ACCIDENT RECOVERY
By David Jack Kenny
Untangling the East River Crash A failure to “mitigate foreseeable risks” proves lethal.
A
VIATION’S APPROACH TO RISK management has evolved into a two-pronged strategy:
■ Try to identify every potential failure point and update your equipment, systems, and procedures to reduce or eliminate those hazards
■ Devise strategies, preferably multilay- ered, for coping with whatever emergen- cies arise from the hazards that remain. The results are safety features that have become so common that they’re taken for granted, from the redundancy of essential equipment to guards protecting flight- critical switches to company procedures limiting pilot discretion in marginal weather. And the risk mitigation process is nec- essarily iterative: when previously
overlooked hazards or rare combinations of circumstances result in accidents or emer- gencies, the industry responds with a fresh round of analysis, ideally leading to further improvements. Human nature and the high cost of equipment retrofits have made progress on some fronts very slow, but the long-term trend of aviation safety should arc toward the reduction of all risks not intrinsic to the act of flight itself. The March 11, 2018, ditching of a Liberty Helicopters AS350 B2 in New York’s East River drew widespread attention for several reasons, from the sequence of events that brought down the ship to the peculiarly awful manner in which all five passengers lost their lives. The accident triggered
renewed scrutiny of the controversial prac- tice of claiming exemption under 14 CFR 119.1(e)(4)(iii) to operate air tours under Part 91 without a letter of authorization through advertising them as photo flights, a prac- tice that the National Transportation Safety Board (NTSB) for many years has urged the FAA to ban. The incomplete inflation of the AS350
B2’s emergency floats prompted a fresh look at the rigging and maintenance of those systems. Most fundamental, though—and most damning—was the fail- ure the NTSB called out as the first contrib- uting factor in its finding of probable cause: the two operators’ “deficient safety man- agement, which did not adequately miti- gate foreseeable risks.”
The accident helicopter before the crash (passengers’ faces redacted). Note the configuration required for FlyNYON’s doors-off operation.
72 ROTOR 2020 Q2
ERIC ADAMS
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