Fuel Exhaustion, Texting, and Killing Passengers!

[SASless]

Reading this article defies the imagination on how utterly stupid one Person can be....and how unorganized one Operator could be. That this guy could obtain and then keep a job as a Pilot in an EMS Operation really begs credulity.


EMS Helicopter Fuel Exhaustion (http://www.aviationweek.com/Article.aspx?id=/article-xml/BC_09_01_2013_p55-602322.xml&p=1)

[Thomas coupling]

Did he die - can't remember. Saves doing him for murder then, anyway.:*

[handysnaks]

Murder? Where is the intent?:rolleyes:

[FH1100 Pilot]

The issue that the NTSB and all these magazine writers keep dancing carefully around is: He was cheating on his pregnant wife. All of that terrible text messaging was going with a FEMALE coworker, not some drinking buddy he was looking to have supper and a few brewskies with after his shift. ...Because if it was a guy he was doing all that texting with, it'd be really, really creepy.

Why is this relevant? It gets to his mindset. Clearly, he was "distracted" through the changeover of helicopters and his preflight; the prospect of sex will do that to a fellow. Did the company have solid procedures in place? Yep. Did he follow them? Nope. He was too busy talking and texting with his little extramarital girlfriend-nursie and, presumably, thinking about what they'd end up doing *after* dinner. Hey, maybe she's a wildcat in the sack! Sex is a powerful distraction, my friends. Or so I've heard. Why, I'm getting a chubby just thinking about all this - I may not be able to finish this post! DOWN BOY! DOWN! THINK ABOUT GRANDMA!

According to that B/C A article by Richard Aaron, the NTSB is confident that the pilot did not intentionally lie about his fuel when he first took off. Which means that at some point in cruise he looked at the fuel gauge and had a real, "Oh sh*t" moment. Maybe he did one of those cartoon double-takes, complete with blurred head and bulging eyes. *GULP* To admit his mistake at that point would have made him look really, really bad. "Sorry guys, we gotta turn around and go back and get some...you know...gas. I...ahhhh...messed up. I thought this thing was fueled." And the med crew would legitimately ask, "Hey bonehead, didn't you, like, check that before we took off?" The incident would probably even get up on some of the internet web boards that discuss this stuff (maybe even this one, but certainly the "bad" JH board!). "MISSION ABORTED BECAUSE PILOT DID NOT CHECK FUEL ON PREFLIGHT!" How would that look?! He'd look like an incompetent fool, all because he was preoccupied about getting laid with someone who was not his wife. ...His pregnant wife.

And no telling what his company would do to him. After the fact they said, "Oh if he'd only just landed back, or not taken off again from Hamilton County Hospital there would have been no repercussions, oh nooooo!" But come on, we all know that there would indeed! ...Just maybe no immediate repercussions. "Never you mind working your shift tomorrow, bub, you just come on into HQ for a little chat with the Chief Pilot." And we all know how THAT would have gone. He's thinking, "My wife's pregnant. How am I going to support her and the baby if I'm unemployed? Plus I've got this sex-kitten girlfriend who's bleeding me dry with these big dinners at that fancy Olive Garden restaurant before she'll even have sex with me...dangit, why, WHY couldn't I have found a chick with Burger King taste??"

So he was in a bind. He's screwed. Fifty-eight miles to the airport with fuel - at two miles per minute that's 29 minutes and probably 29 gallons (never mind startup and takeoff). He's looking at just under 20% on the gauge - "HOW MANY GALLONS IS 18% FOR CRYING OUT LOUD?!?!" God only knows what was going through his mind. In the end he decided to go. Maybe he was hoping and praying for a tailwind. HAH! Once airborne, he did lie this time about how much fuel he had onboard. Of course he wasn't texting much on that last flight - he couldn't! He probably had his fingers and toes crossed the whole time, hoping the thing wouldn't flame out!

