The U.S. National Transportation Safety Board issued similar rulings in late January involving two helicopter emergency medical services (HEMS) crashes involving pilots who flew into localized storms. The first crash, which occurred Sept. 25, 2009 near Georgetown, S.C., involved a Carolina Life Care Eurocopter AS350B2 operated by Omniflight Helicopters. Three people died in the crash, the pilot, a flight nurse and a flight paramedic.
According to the report, the pilot decided to “continue the VFR flight into an area of IMC, which resulted in the pilot’s spatial disorientation and a loss of control of the helicopter.” NTSB noted “inadequate oversight of the flight by Omniflight’s Operational Control Center” as a contributing factor to the accident, which happened at around 11:30 p.m. as the crew was headed back from dropping off a patient.
The second accident took place on March 25, 2011 near Brownsville, Tenn. The Hospital Wing Eurocopter AS350B3, registered to Memphis Medical Air Center, went down after heading straight into a weather cell, resulting in the deaths of the pilot and two flight nurses. The safety board ruled that attempting to fly into “adverse weather, resulting in an encounter with a thunderstorm with localized IMC, heavy rain and severe turbulence,” is the probable cause of the crash.
The report’s narrative describes the pilot’s apparent state of mind leading up to the crash. In a conversation with an oncoming shift pilot, the pilot allegedly said he “wanted to get the helicopter out” after sitting on the helipad at Jackson-Madison County General Hospital and waiting for the flight nurses.
The shift pilot suggested parking the helicopter, but the active duty pilot insisted there was enough time to make it, believing “he had about 18 minutes to beat the storm and return to home base” while leaving the nurses behind, according to NTSB. The shift pilot later spoke with one of the flight nurses, who in fact made it on board and said they were about 30 seconds from arrival, when the helicopter went down. Witnesses reported lighting, thunder and “heavy rain bands” in the area at the time of the crash.
NTSB faults the decision-making process of the pilot, saying that he could have stayed at the helipad, but instead “decided to enter the area of weather, despite the availability of a safer option. Based on the pilot’s statement to the oncoming pilot about the need to ‘beat the storm’ and his intention to leave the flight nurses behind and bring the helicopter back (even though the nurses made it back on board), he was aware of the storm and chose to fly into it.”
The report continues by stating the pilot “made a risky decision to attempt to outrun a storm in night conditions, which would enable him to return the helicopter to its home base and end his shift there, rather than choosing a safer alternative of parking the helicopter in a secure area and exploring alternate transportation arrangements or waiting for the storm to pass and returning to base after sunrise when conditions improved.”
According to NTSB, the pilot “was nearing the end of his 12-hour shift, during which he had flown previous missions and may have had limited opportunities to rest. He had been on duty overnight, and the accident occurred at an early hour that can be associated with degraded alertness.” This situation “provides risk factors for fatigue that could have significantly degraded his decision-making,” the report states. “However, without compete evidence regarding his sleep and rest activities, NTSB was unable to determine whether or to what degree fatigue contributed to the pilot’s faulty decision to attempt to outrun the storm.”
For more on how the NTSB rulings impact training, see the February issue of Rotor & Wing, Editor’s Notebook, “Own Worst Enemy.”