Thoughts from a Helicopter Accident Board Meeting
I spent the morning watching the US National Transportation Safety Board (NTSB) meeting about the January 2020 helicopter crash that killed the pilot and eight passengers in Calabasas, California. This investigation was particularly high-profile because one of the victims was Kobe Bryant of basketball fame. While helicopter accidents happen regularly around the world, when a public figure is involved it becomes newsworthy to a wider audience.
Watching the board meeting, I took notes as multiple thoughts around operations and safety came to mind and I want to share some here. Each warrants a deeper look that may happen in future blog posts. But, for now I want to get them out in the hopes that they will make leaders stop and consider their own decisions as well as pilots and passengers to take pause and consider the risks.
Helicopter operators must have predetermined alternatives outlined in written policies that are clearly understood by all staff.
Obviously, one alternative is to just stay on the ground and cancel a flight if risk is too high or unknown. That is easy to say but in practice proves challenging. Some alternatives may be conducting a flight under IFR rather than VFR, delaying, or even transporting by ground. For an EMS operator this can be something like a predetermined process for requesting ground transport by ambulance or for a VIP/executive transport operator you could have established relationships with car hire services. Not getting bogged down in the specifics, the key here is that there must be a pre-planned and well documented process that makes this decision more routine and less of an urgent scramble to find solutions. Knowing that alternatives exist will help reduce the pressure on flight crews that may feel that flight is the only option.
A Safety Management System (SMS) that is only partially implemented is not enough.
As stated in the board meeting, of the 1,940 operators with an FAA Part 135 Certificate, only 158 (8%) are formal applicants voluntarily pursuing SMS though the FAA and only 17 (<1%) have a fully implemented SMS recognized by the FAA. It is notable that there are other avenues for an SMS besides the FAA, but the numbers are likely similar.
In 2016, the NTSB recommended that the FAA require SMS for Part 135 operators and since that recommendation they have formally reiterated it at least four times. Recently, the FAA Administrator did state that the FAA plans to mandate SMS in 2022, as I discussed in a previous blog post.
The operator did not effectively develop or implement all aspects of a Safety Management System. -NTSB
Many operators have started the process but have not finished implementing what could be described as a mature system. Fortunately, the NTSB’s Most Wanted List of Transportation Safety Improvements is up for renewal in March for 2021 - 2022 and it sounds like SMS mandates may make the “Most Wanted” list this time around. The approach will likely be two-fold, with the NTSB encouraging operators to voluntarily adopt SMS as well as continuing to pressure the FAA to mandate SMS sooner than later.
Photo Credit: CapDfrawy via Unsplash
If your risk assessment always indicates a “low” or “normal” risk, it is time to recalibrate so it reflects reality.
When assessing operations and safety of organizations, I commonly review historic risk assessments to look for this issue. Many times, I find that there are few (if any) risk assessments that reflect initial risk values above “low” even under conditions such as low visibility, night vision goggles, backup aircraft with dissimilar cockpits, or crews that are new to an area or type of flying. Additionally, few of these risk assessments consider compounding factors that may be relatively low risk alone but medium or high risk when combined. If this is the case it is unlikely that risks are being identified and mitigated appropriately.
Two pilots are better than one…except when they are not.
Finally, the topic of single vs. dual pilot operations was discussed by the board, and while on the surface it makes sense that two pilots are safer, that is not always the case. Yes, a second pilot can monitor the pilot flying, serve as a level of redundancy in the event of a medical emergency with the other pilot and can lower the overall workload. But if the operator does not provide an adequate multi-pilot training program or procedures outlining duties for “pilot flying” and “pilot monitoring,” the cockpit instead has two “single-pilots” that will lead to an increase in errors and the lack of tools necessary in recognizing and stopping an error chain from building.
More Reading:
NTSB WebCast: Board Meeting: Helicopter Crash, Calabasas, California
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