Premium on Safety - Issue 35, 2020 - 6

LESSONS LEARNED

A Chain of Cheese

Even professional pilots are not immune from the most basic mistake of all
BY DAVID J. KENNY
It's a question that's perplexed most thoughtful students: How
can an apparently competent pilot run an aircraft out of fuel in
flight? This lapse is particularly baffling when that pilot is not
only a professional flying for a large and respected operator,
but personally responsible for the safety of someone who is
critically injured or ill.
Rarely is there a single explanation. Rather, investigators
must untangle a skein of mistaken assumptions, optimistic
planning, distractions, missed cues, and neglected procedures.
All of those were implicated in the 2011 loss of N352LN, an
Air Methods AS350 B2, and the four souls on board during
a medical transport flight in day VMC conditions. True to the
classic model (chain or Swiss cheese), the accident probably
wouldn't have occurred if just one bad decision had been
caught and corrected in time.
The accident aircraft was one of two company helicopters
based at the Rosecrans Memorial Hospital in St. Joseph,

6

Missouri (STJ). During the week preceding the accident, it
had been used for night vision goggle (NVG) training, an
assignment requiring installation of the copilot's seat and flight
controls and removal of the medical interior. EMS flights were
handled by her sister ship, N101LN (another AS350 B2).
The NVG training was concluded at 3:00 a.m. on August 26.
The helicopter was not refueled afterwards; pilots determined
fuel requirements for EMS flights on a mission-specific basis.
During the 6:30 a.m. shift change, the night pilot advised his
relief that the training was complete and N352LN needed to be
reconfigured and refueled before any medical flights.
The base mechanic arrived at 7:00 a.m. and began the
reconfiguration, finishing about 2:00 p.m.. The pilot joined him
for a walk-around to inspect the work, but was later found not
to have initialed the mechanic's aptly named CYA ("conform
your aircraft") notes in the maintenance log. Nor did he sign off
having completed his preflight inspection, including sampling



Premium on Safety - Issue 35, 2020

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Premium on Safety - Issue 35, 2020 - Contents
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