandingtrainingonthearrivalinSahel

TheCASTmethodhelpstochangethewaywerepresentcrew’sbehavior:

Shinfroman“overconfident”helicoptercrew(ini4altempta4on…)towell-mo4vatedaircrewsmembersthattakeadvantageofeveryopportunitytomaintaintheiropera4onalskills(smartandnecessary

adapta4ontosystemicconstraints)

Page 25: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

LandingZonemarkers–CommandoUnit

SafetyRequirementsandConstraints:q  Chooseandprepareanadequatelandingzoneforairplanesand

helicopter(basicrequirementsofcommandounits)q  Realizeacompleteorasimplifiedmarkingofthelandingzone

UnsafeControlAcKons:q  Choseaflat,dustyandsandyLZlackingofanyclearvisualreferences

Page 26: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

LandingZoneMarkers–CommandoUnit

Mentalmodelflaws:q DidnotknowtherequirementsforthedesignofaLZforhelicopterdustlanding:visualclues(rocks,tree,bush,objects),avoidflatandsandyareaq Thoughtheyhadchosenthe“leastbad”availableLZ

Context:q The4thSFHRdidnottraincommandotothemarkingofhelicopterLZ

Page 27: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

4thSpecialForcesHelicopterRegiment

SafetyRequirementsandConstraints:q Developspecialforcesopera4ngproceduresforsafelandingindust,specifictoH225Mhelicopter(day-4meandnigh-4me)q Definepoliciesfortheuseofthetwolandingmodesinopera4onq Monitorthecrew’sskillsforthetwolandingmodesq Providesufficientaircrewtrainingandaerialac4vityq TrainmarkersfortheLZmarking

UnsafeControlAcKons:q Failedtoprovideguidanceforsafelandingindust,specificforH225Mq Failedtodevelopapolicyfortheuseofthetwolandingmodesq Failtomonitorthecrew’sskillforthetwolandingmodesq Failedtotrainaircrewsufficientlyq Failedtotrainmarkersingroundcommandounits

Page 28: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

MentalModelFlaws:q Procedureswereseenprimarilyasconstraintsandnotasresourcestoguidecrewsintheirriskyac4vi4es

Context:q Highpaceofopera4ons,increaseddemandforinterven4ons,staffturnover,…q LowtechnicalavailabilityoftheH225Mhelicopterfleet

4thSpecialForcesHelicopterRegiment

Year 2009 2010 2011 2012 2013ArmyLightAvia4onH225MTechnicalavailability 57% 53% 43% 33% 31%

Page 29: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Integratedmaintenancestructure

SafetyRequirementsandConstraints:q Establishpubliccontractwithmaintenancecompaniesandmanufacturersq Ensuretechnicalavailabilityofthehelicoptersthatallowunitstocomplywiththeir“opera4onalcontract”mandatedbyArmySpecialForcesCommandandArmyLightAvia4onCommand

UnsafeacKons:q Failuretoensuresufficienttechnicalavailability

Page 30: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Integratedmaintenancestructure

Context:unanKcipatedmaintenanceneedsq EvoluKonofhelicoptermissions:fromC-SARtoanintensiveandpermanentuseinopera4onsq EvoluKonofmilitaryoperaKonaltheatreandtheirconstraints

q Camelgrass:obstrucKonofairinlets(notdesignedforthisenvironment)q Finesandanddust,extremeheat=>prematurewearofturbines

⇒ Usualexpected“lifeexpectancyofturbines:3,000flighthours⇒ Observed"lifeexpectancy“:between60and106flighthours⇒ 24enginesreplacedforaflatrateof15enginesperyear(2014)

FromInformaUonreportN°3323,AssembléeNaUonale,2015

Page 31: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

GeneralstaffoftheArmiesMinistryofArmedforces

SafetyRequirementsandConstraints:q Definethe“opera4onalcontract”thatmandatethecontribu4onofeacharmybranchandunitq Providetheresourcesneededtoimplementtheobjec4vesdefinedinthe“opera4onalcontract”q Controltheabilityofthearmedforcestocarryouttheirmissions

UnsafeacKons:q Allowopera4onalunitstoworkwithinthelimitsofthe“opera4onalcontract”mandatedtothemq FailuretomaintainsufficienttechnicalavailabilityofH225Mhelicopterq Failuretocontroltheabilityofthearmedforcestocarryouttheirmissions(crewtrainingundertheminimalrequirements)

