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.
Personal issues in the pilot's life might have been a source of distraction, said investigators. His wife was pregnant with their first child, his father recently had undergone cardiac surgery, and he had moved recently to a new city but was still commuting to his old base in St. Joseph. In addition, on the day of the accident, he was making social plans to meet his coworker for dinner after his work shift. “During his shift, the pilot needed to focus his attention away from personal issues when performing safety-related tasks, but at such times, both before departure and during the mission, he engaged in personal texting activities.”
The NTSB examined the pilot's personal cell phone records to see whether distraction caused by the pilot's personal electronic communications could have played a role in his incomplete preflight inspection. The pilot received frequent text messages between 1406 and 1455 — a substantial portion of the time period when the helicopter was being prepared for its return to service. However, the pilot only responded to these texts between 1430 and 1450. Therefore, personal electronic communications did not necessarily preclude the performance of a complete preflight inspection, but they could have distracted the pilot.
The change in helicopters caused a break in routine that could also have played a role in the pilot's incomplete preflight inspection. The disruption caused by the change-out would have required the pilot to think purposefully about the actions that he needed to accomplish, and periodic interruptions of his attention caused by text messaging activity could have resulted in his forgetting about tasks that he had not yet completed. Moreover, the effect of such interruptions on the pilot's memory could have been exacerbated by fatigue.
“In this accident, the pilot engaged in nonoperational use of his personal cell phone when the helicopter was being prepared for return to service,” said the Safety Board. “Although this activity did not prevent the performance of a thorough preflight inspection, it was a source of distraction that increased the risk of lapses of attention and errors of omission, which did, in fact, occur. Therefore, it is possible that the pilot's nonoperational use of a portable electronic device contributed to his lack of awareness of the helicopter's abnormally low fuel state.”
Company procedures prohibited pilots from using or turning on cell phones during active flight operations. The overlay of the pilot's personal cell phone records, however, indicates that he sent one text message during the first leg of the mission and three during the accident flight. All of these inflight messages were sent after the pilot became aware of the helicopter's low fuel state. The last outgoing text was sent about 20 min. before the accident, and the pilot did not respond to two incoming text messages sent 15 and 11 min. before the accident.
The Safety Board found no evidence that the pilot's airborne texting activities directly affected his response to the engine failure. “However, the personal texting activities would have periodically diverted the pilot's attention from flight operations and aeronautical decision-making. At a minimum, the pilot's attention would be diverted for the amount of time it took to read and compose messages. Further, from a control usage standpoint, to send a text, the pilot would require at least one hand to be temporarily removed from active control of the helicopter.”
The Safety Board said the pilot exchanged an additional three text messages while he was on the ground between flights waiting for the patient to be loaded into the helicopter. The pilot was working with the communication specialist during this period to address the abnormal low fuel situation and needed to make a critical launch decision. “Careful attention and conscientious problem solving were needed and should have led him to seek additional operational guidance from the company and to reject the launch due to insufficient fuel. Instead, he devoted a portion of the available time to personal texting.”