[情報] 2020卡拉巴薩斯直升機空難結案

NTSB新聞稿

https://www.ntsb.gov/news/press-releases/Pages/NR20210209.aspx

Pilot’s Poor Decision Making, Spatial Disorientation, Led to Fatal
Helicopter Crash

飛行員自加壓力導致做出缺陷判斷
進入儀器飛行氣象條件飛行時沒做好避開惡劣天氣
最終陷入空間迷向

而且調查發現

: 強調了Island Express Helicopters Inc.對其安全管理流程的審查和監督不足。
: Island Express Helicopters Inc.缺乏成文的政策和安全保證評估，以確保其飛行員始: 終如一地正確填寫飛行風險分析表，這妨礙了該表的作為風險管理工具的有效性。

: highlighted Island Express Helicopters Inc.’s inadequate review and
: oversight of its safety management processes. Island Express Helicopters Inc.: ’s lack of a documented policy and safety assurance evaluations to ensure
: its pilots were consistently and correctly completing the flight risk
: analysis forms, hindered the effectiveness of the form as a risk management: tool.

摘要中有提出要把safety management system(SMS)強制化
也要把flight data monitoring (FDM) program導入SMS

最後也提出能承受撞擊的飛航紀錄系統可以記錄這類空難，以避免未來的事故

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