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Safety Recommendation Details

Safety Recommendation A-13-010
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: Inform pilots of helicopters with low inertia rotor systems about the circumstances of this accident, particularly emphasizing the findings of the simulator flight evaluations, and advise them of the importance of simultaneously applying aft cyclic and down collective to achieve a successful autorotation entry atcruise airspeeds.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/8/2017
Response: In your February 12, 2016, letter, you told us that guidance was added to a draft revision of Advisory Circular (AC) 61-140, “Autorotation Training,” to address this recommendation and other critical aspects of autorotation. We note that the AC was published on August 30, 2016; however, we are concerned that it does not discuss the circumstances of this accident or the importance of simultaneously applying aft cyclic and down collective when entering an autorotation. We are also concerned that the AC may not be read by helicopter pilots who are not instructors or training to become instructors. In your December 29, 2016, letter regarding Safety Recommendation A-13-11, you told us that, on April 19, 2016, you published an addendum to the Helicopter Flying Handbook (“Addendum—Change 1”), which contains additional information for helicopter pilots regarding the entry phase of autorotations, emphasizing the importance of immediately and simultaneously applying aft cyclic, lowering the collective to maintain rotor rpm, and trimming the aircraft. We responded that your plan to incorporate this information into the appropriate sections of the Helicopter Flying Handbook during its next revision was responsive to Safety Recommendation A-13-11. Although we do not consider the AC responsive to Safety Recommendation A-13-10, we believe that your planned revisions to the Helicopter Flying Handbook will be. Pending our review of the revised handbook, Safety Recommendation A-13-10 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/30/2017
Response: -From Michael P. Huerta, Administrator: In our previous letter to the Board. dated February 12. 20 16. we noted that the Federal Aviation Administration (FAA) added language to an Advisory Circular (AC) to address this recommendation, and anticipated publication no later than September 30. 2016. On August 30, 20 I 6, the FAA published AC 6 l-l 40A, Autorotation Training. This AC includes guidance regarding the application of appropriate cyclic inputs and lowering collective. And emphasizes other actions aiding the successful completion of an autorotation. This AC is available at: http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_61 -1 40A.pdf. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 4/7/2016
Response: We note that you have added guidance to a draft revision of Advisory Circular (AC) 61-140, “Autorotation Training,” to address this recommendation and other critical aspects of autorotation. Pending our review of the published AC, which should inform pilots of helicopters with low inertia rotor systems about the concerns discussed in this recommendation, Safety Recommendation A 13-10 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/12/2016
Response: -From Michael P. Huerta, Administrator: In our previous letter to the Board dated August I, 2013, we noted that the Federal Aviation Administration (FAA) was drafting an Advisory Circular (AC) to address the subject recommendation, along with other critical aspects of autorotation from initial indications of a situation requiring an autorotation through touchdown and completion. The FAA plans to include guidance regarding applying aft cyclic, as well as emphasizing other actions that may be required depending on the mode and condition of the night. The FAA added this language to AC 61 -1 40. Autorotation Training, initially published on May 23, 2013. The draft of this revision to the AC is currently in internal coordination, and we anticipate publication by September 30, 2016. I will keep the Board in formed of the FAA•s progress on this recommendation and provide an update by December 2016.

From: NTSB
To: FAA
Date: 7/23/2015
Response: The FAA’s only letter concerning Safety Recommendation A-13-10, dated August 1, 2013, stated that you were developing an advisory circular (AC) to inform pilots of helicopters with low inertia rotor systems about the concerns discussed in this recommendation. Based on this information, Safety Recommendation A-13-10 was classified OPEN—ACCEPTABLE RESPONSE on December 10, 2013. We have not received any additional information regarding the status of the AC; accordingly, please inform us about progress that you have made since August 2013 to address Safety Recommendation A-13-10.

From: NTSB
To: FAA
Date: 12/10/2013
Response: Pending our review of an advisory circular that informs pilots of helicopters with low inertia rotor systems about the concerns discussed in this recommendation, Safety Recommendation A 13 10 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/1/2013
Response: -From Michael P. Huerta, Administrator: The FAA is drafting an advisory circular (AC) covering autorotation. The AC will cover this recommendation, along with other critical aspects of the autorotation, from initial indications of a situation requiring one through the touchdown and completion. It will include guidance regarding applying aft cyclic, as well as emphasize other actions that may be required depending on the mode and condition of flight. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an updated response by July 31, 2014.