flight saftey detectives episode 194 - poor aviation decision making kills 7

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
• Focus on accomplishing the mission over operational discipline

“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.
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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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