Bo105 Loss of Control in DVE & Water Impact
Bo105 LOC-I in a Degraded Visual Environment & Water Impact (C-GGGC Canadian Coast Guard, Newfoundland 2005) On 7 December 2005, while supporting lighthouse operations, Canadian Coast Guard (CCG) MBB Bo105 C-GGGC encountered heavy snow showers and impacted the water in Mortier Bay, east of Marystown, Newfoundland. Both occupants survived the impact and egressed the helicopter but died before they were rescued. The Transportation Safety Board of Canada (TSB) issued their safety investigation report 1 November 2006. The Accident Flight The helicopter, based in St John’s, Newfoundland and operated for CCG by operated by Transport Canada (TC) Aircraft Services Directorate (ASD), was first tasked to move personnel and cargo to the Green Island lighthouse, 7 NM off Burin Peninsula. It was then to proceed to Marystown, to pick up a CCG technician and shuttle them to various Aid to Navigation (AtoNs) around the Burin Peninsula. The pilot had been flying helicopters for the CCG in Newfoundland for 27 years and had accumulated over 20,000 helicopter flying hours. He was not instrument rated and did not have a night endorsement. The pilot filed a visual flight rules (VFR) flight plan, foreseeing a completion of the flying programme “by 15:00”. The TSB report later states 17:00. The helicopter departed at 10:29. During the morning the helicopter encountered snow and made an unscheduled shutdown at a shipyard at Marystown to await better weather. There was another weather delay, this time at Winterland Airport, in the afternoon. After completing the Green Island lighthouse tasking, the helicopter arrived at Marystown at c 14:52. After collecting the technician the helicopter flew c 3NM to a small landing site at Go By Point, at the entrance to Mortier Bay. This site is on steep and rocky terrain next to an AtoN. At 15:17, the pilot reported to the flight follower at the CCG’s Marine Communications and Traffic Services (MCTS) that they had landed at Go By Point, anticipating one hour of work on site. While at Go By Point, the pilot took several photographs. Two photographs taken within 10 minutes of arrival showed sunny conditions, clear sky and unrestricted visibility. However, at 15:30, security camera at Cow Head (3.5 NM north) showed a heavy snow shower was underway. Snow was intermittent for about an hour and was light at the time of departure. The exact time of the helicopter’s departure from Go By Point is not known as now radio call was received. The helicopter did a low orbit of Duck Island, just east of Go By Point, likely assessing the landing site for a visit the next day. The helicopter then flew anti-clockwise around the shoreline of Mortier Bay as darkness approached. The helicopter would have gradually encountered heavier snowfall as it flew north. TSB explain that: Once established on a westerly heading towards Marystown, it would have been difficult to turn around when severely reduced visibility was encountered because a turn to the right would have required flight into rapidly rising terrain with a possibility of encountering whiteout conditions. A turn to the left would have placed the helicopter out over the water and caused the pilot to lose visual contact with the coast. When last observed by witnesses, the helicopter was about 1 NM east of Marystown, flying slowly at low altitude, in heavy...
