Accident Common Themes

Accident summaries organized relative to the common themes across groups of accidents.

Accident Common Themes
Flawed Assumptions
Flawed Assumptions
Photo: Eurocopter AS-350BA
May 4, 2004
Brooklyn, New York

Assumptions are essential elements of safety determinations for every aspect of the design, operation, and maintenance of the helicopter.  These are expected results that, if all goes as intended, a safe outcome is produced. However, if the part, human, or feature does not perform as it was assumed it would under the specific situation, a completely different, and in some cases, catastrophic outcome can result.

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Human Error
Human Error
Photo: Agusta A-109-K2
January 10, 2003
Salt Lake City, Utah

This is the most common of all accident themes and exists in one form or another on nearly all accidents. It involves humans that, in the course of doing their work, make errors that are later shown to have caused, or substantially contributed to the accident. These are human actions that, if done correctly, result in a safe outcome, but if done incorrectly, can result in an accident. It also represents one of the greatest opportunities for advancing safety by the application of targeted interventions which are intended to reduce the risks for human error.

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Organizational Lapses
Organizational Lapses
Photo: Robinson R44
March 21, 2013
Bulli Tops, Australia

This is where an institutionalized process, procedure, or requirement that allows vital tasks or information to be handled in such a way so as to prevent an accident precursor from being recognized or safety intervention from being initiated. This breakdown could be in the form of a fleet-wide activity that is later found to be deficient, gaps in safety information flowing from one person or organization to another, or key personnel being unaware of an issue because of organizational impediments to the information.

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Pre-existing Failures
Pre-existing Failures
Photo: Sikorsky S-51
June 6, 1951
Los Angeles, California

This is a failure condition on a single helicopter or possibly a fleet of helicopters that exist, either as a latent condition or an active fault. The failure condition itself may not represent a hazard, but in combination with one or more additional failures or malfunctions, an accident can result.

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Unintended Effects
Unintended Effects
Photo: MD-500
Dec. 31, 2014
Las Vegas, Nevada

This is a situation where an initiative, change, new process, or other activity intended to improve something actually produces, in addition to the improvement, an undesirable outcome. The undesirable outcome may not manifest itself for many years and may not be related to the condition being improved, but an undesirable outcome occurs that would not have otherwise happened.  It also underscores the complex interdependence that all actions have the potential for when assessing issues concerning safety.

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