But flame out it did. And then he screwed up the auto. Back in the 1990's when I was with PHI they used to emphasize that aft-cyclic malarkey for an engine failure in cruise. (I never bought any of that claptrap.) FIRST thing you do, they said, is start coming back on the cyclic (to preserve the rotor RPM *and* maintain altitude), THEN you start to lower the pitch. The old first-slam-the-pitch-down entry may work in helicopters that cruise not too much faster than they auto, they said, but modern, high-speed helicopters require a different technique. If you put the pitch down when the disk is already tilted way forward, they said, the aircraft is GOING to descend...which is not really cool when you're only at a couple of hundred feet of altitude to begin with. Or so they said. Still sounds like a bunch of hokum to me.

You know what I've learned from this accident? Something I've known all along: Not all of us are Chuck. Yeager or Aaron, your choice. Among us genuine skygods are some pretty weak pilots, even those who look good "on paper." This Astar EMS guy was an ex-military Apache pilot (hey, those sonsabitches are sophisticated!), and had a fair amount of total time (2200 hours). He even had over 130 hours in make/model. And he was 35 years old - not a kid! If not him then, who??

Bad pilots make bad decisions all the time. This guy did too, and his decisions turned out to be fatal. Do we know *why* he made them? Not really, but we can make some educated guesses. If he was cheating on his (pregnant) wife with a floozy from his old hospital, then he wasn't exactly a real standup, moral kind of guy with integrity who can be counted on to "do the right thing."

But can we regulate such things as personality disorders? Not bl**dy rikery! If so, a lot of pilots (including yours truly) might be put out of work.

[Devil 49]

Take your pistol into the office (forbidden here, same company), load it, cock it, put the muzzle deep into your mouth... and that's company failure?
The regulations regarding minimum fuel requirements are clear. Fuel management issues of this magnitude would prevent a student aviator from a solo flight endorsement.
Training is a valuable resource, requiring that that time be spent on a near intellectual equivalent of "That mountain is hard. Don't bump it"???

I could make a very long list of issues that I see (vast) room for improvement in my employer's training, some of which potentially effecting the outcome of this event. The importance of having fuel in the tank isn't one of them.

Brother FH1100, I'm chewing my tongue...

[tottigol]

I know of someone doing something just as stupid back in the day in the GOM. He flew over as many as FOUR refueling chances and then flamed out almost on the refueling pad in GLS.
He was cocky enough to tell the safety board that he was confident he could autorotate safely in any condition:rolleyes:, and THAT cost him his job.:ok:

[alouette3]

SAS less,
On most occasions I tend towards agreeing with your posts.In this one instance, I will have to respectfully disagree.
There is nothing more that the Operator could have done.They have given their pilots SOPs and FARs to follow.They train them to do that. The AS350 has a unique fuel monitoring system,in that, it is calibrated in percentage as opposed to gallons or pounds or liters. He had been trained to satisfactory standards in the aircraft and that implies he knew what was what.Moreover, this gentleman had flown adequately in this type to have got the math straight.He just chose to roll the dice and lost.
For once, the operator has very little responsibility towards this accident.So, no, they were not and are not a disorganized outfit,as you claim.
For the human factors part, I will direct you to FH11OOs post.He has very succinctly nailed it.
Alt3.

[SASless]

You suppose the Trainer could have refueled the aircraft to the Base Standard Minimum Fuel level upon ending his training?

You reckon the Mechanic could have confirmed the Pilot had correctly signed off the required entries before legging it for home?

You reckon the Ops Center could have discussed the fuel situation in far more detail? Once the fuel shortage was noted by Ops....why not ground the aircraft and dispatch a fuel truck? Once the Flight departed without the correct amount of fuel....that should have thrown a very huge Red Flag up at OPS.

If one of my pilots had called in telling me he had not checked the Fuel.....I would have assumed control of the situation and gotten to the bottom of it.

If something as basic as checking the fuel in the aircraft was omitted in the Preflight process....I would have heard Alarm Bells going!

