Poor Aeronautical Decision Making and Operational Negligence Kills 7 - Episode 194
ฝัง
- เผยแพร่เมื่อ 28 ส.ค. 2024
- More money than brains? Todd, Greg, and John examine a fatal Bahamas helicopter crash where the pilots’ focus on what their billionaire boss wanted overrode operational discipline.
The 2019 Agusta AW139 helicopter crash at sea killed both pilots and all five passengers. While the crew had flown the route on at least 10 previous occasions, this was their first night flight.
Greg, Todd, and John raise many issues beyond the probable causes listed in the NTSB report:
• Inadequate flight planning
• Lack of a formal safety management system in the company that operated the helicopter
• The long duty day of the flight crew
“There were no mechanical issues. This is all about a lack of planning and poor decision making by the pilots,” John says.
The helicopter CVR does not indicate that the pilots did any of the proper checks for IFR at night. They also were not monitoring their gauges, and seemed to misread the instruments. Fatigue may have been a factor, since the pilots were awakened to make the 2AM flight.
John ends the show by encouraging pilots and aircraft operators to use flight risk assessment tools (FRAT) from the FAA and the NBAA to help prevent accidents.
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Music: “Inspirational Sports” license ASLC-22B89B29-052322DDB8
I thought the same one could have kept his eyes shut.
Yes Thankyou Guys.
From a GA pilot’s perspective, I picked up on a couple of things worthy of note during your presentation.
The first is that although I have around 3000 hours of fixed wing experience in my 51 years of flying, I have all of one rotor training experience. A few years ago, while my airplane was being annualed, I took a helicopter lesson, which lasted less than 2 hours. I was truly flabbergasted at how difficult it was to control-mere pressures on the cyclic, pedals, and collective were all that were necessary. The takeaway for this accident is that if there was spatial disorientation, distraction from passengers, poor CRM, or whatever, it didn’t take much to get bent out of shape. Translating that to typical GA airplanes, the control feel in some airplanes I’ve flown, notably Bonanzas and very light airplanes like C150s, is hugely different and significantly lighter than in other airplanes, such as C210s, PA32s, etc., which are trucks by comparison. Spatial disorientation and distractions can be much more of an issue when the controls are extremely light.
The other item was how different the same make and model can be-buttonology if you will, along with instrumentation, and where it’s all located in a pitch black night environment. My airplane is an over-equipped 63 P172D, actually built in September 1962, and the combination of relatively modern avionics in a 61 year old airplane means that anyone with even extensive 172 experience might feel completely out of place for awhile, until they learned where all the switches are, how the avionics work, even how to lower the flaps! While my airplane is a bit unusual, it’s emblematic of the fact that not all 172s are alike, nor are all of any other make and model.
Altitude, airspeed, brains you need two of the three to survive.
Airline operators need to strengthen quality control to ensure that aircraft are properly maintained and comply with standard operating procedures.
A very sad story. Keep your head on a swivel.
Night time this disorientation due to lighting is very real as I can attest to it. I was performing my night currency in a Cessna 150 which had very poor lighting in the cockpit. Some of the gauges, not really required as minimum equipment either had dim or, non-functioning light inside the instrument. To compensate for this I wore a light headband which I had on the lowest setting to illuminate against the instruments so that I can see clearly. Once you do that, I look straight out into the darkness with no ground lighting, or city lights, you easily become disoriented. A quick check of my attitude indicator on takeoff at approximately 500 feet above the ground I saw that I was in a 20° bank. Being instrument current I was able to easily correct the aircraft attitude, but it made me think about how easy it was to not realize which way is up when it’s dark out and your night vision is not stabilized.
You should have someone touch up the radium paint on those steam gauges :)
Seems like the standard was something along the lines of that 60’s tv series “Whirlibirds”. Seat of the pants flying into any circumstance.
Hey Greg great to see you back👍Always appreciate your input on these incidents🌟Thanks gentlemen.
Airlines need to take necessary measures to ensure engine safety. This includes routine maintenance and employee training on how to operate the engine safely.
FAA maintenance requirements are very specific and rigorous. Not being followed by an airline is a pretty significant violation. Same situation as regards training.
Greg your green screen is a little lacking still good to see you back.👍👍
When will you guys have some merch available? I really like your channel with your informative, accurate analysis and great educational value. I just started watching the channel and the banter between Greg and John is pretty funny. I have some hours in a Cessna 172, but decided it was too expensive. I probably should have turned to aviation as a career when I was younger. My uncle was a former captain for UPS and his son is a first officer for Jet Blue. Excellent work guys. Was there not a hospital where they were where they could have just gone by ambulance and not have to fly somewhere else? This shouldn't have happened.
This also shows the need for measures to be taken to improve pilot training and quality control procedures of airlines.
Airline companies need to take steps to minimize this risk, including adequately training employees, following safety procedures, and implementing strict quality control measures.
Great discussion - I have a question and I see it all over not just in aviation. What has changed in your industry for reports not to be so complete as they used to be? Is it the loss of expertise, poorer / quicker training, or something more insidious?
Welcome back trio. You three have been my “go to” for information and explanation about aviation “incidents” and “ accidents “ since the first episode of Air Crash Investigation. Greg with his compassion, professionalism colourful ties and braces. Todd with his straight faced telling how it is, and John with his many years of knowledge, and his endearing personality. Thanks to the trio for their wonderful, honest and “tell it how it is’, videos,,a big hand shake from a non pilot who would loved to have flown but don’t have the money so vicariously I enjoy it all thru people like you three. Don’t forget your fans. A lot of big channels do. A hello or a short reply to a question goes a long way,, 🌈❤️❤️🦘🦘🦘
Im still a student pilot with about 30 hours. At this point in my journey, my use of checklists are constant and systematic. Will that change at any point in my career? It sounds like use of checklists in this instance may have been could have changed the scenario.
Thankfully legit med-evac companies have procedures to refuse missions and have 3 to go/1 to say no crew policies without repercussions on crews.
True, but it's rather amazing how many fatal crashes medevac helicopters have in recent years.
How much life insurance do you have? Who cares, Greg? Once you're dead, you're dead. Where do they send the insurance money to? Heaven, purgatory or hell, and what are their postal addresses? My last word is: If it's dark outside, there is nothing to see there. Keep pour eyes inside. Keep them on on your instruments. That's what they're there for.
I’m trying to feel sorry for the coal billionaire but I’m really struggling lol. Imagine having enough money to end child hunger in America, but instead just hoarding it all and using .001 percent of the money on parties in the Bahamas. RIP to the pilots and the innocents though.
Re: the altimeter it does sound like they had two different readings, maybe a radar altimeter and a regular one that they hadn’t entered in the right pressure? I can see how at sea level they might just incorrectly assume it stays the same as long as they are near sea level.
I'm with you, its not fair to hold riches against the person but I do anyway.
Not sure about helicopters, but on our 727's there were 3 altimeters plus GPWS. Radio altimeter, one altimeter set to sea level altitude (QNH) and the other to QFE altitude above the field.
"When they put flying nurses on board, oftentimes they put a lot of pressure on the flight crew to do things they shouldn't do". WTF?! Flight nurses and paramedics, besides being active crewmembers themselves with flight veto power in any decent professional HEMS operator, don't want to die any more than the pilots do, and neither of them are going to kill themselves and their patient if they can help it. This is highly insulting and blatantly untrue and you show your prejudice and ignorance by saying such a thing! In fact, HEMS flights have gone down exactly because the pilot ignored the medical crew who 'didn't know anything' and flew when they shouldn't have. Uneffingsub and downvote!