Page 32: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Dynamicsandchangesinthesystemandthesafetycontrolstructurerelatedtotheaccident

Budgetconstraintsondepartmentalbudgets,includingtheMinistryoftheArmedForces(financialcrises,controlofpublicdebtandpublicspending)

GeopoliKcalcontextandlocaKonofoperaKonaltheatres:=>Increaseddemandforlongrangemissions,commitmentoftheunitswithinthelimitsoftheir“opera4onalcontract”,exposuretoextremeenvironments

Technologiesused:Glass-cockpithelicopterwithadvancedavionicssystem=>Needto(re)definethetaskalloca4oninsidecockpitandtheSOPdesign

H225M,2000sPuma-SA330,1960s

Page 33: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Conclusion&PerspecKves

CASTmethodadvantages:q ProvidesausefulframeworkforaccidentanalysisandtheidenKficaKonofperKnentsafetyrecommendaKons

q Makesitpossibletogobeyondthe“personapproach”andallowsarealsystemicperspec4veonsafety

q Focusmainlyonthepreven4onofnextaccident,notwhohasfailed?

Nextsteps:q UseofCASTmethodforallSAAIBexper4serequests(4to8/year)

q IntroduceSTAMPmodelforpa4entsafetymanagementin“pharmacologicalclinicaltrial”andmilitary“traumacenters”

Page 34: INTRODUCING CAST METHOD INTO THE SAFETY ...psas.scripts.mit.edu › home › wp-content › uploads › 2018 › 04 › ...INTRODUCING CAST METHOD INTO THE SAFETY INVESTIGATIONS OF

Thank you for your attention

TheviewsexpressedinthispresentaKonarethoseoftheauthorsanddonotnecessarilyreflecttheofficial

policyorposiKonoftheFrenchMinistryforArmedForcesortheMilitaryAirAccidentInvesKgaKonBoard

Credits: Airbus


Concrete Countertops. Cast in place Pre – Cast Overlay.

Concrete Countertops. Cast in place Pre – Cast Overlay.

City of StocktonASTM NUMBER A48 B145-4A A276 Cast Iron Cast Iron Cast tron Bronze Rubber & Bronze Rubber (7) Bronze 11-13% Chrome Bronze Cast Iron 11-13% Chrome Cast Iron Cast Iron

City of StocktonASTM NUMBER A48 B145-4A A276 Cast Iron Cast Iron Cast tron Bronze Rubber & Bronze Rubber (7) Bronze 11-13% Chrome Bronze Cast Iron 11-13% Chrome Cast Iron Cast Iron

Sequential Puzzles Take Apart Puzzlesstorer/JimPuzzles/RUBIK/... · 2011-11-25 · Cast Ring Cast Ring II Cast S&S Cast Star Cast Violon Cast W-U Catacombs Claw Parlor Puzzle Cowboys

Sequential Puzzles Take Apart Puzzlesstorer/JimPuzzles/RUBIK/... · 2011-11-25 · Cast Ring Cast Ring II Cast S&S Cast Star Cast Violon Cast W-U Catacombs Claw Parlor Puzzle Cowboys

Berkshire mv Berkshire mv - lopistoves.com · Introducing the first model of Lopi’s new moderately priced Standing Pilot Millivolt cast iron gas stoves, the mid-sized Berkshire™

Berkshire mv Berkshire mv - lopistoves.com · Introducing the first model of Lopi’s new moderately priced Standing Pilot Millivolt cast iron gas stoves, the mid-sized Berkshire™

Fine Boring Ø 6 – 125 mm...gray cast iron alloy gray cast iron spheroidal, graphite cast iron, ferritic spheroidal graphite cast iron, ferritic/perlitic spheroidal graph. cast iron,

Fine Boring Ø 6 – 125 mm...gray cast iron alloy gray cast iron spheroidal, graphite cast iron, ferritic spheroidal graphite cast iron, ferritic/perlitic spheroidal graph. cast iron,

CAST STONE WALL™ TECHNICAL INSTALLATION …...Double Sided Cast Stone Wall Aspen. 36" Isokern Fireplace with Cast Stone Wall Face Shells Aspen Single Sided Cast Stone Wall and Cast

CAST STONE WALL™ TECHNICAL INSTALLATION …...Double Sided Cast Stone Wall Aspen. 36" Isokern Fireplace with Cast Stone Wall Face Shells Aspen Single Sided Cast Stone Wall and Cast