Sorry.....but Ops dropped a huge clanger on this one......along with the Pilot and Med Crew.

The Med Crew knew what the Base Standard Fuel was....and any departure brief would have included some discussion of a variance from SOP. Likewise....the Departure Call reporting fuel quantity would have been at variance with the gauge indication as well and that should have alerted the Med Crew to something being wrong.

Far too many shoulders being dropped here on this one.

During the Pilot's time with the Operator, should not his general conduct not been assessed in a much more effective manner?

What was the Base Manager doing all this time.....was he aware of the Pilot's domestic issues?

The Operator does hold supervisory responsibility....even though the Base is at a remote location. How often does the Operator inspect the Base, interview the crews, consult with Hospital Management?

[alouette3]

SASLess,
I have inside information on this investigation.I will tell you how if you send me a private email.However, here are a few more rebuttals to your questions.
The training flight ended very late at night,or very early in the morning, as it was NVG training.The trainer did pass on to the night shift pilot what the fuel load was and the night shift pilot ,as is SOP ,passed this on to the accident pilot during change over brief in the morning.
The mechanic did his part.The pilot not signing the required entries had nothing to do with the accident.It was just documentation over which the mechanic has no operational control.
The "Ops Center" you refer to is actually a communication center.All they are is a center where calls are received requesting helo transfer of a sick/injured patient.They pass on the details to the nearest helicopter and ,if the flight proceeds,flight follow.The Comm.Specialist has neither the authority nor the expertise to question the pilot's decisions.He has to take at face value the fuel load the pilot reports.Even if he feels that the pilot is cutting it fine, he ,on his own ,cannot stop the flight or turn it around. This is still a Part 135 world where the dispatch authority rests solely with the PIC and is not shared with a "dispatcher".
The med crew pays no attention to fuel loads and the like.That is the way things are and if you tell me different, I will need concrete evidence that this ever happens. As an example, I would urge you to walk into a base and ask the medical crew about the fuel burn in the type of aircraft sitting on the pad and how to read a fuel gauge.
The bases around the country are regularly inspected and visited by middle management.However, I would challenge you to tell me how such a visit could have prevented this accident.Ditto for his appraisal.He had spent about 9 months with the company,passed his initial and conversion check rides well.I doubt there is an operator out there who has a magical device to check for brain function.
Finally,Base Manager: Are you kidding me? If your base manager came and asked you about your personal life and whether you were having an affair or not, I presume you would give him the skinny? I don't know which world you live in,but, the last time I looked ,a man's personal life was still his personal life and nobody had the authority to come prying into it.Besides, his affair was discovered after the accident as part of the investigation.
Seems to me you are trying very hard to pin this on the Big Bad Corporation.For once they were actually pretty close to blameless.
Alt3.

[SASless]

What do these guys do?


Air Methods - Operations Control Center (OCC) (http://www.airmethods.com/airmethods/safety/occ#.UomFb5GfsoE)

[Devil 49]

OCC relies on flight plans as filed, basic situational knowledge and computer generated graphic depictions. They do not have the means to remotely check your fuel quantity. The operational control center can, and will, remove your authorization to operate company aircraft. The issue raised here is that they have to be aware of a potential problem before they can exercise 'operational control'.
The flight following com spec is not an aviator and is unlikely to recognize issues. The aviator involved clearly did not recognize the actual situation, and was behind the situation from the beginning.
That- fuel- is the causal issue that inexplicably was not dealt with- texting, fatigue, swapping aircraft, whatever else mentioned on the list of factors are secondary to the basic "keep fuel in your tank" issue. Had this pilot kept the fire lit the entire flight, poor autorotaion training, none of the other issues would have been raised.

P.S. No, I don't expect that some other party should/would fuel my duty aircraft.

[Devil 49]

Alouette 3 said "The med crew pays no attention to fuel loads and the like.That is the way things are and if you tell me different, I will need concrete evidence that this ever happens."

