I. Introduction
On August 6th, 2025, a Ghana Air Force Z-9EH helicopter (GHF-631) crashed into a forested mountainside in the Ashanti Region, killing all eight people on board, including senior government and military officials. The crash resulted in a post-impact fire that destroyed much of the fuselage. The Ministry of Defence established an investigation board and subsequently published a press conference report summarising factual findings.
The report and the press conference on November 11, 2025, represent a remarkable demonstration of transparency and professionalism in Ghana’s safety culture. The report, structured in line with ICAO Annexe 13, reveals growing institutional maturity and public accountability.
However, comparison with the US National Transportation Safety Board (NTSB) and the UK Air Accidents Investigation Branch (AAIB) highlights technical and procedural gaps in evidence handling, human-factors analysis, and publication of factual data, among others. While the report follows a recognised structure and identifies a plausible primary cause, a critical analysis reveals significant weaknesses in its depth and analytical rigour.
This paper critiques the report by highlighting its reliance on assertion over evidence, its superficial treatment of human and organisational factors, and its failure to meet the forensic standards of agencies like the NTSB and AAIB.
The working hypothesis of this study is that air accidents rarely have a single, isolated cause; rather, they typically result from a constellation of interacting factors that align to produce a catastrophic outcome. Therefore, the assertion that a downdraft alone caused the August 6, 2025, accident at best requires corroboration through recorder data, forensic examinations, meteorological reconstructions, and human-factors and organisational analysis.
II. Structural and Philosophical Strengths of the HELI Report
The HELI Report demonstrates several key strengths that align with global best practices in accident investigation. Its structure meticulously follows the canonical ICAO Annexe 13 framework of Factual Information, Analysis, Conclusions, and Safety Recommendations. Its public release reflects a commendable ethos of transparency, which builds public trust, a practice that fosters institutional credibility akin to models used by the NTSB and AAIB.
Beyond its formal structure, the report’s methodological and philosophical approach is equally robust. It effectively grounds its investigation in domestic authority by citing relevant Ghana Air Force Flying Orders and Air Staff Instructions, mirroring the use of statutory authority in other leading jurisdictions. Crucially, the report maintains a safety-driven, non-blame orientation, a core tenet of ICAO’s philosophy that prioritises future prevention over assigning fault. Finally, by situating the investigation within the Air Force’s own command structure, the report reinforces internal accountability and signals that safety oversight is a paramount operational priority.
III. Gaps in Evidence, Weaknesses in Conclusions
A. Insufficient Flight Data Recorder and Meteorological Analysis
The most significant weakness of the report is its failure to present the primary data that underpins its central conclusion. There are two issues here. First, the conclusion that a downdraft caused the accident is technically plausible. However, the report provides no concrete Flight Data Recorder (FDR) information to prove it. Similar reports from an NTSB or AAIB would invariably include graphical, almost 3-D diagrams showing altitude, vertical speed, power settings, and pitch attitude in the seconds before impact. The statement that the helicopter “lost height without change of power or pitch attitude” is a key finding, but without the data trace, it remains an assertion. Essentially, this statement implies that the helicopter encountered a fundamental aerodynamic failure, with the potential problem being failure of the rotor system. It may be that the pilots or flying officers were likely not at fault for a control input error, but they may have inadvertently placed the chopper in a flight position from which recovery was near impossible, save as a miracle. The detailed FDR data will settle the issue as to whether the impact was an issue of control input, a subtle system degradation or even a spatial disorientation. The published report does not provide the data to rule these issues out conclusively.
Second is the meteorological void. The report describes poor weather in general terms but provides no specific Aviation Routine Weather Report – METAR (MÉTéorologique Aviation Régulière) or Terminal Aerodrome Forecast (TAF) data. What were the exact wind patterns, temperature, and dew point spread over the terrain near the accident site? Modern modeling can reconstruct likely atmospheric conditions. The AAIB, for instance, frequently uses such data to analyse weather-related accidents. The absence of this quantitative analysis somehow weakens the environmental component of the downdraft argument.
B. Omission of Cockpit Voice Recorder Findings
Another critical piece of omission is how the press reports handled the Cockpit Voice Recorder (CVR), which is one of the components of the Black Box data. The investigation reveals that the CVR was transported to China for analysis, but mentions almost nothing of its contents. In an NTSB or AAIB investigation, the CVR transcript is often released in a public docket. It is an important piece of data because it provides insight into the crew’s situational awareness, workload management, division of duties, and any confusion or startle factor the flying officers may have experienced.
