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AERONAUTICAL DECISION MAKING ADM RISK MANAGEMENT

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Title: AERONAUTICAL DECISION MAKING ADM RISK MANAGEMENT


1
AERONAUTICAL DECISION MAKING (ADM) / RISK
MANAGEMENT
  • Presented By
  • Greater St. Louis Helicopter Association

2
NTSB ID CHI04MA182
420 AM 911 call received from a motorist about
the injured woman on I-26.
449 AM Providence Hospital is contacted
initially says it will send its LifeReach
helicopter but quickly reconsiders, citing the
weather and CareForces decision not to fly. The
Spartanburg Regional Healthcare System is
contacted and says it will send a helicopter.
533 AM Helicopter lifts off radio
communication is lost.
425 AM Newberry County Emergency Medical
Services ambulance leaves Newberry County
Memorial Hospital ambulance service puts
CareForce helicopter at Palmetto Health Richland
on standby.
541 AM Report received about possible
helicopter crash. The helicopter had been in the
air only about a minute at this time, officials
said.
453 AM Spartanburg hospital helicopter pilot
checks radar screen before leaving.
504 AM Spartanburg helicopter enroute to
Newberry County.
615 AM Med-Trans One crew from Greenville take
off to search for wreckage. Helicopter aborts
search about 10 minutes later because of fog near
Greenville-Laurens county line.
444 AM Shortly after taking off, CareForce
decides fog makes it too dangerous to fly and
returns to the hospital.
520 AM Helicopter pilot reports he is two
minutes from the scene reports no weather
problems.
524 AM Helicopter lands safely at the scene
last radio transmission received. Crew attends
to injured woman who was found between the
eastbound and westbound lanes of I-26
447 AM Greenville Hospital Systems is
contacted but says it wont send its helicopter,
citing the weather.
632 AM A trucker finds the wreckage of the
helicopter in a wooded area, about 1,000 yards
from where it took off.
3
NTSB ID CHI04MA182
4
NTSB ID CHI04MA182Analysis
  • After one in-flight abort and two weather
    turn-downs, why did this pilot accept the flight?
  • Did the pilot not receive the information
    concerning the other services?
  • Did the pilot receive the information and
    overconfidence or subtle pressures lead the pilot
    into doing something that was not prudent?
  • Have any of you accepted flights when others
    wouldnt fly? If so, whats the rationale?

5
NTSB ID CHI04MA182
6
WHAT CAUSES ACCIDENTS?
  • Depending on which study, up to 80 of accidents
    can be attributed to poor decision making.
  • Poor decisions result in
  • Initiating flights under adverse conditions.
  • Continuing flights in deteriorating conditions.
  • Operating aircraft beyond their limits.
  • Operating an un-airworthy aircraft.

7
ADM
  • Is a systematic approach to the mental process
    used by pilots to consistently determine the best
    course of action in response to a given set of
    circumstances.
  • Adept decision making involves
  • Recognition of change.
  • Assessment of alternative actions.
  • A decision to act.
  • A balancing of risks.
  • Continual monitoring of the response to your
    actions.
  • Enhanced ADM techniques have proven to reduce
    human error accidents.

8
REFERENCES
  • FAA AC 60-22, Aeronautical Decision Making
  • FAA AC 61-27C, Instrument Flying Handbook
  • FAA-H-8083, Rotorcraft Flying Handbook
  • FAA Aeronautical Information Manual
  • HAI Pilot Judgment Situational Awareness, HAI
    Safety Committee
  • FAA Aviation News, May/June edition
  • U.S. Coast Guard, Decision Making
  • Fred Harms
  • Skip Barthle

9
DEFINITIONS
  • Attitude Management The ability to recognize
    personal attitudes in oneself and the willingness
    to modify them as necessary through the
    application of an appropriate antidote thought.
  • Crew Resource Management (CRM) The application
    of team management concepts in the flight deck
    environment. Pilots of small aircraft, as well
    as crews of larger aircraft, must make effective
    use of all available resources human resources,
    hardware, and information all groups routinely
    working with the cockpit crew who are involved in
    decisions required to operate a flight safely.
    These groups include, but are not limited to
    pilots, dispatchers, cabin crewmembers,
    maintenance personnel, and air traffic
    controllers.

