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Safety Recommendation Details

Safety Recommendation A-13-009
Details
Synopsis: 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal RegulationsPart 121, 135, and 91 subpart K operators to review their respective general operations manuals to ensure that procedures are in place that prohibit the nonoperational use of portable electronic devices by operational personnel while in flight and during safety-critical preparatory and planning activities on the ground inadvance of flight.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Mosby, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CEN11FA599
Accident Reports: Crash Following Loss of Engine Power Due to Fuel Exhaustion, Air Methods Corporation Eurocopter AS350 B2, N352LN
Report #: AAR-13-02
Accident Date: 8/26/2011
Issue Date: 5/6/2013
Date Closed: 9/3/2015
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/3/2015
Response: 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. We do not believe that your May 20, 2014, Information for Operators (InFO) 14006, titled “Prohibition on Personal Use of Electronic Devices on the Flight Deck,” adequately addresses the recommendations, either. Although the InFO encourages all 14 CFR Parts 135 and 91 Subpart K operators to include operating procedures in their manuals and crewmember training programs prohibiting flight crewmembers from using portable electronic devices for nonoperational use during aircraft operation, InFOs are guidance documents only and are not binding. Although we believe that additional rulemaking is needed to more broadly and effectively address this issue within the industry, you have indicated that you do not intend to address these concerns and that you consider your actions complete. These improvements fall short of providing the safety benefits envisioned in this recommendation, because they do not address the safety risks of distraction for aircraft operations conducted under 14 CFR Parts 135 and 91 Subpart K. Accordingly, Safety Recommendations A-13-7 through -9 are classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 6/2/2015
Response: -From Michael P. Huerta, Administrator: On February 12, 2014, the Federal Aviation Administration (FAA) published the Prohibition on Personal Use of Electronic Devices on the Flight Deck final rule (79 FR 8257). The final rule prohibits flight crew members in operations under part 121 from using a personal wireless communications device or laptop computer at their duty station while the aircraft is being operated. Prohibition on the use of personal electronic devices during preparatory and planning activities on the ground in advance of flight is covered under§§ 121.542 and 135.100 (known as The Sterile Cockpit rule). The FAA has reviewed parts 135 and 91 subpart K (91 K) operations to determine whether additional rulemaking action is necessary to ensure that similar information is included in operators ' training programs. The FAA has no current plans to develop additional rulemaking in response to these recommendations. However, we issued Information for Operators (InFO) 14006, Prohibition on Personal Use of Electronic Devices on the Flight Deck, on May 20, 2014. This InFO is available at the following Web site: http://www.faa.gov/othervisit/aviationindustry/airline_operators/airline_safety/info/all_infos/media/2014/InFO14006.pdf InFO 14006 provides information to part 121 air carriers regarding the prohibition on personal use of electronic devices on the flight deck. The InFO also encourages Directors of Safety and training managers for all operators under parts 135 and 125, as well as part 91 K, to include operating procedures in their manuals and crewmember training programs prohibiting flight crew members from using such devices for personal use during aircraft operation. I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 12/10/2013
Response: We note that Part 121 operators would be required to incorporate appropriate provisions of the regulation into their initial and recurrent training programs and that, upon publication of the final rule, the FAA plans to review Part 135 and 91 subpart K operations to determine whether additional action is necessary to ensure that similar information is included in these operators’ training programs. We further note that, once the final rule is published, the FAA will determine what, if any, additional action is necessary to satisfy the recommendations. Pending our review of the FAA’s findings and completion of the recommended actions, Safety Recommendations A-13-8 and -9 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/1/2013
Response: -From Michael P. Huerta, Administrator: On January 15, 2013, the Federal Aviation Administration (FAA) published the Prohibition on Personal Use of Electronic Devices on the Flight Deck Notice of Proposed Rulemaking (NPRM) (78 FR 2912). The proposed rule would prohibit flight crewmembers operating under part 121 from using a personal wireless communications device or laptop computer while at their duty station on the flight deck during aircraft operation. This proposed rule is meant to ensure that certain non-essential activities do not contribute to the challenge of task management on the flight deck, or contribute to a loss of situational awareness. The comment period for the NPRM closed on March 18, 2013. The Board submitted comments to this NPRM similar to A-13-7, which asked that the proposed rule be expanded to operations under part 135 and 91 subpart K. The FAA has reviewed the comments and is developing a final rule. Currently, part 121 operators are required by sections 121.40l(a)(l), 121.415(a)( l)(ii), and 121.427(b )(2) to incorporate appropriate provisions of the Federal Aviation Regulations into initial and recurrent training programs. The FAA considers the Prohibition on Personal Use of Electronic Devices on the Flight Deck final rule an appropriate provision of the regulations. Therefore, upon publication of the final rule, operators would incorporate it into their training programs. Consequently, the FAA has no plans of specifically mandating that information on pilot distraction due to the use of portable electronic devices be included in part 121 initial and recurrent training programs, as recommended in Safety Recommendation A-13-8. After publication of the Prohibition on Personal Use of Electronic Devices on the Flight Deck final rule, the FAA will reviev1 part 13 5 and 91 subpart K operations to determine if further action is appropriate. The proposed rule does not extend the prohibition on the use of personal electronic devices to preparatory and planning activities on the ground in advance of flight, as proposed in A-13-9. However, upon publication of the final rule, the FAA will review A-13-9 again to determine what additional action, if any, is required to meet the safety intent of this recommendation. The FAA's objective is to publish a final rule in 2014. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by July 31, 2014.