read moreLoss of Control After Powerbank Jams Helicopter Collective
Loss of Control After Powerbank Jams Collective (Executive Helicopters Airbus EC155B1 EI-XHI, Shannon) On 15 September 2022, Airbus EC155B1 EI-XHI of Executive Helicopters was hover taxying on arrival at Shannon airport, when it suffered loss of control. The helicopter suffered substantial damage but no one was injured. The Irish Air Accident Investigation Unit (AAIU) issued their safety investigation report on 11 November 2025. The Accident Flight The helicopter was positioning from Kylebrack helipad to Shannon. The pilot was the sole occupant and had 12,591 hours total experience and 1,096 on type. The helicopter was flying at a ground speed of c 74 knots as it joined D1 taxiway towards the Light Aircraft Parking (LAP) area. The AAIU note that at the time… …cargo aircraft were being loaded and unloaded on the central apron and east apron areas adjacent to the LAP. On approaching the exit to the LAP area, now at c 43 knots… …the Pilot increased the helicopter’s pitch angle and then attempted to flare the helicopter in order to enter a hover. The Pilot stated that despite a number of attempts, the collective pitch lever “…would only move up one to two inches from the full down position” that it had been in during the approach to the LAP. The helicopter lost altitude and impacted the taxiway with considerable horizontal and vertical acceleration. The impact damaged the left main undercarriage, sheared the torque link of the nose landing gear and caused significant structural damage to the helicopter. Witness confirmed the impact was “nose heavy”. Impact marks on the taxiway indicate that the nose wheels impacted the ground to the left of the taxiway centreline, 31 m before the entrance to the LAP area. The impact was sufficient to activate the g-switch of the Emergency Locator Transmitter (ELT). The Multi-Purpose Flight Recorder (MPFR) also stopped recording. Its g-switch was set to 6 g. The residual forward momentum…resulted in the helicopter transiting along the taxiway towards the central and east apron areas of the airport following impact. The helicopter remained upright as it continued to travel along the ground towards ground personnel and cargo trailers that were located on the parking stand side of the ATC boundary line at Stand 24/24A in preparation for the pending arrival of an inbound cargo aircraft Seeing the approaching helicopter ground personnel wisely took what AAIU coyly call “evasive action”! The pilot struggled to slow the aircraft and was cognisant of the risk of an aircraft roll over, steering the helicopter to the left with differential braking to avoid a collision. The helicopter travelled along the taxiway and crossed the ATC boundary line adjacent to parking Stand 24/24A before it turned to the left towards the east apron area, where it came to rest. The nose landing gear torque link was found fractured. The fractured torque link had worn flat scraped along the concrete surface. There was significant structural disruption of the fuselage evident in the nose-to-cabin attachment area. The plot was sat on B/E Aerospace Fischer 230/260 H110 type / 9606 model crashworthy seat with a 5 point harness and was uninjured. The Safety Investigation Following shutdown of the helicopter, the Pilot identified that the collective pitch lever had been restricted from its full motion of travel by the portable power bank unit...
read moreAS350 HESLO Fuel Incident (Superabsorbent Polymer Contamination)
AS350 D-HEWU HESLO Fuel Incident (Superabsorbent Polymer Contamination) On 16 July 2024, Airbus AS350B2 D-HEWU, operated by Heli Transair, made a forced landing in Wiesenbach, Bavaria, while engaged in Helicopter External Sling Load Operations (HESLO). The German safety investigation body, the BFU, released their safety investigation report on 14 May 2025. The Day’s Operations The HESLO task for the day was forest liming, operated under a Part-SPO declaration for specialised operations. This involved a 25 meter line and a ‘bucket’ with a 180 kg empty mass. The 28 year old pilot, who was also the operator’s Flight Ops Manager, had c2,400 hours total, c1,325 hours on single-engine turbine helicopters (c 94 on type) and c1,300 external load flights. The pilot performed a pre-flight check that morning. This including sampling the helicopter’s main fuel tank. Approximately 10 ml of water was found during the first draining, but no water was found during the second draining. The helicopter was refuelled from a 1000 litre Ford Transit fuel bowser with 60 liters of Jet A1 fuel. The use of a mobile fuel source is very common in HESLO to maximise the underslung payload capacity. There were no issues during the first, 50 minute / 35 load, flight during which 130 litres of fuel were burnt. The helicopter was then refuelled with 160 liters of fuel. The next 40 minutes / 26 loads proceeded without incident. The BFU report that: Then, while picking up a new load—the bucket was filled with approximately 750 kg of lime—the pilot noticed that the main rotor speed dropped, but without triggering the audible low-rotor RPM warning. During cruise flight, the parameters remained normal and unremarkable. Therefore, the bucket was subsequently filled with less lime than usual, and the helicopter was flown with a lighter external load. After another 10 minutes and 5 circuits, a sudden yaw occurred while picking up a new external load. The pilot suspected a momentary loss of power and responded accordingly by reducing power and deploying a flare. Then engine power was available again, and he landed the helicopter safely on site at the loading area on a forest path. The pilot took an aircraft fuel sample and found “significant amount of contaminated fuelor a brown-colored liquid”: The tank was drained further until only clear fuel remained. The bypass indicator of the airframe fuel filter did not trigger. After consultation with the [operator’s] CAMO [Continuing Airworthiness Management Organisation] the engine was restarted and the helicopter parked on a level surface, with the assistance of the company’s maintenance manager. After a waiting period, more contaminated fuel was drained, so it was decided to completely empty the tank. Fuel was then delivered to the aircraft from “another vehicle”. There was a 190 litre uplift. After another pre-flight check, first a ground run, then a heavy hover, each lasting several minutes, were performed. Since all parameters were normal, the pilot decided to continue the forest liming operation. [The] pilot positioned the helicopter above the bucket to pick up the load [of] c600 kg of lime. [When] the bucket was about 8 meters above the ground, the helicopter yawed, the main rotor speed decreased, and the low-rotor RPM warning sounded. The pilot initiated an autorotation and headed for an area with flatter vegetation inthe forest. The helicopter landed nose-down...