10
DEFINITIONS
  • Headwork Required to accomplish a conscious,
    rational thought process when making decisions.
    Good decision making involves risk identification
    and assessment, information processing, and
    problem solving.
  • Judgment The mental process of recognizing and
    analyzing all pertinent information in a
    particular situation, a rational evaluation of
    alternative actions in response to it, and a
    timely decision on which action to take.
  • Personality The embodiment of personal traits
    and characteristics of an individual that are set
    at a very early age and extremely resistant to
    change.

11
DEFINITIONS
  • Poor Judgment Chain A series of mistakes that
    may lead to an accident or incident. Two basic
    principles generally are associated with the
    creation of a poor judgment chain (1) One bad
    decision often leads to another and (2) as a
    string of bad decisions grows, it reduces the
    number of subsequent alternatives for continued
    safe flight. ADM is intended to break the poor
    judgment chain before it can cause an accident or
    incident.
  • Risk Management The part of the decision making
    process which relies on situational awareness,
    problem recognition, and good judgment to reduce
    risks associated with each flight.

12
CONVENTIONAL DECISION MAKING
13
  • Based upon previous training, experience, and
    reactionary methodology limited situational
    awareness (SA).
  • Most pilots are well trained to react to
    immediate action requirements i.e. engine
    failures immediate reaction to a given
    situation.
  • However, skills and headwork have to be perfect
    when the demand arises. Being reactionary, SA is
    diminished.

14
PILOT
AIRCRAFT
ENVIRONMENT
OPERATION
SITUATION
CHANGE / EVENT OCCURS
RECOGNIZE CHANGE
SELECT RESPONSE TYPE
SKILLS PROCEDURES
HEADWORK REQUIRED
15
PILOT
AIRCRAFT
ENVIRONMENT
OPERATION
SITUATION
CHANGE / EVENT OCCURS
RECOGNIZE CHANGE
SELECT RESPONSE TYPE
SKILLS PROCEDURES
HEADWORK REQUIRED
INADEQUATE
INADEQUATE
OOPS
16
FLAWED JUDGMENT AND SA
  • The aircraft skidded off the runway onto a busy
    highway narrowly missing a gas station while
    landing. Cleared for the visual approach, the
    flight crew maintained 4,000 feet until on a 4
    mile final. Once descent was initiated, the
    aircraft was too high and fast for a safe
    landing, but the crew continued the approach and
    was unable to stop on the runway.

17
WHY DID THE CREW CONTINUE?
  • Was it ego?
  • Was it over-confidence?
  • Was it fear of embarrassment if they initiated a
    go-around?
  • Was it loss of SA?

18
ADM PROCESS
19
ADM PROCESS
  • ADM builds on the foundation of conventional
    decision making but enhances the process to
    decrease the probability of pilot error.
  • Typically during a flight, there is time to
    examine any changes that occur, gather
    information, and assess risk prior to reaching a
    decision to solve the potential or real problem.

20
SITUATIONAL AWARENESS (SA)
  • The accurate perception or knowledge a crew
    maintains to their operational environment in
    order to anticipate contingencies and apply
    appropriate action.
  • Requires knowledge of where you have been in
    position, time, and space where you are in
    position, time and space and where you will be
    in position, time, and space.

WE DONT CONTROL THE ENVIRONMENT, WE ADAPT TO THE
ENVIRONMENT WITH OUR SKILL.
21
  • SA is the additional key element in the ADM
    decision making process.
  • SA is an important factor in preventing accidents
    as it encompasses all available information.

22
PILOT
AIRCRAFT
ENVIRONMENT
OPERATION
SITUATION
C H A N G E
E V E N T
SELECT RESPONSE TYPE
SKILLS PROCEDURES
HEADWORK REQUIRED
CREW MANAGEMENT (if present)
ATTITUDE MANAGEMENT
HEADWORK RESPONSE PROCESS
STRESS MANAGEMENT
CRITIQUE ACTIONS (post-situation)
RISK MANAGEMENT
23
EXAMINING CHANGES, GATHERING INFORMATION,
DEFINING THE PROBLEM
  • Problem definition is the first step in ADM.
  • Defining the potential or real problem begins
    with recognizing a change has occurred, will
    occur, or an expected change did not occur.
  • A problem is perceived first by the senses, then
    is distinguished through insights and experience.

24
DECIDE MODEL
  • Detect the fact that a change has occurred.
  • Estimate the need to counter or react to the
    change.
  • Choose a desirable outcome for the success of the
    flight.
  • Identify actions which could successfully control
    the change.
  • Do the necessary action to adapt to the change.
  • Evaluate the effect of the action.
  • The DECIDE model can provide a framework for
    effective decision making.

