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Safety Recommendation Details

Safety Recommendation A-13-011
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: Revise the Helicopter Flying Handbookto include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation.
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: 4/6/2017
Response: We note 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 also note that you intend to incorporate this information into the appropriate sections of the Helicopter Flying Handbook during its next revision, which is currently being developed. Pending our review of the revised handbook, Safety Recommendation A-13-11 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/6/2017
Response: -From Michael P. Huerta, Administrator: As previously indicated. in Fiscal Year (FY) 2000. the federal Aviation Administration (FAA) started a program to expedite improvements for runway safety areas (RSA) at commercial service runways that did not meet FAA design standards. The FAA evaluated more than 1.000 runways at all airports certificated under Part 139 for compliance with current standards. The FAA continues to implement this program to improve RSAs to the extent practicable. We have been tracking RSA completion projects in two categories: • The first category of RSA improvements involved airports making improvements to meet geometry standards. Airport Improvement Program grants funded a major portion of most of these projects. These RSA improvements were successfully completed to the extent practicable by December 31, 2015. • The FAA ·s Air Traffic Organization is carrying out the second category or RSA improvements. These improvements involve relocating or making frangible r AA-owned navigational aids (NAVAIDS) that arc located in the RSAs. The r AA uses facilities and equipment (F&E) funds for these projects. They are on track for completion by the end or 2018. The FAA improved 84 percent of RSAs with NA VAIDS by the end or FY 2016. Enclosed is a list of RSAs with required F&E improvements remaining. I will keep the Board informed of the FAA ·s progress on this safe ty recommendation and provide an update by February 2018.

From: FAA
To: NTSB
Date: 10/29/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) Industry Airman Certification System Work Group completed a review of the Helicopter Flying Handbook (FAA-H-8083-2 1A). As an interim step, in response to this recommendation, on April19, 2016, the FAA issued Addendum- Change 1 to the Helicopter Flying Handbook. This addendum fully addresses the Board's concerns by including a discussion of the urgent nature of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation. However, until the information contained in Addendum- Change I can be incorporated into the appropriate sections of a revised Helicopter Flying Handbook, Addendum- Change I is available at the following Web site: http://www.faa.gov/regulations policies/handbooksmanuals/aviation/media/hfuaddendum.pdf. A revision to the Helicopter Flying Handbook, which will include the information contained in Addendum - Change I. is in development. A revision to the handbook takes approximately 24 months to complete and we anticipate publication of the next revision by fall of 20l8. I will keep the Board informed of the FAA's progress on this safety recommendation and update the Board once the handbook is revised.

