EUROCOPTER AS-350-B2Air Methods Corporation
Mosby, MO, USA · 2011-08-26·N352LN
What happened
NTSB summary, verbatimThe Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/02. On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH.
Photographs
43the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe pilot's failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion. Contributing to the accident were (1) the pilot's distracted attention due to personal texting during safety-critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator's lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot's autorotation training in the accident make and model helicopter.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · EnrouteLoss of engine power (total)defining event
- 2 · Uncontrolled descentCollision with terr/obj (non-CFIT)
Findings
6 causal · 1 contributing- CAUSEPersonnel issues › Task performance › Planning/preparation › Fuel planning — Pilot
- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Pilot
- CAUSEPersonnel issues › Action/decision › Action › Incorrect action performance — Pilot
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Training — Operator
- CAUSEPersonnel issues › Psychological › Attention/monitoring › Attention — Pilot
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Not installed/available
Safety recommendations
9 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Prohibit flight crewmembers in 14 Code of Federal RegulationsPart 135 and 91 subpart K operations from using a portable electronic device for nonoperational use while at their dutystation on the flight deck while the aircraft is being operated.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal RegulationsPart 121, 135, and 91 subpartK operators to incorporate into their initial and recurrent pilot training programs information on the detrimental effects that distraction due to the nonoperationaluse of portable electronic devices can have on performance of safety-critical ground and flight operations.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal RegulationsPart 121, 135, and 91 subpart K operators to review their respective general operations manuals to ensure that procedures are in place that prohibit the nonoperational use of portable electronic devices by operational personnel while in flight and during safety-critical preparatory and planning activities on the ground inadvance of flight.
TO THE FEDERAL AVIATION ADMINISTRATION: Inform pilots of helicopters with low inertia rotor systems about the circumstances of this accident, particularly emphasizing the findings of the simulator flight evaluations, and advise them of the importance of simultaneously applying aft cyclic and down collective to achieve a successful autorotation entry atcruise airspeeds.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise the Helicopter Flying Handbookto include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation.
TO THE FEDERAL AVIATION ADMINISTRATION: Require the installation of a crash-resistant flight recorder system on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder and are operating under 14 Code of Federal RegulationsParts 91, 121, or 135. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.”
TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.”
TO AIR METHODS CORPORATION: Expand your policy on portable electronic devices to prohibit their nonoperational use during safety-critical ground activities, such as flight planning and preflight inspection, as well as in flight.
TO AIR METHODS CORPORATION: Revise company procedures so that pilots are no longer solely responsible for nonroutine operational decisions but are required to consult with the Air Methods Operational Control Center for approval to accept or continue a mission when confronted with elevated risk situations, such as fuel-related issues and unplanned deviations.
NTSB analysis
from the final reportThe Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/02. On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH.