Organizational Pressure and Pilot Decision-Making in Adverse Weather: A Naturalistic Decision-Making Analysis of Helicopter Accidents

Abstract

This paper aims to analyze helicopter accidents occurring in meteorological scenarios where flights should have been avoided, identifying patterns that influence pilots’ misjudgments. This work uses two analytical frameworks: the Human Factors Analysis and Classification System (HFACS) and bow tie diagrams, applied to four selected helicopter accident cases. The HFACS model systematically categorizes failures at four hierarchical levels (organizational influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts), whereas bow tie diagrams visually map threats, preventive barriers, the critical top event, and mitigation barriers related to the accidents. The results consistently revealed organizational and self-imposed pressures influencing the decision-making of pilots to proceed under unsafe weather conditions, but these decisions were also shaped by additional factors, such as inadequate training, insufficient operational oversight, fatigue, poor risk perception, spatial disorientation, and misuse of onboard instruments, such as the meteorological radar. The bow tie diagrams highlighted latent conditions, the inadequacy or absence of safety barriers, and the critical short timeframe available for mitigating actions once control was lost. The study concludes that enhancing organizational oversight, structured training, and proper understanding of avionic systems, particularly weather radar capabilities and limitations, are important to preventing similar accidents in the future.