) MIT STAMP Workshop MIT, Cambridge, USA March 2017 ...psas.scripts.mit.edu/.../2017/...CAST-Runway-Incursion-Case-Study.pdf · (CAST) Accident Analysis Case Study: ... RMS Titanic

) MIT STAMP Workshop MIT, Cambridge, USA March 2017 ...psas.scripts.mit.edu/.../2017/...CAST-Runway-Incursion-Case-Study.pdf · (CAST) Accident Analysis Case Study: ... RMS Titanic

CAST CARBON STEEL CAST STAINLESS STEEL

CAST CARBON STEEL CAST STAINLESS STEEL

EL EME NTS. · eme nts. introducing. 110 solids. 57 textures. 15 jacquards. 38 stripes. solids. textures. cast silver 40433-0000 cast mist 40429-0000 canvas spa 5413-0000 hybrid sky

EL EME NTS. · eme nts. introducing. 110 solids. 57 textures. 15 jacquards. 38 stripes. solids. textures. cast silver 40433-0000 cast mist 40429-0000 canvas spa 5413-0000 hybrid sky

CAST IRON - Apavisa I… · cast iron oxidum natural inside 30x120 - cast iron white natural 60x120 - 7 CAST IRON oxidum Cast Iron oxidum natural decor ramp 30x60 (29,75 x 59,55 cm

CAST IRON - Apavisa I… · cast iron oxidum natural inside 30x120 - cast iron white natural 60x120 - 7 CAST IRON oxidum Cast Iron oxidum natural decor ramp 30x60 (29,75 x 59,55 cm

New Applications of STAMP: Workplace safety, Engineering ...psas.scripts.mit.edu/home/wp-content/uploads/2016/... · • Create the system engineering hierarchical control structure

New Applications of STAMP: Workplace safety, Engineering ...psas.scripts.mit.edu/home/wp-content/uploads/2016/... · • Create the system engineering hierarchical control structure

CAST analysis of the 2003 critical baby food disastrous ...psas.scripts.mit.edu/home/wp-content/uploads/2017/04/Daniel-Hartmann... · CAST analysis of the 2003 critical baby food

CAST analysis of the 2003 critical baby food disastrous ...psas.scripts.mit.edu/home/wp-content/uploads/2017/04/Daniel-Hartmann... · CAST analysis of the 2003 critical baby food

The Greentown Crime Network: Introducing its Cast of Principal … · 2018-12-03 · The Greentown Crime Network: Introducing its Cast of Principal Actors Dr Sean Redmond1 Summary:

The Greentown Crime Network: Introducing its Cast of Principal … · 2018-12-03 · The Greentown Crime Network: Introducing its Cast of Principal Actors Dr Sean Redmond1 Summary:

Introducing an Invention: Puzzle Shaped Cast for Upper Limb Fractures · 2020-07-29 · physical activity level in adolescents with limb fractures: an acceler-ometry-based activity

Introducing an Invention: Puzzle Shaped Cast for Upper Limb Fractures · 2020-07-29 · physical activity level in adolescents with limb fractures: an acceler-ometry-based activity

P.C. Cast and Kristen Cast

P.C. Cast and Kristen Cast

Implantable Receiver Stimulator for Profoundly Deaf People ...psas.scripts.mit.edu/home/wp-content/uploads/2017/... · Implantable Receiver Stimulator for Profoundly Deaf People –

Implantable Receiver Stimulator for Profoundly Deaf People ...psas.scripts.mit.edu/home/wp-content/uploads/2017/... · Implantable Receiver Stimulator for Profoundly Deaf People –

Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs/Sinks · Acrylic Tubs Cast Iron Sinks/Pan P1154 - Acrylic 70” without holes P1153 - Acrylic Black & White

Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs Cast Iron Tubs/Sinks · Acrylic Tubs Cast Iron Sinks/Pan P1154 - Acrylic 70” without holes P1153 - Acrylic Black & White

Fatigue Characteristics and modeling of Cast and Cast ...

Fatigue Characteristics and modeling of Cast and Cast ...

CAST - Advanced Metasploit Decoded Brochure CAST-617

CAST - Advanced Metasploit Decoded Brochure CAST-617

Introducing Diversity to Younger Viewers · The cast includes strong, stereotype–defying women (one of whom is Latina) and several African Americans and Asian Americans, including

Introducing Diversity to Younger Viewers · The cast includes strong, stereotype–defying women (one of whom is Latina) and several African Americans and Asian Americans, including