read moreFirefighting K-Max Water Impact After A Close Pass by a S-64 Skycrane
Firefighting Kaman K-Max Water Impact After A Close Pass by a Sikorsky S-64 Skycrane (Precision Lift N171PL) On 22 August 2025 Kaman K-1200 K-Max N171PL of Precision Lift LLC impacted a lake near Eagle, Colorado while refilling an underslung firefighting bucket with water. The US National Transportation Safety Board (NTSB) published a rapid brief, final safety investigation report on 17 October 2025. The K-Max pilot had: 26091 hours (Total, all aircraft), 1445 hours (Total, this make and model) The pilot stated that (our emphasis added)… …there had been wind gusts throughout the day and a right quartering tailwind of approximately 15 kts was present when he was refilling the bucket. When… …another helicopter flew by his helicopter about 50-100 yds right and 150 ft above his position, he felt a push to the left. While not mentioned in the NTSB report, the accident report form reveals this was a much larger 19 t Erickson S-64 Skycrane. The NTSB remarkably does not comment on this loss of separation and the downwash risk. The K-Max pilot… …pulled back on the cyclic control, but he could not recover the helicopter, which continued pitching to the left. The K-Max descended and impacted the lake and “sustained substantial [damage] to the main rotor blades”. The pilot was able to egress the aircraft and swan to the bank, where the Helico (Helicopter Coordinator) landed and flew him to hospital for a check-up. The pilot stated there was no prior aircraft malfunction or failure. NTSB determined the probable cause to be a rather simplistic and unhelpful: The pilot’s failure to maintain helicopter control which resulted in an uncontrolled descent and impact with terrain. The NTSB make no formal safety recommendations nor do they highlight any safety messages. In contrast the pilot made the following recommendation in the accident report form: More separation of rotorcraft. I had been working one part of the fire and dipping out of this pond. The sky cranes had been working another section of the fire until they got smoked out. Air attack moved them over to the side I had been working. When the sky crane flew by it caused a downwind vortice [sic – vortex] which I could not recover from. A thorough investigation would have considered the coordination of firefighting aircraft and sought statements from other stakeholders. Safety Resources The European Safety Promotion Network Rotorcraft (ESPN-R) has a helicopter safety discussion group on LinkedIn. You may also find these Aerossurance articles of interest: Limitations of See and Avoid: Four Die in HEMS Helicopter / PA-28 Mid Air Collision Alpine MAC ANSV Report: Ascending AS350B3 and Descending Jodel D.140E Collided Over Glacier Mid-Air Collision of Guimbal Cabri G2 9M-HCA & 9M-HCB: Malaysian AAIB Preliminary Report AAIB Highlight Electronic Conspicuity and the Limitations of See and Avoid after Mid Air Collision Military Mid Air Collisions Fatal Biplane/Helicopter Mid Air Collision in Spain, 30 December 2017 A319 / Cougar Airprox at MRS: ATC Busy, Failed Transponder and Helicopter Filtered From Radar Mid Air Collision Typhoon & Learjet 35 UK CAA HOFO ACAS Rulemaking 2025 & a 2004 Tornado / AS332L Airprox Firefighting Bucket Snags Trees During Autorotation Helicopter Tail Rotor Strike from Firefighting Bucket Crew Confusion in Firefighting 737 Terrain Impact Aerossurance has extensive air safety, flight operations, aerial firefighting, airworthiness, human factors, aviation regulation and...