25
Detect the fact that a change has occurred
  • or Detect change
  • You cant solve a problem unless you know it
    exists.
  • Change exists when there is a difference between
    what is happening and what is desired to
    happen.

26
Estimate the need to counter or react to the
change
  • or Estimate its effect on the situation.
  • Requires that the pilot verify information and
    its effect on the situation.
  • Also requires us to determine if we need to react
    to the change.
  • Questions that help estimate the significance
    include
  • WHO is effected who is not?
  • WHAT situation is effected what related things
    are not effected?
  • WHERE is the problem?
  • WHEN did the problem occur?
  • Do areas effected by the problem effect other
    areas? to what extent?
  • Pitfall Too often, pilots detect change and
    want to immediately take action without thorough
    analysis.

27
Choose a desirable outcome for the success of the
flight
  • or Choose an objective
  • An objective is not an alternative it is the
    final measure of success.
  • Could also be an intermediate objective that will
    get the pilot back on track with the planned
    flight, or an entirely new objective.
  • Objective selection may be the most important
    step in the process as the final solution will be
    driven by the objective that is selected.
  • Pitfall Select the wrong objective and you will
    probably arrive at an incomplete or incorrect
    solution. As a result, the pilot may become
    wrapped up in crisis management.

28
Identify actions which could successfully control
the change
  • or Identify alternatives
  • The more choices available to decision makers,
    the more likely an optimal solution can be found.
  • Pitfall Too often, pilots believe that they
    dont have the time to consider other
    alternatives. Usually the first course of action
    considered is the one taken. Conducting only a
    superficial search for alternatives results in
    less than optimum decisions.

29
Do the necessary action to adapt to the change
  • or Do the best alternative
  • The risk to safety of each alternative should be
    assessed along with its conformance to
    established policies/laws/ rules/regulations/limit
    ations.
  • Effective pilots routinely update contingencies
    during the flight so that the time it takes to
    affect this step is minimal.
  • Act in accordance with the alternative that best
    satisfies flight and safety criteria.
  • Pitfall Too often, pilots take shortcuts in
    choosing the best alternative by willfully not
    complying with known policies/laws/rules/regulatio
    ns/limitations and/or ignoring effective risk
    management principles.

30
Evaluate the effect of the action
  • or Evaluate the decision
  • Provides the pilot/crew with feedback on the
    effects of their decisions.
  • In turn, provides information regarding the need
    to adjust to additional change.
  • If the alternative selected does not meet the
    objective, the process starts over again.

31
ADM GUIDING PRINCIPAL
  • Everyone knows the policies, regulations,
    procedures, and therefore will comply

WILL EVERYONE COMPLY???
32
ADM INADVERTENT DEPARTURES FROM POLICY
REGULATIONS
  • Attention Momentarily diverted to another task.
  • Memory Humans naturally forget information from
    disuse.
  • Attitude Sometimes the mind is not focused on
    the task at hand.
  • Stress The insidious nature of stress has a
    profound effect with respect to performance
    levels.

These momentary departures are not deliberate.
33
ADM PURPOSEFUL DEPARTURES FROM POLICY REGULATION
  • Mind Traps I know I can do thisdone it
    before
  • Lack of regard for perceived Meaningless
    regulations.
  • Perceived or actual pressure.

