A very normal accident

It was early evening on the 24th September 2022 when an offshore AW139 helicopter inbound to Houma-Terrebonne Airport in Louisiana, USA, declared a mayday. A lot had already happened in the cockpit by the time the co-pilot hit the press to transmit… 

We take a look at Normal Accident theory in the light of a recent accident: Technology is both a risk control and a hazard itself. The act of adding technology is at best risk neutral. Continually adding more technology in the belief that we are adding more layers of defence in a system is flawed because we are in fact adding more combinations of possible failure modes. In other words, there is a direct trade- off between increasing safety by adding in more controls, and decreasing safety by adding complexity.

Helicopter human factors in focus

“For no other vehicle is the need for human factors research more critical, or more difficult.” Sandra G. Hart.

That’s a bold assertion that I had never heard anyone make before and consequently had never given much consideration to whether or not it might be the case. So let’s unpack that proposition a little by looking at the arguments that the author offers to back it up…

The safety dividend of aviation’s professional culture?

How much does an aviator’s own cultural identification with safety have a role in contributing to safety outcomes? Certain professions have strong and distinctive professional cultures. Aviation is one of these. Does a belief in a deep-rooted safety culture underpin how aviators identify as professionals?

Towards E-VFR flight: The dawn of mixed reality in the rotary wing cockpit? 

How progress in head-mounted display technology could revolutionise critical helicopter missions. Envision a world in which emergency aircraft and their crews can launch in response to medical and other critical missions in almost any flight conditions imaginable. E-VFR (Electronic-VFR) speaks of this future thanks to electronically augmented visual flight which gives a sufficiently enhanced viewContinue reading “Towards E-VFR flight: The dawn of mixed reality in the rotary wing cockpit? “

The need for speed? How slowness has a value all of its own.

Human exploits in aviation have always been closely linked to our fascination for speed. We admire speed in its many guises and it remains a marker of achievement in almost any field you care to think of. In aviation, just as in many other walks of life, we often assume the faster the better. We associate speed with competence. But what if we could disassociate the idea of slowness with incompetence? What if instructors were made to teach the opposite? What if we came to associate a slow response with higher skill levels and greater professionalism?

Developing resilience to startle and surprise in helicopter operations

Also published in AirMed&Rescue April 2022 edition. https://www.airmedandrescue.com/latest/long-read/developing-resilience-helicopter-operations

What should startle and surprise training mean in an applied sense and how should we be approaching it? Do the differences between airline transport flight profiles and helicopter operations mean that we should be looking critically at how to approach the startle and surprise from a rotary wing perspective? Is it as significant a hazard in the low level, high workload, high obstacle environment in which helicopter crews spend much of their time?

The automation explosion: examining the human factor fallout

Also published in AirMed&Rescue, Nov 2021 edition.

Automation reduces workload, frees attentional resources to focus on other tasks, and is capable of flying the aircraft more accurately than any of us. It is simultaneously a terrible master that exposes many human limitations and appeals to many human weaknesses. As we have bid to reduce crew workload across many different tasks and increase situational awareness with tools including GPS navigation on moving maps, synthetic terrain displays, and ground proximity warning systems, we have also opened a Pandora’s Box of human factors to bring us back down to the ground with a bump. Sometimes literally.

Distributed Situation Awareness

Pretty much everyone in aviation is familiar with the concept of situation awareness. But as research interest in SA grew, the concept expanded from the individual level to how SA might apply in the context of larger and more complex systems. What does distributed SA actually mean? The idea is that SA is held by both human and non-human agents. Myriad technological artefacts within a system also hold some form of SA. Now if, like me, you initially struggle with the idea that an artefact (such as a radio, or altimeter) can have ‘awareness’, then bear with me…

Processing information in flight: Understanding the limits of cognitive capacity in the cockpit.

Hands up if you have ever experienced a mental meltdown, ‘cognitive freeze’, or intense tunnel vision in flight or in training? Most of us will recognise these phenomena happening to us at some point or other. They are intimately related to levels of workload, stress, or perhaps the surprise and startle effect. In CRM trainingContinue reading “Processing information in flight: Understanding the limits of cognitive capacity in the cockpit.”


Most of us will recognise amongst our colleagues that figure who has an unmatched knowledge of their aircraft and operational procedures but isn’t a natural team player, doesn’t share thought processes much, and just perhaps doesn’t quite integrate with the rest of his/her colleagues as comfortably as others. We admire technical knowledge in aviation, butContinue reading “ARE YOU A SPECIALIST AVIATOR? WHY DEVELOPING RANGE IS PART OF YOUR JOB.”