read moreH130 Sucks Out Hangar Window; Main Rotor Blade Damaged by FOD
Airbus H130 (EC130T2) Sucks Out Hangar Window; Main Rotor Blade Damaged by FOD (N3WL, Moab, UT) On 13 February 2025 privately owned Airbus H130 (EC130T2) N3WL was damaged by FOD in the hover at Canyonlands Regional Airport (CNY/KCNY), Moab, Utah. The US National Transportation Safety Board (NTSB) rapidly released a short final report on 9 May 2025. The pilot told the NTSB that shortly lifting into the hover, a window dislodged from a nearby hangar door and impacted a main rotor blade from behind. The pilot initiated an emergency landing, landing hard, but without injuries to the 7 occupants. Although the image below seems to indicate damage to the skids, no such damage is reported by NTSB. The pilot made two suggested safety recommendations to prevent a reoccurrence: A more detailed inspection of the hangar Departing from a position further away from the hangar Safety Resources The European Safety Promotion Network Rotorcraft (ESPN-R) has a helicopter safety discussion group on LinkedIn. You may also find these Aerossurance articles of interest: Fire Extinguisher Cover Fenestron FOD FOD and an AS350B3 Accident Landing on a Yacht in Bergen Air Ambulance Helicopter Downed by Fencing FOD Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital HEMS Downwash Injuries: Two More Case Studies Tool Bag Takes Out Tail Rotor: Fatal AS350B2 Accident, Tweed, ON Loose Clothing Downs Marijuana Survey Helicopter When Habits Kill – Canadian MD500 Accident EC120 Forgotten Walkaround Fenestron Failure EC130B4 Hawaii Business Jet Apron Jet Blast Injury BP has shared a video on the threat of downwash (albeit with larger helicopters). Aerossurance has extensive air safety, flight operations, airworthiness, human factors, helideck, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn, Blue Sky @aerossurance.bsky.social and Twitter @Aerossurance for our latest...
read moreA Screw in the Wrong Place…A Loss of Hoist Cable
A Screw in the Wrong Place…A Loss of Hoist Cable (Honda Airways AW139 JA03FD Breeze-Eastern Hoist) On 17 February 2024, Leonardo AW139 JA03FD of Honda Airways, operated for the Saitama Disaster Prevention Air Squadron, inadvertently released the hoist cable and test load during a post-maintenance hoist check at Honda Airport, Kawajima. The Japan Transport Safety Board (JTSB) issued their safety investigation report on 25 May 2025. The Serious Incident Flight The helicopter’s hoist cable had been replaced and so a post-maintenance check flight was necessary. On board were two pilots, an Air Squadron Officer (ASO – the hoist operator) and a mechanic (‘Mechanic A’, acting as a hoist instructor). The JTSB explain: The load test required after cable replacement, confirms each function of hoist operates normally with maximum hoist load, 600lb (about 272 kg). In this case, the cable had been replaced the day before by Mechanic B and C, and it was planned to conduct load test, with 136 kg…and [then] 272 kg….on the hook at the end of the cable. This would be achieved using two and then four 68 kg weights. At about 10:17, for the first load test, the helicopter reeled out the cable to the ground at a hovering height of about 50 ft, and ground crew hooked a 136 kg weight. The helicopter then climbed to hovering altitude of about 340 ft, the Air Squadron Officer began to reel out cable to the maximum length (about 300 ft), which was for Mechanic A to confirm that it would automatically stop at the maximum length. As the cable reached its maximum extension “the weight fell to the ground along with the cable” near Taxiway E4. There were no injuries or damage. The helicopter had an electrically operated Breeze-Eastern hoist: The cable is 307 ft (about 93.5 m) long, has a diameter of 4.75 mm, and is wrapped on an aluminum drum. The cable is inserted in the slot of drum and fixed by tightening the screw against the cable strand. As the end of the cable is welded to prevent fraying, the screw must contact the cable strand and not the welded end. The hoist is fitted with limit switches which automatically stop the drum when remaining cable gets to 3.5 to 4.5 wraps. Unacceptable ‘bird caging‘ damage had been found on the previous cable fitted to the hoist so on 15 February 2024 ‘Mechanic B’ (a licenced engineer) began to unwind the old cable using the thumb wheel on the hoist pendant. Mechanic B stopped unwinding when the full-out limit switch actuated and the drum stopped, confirmed that the number of cable wrap which was 4 remaining on the drum and took a photo with his smartphone. And then, Mechanic B removed the screw which fixed the cable end…to pull out the old cable from the slot on the drum and completed the day. The AW139 Aircraft Maintenance Manual (AMM) however required the limit switch be overridden and the cable fully paid out. The AMM also discusses this screw, saying: Make sure that the screw engages sufficiently the cable end to safety the cable correctly into the drum shoulder. To do this, you can see only a small part of the cable white mark that goes out of cable housing in the drum shoulder...
