The Safety Board believes the pilot missed three discrete opportunities to identify that the helicopter had inadequate fuel to complete the assigned mission — (1) during a required preflight inspection, (2) immediately before takeoff and (3) during the post-takeoff status report to AirCom. The electric fuel gauge was operating correctly and should have accurately displayed the helicopter's fuel state, about half of the normal 2-hr. fuel load, at these times.

It is unlikely, said the Safety Board, that the pilot deliberately misreported the fuel level because Jet-A fuel was available at the takeoff airport, and the pilot could have had fuel added without difficulty or penalty. It also seems unlikely that the pilot repeatedly misread the gauge indication, especially given the obvious difference in visual indication between the actual level (35%) and the reported level (70%).

Although the pilot had been advised during the shift change briefing that the helicopter was low on fuel, said the Safety Board, it is possible he forgot about this communication during the intervening 11 hr. before the first leg of the mission. If so, he might reasonably have expected the normal 70% level for an active helicopter.

“Such an expectation would be consistent with the incorrect fuel status report he provided after takeoff. Also, consistent with what the pilot subsequently stated, he had performed a preflight inspection on the earlier active helicopter (N101LN), and it was fueled to 70%.” Past Safety Board investigations have identified instances in which pilots made callouts without first verifying the cockpit indication that corresponded with the callout. Therefore, it is likely in this case that the pilot reported the fuel he expected to be in the helicopter without effectively referencing the fuel gauge.

The pilot's plan to proceed from Harrison to Liberty “was highly risky because of the limited fuel on board, said the Board. The plan did not meet 20-min. reserve fuel requirements for Part 135 operations. The difference between the actual fuel situation (30 min. or about 18%) and the fuel the pilot reported in his post-takeoff report (45 min. or about 26%) corresponded to a difference of about one marked increment on the fuel quantity gauge and should have been apparent to the pilot as he waited on the ground and considered his abnormal fuel situation. Further, the difference between the actual fuel situation and the minimum fuel required for the trip (52 min. based on the estimated time en route to GPH of 32 min.) was even greater. “Therefore, the pilot almost certainly knew that he did not have the required fuel reserve and misrepresented his fuel situation in his post-takeoff report because he wanted to give the appearance of compliance with the 20-min. fuel reserve requirement.”

The pilot undoubtedly knew that his decision to proceed with the mission was risky, and company personnel uniformly reported that the pilot could have aborted the mission at Harrison County Community Hospital without fear of serious negative consequences from the company, said the Safety Board. “This raises questions about the reasons for the pilot's decision to proceed. The pilot was new to the company and might have been concerned that aborting the mission as a result of an error during preflight preparation would negatively affect others' perceptions of his reliability as an employee. In addition, aborting the mission would likely have involved inconveniences (such as waiting at the hospital for fuel to be delivered) that the pilot probably preferred to avoid. Finally, he might have been influenced by time pressure associated with the urgency of the patient's medical condition and the implications of a delay in treatment.
“Although the pilot did not express such concerns during any recorded communication, such concerns have played [roles] in past safety-related incidents involving EMS flights. At the very least, the pilot would have expected that aborting the mission would result in some degree of discomfort for him and the patient. The NTSB concludes that the pilot departed on the second leg of the mission despite knowing that the helicopter had insufficient fuel reserves likely in order to avoid delays and other possible negative outcomes that could have resulted from aborting the mission.”

During the accident flight, the pilot was likely monitoring the fuel gauge closely and watching the fuel level decrease. As he approached GPH, the indicated fuel level would have approached zero. This might have prompted the pilot to consider landing the helicopter somewhere off-airport as a precautionary measure, said the Safety Board, “however, by the time the fuel gauge was near zero, the airport was in sight and the pilot was very close to successfully concluding the flight, and he may have been reluctant to land because it would have revealed his noncompliance with the 20-min. fuel reserve requirement. The pilot's decision to continue the flight rather than make a precautionary landing, despite mounting evidence that fuel exhaustion was imminent, was a decision error.”

The Safety Board stressed that there is no evidence that the pilot performance deficiencies were common in company operations or consistent with company policy. Rather, the company had formal operational procedures, including the completion of a preflight inspection and use of the before-takeoff checklist that, if complied with, would have led the pilot to detect the helicopter's low fuel level before departing on the first leg of the mission.