From: NTSB
To: FAA
Date: 7/23/2015
Response: We do not believe that your publishing the guidance contained in AC 61-140, Autorotation Training, on May 23, 2013, constitutes an acceptable interim solution to the issue that is the subject of this recommendation. Specifically, we are concerned that the guidance (1) is targeted at flight instructors and may not be read by helicopter pilots who are not instructors or training to become an instructor, (2) lacks a thorough discussion of the entry phase of autorotations, and (3) does not highlight the rapid rate of rotor rpm decay or the urgency for the pilot to respond following an engine failure. As a result, we remain concerned that helicopter pilots may continue to believe that lowering the collective (with no other control inputs) will always result in a successful autorotation entry. Following the accident that was the subject of our investigation, Air Methods changed the guidance regarding autorotations in its Eurocopter AS350 pilot training program to emphasize the importance of applying simultaneous control inputs when entering an autorotation. The changes included adding a discussion of autorotations to the AS350 Flight Training Maneuvers Handbook that states, in part, “It is imperative that the pilot take immediate action to change to an autorotative attitude; i.e., simultaneously applying aft cyclic, lowering the collective to maintain rotor rpm, and trimming the aircraft. Failure to apply aft cyclic while lowering the collective will result in a nose low attitude; this condition may be unrecoverable at low altitudes.” Also, a note was added to the procedure in the Air Methods AS350 Flight Training Maneuvers Handbook for performing practice autorotations, stating that initial cyclic, collective, and antitorque pedal adjustments “must occur simultaneously to preclude an excessively nose low attitude from developing that may be unrecoverable at low altitude.” Additionally, the first step in performing a practice autorotation was changed to “Cyclic: Adjust to maintain 65 knots,” followed by lowering the collective as the second step. We recognize that the motions of a helicopter following an engine power loss vary greatly from one make and model helicopter to another and from one flight condition to the next. Therefore, the technique required for safely entering an autorotation will vary, and there is no technique of universal applicability. However, in discussions with experienced helicopter flight instructors and test pilots, our investigators found agreement that simultaneous control inputs, as opposed to only lowering the collective, should be used when entering an autorotation and that the critical task when entering an autorotation is to establish airflow upward through the main rotor system. Further, the instructors and test pilots interviewed reported that the Eurocopter AS350 B2 is not unique in requiring simultaneous application of aft cyclic and down collective to safely enter an autorotation at cruise airspeeds; rather this technique is applicable to many, if not all, helicopters with low inertia rotor systems. Therefore, we encourage you to revise the Helicopter Flying Handbook to include a discussion of the urgent nature of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation. Pending our review of the revised handbook and our determination that it addresses the concerns described above, Safety Recommendation A-13-11 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/4/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration's (FAA) next review of the Helicopter Flying Handbook is scheduled for the fall of 2015. Meanwhile, the FAA is also reviewing this topic with our FAA-Industry Airman Certification System Work Group to formulate recommendations on specific revisions to the handbook; we anticipate completing this second review this spring. On May 23, 2013, we also published Advisory Circular (AC) 61-140, "Autorotation Training, "to raise awareness of the risks inherent in performing autorotation. Autorotation is an emergency procedure unique to the helicopter and is incorporated into training programs not only to build confidence, but also as a maneuver designed to help pilots cope with an emergency requiring its use. To successfully perform an autorotation, the pilot must be able to apply the collective, cyclic, and tail rotor controls in a simultaneous or coordinated manner to stabilize the airspeed, rate of descent, and rotor RPM. Autorotation is the process of producing lift with airfoils that rotate freely and are not engine-driven. When a helicopter enters into autorotation, the air flows upward through the main rotor system, rather than downward, as when the rotors are engine-driven. We feel that it is important to provide information regarding the theory and factors of the autorotation, the basic overview of the process and, where practicable, provide and emphasize the areas of concern. AC 61-140 has recommendations for both straight-in autorotation and autorotation with turn, and discusses common errors, such as entry phase of autorotation, managing energy, and the factors affecting rotor RPM decay. We will incorporate the additional emphasis regarding autorotation training and incorporate the applicable sections from AC 61-140 during the fall 2015 Handbook review. The AC is available at the following Web site: http://www.faa.gov/regulationspolicies/advisory_circulars/index.cfm/go/document.information/documentl0/1021176. It is important to emphasize that the coordinated control inputs vary between make and model of the helicopter along with other variables such as aircraft loading, airspeed, altitude, wind factors, density altitude, rotor RPM, and pitch attitude. These variables are introduced in training situations that heighten the airman's awareness of the performance factors available to them in order to place the helicopter into a suitable landing area. It is also important that the manufacturer's Rotorcraft Flight Manual (RFM) serves as the final word for the operation of their specific helicopter. In their RFMs, each manufacturer provides information and graphs explaining situations in which an autorotation can be successful and situations in which they may pose a hazard. A helicopter pilot's training should also follow the specific helicopter's RFM procedures regarding emergency situations in which an autorotation might be applicable, including responding to engine failures, fire, tail-rotor failure, or system-related, helicopter-specific procedures. I believe these efforts are responsive to the intent of this recommendation and will provide an update by February 2016.

From: NTSB
To: FAA
Date: 12/10/2013
Response: The Helicopter Flying Handbook and Helicopter Instructor Handbook located at the web addresses specified in your letter do not contain the recommended revisions and are the same editions that were available at the time of our investigation. Our review of the guidance for performing autorotations in the FAA’s Helicopter Flying Handbook found that it emphasizes lowering the collective as the initial step in entering an autorotation, does not address the use of simultaneous control inputs in response to an engine failure, and contains minimal information on the entry phase of autorotations. We remain concerned by this lack of information because, as this accident demonstrates, if the entry is not performed correctly, an unrecoverable loss of rotor rpm can occur. The handbook does not inform pilots that the rate of rotor rpm decay following an engine failure is most rapid when the helicopter is at high gross weight, high forward speed, or in high density altitude conditions, or that, in the most severe cases, it takes only seconds for the decay to become unrecoverable. Nor does the handbook inform pilots that the procedure for safely entering an autorotation varies with the flight condition and with the make and model of the helicopter, nor point out that, when entering an autorotation at cruise airspeed, aft cyclic can help prevent excessive rotor rpm decay. Although some information about the entry phase of an autorotation is included in the FAA’s Helicopter Instructor’s Handbook, this publication is targeted at flight instructors and may not be read by helicopter pilots who are not instructors or training to become an instructor. Nor does the handbook point out that the procedure for safely entering an autorotation varies with the make and model of the helicopter, or point out that, when a helicopter is entering an autorotation at cruise airspeed, aft cyclic can help prevent excessive rotor rpm decay. Pending our review of the revised handbooks and our determination that they address the concerns described above, Safety Recommendation A-13-11 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/1/2013
Response: -From Michael P. Huerta, Administrator: FAA-H-8083-21A, Helicopter Flying Handbook, and FAA-H-8083-4, Helicopter Instructor Handbook, were revised in January 2013. These revisions already include information on the immediate and simultaneous inputs necessary to enter auto rotation if rotor rpm were to decay, and fulfill the intent of this recommendation. These documents are available at the following Web addresses: • Helicopter Flying Handbook: http://www.faa.gov/regulations_policies/handbooks_manuals/aircraft/helicopter_flying_handbook/media/helicopter _flying_ handbook. pdf • Helicopter Instructor Handbook: http://www.faa.gov/regulations_policies/handbooks_ manuals/aviation/media/F AA-H -8083-4.pdf I believe the FAA has effectively addressed this recommendation and consider our actions complete.