Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
National Transportation Safety Board
Opening Remarks
Washington, DC - April 9, 2013
Aircraft Accident Report - Loss of Engine Power Eurocopter AS350
Mosby, MO - August 26, 2011
(As Prepared for Delivery)


Good morning. Welcome to the Boardroom of the National Transportation Safety Board. I am Debbie Hersman, and it is my privilege to serve as Chairman of the National Transportation Safety Board. Joining me are my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind and Member Earl Weener.

Today, we meet in open session as required by the Government in the Sunshine Act to consider two reports: a 2011 helicopter crash in Missouri and a 2011 marine accident in the Gulf of Mexico. We begin with the first item on our agenda, the August 26, 2011, helicopter crash of a Eurocopter AS350 near Mosby, Missouri.

The crew was transporting a patient from a hospital in Bethany, Missouri, to a hospital in Liberty, Missouri, when the helicopter crashed approximately one mile short of the Midwest National Air Center in Mosby. All onboard - pilot, flight nurse, flight paramedic and patient - perished in the crash.

On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the families and friends of the four individuals who died in this unfortunate accident. We know that nothing can replace the loss of your loved ones. But, we hope that our work today to understand the circumstances of this accident; determine the probable cause; and identify ways to prevent future tragedies will provide you some comfort.

The NTSB has investigated scores of helicopter emergency medical services, or HEMS, crashes. Currently, we are investigating 11 other HEMS accidents. In 2009, we held a hearing on HEMS safety. In 2006, we issued a special investigation report on emergency medical services operations.

Over the years, we have seen recurring safety issues in these investigations and have issued numerous recommendations to the FAA and others to improve the safety of these operations.

HEMS is a specialized segment of aviation with one goal: saving lives. The flights are not scheduled. Nor are they routine. By definition, these flights involve emergencies and urgency - transporting individuals who are in critical condition or delivering donor organs. There is always pressure to accomplish the mission.

In so many of our investigations we see the same factors. The classic HEMS crash is at night ... in bad weather ... in unfamiliar territory.

Yet, what happened near Mosby, Missouri, on August 26, 2011, did not have these classic characteristics.

The helicopter went down in visual meteorological conditions near a known landing site.

But, in other respects, as we'll hear this morning, it was a classic aviation accident. That is because this fatal crash involved perhaps the most crucial and time-honored aspect of safe flight: aeronautical decision making.

Decision making - from which route to fly, what load to carry, what to do if weather deteriorates, how much fuel is needed, down to the basics of go/no-go. Those decisions are essential in aviation. That's why there are literally thousands of articles, books, manual references, and more - all designed to instill in airmen the absolute importance of sound decision making.

Wilbur Wright, who did not live long enough to see the scope and scale of what he and his brother invented on that stretch of North Carolina sand, was a brilliant man and he surely understood both man and machine.

More than a century ago when talking about the safety of flight he said, "Greater prudence is needed rather than greater skill."

Greater prudence. We will hear about greater prudence today. We will also hear about an accident that juxtaposes old issues of pilot decision making with a 21st century twist: distractions from portable electronic devices.

Dr. Mayer, will you please introduce the staff.