Helicopter Hoisting and the Human in the system:

Applying the 3Hs to decision-making during helicopter hoist operations. On the 29 April 2020 at Biscarosse near Bordeaux in France, two crew members of a French Air Force H225 fell to their deaths when a hoist cable parted during a winch training exercise. (Summary report in English from Aerossurance.) The tragic outcome coupled with theContinue reading “Helicopter Hoisting and the Human in the system:”

On Lookout and helicopters

The importance of an effective lookout. We’ve heard it from day one in aviation, a constant through our flying training days and beyond. The dangers of mid-air collision, obstacles, and controlled flight into terrain (CFIT) will always be there.  These are not static threats however, but are always evolving. Take the proliferation of drones asContinue reading “On Lookout and helicopters”

Developing Competency in Problem-Solving and Decision Making: The importance of Process vs Outcome.

Separating the quality of a decision from the quality of the processes which lead to a decision being made sounds like it should be straight-forward, but it isn’t. This is especially true if we judge a decision to be a bad one, or a wrong one, when our negative perception of the choice can easily overwhelm what could have been a perfectly acceptable, collaborative, and well-communicated thought process.

The distinction between the quality of the decision-making process and the decision itself is an important one to make in the context of training for competency because although we won’t always make the right, or the best, decisions in any given situation, the ability to develop and improve our decision-making processes, is what competency-based training is all about.

Competency based training. By trying to solve one training problem are we creating another?

At the beginning of this month I tuned in to the Royal Aeronautical Society’s webinar titled, Flight Crew Competence; Assessing what and how? The webinar aimed to address the concept of Evidence Based Training and Competency Based Training (EBT/CBT) and consider the impact it has had on the experience of instructors, examiners and trainees. TheContinue reading “Competency based training. By trying to solve one training problem are we creating another?”

Small Talk, Big distraction: Taking a look at the sterile cockpit concept through the lens of helicopter operations

The concept of the ‘Sterile Cockpit’ as a defence against distraction is a well known one, even well below the cruising levels of the world’s airline operations. The chances are most helicopter pilots will be familiar with it as a company Standard Operating Procedure. Not so many will know that it is in fact aContinue reading “Small Talk, Big distraction: Taking a look at the sterile cockpit concept through the lens of helicopter operations”

The checklist in the rotary wing cockpit: Understanding what, why, and how.

Do helicopter crews have as good an understanding of the proper use of checklists and checklist philosophy as their airline pilot brethren? Like everyone else, I have worked with checklists since I first set foot in the world of aviation. They are omni-present. But my in own experience – as far as I can recollectContinue reading “The checklist in the rotary wing cockpit: Understanding what, why, and how.”


What Nobel Prize Winner Daniel Kahneman can teach us about why taking the hardest decisions of them all is so hard. In his book Thinking Fast and Slow Nobel Prize winning economist and thinker Daniel Kahneman introduces us to many fascinating insights into the human decision-making process. Loss Aversion is one of these. He beginsContinue reading “AERONAUTICAL DECISION-MAKING AND LOSS AVERSION:”

Crew Resource Management Training from Classroom to Cockpit. Are we missing a link?

When preparing for a trip to the simulator most of us start by reaching for the emergency and abnormal checklist to refresh ourselves on the inevitable bevvy of aircraft malfunctions that we know will be coming our way in due course. Who hasn’t come across that sim instructor who feels it would be a derelictionContinue reading “Crew Resource Management Training from Classroom to Cockpit. Are we missing a link?”

Don’t neglect your CRM: The value of telling stories

Last week was a CRM week. I was immersed in a Crew Resource Management course for aspiring facilitators with three full days dedicated to talking, listening, and learning about flying, human factors, and facilitation. Learning from the experiences of others is a lot of what human factors training is about. You don’t do that withoutContinue reading “Don’t neglect your CRM: The value of telling stories”

Flying SAR in the sunshine: What’s not to like?!

From the Atlantic to the Mediterranean: The Weather. Learning to adjust. And just learning. On moving to Valencia last year to try my hand at flying a Search and Rescue helicopter in Spain, the predominantly anti-cyclonic picture of Spain’s Mediterranean-facing east coast presented an entirely new meteorological situation to me. “SAR in the sunshine, what’sContinue reading “Flying SAR in the sunshine: What’s not to like?!”

