006/16

Recommendation Date
Recipient Name
CAA
Text
On 25 February 2016 the Commission recommended to the Director of Civil Aviation that he review all modifications to the cockpit lighting on BK117 helicopters for night vision use, to ensure they do not unduly increase the risk of a similar incident occurring. If they do introduce an unacceptable level of risk, changes to the installation, such as a low-fuel-level aural warning or brighter LED caution lights, should be required.
Reply Text
On 14 December 2015, the CAA responded to the draft final report and made observations and specific comment to the proposed recommendation.

Based on those observations and comments, the Director considered that the weight of evidence indicated pilot mismanagement of the engine start process not the annunciator lighting. Therefore, the subsequent safety lessons are more aligned to the pilot and the operator's adherence to the recommended practices contained within the aircraft flight manual and the observance of rules. Therefore, the Director will not implement the recommendation.
Related Investigation(s)