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Safety Recommendation Details

Safety Recommendation A-13-014
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 AIR METHODS CORPORATION: Expand your policy on portable electronic devices to prohibit their nonoperationaluse during safety-critical ground activities, such as flightplanning and preflightinspection, as well as in flight.
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: Air Methods Corporation (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Air Methods Corporation
Date: 9/16/2015
Response: We note that, although your General Operations Manual (GOM) (Revision 8) was not accepted by the Denver Flight Standards District Office (FSDO) until March 11, 2014, it had been submitted to the FSDO on November 30, 2012, before we issued these recommendations. We also note that, during the FSDO’s 15-month review of GOM (Revision 8), you made multiple attempts to work with the FSDO to revise the language in that version of the document, as recommended; however, you were told that the Federal Aviation Administration (FAA) could not work with you on such revisions until after the FAA Modernization and Reform Act of 2012 went into effect. We are pleased to learn that, despite these challenges, GOM (Revision 9), submitted to the FSDO on May 20, 2015, would (1) expand your policy on PEDs to indicate that these devices must be powered off and remain off during all pre-flight activities, the use of any checklist, and flight operations and (2) expand your risk assessment program to include a risk threshold that triggers the recommended mandatory OCC consultation. Pending our timely review of GOM (Revision 9) as described, Safety Recommendation A-13-14 remains classified OPEN—ACCEPTABLE RESPONSE and Safety Recommendation A-13-15 is classified “Open?Acceptable Response.”

From: Air Methods Corporation
To: NTSB
Date: 6/1/2015
Response: -From Michael D. Allen, President, Domestic Air Medical Services, Air Methods Corporation: Thank you for your letter dated April 1, 2015 concerning Safety Recommendations A-13-14 and -15 (collectively, the "Safety Recommendations"). We appreciate the opportunity to update you on Air Methods' progress to date, as well as share a few challenges we experienced while trying to incorporate such Safety Recommendations. Prior to outlining our efforts to date, we thought it would be useful to provide you with additional background information. As you know, on May 6, 2013 Air Methods received a letter (the "Letter") outlining recommendations of the National Transportation Safety Board ("NTSB"). The Safety Recommendations were driven by an accident that occurred on August 26, 2011 in Mosby, Missouri. Prior to receipt of the Letter, Air Methods had already proactively revised our General Operations Manual to include a preflight risk assessment program. Such revision was included in the General Operations Manual (Revision 8). Note, however, that the General Operations Manual (Revision 8) did not identify a numerical value that triggered a mandatory consultation with the Operations Control Center. Air Methods submitted the General Operations Manual (Revision 8) (which incorporated the foregoing revision) to the Denver Flight Standards District Office (the "FSDO") on November 30, 2012. Unfortunately, the revisions set forth in the General Operations Manual (Revision 8) were not accepted by the FSDO until March 11, 2014. After receipt ofthe Letter and during the FSDO's 15-month review period of our General Operations Manual (Revision 8), Air Methods undertook the following actions to incorporate the Safety Recommendations into its operations and manuals: • In response to safety recommendation A-13-14, Air Methods issued a bulletin titled "Crew Member Use of Wireless Devices". Air Methods fully intended on including the contents ofthis bulletin into its next revision of the General Operations Manual, but was unable to do so during the FSDO's 15-month review period of its General Operations Manual (Revision 8). In fact, General Operations Manual (Revision 9) which was submitted to the FSDO on May 20, 2015 fully incorporates the contents of the bulletin. We are happy to provide you with a copy of the General Operations Manual (Revision 9) upon its acceptance by the FSDO. • As noted above, prior to receipt of the Letter, Air Methods had already revised its General Operations Manual (Revision 8) to include a preflight risk assessment program. Although the revisions did not identify a numerical value that triggered a mandatory consultation with the Operations Control Center, Air Methods' was already trying to proactively address the recommendations set forth in A-13-15. Although Air Methods could have issued a bulletin incorporating the safety recommendations set forth in A-13-15, we were hesitant to do so in light the pending rules likely to be promulgated under the FAA Modernization and Reform Act of2012 (Public Law 112-95), which is now codified at 49 U.S.C. 44730 (the "Act"). The Act, among other things, sought to address an approved preflight risk assessment program, and therefore, Air Methods' wanted to preview the new rules and avoid having any conflicting guidance on the matter. In light of the pending legislation, Air Methods' attempted to work with the FSDO on multiple occasions to revise the language in the General Operations Manual (Revision 8) to comply with the Act. Despite our attempts to work in cooperation with the FSDO to incorporate a preflight risk assessment program into our General Operations Manual (Revision 8), we were informed that the FAA could not work with us on such revisions until the Act was effective. For example, our Director of Operations received an e-mail from our Principal Operations Inspector stating that, "/ will check today as well to see if there have been any changes to my guidance that we cannot discuss the new rule with the operator until our FAA guidance has been published. " FSDO officials scheduled their first meeting to discuss the Act and the incorporation of the preflight risk assessment program into our General Operations Manual on April 13, 2015 (nine days before the Act went into effect). Note that prior to such meeting we did elevate our concern over our FSDO's lack of engagement to John Duncan and he quickly directed our FSDO to engage with our Certificate Management Team. In hindsight we should have elevated our issue much sooner. We hope the background detailed above demonstrates our efforts to comply with the Safety recommendations. Our General Operations Manual (Revision 9), while still not accepted, is in effect for our operations and our approved risk assessment program exceeds NTSB recommendations. It would be an honor if I could meet with you in Washington, D.C. later this summer to discuss our response and other measures Air Methods is pursuing to continue to drive towards ever safer operations. I look forward to meeting with you.

From: NTSB
To: Air Methods Corporation
Date: 4/1/2015
Response: We are encouraged to learn that, on November 4, 2013, you issued a bulletin, titled “Crew Member Use of Wireless Devices,” which states that PEDs must be powered off and remain off during all pre-flight activities, the use of any checklist, and flight operations. You stated that the same information would be incorporated into the appropriate manual at its next revision; however, we did not find the information in General Operations Manual, Revision 8: March 11, 2014, which was issued 4 months after the bulletin. In order to fully satisfy the intent of this recommendation, you must also incorporate the guidance into your general operations manual. Pending our timely review of your updated manual, Safety Recommendation A-13-14 is classified OPEN—ACCEPTABLE RESPONSE.

From: Air Methods Corporation
To: NTSB
Date: 1/2/2015
Response: -From Crystal L. Gordon, General Counsel and Corporate Secretary: This letter is provided in response to your request for additional information regarding the actions undertaken by Air Methods Corporation (the “Company”) in connection with the NTSB Safety Recommendations A-13-14 and -15 (collectively, the “Safety Recommendations”), which were issued to the Company on May 6, 2013. Set forth on Exhibits A and B hereto are the policies that address Safety Recommendation A-13-14. In addition, we have enclosed several pages of our General Operations Manual that are responsive to Safety Recommendation A-13-15 (Exhibits C and D).

From: NTSB
To: Air Methods Corporation
Date: 10/3/2014
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. To date we have received no information from you regarding actions you have taken to implement our recommendations. We would appreciate receiving a response within 90 days indicating actions that you have taken or plan to take; in the meantime, Safety Recommendations A 13 14 and 15 will retain their current classification of OPEN—AWAIT RESPONSE.