Premium on Safety - Issue 35, 2020 - 7

the fuel and confirming the available quantity, in the flight
log-all actions required by Air Methods' General Operations
Manual. He did, however, send and receive a number of text

This accident was caused by a tangle of
distractions, neglected procedures, missed
cues, and optimistic assumptions.
messages between 2:00 and 3:00 p.m. The helicopter was
approved for return to service and moved from the hangar
to the ramp around 3:30 p.m.
Air Methods' Communications Center (AirCom) called the
pilot at 5:20 p.m. with a request to transport a patient from
the Harrison County Community Hospital to Liberty Hospital.
The pilot accepted the flight during the initial call and N352LN
lifted at 5:28 p.m. crewed by the pilot, flight paramedic, and
flight nurse. At 5:30 p.m. the pilot contacted AirCom to report
that they were underway with two hours of fuel and three
souls on board. He also sent one text message while en route,
presumably having secured the collective with its friction lock.
The helicopter had never been refueled, and in a follow-up call
after landing, just before 6:00 p.m., the pilot advised AirCom
that he "did not have as much fuel as he'd originally thought,"
having mistakenly reported the fuel status of N101LN instead. The
communications specialist calculated that Liberty Hospital was 62
nautical miles away, with an estimated flight time of 34 minutes.
The pilot replied, "That's going to be cutting it pretty close.
I'm probably going to need to get fuel before that." They
determined that the nearest airport with Jet-A was the Midwest
National Air Center in Mosby (GPH)-a distance of 58 nautical
miles. The pilot commented, "So it would save me ... four
nautical miles and two minutes. I think that's probably where
I'm going to end up going."
Electing to board the patient and refuel en route, he added,
"I don't want to run short and I don't want to run into that
20-minute reserve ... we'll take off. I'll see how much gas I have
... and I'll call you when we're in the air." Neither the pilot nor the
specialist raised the possibility of discussing the fuel situation
or route change with Air Methods' Operational Control Center,
where another experienced helicopter EMS pilot was available
to review operational concerns. The helicopter took off at 6:11
p.m. The pilot reported 45 minutes of fuel on board and asked
AirCom to contact the FBO at GPH to arrange for fueling.

A combination of radar and company satellite tracking data
showed that N352LN flew directly toward GPH at altitudes of
400 to 600 feet and groundspeeds of about 115 knots. The
pilot sent three more text messages and received two while
airborne, receiving the last incoming message at 6:30 p.m. The
last few minutes of the flight track showed a gradual descent,
with a final hit at 6:41 p.m. indicating 116 knots groundspeed at
373 feet above the ground.
When the pilot failed to report having arrived, AirCom
contacted the FBO. The heavily fragmented wreckage was
found shortly afterwards just a mile from the threshold of
Runway 18. Damage to the fuselage suggested impact in a
40-degree nose-low attitude. The main rotor blades were bent
but not twisted and the tail rotor blades remained straight,
indicative of low rotor rpm. There was no post-impact fire, and
the fuel system, which remained largely intact, contained less
than one liter. Metal shavings in the engine showed that it was
still rotating at high speed, implying that the crash occurred
within 10 seconds of flameout.
The low rotor speed and nose-low attitude demonstrated
that the helicopter had not entered autorotation after power
was lost. The NTSB's report took particular note of simulator
tests conducted during the investigation, which showed
that successful autorotation from cruise speed required
simultaneously lowering collective and applying substantial
aft cyclic within one to two seconds of engine failure. Typical
autorotation practice, conducted from a starting airspeed of
about 80 knots, is more forgiving of slow or uncoordinated
control inputs. Autorotation from cruise flight cannot be
practiced safely in the AS350 B2 due to the rapid loss of rotor
rpm after an imperfect response, and simulator training is not
widely available.
The pilot's texting before the flight didn't prevent him from
pre-flighting the helicopter, but the resulting distraction could
explain that omission. Likewise, the in-flight messages didn't
necessarily keep him from successfully entering autorotation;
the last was received 11 minutes before the accident. But even
if the aircraft hadn't been in a fuel-critical state, carrying
on personal communications en route scarcely qualifies as
devoting full attention to the safe conduct of the flight. (Air
Methods responded with a zero-tolerance policy for in-flight
use of personal electronic devices.)
Perhaps most problematic was the pilot's conclusion that
shortening the flight by two minutes provided an adequate
margin of safety; and his subsequent decision to take off
without knowing the actual quantity of fuel onboard. By the
time of the crash, the pilot had been on duty for more than 12
hours and awake for at least 13; and after only five hours of
contd. next page



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