NTSB · Safety Recommendation
Safety Recommendation A-13-012
Recommendation
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.”
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
July 30, 2026 · NTSB Correspondence · FAA
Aviation Investigation Report AIR-26-05 “In-Flight Loss of Control and Impact with Pack Ice Bering Air Flight 445 Textron Aviation 208B, N321BA, Near Nome, Alaska February 6, 2025” published on July 30, 2026:
2.6 Crash-Resistant Flight Recorder Systems
The accident airplane was not equipped with a cockpit voice recorder or a flight data recorder and was not required to be equipped under the applicable regulations. Despite the absence of a requirement for recording equipment, the installed Garmin G1000 integrated flight deck system recorded multiple flight parameters that provided the basis for the NTSB’s airplane performance study and weight and balance analysis of prior flights that were key to identifying the causes of this accident. Our investigation was only able to perform these analyses because the G1000 SD card was recovered in sufficiently good condition.
The G1000 system and the SD card required to enable the data logging function are not crash-resistant. Footnote: The types of cockpit voice recorders and flight data recorders that are required by regulation to be installed on certain aircraft are designed to stringent crash-survivability standards. Crash-resistant flight recorders, which are designed to a less stringent survivability standard, are generally less expensive, lighter weight, and able to record much of the same information as cockpit voice recorders and flight data recorders, as well as cockpit images.
In the case of this accident, the SD card was recoverable mainly due to the wreckage location (on sea ice rather than submerged in water) and lack of a postcrash fire. Under different circumstances, the SD card could have been destroyed or its data unrecoverable, leaving little more than ADS-B data and the physical wreckage to reconstruct the accident sequence.
Even with the successful recovery of the G1000 flight data, the absence of cockpit audio and image recordings left gaps in the investigation’s understanding of the pilot’s actions and awareness of the airplane’s state during the critical final minutes of the flight (the pilot’s actions and awareness are explored in section 2.2.3). Without cockpit image recording, investigators could not observe the pilot's instrument scan, his interaction with the flight controls or avionics, or whether the icing conditions outside the airplane were visually apparent from the cockpit.