Aircraft Accidents: Investigating Human Error

On August 15, 1995, at approximately 2000 hours, a flight of two (2) United States (US) Army UH-60A BLACKHAWK helicopters departed from Royal Air Force (RAF) Akrotiri (in southern Cyprus) for the US Embassy in Beirut, Lebanon utilizing Night Vision Goggles (NVG). Not long after departure, with both aircraft at approximately 800 feet above ground level (AGL) over the Mediterranean Sea, the second aircraft radioed the first aircraft informing them there "#1engine was on fire." Approximately 45 seconds later, the lead aircraft impacted the water at over 200 knots killing all four crewmembers and destroying the aircraft. After learning of the mishap, the US Army Safety Center (USASC) dispatched a team to the site. The accident investigation process had process. The Accident Investigation Board would utilize its 3W approach to answer three questions: "what happened?", "why did this happen?", and "what can we do to prevent it from happening again?"1 The investigation would be conducted in four phases and focus on three areas: material factors, environmental factors, and human factors. It was determined that the aircraft crashed as a result of human error. But why the human error occurred was not determined. In order to answer this question, two exhaustive studies were initiated.