read moreCold Comfort Conference Call: USAF F-35A Alaska Accident
Cold Comfort Conference Call: USAF F-35A Alaska Accident On 28 January 2025 US Air Force Lockheed Martin F-35A 19-5535 of the 355th Fighter Squadron crashed and was destroyed at Eielson Air Force Base (AFB), Alaska (a total loss valued at $196.5 mn). The pilot ejected and suffered only minor injuries. The USAF released their Accident Investigation Board (AIB) report on 26 August 2025. A USAF AIB does not conduct a safety investigation (a separate Safety Investigation Board [SIB] is convened but their report is not released publicly), instead (our emphasis added): In accordance with AFI 51-307, Aerospace and Ground Accident Investigations, this accident investigation board conducted a legal investigation to inquire into all the facts and circumstances surrounding this Air Force aerospace accident, prepare a publicly-releasable report, and obtain and preserve all available evidence for use in litigation, claims, disciplinary action, and adverse administrative action. The Accident Flight A Landing Gear Fault After Take Off The accident aircraft was number 3 of a flight of four 355 FS F-35As, callsign YETI, that was to conduct an Air Combat Maneuvers (ACM) sortie with two other F-35As, callsign CHEVY. The 355 FS is part of the 354th Fighter Wing (354 FW). The pilot of YETI 3 was a current F-35A evaluator and instructor pilot with 2702 hours in total (555 hours on type). Shortly after takeoff, the pilot of YETI 3 received an OVERSPEED GEAR caution. They identified that instrumentation showed yellow and black hash marks for the Nose Landing Gear (NLG) that indicated ‘gear in-transit’. Their wingman reported the NLG door was “open by about 2 inches”. The pilot followed the necessary checklists, which included lowering the gear and conducting flight control system resets. The NLG was initially angles c25 degrees left. This was reduced to c17 degrees during this fault finding. Calling a ‘Conference Hotel’: Fault Finding Technical Support Call with Lockheed Martin The pilot then requested a ‘Conference Hotel’, namely a conference call with Lockheed Martin engineers. This was swiftly organised through the on-duty Supervisor of Flying (SOF) at Eielson AFB. Although the AIB don’t say when this call was requested it appears to have been set up in less than 20 minutes. On the call were the Eielson SOF, a “senior 354 Operations Group (354 OG) leader” and 5 Lockheed Martin engineers (a senior software engineer, a flight safety engineer and three landing gear systems engineers). The Eielson SOF was in turn in contact with the pilot. According to the AIB report the engineers… …requested information on, among other things, how much fuel the MA [Mishap Aircraft] had remaining, direction of the NLG wheel, and health reporting codes [HRCs]. The AIB then says that they… …did not request or receive information about where the mishap was occurring and ambient air temperature. That’s an odd observation because presumably they did know the call was arranged by the Eielson SOF, that Eielson AFB is in Alaska and that in January Alaska is rather chilly…! Initially an arrestor landing was mooted, but the pilot pointed out that “cable arrestment must be in a 3-point attitude” according to the published procedures, meaning the NLG would have to be on the ground prior to the cable engagement. That course of action was abandoned because of the concern that an uncentered nose wheel could...
