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MY 2 CENTS WORTH Why is this a red flag?


Section 4.17.2 “Bases not allowed to go out of service” reads:


Several current and former pilots relayed concerns that they were never able to issue a “red” risk assessment and take the base out of service for any reason including, maintenance, fatigue, or weather.


One pilot stated that if that happened the “owner would be calling blowing up our phones, hey...why are you guys still out of service, why are you still out of service, where is the mechanic, is the mechanic working on it, is he done with that inspection yet or – put the cowlings back on. Put it back together. We got to get back – this is the culture of like ‘hurry, hurry, hurry, we cannot be out of service for anything.’”


Why is this a red flag?


I have listed only a few of the incidents from this report, as a way to highlight the importance that human factors play in the formulation of an accident. I cannot think of


anything more tragic (and frustrating) than holes in Reason’s “Swiss cheese” model of identified factors, but no action taken to address them. Rachel Cunningham, the flight nurse who lost her life in that crash, voiced her concerns in a six-page email to her management 13 months before the accident. The NTSB report titled it Attachment 4, “Accident Nurse Letter to Human Resources.”


I am heartened to see the NTSB examining the human factors relating to this helicopter accident, because that isn’t normally done. The NTSB should examine the human factors in every HAA accident, as is done in every airline accident, because the data accumulated by Dr. Ira Blumen and his “Opportunities for Safety Improvement” study showed that 94% of HAA accidents have an element of human error. For that reason, it came as no surprise to me that the Survival Flight crash in January was no exception.


Randy Mains is an author, public speaker, and AMRM consultant who works in the helicopter industry after a long career of aviation adventure. He currently serves as chief CRM/AMRM instructor for Oregon Aero.


He may be contacted at: info@randymains.com


rotorcraftpro.com


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