NTSB: Pilot's texting contributed to medevac crash

Safety recommendations include banning crewmembers from using cell phones for non-operational use and improving training


By Sarah Calams
FireRescue1 Staff

WASHINGTON — The NTSB issued a safety alert Tuesday after accident investigators ruled that texting by the pilot of an air medical helicopter contributed to a crash that killed all four people on board.

The five-member board that looked into the cause of the August 2011 crash unanimously agreed that it was caused by a distracted and tired pilot who skipped preflight safety checks, which would have revealed his helicopter was low on fuel, according to the Associated Press.

 
Photo NTSB
The five-member board that looked into the cause of the August 2011 crash unanimously agreed that it was caused by a distracted and tired pilot who skipped preflight safety checks, which would have revealed his helicopter was low on fuel.
 

 

Photo NTSB
The five-member board that looked into the cause of the August 2011 crash unanimously agreed that it was caused by a distracted and tired pilot who skipped preflight safety checks, which would have revealed his helicopter was low on fuel.

 

Board Chairman Deborah Hersman said at the hearing in Washington, DC, that the case "juxtaposes old issues of pilot decision making with a 21st century twist: distractions from portable electronic devices."

The Associated Press reported that one board member dissented on the safety alert decision, saying the cases cited as the basis for it were caused by bad decisions by pilots rather than the use of distracting devices.

However, other board members reportedly disagreed. "We see this as a problem that is emerging, and on that basis, let's try to get ahead of it," Chris Hart said.

The crash in Mosby, Mo., nearly two years ago claimed the lives of patient Terry Tacoronte, Pilot James Freudenbert, Randy Bever, a flight nurse, and Chris Frakes, a paramedic

According to the NTSB report, the safety issues identified in the accident include:

  • Distraction due to non-operational use of personal electronic devices during flight and ground operations: The pilot’s texting, which occurred while flying, while the helicopter was being prepared for return to service, and during his telephone call to the communication specialist when making his decision to continue the mission, was a self-induced distraction that took his attention away from his primary responsibility to ensure safe flight operations. Further, although there is no evidence that the pilot was texting at the time of the engine failure, his texting while airborne violated the company’s cell phone use policy.
  • Lack of Air Methods Operational Control Center (OCC) involvement in decision-making: Although the pilot reported his low fuel situation to the communication specialist, he did not request and was not referred to the company’s OCC or to someone such as the chief pilot who would likely have asked how much fuel was on board the helicopter and proposed canceling the mission.
  • Inadequate guidance on autorotation entry procedures: The pilot’s autorotation training was done at airspeeds below cruise where less aft cyclic is needed to enter an autorotation.
  • Need for simulator training of helicopter emergency medical services pilots: The pilot had not received any flight training in a simulator.

The NTSB ruled the probable causes of the accident were the pilot’s failure to confirm that the helicopter had adequate fuel onboard 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.

It cited the pilot’s distracted attention due to personal texting during safety-critical ground and flight operations, his degraded performance due to fatigue and the operator’s lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations. 

As a result of this investigation, the NTSB made a range of safety recommendations to the FAA including banning flight crewmembers from using cell phones for non-operational use and improving training on the dangers of cell phone use. 

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