Due to their inherent hazards and lethal potential, aviation accidents constitute critical events requiring thorough investigations. Their major purpose is the identification of the primary causes and the development of possible ways to eliminate future occurrences. However, experience has demonstrated that a single factor, which may be evident at first glance, should never be treated as the sole contributor. Based on it, the International Civil Aviation Organization (2018) has adopted a “Swiss-Cheese” model implying that accidents always involve breaching several associated lines of defense belonging to various activity areas.
Moreover, the latest trend provides for focusing on the organizational issues and interactions between various components of the aviation system instead of simply considering technical and human factors (International Civil Aviation Organization, 2018). The two helicopter accidents, selected for review within this paper, perfectly demonstrate the correctness of such an approach and the complexity of causes lying behind them. Therefore, identifying the similarities between them and the ways they could be prevented by a mature safety management system is crucial for eliminating their future repetitions.
To begin the review, it is essential to note certain common aspects, that led to both accidents. First, a noticeable point is the lack of proper preflight planning and insufficient crew qualification for the mission complexity. In the case of the Alaska crash, the pilot failed to obtain a formal weather briefing, which could preclude him from performing the flight without instrument flying equipment and currency (National Transportation Safety Board, 2013). A similar situation developed in New Mexico where the pilot initially refused to perform the mission but finally agreed due to its perceived simplicity (National Transportation Safety Board, 2009).
The next step was the high evaluation of the goal and pilots’ willingness to fulfill it despite the emerging hazards. It was also supported by the dominant attitude in the organizations, which insisted on completing the missions and accepting the inherent risks. Then, both pilots had limited support from the ground crews as they did not receive full information about the state of the people to be rescued. Finally, willingness to return home persuaded the flight crew into making risky decisions. Combined, this created all the prerequisites for both accidents to take place.
The major part, which could contribute to the prevention of such accidents, is an implementation of a mature safety management system. It should constitute a comprehensive safety-oriented approach “including the necessary organizational structures, accountability, responsibilities, policies and procedures” (International Civil Aviation Organization, 2018, p. viii). Still, the investigation reports mention the absence of such a system in the organizations owning the accident helicopters (National Transportation Safety Board, 2009). Moreover, public aircraft were excluded from the relevant requirements imposed by the Federal Aviation Administration.
Following the safety management principles would require an organization to conduct a full risk assessment prior to accepting a mission. Moreover, it would modify the decision-making process during the flight and give priority to the mitigation of emerging hazards. The relevant training would reduce the mission-induced pressure and prevent the “tendency toward risk-taking in the line of duty” (National Transportation Safety Board, 2009, p. 53). Finally, more stringent control over duty time would decrease the likelihood of fatigue. Therefore, the development of a safety-oriented culture in the organization could restore many lines of defense, which needed to be broken for these accidents to happen.
Another critical aspect of the required system is safety data analysis and reporting. The primary goals in this regard are to “discover useful information, suggest conclusions and support data-driven decision-making (International Civil Aviation Organization, 2018, p. 6-1). Thus, such an approach would be capable of identifying certain hazard areas mentioned as contributing factors during the investigations. First, it would raise the issue of inadequate pilot training.
Although the search and rescue missions are supposed to be conducted under visual conditions, their character and duration are often unpredictable, and mountainous areas are prone to unforeseen weather changes. Analysis of previous encounters with instrument meteorological conditions would demonstrate the need for specialized pilot training and onboard equipment. Besides, such a system would preclude the focus on blaming the flight crews for the accidents, which was mentioned by the investigators (National Transportation Safety Board, 2013). In the case of the Alaska crash, this change might have made the pilot more willing to conduct a precautionary landing instead of accepting the risk of a weather-related accident. Thus, analysis of previous incidents and existing trends could improve situational awareness and enhance the decision quality.
The review of the two accidents provided in this paper demonstrates striking similarities between them and identifies critical advances, available through the implementation of a safety management system. Although the crashes were separated by several years and thousands of kilometers, the same human and organizational factors played their role. They included inadequate pilot training and preparation, their willingness to accept the hazards and complete the mission, lack of ground support, and failure of the management to establish a proper safety culture. The development of a comprehensive system could adjust the priorities and make risk assessment a prerequisite for any flight.
It would also identify the existing hazards and lead to introducing changes to the required flight crew qualifications. Finally, the new approach would detect dangerous trends in pilots’ behaviors prior to any undesired outcomes. Therefore, a safety management system is a powerful tool allowing to break the error chains and prevent many lethal accidents.
References
International Civil Aviation Organization. (2018). Safety management manual (4th ed.). Web.
National Transportation Safety Board. (2009). Crash After Encounter with Instrument Meteorological Conditions During Takeoff from Remote Landing Site New Mexico State Police Agusta S.p.A. A‐109E, N606SP. Web.
National Transportation Safety Board. (2013). Crash Following Encounter with Instrument Meteorological Conditions After Departure from Remote Landing Site Alaska Department of Public Safety Eurocopter AS350 B3, N911AA. Web.