Is Human Factors in aviation at a crossroads?

Now seems like a good time to look beyond the dark prism of the current COVID-induced crisis in aviation to consider a future beyond the mire. The Chartered Institute of Ergonomics and Human Factors (CIEHF) recently published a White Paper called “The Human Dimension in Tomorrow’s Aviation System”. It’s made up of a series ofContinue reading “Is Human Factors in aviation at a crossroads?”

Can you learn to deal with the unexpected & unpredictable?

Cognitive Readiness in Search and Rescue operations: What is it? Do you have it? How do you get it? There’s a problem with training to learn to deal with the unexpected: we simply don’t know in advance what the objectives of any training or instruction should be. If you haven’t come across it already, CognitiveContinue reading “Can you learn to deal with the unexpected & unpredictable?”

Can a fatal accident provide proof that CRM training does save lives?

On July the 4th last year an AW139 departing from Big Grand Cay in the Bahamas at night hit the water shortly after take off killing all on board. The US National Transport Safety Board (NTSB) has just released the transcript from the cockpit voice recorder carried on board. Perhaps the most shocking part ofContinue reading “Can a fatal accident provide proof that CRM training does save lives?”

Full Crew Flight Monitoring: mitigating the unique hazards in HEMS operations.

EASA’s Annual Safety Recommendations Review 2019 has identified HEMS as one of its key safety topics noting that, “EASA has received several Safety Recommendations over the last years related to this topic.” before going on to comment that, “There are several unique hazards faced by Helicopter Emergency Medical Services (HEMS) operations. The time pressure, planning challengesContinue reading “Full Crew Flight Monitoring: mitigating the unique hazards in HEMS operations.”

Decision Making in a complex environment: The role of experience, intuition, and the contribution of team behaviours.

What is a complex environment? Put simply, a complex environment is a system or situation that has too many elements and relationships to understand in simple analytical or logical ways. It is a landscape with multiple and diverse connections, and dynamic and interdependent relationships, events, and processes. While there may be trends and patterns, theyContinue reading “Decision Making in a complex environment: The role of experience, intuition, and the contribution of team behaviours.”

Crew Resource Management for Search and Rescue Operations.

It’s a personal opinion, but I think that one of the most enduring fallacies of Search and Rescue, (and one that SAR practitioners worldwide are unlikely to be working hard to shake off!), is that it is somehow an elite branch of the helicopter world that requires a higher level of skill or ability thanContinue reading “Crew Resource Management for Search and Rescue Operations.”

Flattening the gradient

What former US Navy Captain and leadership guru David Marquet can teach us about managing power gradient. The premise of David Marquet’s book Leadership is Language, (For more on Marquet click to his website) is that the deliberate and self aware choice of language in how we communicate within teams can transform the way we communicateContinue reading “Flattening the gradient”

The Chimp, the Virus, and the Helicopter:

Coping with confinement and COVID-19 induced stress. What is the link between a chimp and a helicopter?… apart from the fact that every instructor you ever had told you that any monkey can be taught to fly one! In his best-selling book The Chimp Paradox, Professor Steve Peters (click for further information) describes a sevenContinue reading “The Chimp, the Virus, and the Helicopter:”

Crew Resource Management: Is it time to rethink our approach?

Let’s not beat around the bush, Crew Resource Management has an image problem. For many, CRM training means little more than a day in the classroom which generally inspires at best a resigned ambivalence. CRM has an image problem… Perhaps, there has been a failure to attempt to define CRM for what it really is.Continue reading “Crew Resource Management: Is it time to rethink our approach?”

“Engine failure! Cut cut!” Power loss during winching operations: the pre-eminent risk in your assessment?

“Clear door, ready to winch.” “Power assessment/hover scenario: Ditching/Committed/Flyaway/Safe Single Engine.” For most of us who fly multi-engine helicopter types, single engine performance and the choice of flight profiles deriving from this was introduced as a predominant consideration from the beginning of our flying training, and has remained there ever since.  Our pre-flight calculations, ourContinue reading ““Engine failure! Cut cut!” Power loss during winching operations: the pre-eminent risk in your assessment?”

