A pilot’s decision to depart on a mission despite a critically low fuel level, as well as his inability to perform a crucial flight manoeuver following the engine flameout from fuel exhaustion, was the probable cause of a 2011 helicopter emergency medical services (HEMS) accident that killed four in Missouri (see https://www.airmedandrescue.com/latest/news/fatal-air-methods-accident-missouri), the US National Transportation Safety Board (NTSB) said in a statement issued on 9 April. The NTSB also found that the pilot’s use of a mobile phone for non-operational texting and calls may have ‘contributed to errors and poor decision-making’.
“This accident, like so many others we've investigated, comes down to one of the most crucial and time-honoured aspects of safe flight: good decision making,” commented NTSB chairman Deborah A. P. Hersman.
On 26 August 2011 at around 18:41 hrs, the Eurocopter AS350 B2 helicopter, operated by Air Methods under its LifeNet in the Heartland programme, crashed while en route from Harrison County Community Hospital to Liberty Hospital.Paramedic Chris Frakes, flight nurse Randy Bever, and pilot James Freudenbery were onboard the aircraft and received fatal injuries in the accident, along with the patient.
The accident occurred following a loss of engine power as a result of fuel exhaustion a mile from an airport in Mosby, said the Board. According to the NTSB’s investigation, the pilot did not comply with standard company operating procedures that would have led him to detect the helicopter’s low fuel state before beginning the first leg of the mission. The NTSB also asserted that it was likely that self-induced pressure had caused the pilot to fixate on the intended refuelling point, rather than making a precautionary landing as the fuel gauge indication approached zero.
Explaining the events leading up to the accident, the NTSB said: “At about 17:20 hrs, the HEMS operator, located in St. Joseph, Missouri, accepted a mission to transport a patient from a hospital in Bethany to a hospital 62 miles away in Liberty. The helicopter departed its base less than 10 minutes later to pick up the patient at the first hospital. Shortly after departing, the pilot reported back to the company that he had two hours' worth of fuel onboard.
“After reaching the first hospital, the pilot called the company’s communication centre and indicated that he actually had only about half the amount of fuel (Jet-A) that he had reported earlier, and that he would need to obtain fuel in order to complete the next flight leg to the destination hospital. Even though the helicopter had only about 30 minutes of fuel remaining and the closest fuelling station along the route of flight was at an airport about 30 minutes away, the pilot elected to continue the mission. He departed the first hospital with crew members and a patient in an attempt to reach the airport to refuel.”
However, said the Board, the helicopter ran out of fuel and the engine lost power within sight of the airport and crashed ‘after the pilot failed to make the flight control inputs necessary to enter an autorotation’ (an emergency flight procedure than can allow for a safe landing).
The NTSB found that the pilot would have been better prepared had he received autorotation training in a simulator rather than in a helicopter, allowing the simulate to move as if it were cruising. The NTSB commented: “The investigation found that the autorotation training the pilot received was not representative of an actual engine failure at cruise speed, which likely contributed to his failure to successfully execute the manoeuvre. Further, a review of helicopter training resources suggested that the accident pilot may not have been aware of the specific control inputs needed to successfully enter an autorotation at cruise speed. The NTSB concluded that because of a lack of specific guidance in Federal Aviation Administration (FAA) training materials, many other helicopter pilots may also be unaware of the specific actions required within seconds of losing engine power and recommended that [the] FAA revise its training materials to convey this information.”
The NTSB highlighted that mobile phone records showed that the pilot had made and received multiple personal calls and text messages throughout the afternoon while the helicopter was being inspected and prepared for flight, during the flight to the first hospital, while ‘on the helipad at the hospital making mission-critical decisions about continuing or delaying the flight due to the fuel situation’, and during the accident flight. The Board’s statement continues: “While there was no evidence that the pilot was using his cell phone when the flameout occurred, the NTSB said that the texting and calls, including those that occurred before and between flights, were a source of distraction that likely contributed to errors and poor decision-making.”
Hersman commented: “This investigation highlighted what is a growing concern across transportation: distraction and the myth of multi-tasking. When operating heavy machinery, whether it’s a personal vehicle or an emergency medical services helicopter, the focus must be on the task at hand: safe transportation.”
As a result of the investigation, the NTSB has called for the FAA to prohibit flight crew members on the flight deck from using ‘portable electronic devices’ for non-operational purposes while the aircraft is being operated under the 14 Code of Federal Regulations Parts 135 and 91 subpart K, and to require that providers include this restriction in their training programmes and procedure manuals. The Board also urged Air Methods to extend its policy on ‘portable electronic devices’ to prohibit their use for non-operational purposes during safety-critical ground activities, and to revise its procedures so that pilots must consult with the company’s Operational Control Centre when confronted with elevated risk situations.
In conclusion, the NTSB cited four factors as contributing to the accident: ‘distracted attention due to texting; fatigue; the operator’s lack of policy requiring that a flight operations specialist be notified of abnormal fuel situations; and the lack of realistic training for entering an autorotation at cruise airspeed’.
For a synopsis of the NTSB’s report into the accident, including the probable cause, findings and a list of safety recommendations made to Air Methods and the US Federal Aviation Administration, go to www.tinyurl.com/waypoint-mo.