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ASN Wikibase Occurrence # 150535
Last updated: 23 June 2020
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Time:14:32 UTC
Type:Eurocopter EC 155 B1
Owner/operator:Hong Kong Government Flying Service (HKGFS)
Registration: B-HRX
C/n / msn: 6635
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Tung Chung Gap, near Hong Kong International Airport (HKIA) Latitude: -   Hong Kong
Phase: En route
Departure airport:Chek Lap Kok
Destination airport:Cheung Chua island
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.


Air Forces Monthly, October 2003, p73

Accident investigation:
Investigating agency: 
Status: Investigation completed
Download report: Final report

Revision history:

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]

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