NTSB新闻稿
https://www.ntsb.gov/news/press-releases/Pages/NR20210209.aspx
Pilot’s Poor Decision Making, Spatial Disorientation, Led to Fatal
Helicopter Crash
飞行员自加压力导致做出缺陷判断
进入仪器飞行气象条件飞行时没做好避开恶劣天气
最终陷入空间迷向
而且调查发现
: 强调了Island Express Helicopters Inc.对其安全管理流程的审查和监督不足。
: Island Express Helicopters Inc.缺乏成文的政策和安全保证评估，以确保其飞行员始
: 终如一地正确填写飞行风险分析表，这妨碍了该表的作为风险管理工具的有效性。
: 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)强制化
也要把flight data monitoring (FDM) program导入SMS
最后也提出能承受撞击的飞航纪录系统可以记录这类空难，以避免未来的事故