Show: March 4 - 7, 2019 | Exhibit March 5 - 7 | Atlanta, Georgia
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    October 16, 2000 – One Fatality

    SuperUser Account LAND & LIVE Case Studies

    Repositioning Flight – 1 fatality

    Summary:

    About 5 minutes before landing at a hospital to drop off a patient, a transmission oil pressure warning light illuminated. At the hospital, the pilot performed an abbreviated shutdown, eliminating the cool down procedure. The flight nurse reported to the pilot that she smelled burning, but the pilot dismissed this as being a result of the shutdown without cool down. A mechanic was dispatched and disconnected the light and suggested a ground run, hover and night time ferry flight back to the base hospital. The pilot crashed 1 mile from the hospital.

    Land and LIVE Factors:

    Landing 5 minutes short of a hospital with a patient on board would not be an easy decision to make, but in this case, it would have been exactly the right thing to do. Following that first bad decision, the pilot elected to follow bad advice and perform a night time ferry flight with a critical indicating system deliberately disabled despite possible convictions otherwise. The pilot clearly understood the urgency of the emergency because of his abbreviated shutdown. “Stay on Land… and Live” is a more fundamental decision that can be seen in many land and live scenarios. Did this pilot rationalize his decision and dismiss gut instincts? Did he smell something? Feel something? KNOW something?

    Thought:

    Plan Continuation Bias combined with can do attitudes is a powerful combination that can override good decision making.

    Read the NTSB probable cause narrative: MIA01FA006

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