Could texting distraction have led to a series of disastrous mistakes?
The helicopter was based at Rosecrans Memorial Airport (STJ), St. Joseph, Mo. When used for EMS flights, the AS350 was equipped with one pilot seat and a single set of controls along with a medical interior kit to accommodate one patient and two medical attendants. During the week before the accident flight, the accident AS350 was reconfigured to conduct night vision goggle (NVG) pilot training. The medical interior had been removed and the copilot's seat and controls installed. While the accident helicopter (N352LN) was used for training, the St Joseph base used another Air Methods AS350 (N101LN) for EMS flights.
The last NVG training flight in N352LN was completed about 0300 on the day of the accident. The NVG instructor told investigators he did not have the helicopter refueled because the EMS pilot coming on duty needed to determine the amount of fuel required after the helicopter had been returned to service in EMS configuration. The EMS duty helicopter was typically loaded with a 70% fuel load that provided about 2 hr. flight time.
The 35-year-old, U.S. Army-trained accident pilot reported for duty on Aug. 26 at 0630, about an hour after he woke up at his layover hotel. The departing night shift pilot briefed the accident pilot on the status of the active helicopter (N101LN) and the status of the accident helicopter (N352LN). Eurocopter N101LN would remain the active EMS helicopter until N362LN was reconfigured. The lead pilot also told the accident pilot that N352LN would have to be refueled once the mechanic completed the changeover.
The accident pilot conducted a preflight inspection of N101LN and signed its daily flight log as required by the Air Methods General Operations Manual (GOM). The helicopter mechanic began to reconfigure the accident helicopter for EMS work at 0700. About 1400, the mechanic told the accident pilot that the reconfiguration work was complete, and together they performed a walk-around inspection so the mechanic could show the pilot what had been done.
Once the walk-around was finished, the flight nurse and flight paramedic prepared the cabin for duty while the pilot transferred his gear and paperwork from the active helicopter to the accident helicopter. The crew had completed the transfer by 1530.
Company procedures required that the pilot perform a preflight inspection including a fuel quantity check before it was returned to service. Examination of the helicopter's daily flight log revealed that the pilot did not sign it as required by the GOM to indicate that he had completed the preflight inspection. The pilot failed to take fuel samples as required by the GOM. The mechanic had made three “conform your aircraft” (CYA) entries in the maintenance log after the reconfiguration operation, but the pilot did not initial the CYA entries as also required by the GOM.
The Air Methods Communication Center (AirCom) received a request at 1719 to transport a patient from Harrison County Community Hospital in Bethany to Liberty Hospital in Liberty, both in Missouri. AirCom notified the pilot at 1720. The pilot accepted the flight.
The helicopter departed about 1728. Two minutes later, the pilot reported by radio to the AirCom communications specialist that the helicopter had departed STJ with 2 hr. of fuel and three persons on board. Thirty minutes later, the helicopter landed at the Harrison County Community Hospital helipad to pick up the patient.
The flight nurse and flight paramedic took their stretcher to the hospital's emergency room to prepare the patient for flight. The pilot stayed in the helicopter and, about 1759, contacted AirCom using his company-provided cell phone. He told the communications specialist that he had realized about halfway through the flight from STJ that the helicopter did not have as much fuel on board as he originally thought. The pilot said he had mistakenly reported the fuel from N101LN, not from the accident helicopter, and that he would have to stop somewhere and obtain fuel.
The communication specialist asked the pilot if he could make it to Liberty Hospital, some 62 nm distant with an estimated time en route of about 34 min. The pilot answered, “That's going to be cutting it pretty close. I'm probably going to need to get fuel before that.”
The communications specialist and pilot determined the only airport with Jet-A fuel along the route of flight to Liberty Hospital was Midwest National Air Center (GPH) in Mosby, about 58 nm away from Harrison and just 4 mi. short of Liberty Hospital. The pilot said, “Fifty-eight nautical miles. So it would save me, save me 4 nm and 2 min. I think that's probably where I'm going to end up going.”
The pilot said he would refuel at GPH with the patient on board. “I don't want to run short and I don't want to run into that 20-min. reserve if I don't have to . . . We'll take off. I'll see how much gas I have when I go and I'll call you when we're in the air.”
Neither the pilot nor the busy communication specialist discussed contacting the Air Methods Operational Control Center (OCC) to inform the OCC of the low fuel situation or the changed flight route. (Thebelieves operational specialists might have overridden the pilot's decision to depart Harrison County.)
Minutes later, the flight nurse and flight paramedic arrived back at the helicopter and loaded the patient into the helicopter. At 1811, the helicopter lifted off and the pilot reported via radio to AirCom that he had 45 min. of fuel and four persons on board and was en route to GPH. About 1813, the pilot requested that AirCom contact the FBO at GPH to indicate that the helicopter was inbound for fuel, and that was done.
At 1815, the AirCom communication specialist notified the AirCom supervisor that the helicopter was low on fuel and would be refueling with the patient on board at GPH. About 1827, AirCom notified the pilot via radio that the fuel arrangement had been made at GPH. The pilot acknowledged the radio transmission. It was the last recorded transmission from the pilot.
The helicopter headed directly toward GPH cruising between 400 and 600 ft. AGL with an average ground speed of 111 to 116 kt. At 1841, the last satellite tracking system position recorded was about 0.9 nm from the accident site and showed the helicopter was at 373 ft. AGL with a 116-kt. ground speed. When the pilot did not report arriving at GPH, AirCom called the FBO, and the wreckage was located shortly thereafter in a farm field about 1 nm from the approach end of Runway 18 at GPH. There were no witnesses to the accident.
The aircraft structure was heavily fragmented and scattered along a 100-ft.-long debris path. No one had survived. The damage to the rotor blades was consistent with a low rotor rpm at impact. Initial impact was about 40-deg. nose-low at high speed. There was no post-impact fire. Indeed, no fuel was located at the accident site other than a liter or so in the fuel system plumbing. The evidence was consistent with a loss of engine power due to fuel exhaustion. Engine manufacturer metallurgic studies suggest impact must have occurred within the first 10 sec. after flameout.