Between the February 2009 Colgan 3407 crash and May 2021, there were 2 fatalities on more than 100 million Part 121 domestic passenger flights.

Over that period and many fewer flights, the National Transportation Safety Board (NTSB) database recorded 34 fatal helicopter accidents with the loss of 105 people. Even worse, 16 of those accidents followed the same pattern: the crew continued flight into dangerous flight visibility conditions, most clearly known or forecast, and spatial disorientation resulted in a crash.

Many of these accidents occurred in IFR-capable helicopters, some with instrument-rated pilots. Most occurred over terrain familiar to the crew, with numerous divert or alternate landing sites available. If we accept Heinrich’s accident pyramid of 300 instances where the conditions for an accident existed for every actual accident, then crews followed this pattern more than 4,800 times over this period.

So, why did crews continue flights into conditions that so many people had told them to avoid? Why would they choose a course of action with so many potential negative outcomes and only one positive outcome?

Management Isn’t the Problem
It’s not management, as many leadership models might suggest. If crews had asked their CEOs or chief pilots before the accident flights (or any other flight, for that matter), those senior managers would never have told the pilot to risk everyone’s life and the aircraft in that manner.

The answer, simply, is culture. Amy D. Grubb, one of our speakers at HAI HELI-EXPO 2022, has said that “culture is the story of an organization as told through the behaviors of its employees,” and the organization in this case is an industry, not a single company. I would add that culture is a result of all organizational leadership influences, not management. Culture then leads by defining the limits of acceptable behavior and performance, with little regard for the actual limits defined by the organization’s policies and statements.

A Different Breed
To exaggerate the views of helicopter crews, airlines, with their enviable accident record, are a culture of starched shirts, pilots who show up, receive the dispatcher’s flight plan over a known route to a known destination, complain that they don’t get enough days off, and simply drive the airplane. If someone is dying, it’s an emergency.

In the helicopter world, especially air ambulance, where many of these accidents occur, if someone is dying, it must be Thursday. The helicopter industry just doesn’t work the same way as the airlines, and many have rationalized the helicopter safety record with that difference in mind. The cultures of the two industries, however, also reflect that difference.

As Peter Drucker, the famous management guru, reportedly said, “culture eats strategy for breakfast,” so new management strategies aren’t the answer. Rather, the answer must come from the people who influence the culture, people like YOU who simply say that completing this flight in unsafe conditions isn’t worth risking the lives of passengers, fellow crewmembers, and people on the ground. Management then does its part by rewarding (or at least not punishing) the employee for that decision. Even if they don’t, though, what civilian flying job is worth your life or someone else’s?

You don’t need more managers and experts telling you what to do. You already know the right answer.

Editor’s note: To see internationally acclaimed speaker and FBI Digital Transformation Advisor to the Chief Information Officer Amy D. Grubb, PhD, explain more about how our minds can assimilate into a safety culture, come to HAI HELI-EXPO 2022 and join the Safety Town Hall on Wednesday, Mar. 9, 2022, from 9:30 am to 11:30 am. You don’t want to miss this event!  To learn more about this and other safety-focused events and resources, go to heliexpo.com/safety.

Author

  • Mike Ott is director, program operations, at Phoenix Air Group and a senior aviation advisor at the US Department of State. A member of the IS-BAO Standards Board and winner of the 2019 Safety Standdown Award, he serves as the NBAA Safety Committee Liaison to the HAI Safety Working Group.

Michael Ott, FRAeS

Michael Ott, FRAeS

Mike Ott is director, program operations, at Phoenix Air Group and a senior aviation advisor at the US Department of State. A member of the IS-BAO Standards Board and winner of the 2019 Safety Standdown Award, he serves as the NBAA Safety Committee Liaison to the HAI Safety Working Group.