The report states that the crew said they “could see high ground below” seconds before impact. If that was the case, the following questions remain unanswered: What was their tone? Was it a calm observation or a panicked warning? What discussions did they have before and after entering Instrument Meteorological Condition (IMC), i.e. flying the chopper solely from the guidance of instruments as a result of poor or lack of visibility? Did they initiate a standard instrument climb-out procedure? The absence of this information leaves a critical gap in understanding human performance in the final moments. This silence prevents a proper assessment of whether the flying officers’ actions were in accordance with their training and whether their instrument proficiency was a factor.
C. Superficial Treatment of Human Factors
The report notes that the flying officers delayed takeoff due to weather conditions, demonstrating their caution. Yet, they subsequently took off under Visual Flight Rules (VFR) into a known marginal weather environment with no en-route weather information. This is a critical decision point. An NTSB report would delve into the operational pressures, the ‘get-there-itis’ culture, and the risk-assessment processes that influenced this decision. ‘Get-there-itis’ is an aviation psychological concept of self-imposed pressure to complete a flight as planned, even when conditions such as weather, fuel, fatigue, or technical issues clearly suggest that aborting the flight, delaying, or diverting would be safer. The report or the press-briefing is silent on this, creating a significant gap in the sequence of causality.
Again, the report’s recommendation for simulators implies a training deficiency, but the analysis section does not explicitly link this lack to the crew’s ability to respond to the emergency. Given the diverse range of aircraft and helicopters from different manufacturers that the Ghana Air Force operates, the recommendation for flight simulators does not fully address the challenge of preventing similar accidents in the future.
Realistically, does the nation possess the resources to acquire and maintain separate, type-specific simulators for each aircraft and helicopter model in service? Rather than acquiring separate, type-specific flight simulators for every aircraft and helicopter in the fleet, a financially unsustainable approach for a developing defence budget, the Ministry of Defence could adopt a tiered and collaborative simulation strategy. This would involve establishing a centralised simulation centre equipped with re-configurable or modular simulators capable of emulating multiple cockpit environments through software and hardware re-configuration.
D. The Culture of Complacency
While the report lists organisational failures, it treats them as a separate list of deficiencies rather than weaving them into the overall chain of causation. We are told that the aircraft was operating beyond its 10-year service threshold on a 90-day extension and lacked critical safety systems like HTAWS.
The HTAWS means Helicopter Terrain Awareness and Warning System. It is a sophisticated, proactive safety net designed to prevent one of the most common causes of aviation accidents, referred to as Controlled Flight Into Terrain (CFIT), where a fully functional aircraft is inadvertently flown into the ground, water, or an obstacle.
In simple terms, HTAWS is dubbed the guardian angel system that constantly monitors the aircraft’s position, altitude, and flight path, and compares it to a highly detailed digital map of the terrain and obstacles below and ahead. For students of air crash investigations, a familiar phrase to hear is: “Terrain, Terrain, Pull-Up”. This is the kind of warning system that the helicopter in question did not have. This points to a systemic acceptance of risk. A UK AAIB report would often include a dedicated section on the Safety Culture of the operator, examining how economic, operational, and hierarchical factors led to the acceptance of such known risks.
IV. Comparative Insights of Helicopter Accidents
On June 9, 2023, a Eurocopter EC130 B4 helicopter crashed in Massachusetts, USA, during a night flight under adverse weather conditions, resulting in the fatal injuries of all three persons on board. The passengers were Dr Herbert Wigwe, the Group Chief Executive Officer of Nigeria’s Access Bank, and his associate. The NTSB investigation determined the probable cause to be the pilot’s decision to continue visual flight rules (VFR) flight into instrument meteorological conditions (IMC), which led to spatial disorientation and subsequent controlled flight into terrain. The pilot, who was certified for VFR operations only, likely experienced a loss of visual reference in low clouds and rain, underscoring the critical dangers of inadvertent IMC entry for non-instrument-rated pilots.
In 2020, the basketball legend Kobe Bryant was involved in a crash of a Sikorsky S-76B helicopter in the US. The NTSB investigation into this crash provided a stark reminder of the critical importance of instrument flying proficiency.