You start with a bag full of luck and an empty
bag of experience.
The trick is to fill the bag of experience
before you empty the bag of luck
34
NTSB ID FTW01LA166
The twin-engine helicopter departed on a
positioning flight to pick up a medical patient.
While in cruise flight, at 2,000 feet, both
engines experienced a total loss of power. The
pilot attempted to autorotate to a field
however, the helicopter impacted trees and came
to rest on its right side. The pilot reported
that he did not notice any warning lights
immediately prior to or during the loss of engine
power events. However, it was noted during a
post-accident examination of the helicopter that
the pilot instrument light and console light
variable resistor control was in the ON position.
This control dims the master caution and
annunciator panel lights for night operations.
The NTSB IIC noted that the master caution and
annunciator lights were not visible in daylight
with the pilot and console variable resistor
control in the ON position. Although the two
fuel transfer pump switches were found in the ON
(normal operating) position, examination of the
fuel system provided evidence that the dual
engine power loss was the result of fuel
starvation due to these switches not being ON
during the majority of the flight. The fuel
lines to the engines were found empty, a nominal
amount of fuel was found in the fuel filters, and
the fuel quantity indicator displayed 4, 0, and
15 gallons of fuel in the 1 supply, 2 supply,
and forward main fuel tanks, respectively. The
function of the fuel transfer pumps is to
transfer fuel from the forward main tank to the
two supply tanks. The fuel transfer pumps were
operated during the post-accident examination by
turning on their respective switches and it was
noted that fuel began to flow into the supply
tanks. Additionally, it was noted that the fuel
transfer pump caution lights (which are
illuminated when the pumps are off) extinguished
when the pumps were turned on. The engines were
placed in a test cell and both operated with no
anomalies noted. The normal operating checklist
calls, in part, for the pilot to set the
instrument lights as required, test the
annunciator panel for operation, and turn on the
transfer pumps after engine start.
35
NTSB ID FTW01LA166
36
ERRORS THE DECISION MAKING PROCESS
37
ENGINE OIL P
DOES THIS ALONE INDICATE A LOSS OF ENGINE OIL
PRESSURE?
38
ENGINE OIL P
IT MAY BE, BUT WITH ONLY ONE INDICATION, IT COULD
BE AN INDICATING PROBLEM.
39
ENGINE FAIL
DOES THIS ALONE INDICATE AN ENGINE FAILURE?
40
ACCURATELY DEFINE THE PROBLEM PRIOR TO INITIATING
CORRECTIVE ACTION!!!
41
DOES THIS INDICATE AN ENGINE FAILURE?
42
SUCCESSFUL ADM
  • Use all available information from human and
    hardware sources in identifying potential or real
    problems.
  • Always evaluate and crosscheck the available
    information in the operational environment to
    support or re-evaluate your actions.
  • Successful ADM requires a pilot to evaluate an
    entire range of possible responses to the
    detected change and determine the best course of
    action.

43
OPERATIONAL PITFALLS
  • Operational pitfalls are factors leading pilots
    into deteriorating situations with quite possibly
    disastrous ramifications.

44
  • Peer Pressure Poor decision making may be based
    upon an emotional response to peers, rather than
    evaluating a situation objectively.
  • Mind Set A pilot displays mind set through an
    inability to recognize and cope with changes in a
    given situation.
  • Get-There-It is This disposition impairs pilot
    judgment through a fixation on the original goal
    or destination, combined with a disregard for any
    alternative course of action.
  • Duck-Under Syndrome A pilot may be tempted to
    make it into an airport by descending below
    minimums during an approach. There may be a
    belief that there is a built-in margin of error
    in every approach procedure, or a pilot may want
    to admit that the landing cannot be completed and
    a missed approach must be initiated.
  • Scud Running This occurs when a pilot tries to
    maintain visual contact with the terrain at low
    altitudes while instrument conditions exist.
  • Continuing VFR into IMC Spatial disorientation
    or collision with ground/obstacles may occur when
    a pilot continues VFR into instrument conditions.
    This can be even more dangerous if the pilot is
    not instrument rated or current.
  • Getting Behind the Aircraft This pitfall can be
    caused by allowing events or the situation to
    control pilot actions. A constant state of
    surprise at what happens next may be exhibited
    when the pilot is getting behind the aircraft.
  • Loss of Positional or Situational Awareness In
    extreme cases, when a pilot gets behind the
    aircraft, a loss of positional or situational
    awareness may result. The pilot may not know the
    aircrafts geographical location, or may be
    unable to recognize deteriorating circumstances.
  • Operating Without Adequate Fuel Reserves
    Ignoring minimum fuel reserve requirements is
    generally the result of overconfidence, lack of
    flight planning, or disregarding applicable
    regulations.
  • Descent Below the Minimum En Route Altitude The
    duck-under syndrome can also occur during the en
    route portion of an IFR flight.
  • Flying Outside the Envelop The assumed high
    performance capability of a particular aircraft
    may cause a mistaken belief that it can meet the
    demands imposed by a pilots overestimated flying
    skills.
  • Neglect of Flight Planning, Preflight
    Inspections, and Checklists A pilot may rely on
    short- and long-term memory, regular flying
    skills, and familiar routes instead of
    established procedures and published checklists.
    This can be particularly true of experienced
    pilots.

White Knight Syndrome In air medical
operations, a pilot or crew may feel the need to
save the day. This involves taking unnecessary
risks under an assumption that the pilot has to
safe a life.
WE ALL HAVE VARYING LEVELS OF EXPERIENCE, BUT
DONT LET THE EXPERIENCE AT ANY LEVEL LEAD YOU
INTO A FALSE SENSE OF SECURITY WITH RESPECT TO
SAFETY. HIGH TIME, EXPERIENCED PILOTS ARE NOT
IMMUNE TO ACCIDENTS!!!
45
HAZARDOUS ATTITUDES
46
  • Anti-authority Dont tell me
  • Impulsivity I must do something quickly.
  • Invulnerability It wont happen to me.
  • Macho I can do it!
  • Resignation Whats the use?