read moreFlat Light B206L4 Alaskan CFIT & 11 Hour Emergency Response Delay
Flat Light B206L4 Alaskan CFIT & 11 Hour Emergency Response Delay (Maritime Helicopter, Bell 206L4 M311NH) On 20 July 2023 Bell 206L4 N311MH of Maritime Helicopters, was destroyed when it impacted the surface of Lake Itinik, c30 miles east of Wainwright, North Slope, Alaska. The pilot and three passengers died. The helicopter was contracted by the Alaska Department of Natural Resources (DNR) to transport scientists to various remote locations. The US National Transportation Safety Board (NTSB) published their safety investigation report on 20 August 2025. The Accident Flight The NTSB explain the pilot recently retired from the US military and this was his first civil job as a pilot, commencing in October 2022. NTSB state he had about 1,900 hours of flight experience in helicopters, 80 on type, 140 in Alaska. The pilot flew the helicopter from Fairbanks to Utqiagvik (formerly Barrow) two days before the accident flight and had flown the previous day. On the day of the accident the helicopter departed on a Visual Flight Rules (VFR) flight at c 10:01 Local Time according to data from the aircraft’s Honeywell SkyConnect satellite tracking system, which broadcast every 3 minutes. According to the NTSB: Management personnel from Maritime Helicopters, as well as personnel from DNR had real-time flight following capabilities of the accident helicopter. It appears the morning departure had been delayed by fog according to a message to the DNR from one of the passengers. It was on the ground for c10 minutes Atqasuk Airport (PATQ) but the satellite tracking system last received data at 11:04. Noticeable is the helicopter was never above 266 ft msl. NTSB note that the day before Sky Connect Tracker data for the same pilot and helicopter showed “an average altitude of about 200 ft msl with an average airspeed of about 105 knots”. No information is provide by NTSB on where the helicopter was heading of what the scientists’ objectives were. At about 11:12 the Sky Connect system sent out an overdue aircraft report, but that report went unnoticed by the operator or the DNR. The accident helicopter was expected to return to Utqiagvik by 20:30 The helicopter was reported overdue at 22:30 by an employee of the State of Alaska Geological Survey [part of DNR]. The North Slope Borough (NSB) Search and Rescue (SAR) Sikorsky S-92A was tasked to search for the missing helicopter. NSB have an S-92A and a Bell 412 that are being replaced by two Leonardo AW189s. The partially submerged, fragmented helicopter wreckage was found in the shallow waters of Lake Itinik…a large, oval-shaped arctic lake more than three miles wide in some areas. The lake is surrounded by “flat, featureless, arctic tundra“. The NTSB Safety Investigation Examination of the wreckage revealed no pre-impact issues with the helicopter. NTSB comment that: Archived satellite tracking data indicated that the helicopter was flying about 88 ft above ground level (agl) at 93 knots shortly before impacting the water. Although there was a possibility of some overcast clouds and restricted visibility in fog/mist over the accident site, there were no observations or forecasts for any significant turbulence, low-level wind shear, convective activity, or icing over the area at the time of the accident. However, the NTSB mention: Due to fiber optic outages, there were a limited number of FAA weather...
read moreAir Methods Helicopter Air Ambulance Night Take Off Tree Strike
Air Methods Helicopter Air Ambulance Night Take Off Tree Strike (BK117B2 N880SL, Hartford, IL) On 24 April 2025 Air Methods (ARCH) Airbus BK117B2 air ambulance N880SL was destroyed taking off from outside a fire station in Hartford, Illinois. The three occupants were all seriously injured. The US National Transportation Safety Board (NTSB) issued a remarkably rapid but sadly perfunctory final report on 20 June 2025. This article has had to draw heavily on content from the NTSB Docket that were unused in the final report. The Accident Flight The pilot (7404 hours total, 1277 on type) arrived at the Air Methods’ Granite City, Illinois base at c 18:30 for a night shift. Shortly after completing the pre-flight on the helicopter the flight nurse asked if the helicopter would still being going to a ‘public relations’ event at the Hartford Fire Department, landing at an ad hoc “confined area landing zone” next to the fire station. The PR event was actually inter-agency training. The pilot recalled that the outgoing pilot… …described the obstacles surrounding the LZ, powerlines on the north and east sides with trees on the west and south side. I also reviewed the aerial photo of the LZ in Google Earth. I anticipated landing either from the north or south along the north/south road just east of the grass LZ. I also noted some map features to help me locate the LZ once I was over Hartford. Ryan offered to drive up to the LZ to be present on the ground with a flashlight to help me locate the LZ. Given the information I received I made the decision to go forward with the PR. The manifest and Air Methods Flight Risk Assessment Tool (FRAT) were completed and submitted to the company Operational Control Center. The FRAT score, timed at 19:11, was 18 based on four items scoring 4 or 5 each (a PR flight scores a 4). There is no information that elaborates on the current Air Methods FRAT methodology in the Public Docket. The form used has 43 questions scoring from -1 to 150, suggesting 18 is probably a low score. The NTSB report doesn’t discuss Air Methods’ procedures. The public docket contains two brief extracts from the Air Methods’ General Operations Manual (GOM) (2 pages) and Training Manual (4 pages). An extract from each follows: The BK117B2 has a D-value (i.e. overall dimension) of 13 m (42 ft 8 in) and a main rotor diameter of 11 m (36 ft 1 in). On arrival at Hartford, the pilot performed a high level recce to identify the site and the adjacent obstacles (a tree and power lines). The site is shown below: The BK117B2 width quoted above by the NTSB is the 7.78 m minimum width when parked, not the width of the rotating main rotor! Strictly, with the east/west road closed the site width would be greater than 70 ft so assuming the minimum dimension is indeed (as shown) 77 ft and the BK117B2 D-value this is a 1.8 D site vs the ‘normally’ 2 D size specified in the GOM. Seen from ground level the site has trees on two sides (we estimate as c 15 m high) and electricity wires (c 8 m high) on the other two (the wires along the north/south road...