The key lesson from this tragedy was the lethal combination of poor weather and a pilot’s inability to transition from VFR to instrument flight (IMC). Analysis of the CVR and FDR revealed that the pilot, after entering instrument meteorological conditions (IMC), became spatially disoriented.
The detailed reconstruction showed uncontrolled manoeuvres consistent with a loss of situational awareness, where the pilot’s sensory perceptions fatally contradicted the instrument readings. This accident underscores that for pilots operating in environments where unexpected IMC is a possibility, ongoing instrument training is not merely an advanced skill but a fundamental survival necessity.
Similarly, the 2009 crash of a PHI Air Medical EC135 investigated by the NTSB offers a proactive lesson in risk management. This accident emphasised that reactive investigations, while vital, must be supplemented by robust preventive measures. The findings pointed to a critical need for the thorough integration of formal Safety Management Systems (SMS) and structured risk-assessment programs into daily flight operations.
Such systems compel organisations to proactively identify hazards such as night flight, adverse weather, and pressured operational deadlines and implement concrete mitigations before an accident occurs. The key insight is that safety is not just a matter of individual skill or robust design but of embedding a continuous, organisation-wide culture of risk assessment and management.
V. The Swiss Cheese Theory
The ‘Swiss Cheese Theory’, more formally known as the Swiss Cheese Model of accident causation, was developed by psychologist James Reason. It posits that in a complex system, accidents are rarely caused by a single point of failure. Instead, multiple layers of defences, barriers, and safeguards exist within an organisation, such as procedures, training, technology, supervision, etc. Each of these layers is imperfect and contains inherent defects analogous to slices of Swiss cheese. These holes/defects, which can be latent conditions like inadequate training, flawed procedures, cultural issues, or active failures like immediate human errors, are dynamic and constantly shifting. A catastrophic accident occurs only when the holes in multiple layers momentarily line up or align, allowing a trajectory of opportunity for a hazard to pass through all the defences and result in a failure.
The model emphasises that while a single error might create a hole, the accident was only possible because the successive layers of defence also failed.
This model ought to have guided the investigation committee of the August 6 helicopter accident. For this accident to occur, it means the holes in the multiple layers of defences aligned with latent organisational weaknesses deeper in the system.
A critical layer of defence is training, which may have had a hole if pilots were not sufficiently drilled in drastic power application and recovery techniques specific to spatial disorientation or vortex. Another layer may be a hole in the organisation’s safety culture, which could have existed if there was unspoken pressure to complete the mission despite marginal weather, discouraging pilots from turning back or delaying when conditions felt unsafe.
The downdraft was the physical cause, but the accident may have been the product of the entire system’s vulnerabilities lining up at that precise moment, allowing a known environmental risk to result in this tragic outcome.
VI. Conclusion
The MoD’s investigation into the Z9-EH crash is a necessary first step. Its safety recommendations are excellent, and if implemented, would be a powerful legacy for the victims. However, the public report seems deficient because of a lack of transparent evidence, a superficial analytical depth, and a structure that fails to draw the necessary causal links between organisational failures and the tragic outcome. Without a more comprehensive final report that addresses these gaps with the rigour of an NTSB or AAIB investigation, this report risks being perceived as having reached a convenient, weather-based conclusion that obscures deeper systemic problems.
It is essential to acknowledge the considerable constraints under which the investigation committee operated. The pursuit of truth was challenged not only by the technical complexities of the crash itself but also by a scarcity of proper investigation equipment, finite resources, and a pressing need for specific expertise, all while navigating the intense scrutiny of a grieving public.
About the author:
Dr A. M. Mashood is an international legal practitioner, admitted to the bar in both New York, USA, and Ghana. His legal practice, focused on complex cross-border issues, ignited a deep fascination with the intricate systems that govern modern life, particularly in high-stakes, technologically advanced fields, including aviation. Driven by a desire to understand the confluence of technology, human factors, and the law, he has undertaken a rigorous self-directed study of air crash investigation since 2017.
This has involved the systematic study of over 100 episodes of documentary investigations from agencies like the NTSB and AAIB. He has developed an understanding of the technical, legal, and human elements of aviation disasters, with a specific interest in how systemic failures in regulatory oversight, organisational culture, and resource allocation align to cause tragedy.