NTSB · Safety Recommendation
Safety Recommendation A-13-007
Recommendation
TO 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.
Safety Issue and Context
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. The helicopter impacted the ground in about a 40° nose-down attitude at a high rate of descent with a low rotor rpm.
Wreckage examination determined that the engine lost power due to fuel exhaustion and that the fuel system was operating properly. The investigation revealed that the pilot did not comply with several company standard operating procedures that, if followed, would have led him to detect the helicopter’s low fuel state before beginning the first leg of the mission (from the helicopter’s base in St. Joseph, Missouri, to Harrison County Community Hospital). After reaching the hospital, the pilot reported to the company’s EMS communication center that he did not have enough fuel to fly to Liberty Hospital and requested help locating a nearby fuel option.
During their conversation, the pilot did not report and the communication specialist did not ask how much fuel was on board the helicopter, and neither of them considered canceling the mission and having fuel brought to the helicopter. After determining that GPH was the only airport with Jet-A fuel along the route of flight to Liberty Hospital, the pilot decided to proceed to GPH, although the estimated flight time to GPH was only 2 minutes shorter than that to Liberty Hospital. The engine lost power about 1 nm short of the airport, and the pilot did not make the flight control inputs necessary to enter an autorotation, which resulted in a rapid decay in rotor rpm.
Response History
September 3, 2015 · NTSB Correspondence · FAA
We note that your February 12, 2014, final rule, “Prohibition on Personal Use of Electronic Devices on the Flight Deck,” prohibits flight crewmembers in operations under 14 CFR Part 121 from using a personal wireless communications device or laptop computer for personal use while at their duty station on the flight deck during aircraft operation. Consequently, Part 121 operators are required to incorporate appropriate provisions of the regulation into their initial and recurrent training programs. Although we believe that this is an improvement over the previous regulations, we remain concerned that the rule affects only flight crewmembers operating under 14 CFR Part 121.
We point out that this accident, which was a Part 135 medical flight, demonstrates that flight crewmembers using portable electronic devices for nonoperational use while operating under Part 135 and Part 91 Subpart K are equally susceptible to the potentially catastrophic consequences of distraction, and their passengers are all placed at the same risk. Therefore, the rule only partially addresses the problem of distraction caused by these devices on the flight deck, and fails to protect flight crewmembers or passengers (or persons on the ground) in other operations.