The Structured Debrief: The Big 7

The Structured Debrief During my time in the military a debrief often began with the question, “Any flight safety points?” A closed question. A question that invites a no. It was meant to show the primacy of flight safety in what we were doing. What it actually did was immediately put people on the spotContinue reading “The Structured Debrief: The Big 7”

Debrief to learn: El debriefing para aprender

El empleo del ‘debriefing’ como herramienta de entrenamiento para los profesionales aeronáuticos es la manera más eficaz para aprender, hablar de la toma de decisiones, adquirir/revisar habilidades técnicas y mejorar el trabajo en equipo. Effective debriefing as a training tool for aviation professionals is the most effective way to learn, to talk about decision-making, toContinue reading “Debrief to learn: El debriefing para aprender”

What does the language barrier mean to the multi-national cockpit?

  The challenges of piloting an aircraft can often load us up enough without overlaying the cognitive effort involved in transmitting and receiving information in a language other than our own. But plenty of pilots out there do just that every day. In aviation, those of us lucky enough to have English as our motherContinue reading “What does the language barrier mean to the multi-national cockpit?”

What delivering two years of CRM training has taught me.

Something over two years ago I decided I would throw my hand in at applying to be a CRM Trainer and Human Factors Facilitator. CRM had never really been my thing. My experience of Human Factors/CRM training up to that point was that ‘facilitators’ tend to be either evangelical to the extent that their fervourContinue reading “What delivering two years of CRM training has taught me.”

Sting in the tail: keeping the back end at the front of your mind.

Following the accident at Leicester City Football Club at the end of last month, all of which was caught on camera, and replayed very publicly, tail rotor failures are back in focus, and for those of us who fly the machines, are very much at the forefront of our minds. It was following a similarContinue reading “Sting in the tail: keeping the back end at the front of your mind.”

A machine for jumping to conclusions:

Human Decision-making: Extracts from Daniel Kahneman’s Thinking Fast and Slow. Daniel Kahneman, a Nobel prize winner for his work, first became famous for his article Judgement under uncertainty (1974) Heuristics and Biases. The Article was produced from research funded by US Department of Defense and Office of Naval Research. He expanded this into a bookContinue reading “A machine for jumping to conclusions:”

Aviation safety culture and the paradox of success:  Can safety innovation keep pace with technological progress?

The aviation industry is hailed as a pioneer of safety practices, of open reporting, of just culture, and in learning from its mistakes. And given its remarkable safety record, this reputation is perhaps justified. Nevertheless, it would be both complacent and counter to those values themselves to believe that the goal of safety has alreadyContinue reading “Aviation safety culture and the paradox of success:  Can safety innovation keep pace with technological progress?”

“PF & CM:” Pilot Flying & Crewman Monitoring

Training Monitoring for Helicopter Technical Crew (Part 2) The response to my last post underlined how little technical or non-technical material out there is written with the niche skill-set of the helicopter technical crew community in mind. There is certainly an interest and appetite for its consumption among those who play a part in thisContinue reading ““PF & CM:” Pilot Flying & Crewman Monitoring”

Training Monitoring for Helicopter Technical Crew

I have been asked to deliver training on Monitoring to Technical Crew as part of a bespoke course to qualify them to assist single-pilot operations from the front seat. After considering how to approach the session and content I have been left asking more questions than I started with. Being a fan of simplicity, IContinue reading “Training Monitoring for Helicopter Technical Crew”

EBT & ATQP…What now for CRM?

  Let’s start by unravelling that jumble of acronyms: EBT – Evidence Based Training ATPQ – Alternative Training and Qualification Programme CRM – Crew (Cockpit) (Complete) Resource Management What is Evidence Based Training? EBT is a shift in philosophy away from traditional, prescriptive training and checking methods in which, for example, you repeat the setContinue reading “EBT & ATQP…What now for CRM?”

Human perception & the mental model

Memory and meaning I cdnuol’t blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid. Aocdcrnig to rscheearch at Cmadrigbe Uinervtisy, it deosn’t mttaer in waht odrer the ltteers in a wrod are, the olny iprmoatnt thnig is taht the frist and lsat ltteer be in the rghitContinue reading “Human perception & the mental model”


Texting & Flying: Pilot distraction & the myth of multi-tasking. On August 26, 2011, at about 6:41 pm CDT, a Eurocopter AS350 B2 helicopter operated by Air Methods on an EMS mission crashed following a loss of engine power as a result of fuel exhaustion a mile from an airport in Mosby, Missouri. The pilot,Continue reading “TEXTING AND FLYING?”