I wish this were true, but the medics I fly with regularly quiz me about gauges:
"Why is the 'X' doing 'Y'?
"Why do you have 'A' set for 'B'?
"I can't tell what (name a gauge) is reading."
These crews couldn't say that our traditional departure fuel load is 60, 65, or 70%, but they do question unbriefed light fuel loads.
In that light, what is more interesting to me is that the accident med crew apparently never raised meaningful objections to the pilot inflight texting. I quizzed all mine about that possible action after this accident and they all said they would have made noises. But, I am pretty certain that pilots have been observed using unauthorized devices in flight without objection from the crew who told me about that after the fact.

I am coming around to believing that more separation and respect for professional competence is preferable to "Three to go and one to say no". The fact that an accident might kill all onboard doesn't make an uninformed opinion any more correct. Making an uninformed opinion authoritative is institutional endorsement of ignorance. The implied authority without explicit responsibility can reasonably be expected to create conflict which will adversely affect safety.

[SASless]

I find it difficult to believe the Med Crew did not smell a Rat out of all this.

My experience at Five different bases with two different Operators....challenge the idea that the Med Crews are unaware of the fuel load, endurance, and deviations from established base procedures.

In fact....it was usually exactly the opposite. Deviate and you would hear of it again even if it was for very simple basic commonsense reasons.

That is why most bases and operators use a Briefing system that requires a Start of Shift Brief, Pre-Takeoff Brief, and a Post Flight Debrief (which normally was a written document).

I can assure you....had a fuel low warning light illuminated on any of my flights....the Med Crew would have been more than idly curious about that happening.

As there are over 800 EMS Helicopters in the USA....and dozens of Operators....I am sure there is quite a diverse range of base SOP's and such.

Perhaps this accident report should be the catalyst for every Pilot and Med Crew Member to sit down with one another and discuss the issues raised by what happened.

One Man's Opinion....if you as a Pilot have not done so....you are hiding something from yourself and your Med Crew.

[alouette3]

It comes and goes.After the initial accident report came out, every crew member in my program and their uncle wanted to know how the gauge was calibrated,when the low level came on, how long after that we could fly,percentage to Gallons conversion , fuel consumption,reserves, etc. For a while, every time we finished a flight I would be asked if we were going to make it back with the fuel load or whether we were going to stop for fuel.One nurse even forced a fuel stop because she wasn't "comfortable" with the fuel state as the winds "appeared to be increasing". I could have shut her down right there but, as SAS Less says, I would have heard about it.It was simpler to land at the airport and throw on 20 gallons of token fuel to keep her happy.
Two years and change later, nobody cares.I brief 70% fuel load in the shift brief and nobody is really listening. An email goes out to middle management with the fuel load and the payload for the day.Just to test the theory out, the other day, I briefed 70% while I had 55% on board. We left on a flight and returned to the airport, after completion, for refuelling.No one even looked at the gauge or queried the inconsistency.I debriefed accordingly.The most telling response? the medic said " we take your word for it since you know best":rolleyes: To me, that can cut both ways.
Point is, after every accident or incident there is a sudden burst of interest in a particular system or a phenomenon.It dies down after a while.Last summer I had a hydraulic change over in a BK117.You guessed it, lot of interest in the hydraulic system of the BK.:ugh:After a spate of icing related crashes last winter, there was a sudden concern over how ice forms and what I look for to avoid icing etc.A "well read" medic wanted to know why my company would not invest in heated blades! Spring rolled around and icing,and heated blades, is now a distant memory.
The bottom line is the fact that med crew get complacent and trusting of you like everyone else.Whether this guy had text ed before or if his crew had queried him about fuel load and low level light or not ,we will never know.
No amount of crew involvement or lack thereof should make you act differently. The last line of defense is your integrity and your head work.If it has come to a situation that a nurse or an OCC guy sitting 600 miles away has to look over your shoulder as you go about your business, we maybe in bigger trouble than we thought.
Alt3.