ASN Wikibase Occurrence # 150535
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| Date: | Tuesday 26 August 2003 |
| Time: | 14:32 UTC |
| Type: |  Eurocopter EC 155 B1 |
| Owner/operator: | Hong Kong Government Flying Service (HKGFS) |
| Registration: | B-HRX |
| MSN: | 6635 |
| Year of manufacture: | 2002 |
| Fatalities: | Fatalities: 2 / Occupants: 2 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Tung Chung Gap, Lantau -
 Hong Kong
|
| Phase: | En route |
| Nature: | Ambulance |
| Departure airport: | Chek Lap Kok |
| Cheung Chua island | |
| Confidence Rating: |  Accident investigation report completed and information captured |
Crashed on a hillside.
Causal factors (active and latent failures)
1. The pilot did not conduct a pre-flight briefing.
2. The pilot made an inappropriate decision to navigate via Tung Chung Gap at a low altitude and high cruise speed, at night, in marginal meteorological conditions.
3. The pilot suffered from an error of perception (confirmation bias).
4. The pilot did not comply with GFS weather minima.
5. The pilot did not comply with GFS teaching and common practice for navigating via Tung Chung Pass and Gap at night.
6. The pilot suffered from a loss of situational awareness.
7. The pilot was affected by mission pressure to achieve the GFS on-scene target times.
8. The crew accepted an unnecessary hazard.
9. A degree of complacency affected both crewmembers, created by the fact that they flew regularly together and that the accident flight was over a familiar route and was perceived by the crew as being routine in nature.
10. The pilot showed impaired reasoning power and decision-making capabilities. This may have been due to insufficient rest combined with circadian disruption.
11. Both crewmembers were affected by low levels of alertness and arousal.
12. The crew did not adhere to a number of the basic tenets of CRM.
13. The GFS Operations Manual did not include an absolute minimum en route height above the surface for night casevac operations.
14. The GFS did not have a documented system for the proactive identification of hazards and systematic management of risk in flight operations.
15. The discretion given to pilots, in relation to the level of risk associated with casevac missions carried out by the GFS, was not necessarily matched to the operational need.
Accident investigation:
 |
|
Sources:
Air Forces Monthly, October 2003, p73
https://www.thb.gov.hk/aaia/doc/Accident_Report_1-2006_of_B-HRX.pdf
https://www.scmp.com/magazines/post-magazine/short-reads/article/3231794/when-rescue-helicopter-crashed-hong-kong-soon-after-take-nighttime-mission-killing-both-crew
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 05-Nov-2012 12:49 | TB | Added |
| 05-Nov-2012 13:04 | TB | Updated [Registration, Cn, Operator] |
| 22-Mar-2013 15:15 | TB | Updated [Aircraft type] |
| 31-Oct-2014 20:19 | TB | Updated [Aircraft type] |
| 10-May-2020 19:27 | KagurazakaHanayo | Updated [Time, Location, Source, Narrative] |
| 30-Dec-2020 16:56 | TB | Updated [Location, Accident report] |
| 24-Dec-2021 18:06 | harro | Updated [Accident report] |
| 24-Dec-2021 18:07 | harro | Updated [[Accident report]] |
| 22-Aug-2023 06:20 | gerard57 | Updated [[[Accident report]]] |
Corrections or additions? ... Edit this accident description
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