47
COUNTERACTING HAZARDOUS ATTITUDES
  • Hazardous attitudes, which contribute to poor
    pilot judgment, can be effectively counteracted
    by redirecting that hazardous attitude so that
    corrective action may be taken.
  • Recognition of hazardous thoughts is the first
    step toward neutralizing them.
  • After recognizing the thought as hazardous, the
    pilot should label it as hazardous, and apply the
    corresponding antidote.

48
5 HAZARDOUS ATTITUDES ANTIDOTES
49
NTSB ID FTW89FA049
  • The aircraft crashed after contacting 70 tall
    high tension power lines while on a night
    non-emergency EMS mission. According to
    witnesses, weather was IMC with low overcast
    ceilings, ¼ to 1 mile visibility with rain and
    fog and thunderstorms throughout the area.
    Witnesses stated the rain varied from drizzle to
    very heavy. The pilot received three briefings
    from AFSS and was fully aware of the conditions.
    He had the authority to refuse the mission if, in
    his judgment, the weather was questionable or
    unacceptable. The hospital had written
    procedures for inadvertent flight into IMC which
    the pilot did not follow. Records fail to
    indicate that the pilot had reviewed these
    procedures nor do they indicate that the pilot
    had received any IFR training during his one
    month employment.

50
NTSB ID FTW89FA049
The NTSB determines the probable cause(s) of this
accident as follows THE PILOTS FAILURE TO
EXECUTE THE PUBLISHED INADVERTENT IMC RECOVERY
PROCEDURES WHEN HE ENCOUNTERED ADVERSE WEATHER
CONDITIONS.
51
RISK MANAGEMENT ASSESSMENT
52
RISK MANAGEMENT
  • Risk management is part of the decision making
    process which relies on SA, problem recognition,
    and good judgment to reduce risks associated with
    each flight.
  • It envelops both technical and non-technical
    skills.

53
RISK MANAGEMENT TECHNICAL SKILLS
  • Motor activities skills
  • Visual acquisition/interpretation of hazards
  • System control
  • Aircraft control
  • Procedural activities skills
  • Emergency/abnormal
  • Flight maneuvers
  • ATC communications
  • System operation
  • Information base/knowledge
  • Company policies/laws/rules/regulations
  • ATC/airspace
  • Weather
  • Aircraft limitations/performance

54
RISK MANAGEMENT NON-TECHNICAL SKILLS
  • Communications processes and decision making
  • Briefings
  • Inquiry/advocacy/assertion
  • Crew self-critique
  • Communications/decisions
  • Conflict resolution
  • Team building and maintenance
  • Leadership/followership/concern for tasks
  • Interpersonal relationships/group climate
  • Workload management and situational awareness
  • Preparation/planning/vigilance
  • Workload distributed/distractions avoided

55
RISK EVALUATION
  • Use information from CRM/AMRM resources to
    enhance SA
  • Human resources Solicit flight information from
    all groups working with pilots to insure flight
    safety.
  • Hardware Information from automated systems
    need to be consistently monitored to maintain
    situational awareness.
  • Information Manage information workloads for
    specific phases of flight. By planning ahead, a
    pilot can effectively reduce workloads during
    critical phases of flight.

56
RISK EVALUATION 3-P MODEL
  • A pilot should evaluate each segment in the 3-P
    model to enhance SA
  • Perceive.
  • Process.
  • Perform.

57
PERCEIVE PAVE
PROCESS CARE
PERFORM TEAM
58
PERCEIVE
  • Goal is to identify hazards, which are events,
    objects, or circumstances that could contribute
    to an undesired event.
  • Main rotor blade delamination would be considered
    a hazard.

59
PROCESS
  • Goal is to determine whether the hazards you have
    identified constitute risk, which is the future
    impact of a hazard that is not controlled or
    eliminated.
  • Degree of risk posed by a given hazard can be
    measured in terms of
  • Exposure Number of people or resources
    affected.
  • Severity Extent of possible loss.
  • Probability Likelihood that a hazard will cause
    a loss

60
  • Main rotor blade delamination hazard.
  • Poses a risk only if the helicopter is flown.
  • If exposed to normal operation, there is a high
    risk that it could fail and cause catastrophic
    damage to the helicopter, occupants, and
    persons/property on the ground.
  • No risk if the helicopter does not fly.