read moreOceanGate Titan: Toxic Culture & Fatal Hubris
OceanGate Titan: Toxic Culture & Fatal Hubris – An Analysis of the USCG Investigation The US Coast Guard (USCG) released its Report of Investigation (ROI) on the loss of the Titan submersible, built and operated by US company OceanGate, on 18 June 2023. The Titan imploded at a depth of c 3350 m after a catastrophic loss of structural integrity of the submersible’s carbon fibre hull. This occurred during a commercial dive to the wreck of the RMS Titanic, killing five people, including Stockton Rush, the CEO of OceanGate, and 3 fare paying passengers (or ‘Mission Specialists’ in OceanGate’s lexicon). Viewers of the Netflix documentary Titan: The OceanGate Disaster will not be surprised that investigators commented on a toxic workplace environment within OceanGate that was the antithesis of ‘psychological safety‘. The Hubris of Oceangate CEO Stockton Rush It is claimed that Rush saw his company as the “SpaceX for the ocean” and in a crucial January 2018 meeting that resulted in terminating a highly experience dissenting director (discussed further below) described his approach as being “a religion”. In March 2018 the Marine Technology Society (MTS) presciently warned Rush that OceanGate’s approach, in contrast to the “diligent engineering discipline and professional approach…and adherence to a variety of safety standards” by the rest of the industry, could lead to “catastrophic” results. “I think it was General MacArthur who said ‘You’re remembered for the rules you break’,” Rush said in one 2021 interview: @swiftness0427 CEO Stockton Rush: “I have broken some rules to make this. (…) The carbon fiber and titanium there is a rule that you don’t do that. Well, I did.“ Titan ship built by Ocean Gate Expeditions #titan #titanic #oceangate #oceangateexpeditions #implosion ♬ original sound – Mike Swift ❌⭕❌⭕ – Swiftness ❌ “You know I’ve broken some rules to make this [the Titan submersible]… It’s picking the rules you break that are the ones that will add value to others and add value to society”. In a Vanity Fair article in August 2023 reported that Rush declared “If you’re not breaking things, you’re not innovating,” at the 2022 GeekWire Summit, echoing the Silicon Valley ‘move fast and break things’ ethos. Rush added: If you’re operating within a known environment, as most submersible manufacturers do, they don’t break things. To me, the more stuff you’ve broken, the more innovative you’ve been. Vanity Fair commented: In a culture that has adopted the ridiculous mantra “move fast and break things,” that type of arrogance can get a person far. But in the deep ocean, the price of admission is humility—and it’s nonnegotiable. The abyss doesn’t care if you went to Princeton, or that your ancestors signed the Declaration of Independence. If you want to go down into her world, she sets the rules. Rush was a indeed a Princeton graduate with two distant relatives who had signed the US Declaration of Independence. His wife, Wendy Rush, was descended from a couple who died on the Titanic. Rush boasted he could “buy a congressman” if needed. The generic characteristics of hubris include: Rush would score high against this list. OceanGate: A Toxic Workplace Environment This article will primarily focus on the workplace culture at OceanGate (and three organisationally focused sections [from pages of 296-304] of the USCG report) as it provides relevant lessons for safety...
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