Aviation accidents are rarely the result of a single error. NTSB findings of probable cause have frequently listed a number of factors which contribute to a crash. A false positive warning light commanding the crew’s attention, some event (weather or mechanical) creating a real threat, the crew identifying the real problem late and a unduly precipitous response by one of the crew is a stereotypical string of events on the way to an accident.
The NTSB has issued a determination of probable cause as to the above helicopter crash in Mosby, MO. The report lists a string of contributing factors:
- the pilot’s distracted attention due to personal texting during safety-critical ground and flight operations,
- his degraded performance due to fatigue,
- the operator’s lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and
- the lack of practice representative of an actual engine failure at cruise airspeed in the pilot’s auto-rotation training in the accident make and model helicopter.
The point of determining probable cause is to create lessons for pilots and aviation companies so they can avoid the errors found by the NTSB. Here, the Board identified 4 contributing factors. Fatigue, inadequate policies, and inadequate training are common themes.
What is notable here is the NTSB’s inclusion of a probable cause that is on their Most Wanted List — ELIMINATE DISTRACTION IN TRANSPORTATION.
Chairman Hersman highlighted this factor in her opening statement:
“More than a century ago when talking about the safety of flight he said, ‘Greater prudence is needed rather than greater skill.’ Greater prudence. We will hear about greater prudence today. We will also hear about an accident that juxtaposes old issues of pilot decision making with a 21st century twist: distractions from portable electronic devices.”
Was texting highlighted to support an NTSB thematic concern or was it truly justified? There is little or no doubt that texting should not be an activity of a crew member in flight; the only question is whether the pilot’s messaging contributed to the chain of events that caused the crash.
Oddly enough, according to reports, one NTSB member, Earl Weener, PhD, dissented stating from his perspective that there was no causal link between the texting and the accident. He laid blame on a tired pilot who made a series of bad decisions.
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