Swiss Cheese Slices

Swiss Cheese Slices

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Let’s break it down and look at the points at which a different decision or action would have prevented the accident.

  1. The culture of this organisation. Operations Manual required 2000 feet ceiling and 5 km visibility for night operations, but pilot felt it was OK to depart without this. New female pilot in a male dominated environment was not supported as she could have been.
  2. Using an alternative route/aircraft.
  3. Having a viable Plan B.
  4. Continuation bias. Elected to continue on into cloud rather than turn back.
  5. GPS readout. Difficult to read at night, located below and away from the pilot, difficult to confirm waypoint on the ground with no features, and confusion over 3 or 0.3.