61
HIGH
SEVERE
MEDIUM
LOW
62
PERFORM
  • Alleviate the risk identified in the perceive and
    process stages
  • Determine what you can do to maximize safety
    free yourself from those conditions that can
    cause
  • Death, injury, or illness
  • Damage to equipment, property, or the environment
  • What constitutes an acceptable level of risk?

63
FOUR BASIC RULES
  • Accept no unnecessary risk.
  • Make risk decisions at the appropriate level.
  • Accept risk when benefits outweigh costs
    (dangers).
  • Integrate risk management into planning at all
    levels.

64
UNECESSARY RISKS
  • Hover solo a student during second lesson.
  • Accepting a flight below personal weather
    minimums.
  • Flying into thunderstorms.

65
RISK DECISIONS AT APPROPRIATE LEVEL
  • Decisions should be made by the person who can do
    something to reduce or eliminate the risk.
  • Who is final authority???

66
BENEFITS OUTWEIGH COSTS
  • With a student flight instructor, the benefits of
    performing touchdown autorotations may outweigh
    the potential dangers.
  • Must be a careful risk assessment and
    implementation of appropriate risk controls.

67
RISK MANAGEMENT PLANNING AT ALL LEVELS
  • Risk is an unavoidable part of flying.
  • Safety requires the use of appropriate and
    effective risk management before every flight.
  • We must develop risk management skills that are
    required to handle challenges that are not
    addressed by rules, policies, or beyond our
    experience.
  • Confined area operations.
  • At night.

68
ASK QUESTIONS
  • Most fundamental way to implement 3-P model.
  • To perceive Try to make a mental list of the
    hazards that can hurt you or others.
  • To process Consider how likely it is that a
    given hazard will hurt you, and how bad the
    injury or damage would be.
  • To perform Ask yourself what you can do to
    reduce or eliminate each hazard or risk you have
    identified, and then implement the measures you
    have selected.

69
USE CHECKLISTS
  • More structured approach to 3-P model.

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73
PERCEIVE PAVE
PROCESS CARE
PERFORM TEAM
74
INADEQUATE ADM
  • Dont overlook the basic airman tasks at hand
    while addressing other priorities.

The aircraft experienced a landing gear problem
while on approach to runway 28R at Portland
International Airport. The aircraft ran out of
fuel while the crew circled in an attempt to
remedy the problem.
75
EFFECTIVE ADM
  • Although the aircraft crashed, the crew managed
    to land on a runway saving 187 of 298. The CRM
    ADM utilized by the crew is of unparalleled
    competency and professionalism in aviation.

A United Air Lines DC-10 crashed at Sioux City,
Iowa after an engine explosion caused the total
loss of all hydraulics at FL370.  The crew was
able to control the plane only with engine
throttle settings. Miraculously, 187 of 298
aboard survived. (July 19, 1989)
76
THINGS THAT MAKE YOU GO
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80
NTSB ID CHI02FA288
  • The helicopter was destroyed when it impacted
    terrain during an emergency medical service
    flight. The accident occurred during a dark
    night, in a sparsely populated area with no
    lighted ground references. Marginal visual
    flight rules conditions prevailed along the route
    of flight. The pilot had a documented history of
    having difficulty flying at night without lighted
    ground references. The company base and safety
    managers reported the pilots night flying
    deficiency to the company chief pilot. The chief
    pilot subsequently evaluated the pilot during a
    night flight. After the evaluation, the chief
    pilot decided to increase the pilots nighttime
    weather minimums for a period of 25 night hours
    as he gained night experience. The accident
    flight occurred on the pilots fourth night
    mission after being evaluated by the chief pilot.
    Inspection of the helicopter wreckage did not
    reveal any evidence of a pre-impact malfunction.
    A review of the helicopters daily usage logs
    indicated that there were no unresolved
    maintenance discrepancies. The pilot who flew
    the helicopter prior to the accident flight did
    not report any malfunctions.
  • Probable cause Pilot spatial disorientation
    while flying in dark night conditions, resulting
    in a loss of aircraft control and the companys
    inadequate remedial actions after identifying the
    pilots night flying deficiency over areas
    without lighted references. A factor to the
    accident was the dark night conditions.

81
  • FOUR FATALITIES

82
PROFICIENCY
SKILL
DISCIPLINE
WHAT IS YOUR ATTITUDE?
83
END
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