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