NTSB Urge Air Care
June 14, 2010 -
National Transportation Safety Board (NTSB) urges the Air Care Alliance
(ACA) to take action on the safety recommendations. The NTSB is vitally
interested in these recommendations because they are designed to prevent
accidents and save lives.
recommendations address verification of pilot currency; passenger
awareness of operating standards; and the need for dissemination of
safety guidance, information about best practices, and training material
for pilots and organizations providing charitable medical transport
recommendations are derived from the NTSB?s investigations of four
accidents that killed eight people and seriously injured two between
September 26, 2007, and August 12, 2008; each involved flights providing
charitable medical transportation.
These recommendations are derived from the NTSB?s investigations of four accidents that killed eight people and seriously injured two between September 26, 2007, and August 12, 2008; each involved flights providing charitable medical transportation.
These recommendations are supported by the evidence collected and the analysis performed during each investigation; supporting information. On August 12, 2008, a Beech G35, operating as a 14 Code of Federal Regulations (CFR) Part 91 charitable medical flight, descended uncontrolled and crashed into a shopping plaza parking lot in South Easton, Massachusetts. The flight had been arranged by Angel Flight Northeast, a member of ACA.
volunteer pilot and the two passengers, a cancer patient and his wife,
were killed. Radar data and communications records show that the pilot
failed to intercept the localizer on his initial approach to the airport
and was receiving vectors from the controller to re-intercept the
localizer when the flight was lost from radar.
instrument-rated pilot had not logged actual or simulated instrument
flight time between August 4, 2006, and February 3, 2008, and there was
no record that he had completed an instrument proficiency check. The
NTSB determined that the probable cause of this accident was the pilot?s
failure to maintain control of the airplane while attempting to execute
an instrument approach in instrument meteorological conditions.
Contributing to the accident was the pilot?s lack of instrument
On July 17, 2008,
a Beech A36, operating as a 14 CFR Part 91 charitable medical flight,
colliding with an airport glideslope antenna during takeoff from
Tampa Executive Airport, Tampa, Florida. The flight had been arranged by
ACA member Mercy Flight Southeast, Inc., to transport a cancer patient
for medical treatment. The 81-year-old volunteer private pilot, the
cancer patient, and a family friend accompanying her were killed.
determined that the probable cause of this accident was the pilot?s
improper decision to take off with a tailwind and his failure to
maintain runway alignment during initial takeoff climb.
On June 3, 2008, a
Socata TBM 700, operating as a 14 CFR Part 91 charitable medical flight,
crashed during initial climbout from
The child died in
the crash; the mother and the 57-year-old volunteer private pilot were
seriously injured. The NTSB determined that the probable cause of this
accident was the pilot?s improper decision to depart with a preexisting
tailwind and failure to abort the takeoff.
On September 26,
2007, a Piper PA-32R-301T, operating as a 14 CFR Part 91 flight,
descended uncontrolled and crashed in Defiance,
In Part 91
operations, the pilot is solely responsible for evaluating his own level
of proficiency, determining if the flight can be safely conducted, and
ensuring he is operating an airworthy airplane; the Federal Aviation
Administration (FAA) provides no oversight of Part 91 operations.
However, each of
the four pilots in these accidents failed to fully accomplish these
tasks: two pilots failed to properly evaluate the winds when selecting a
departure runway and did not maintain directional control of the
airplane; one pilot became spatially disoriented in convective
turbulence; and the other pilot had difficulties performing an
instrument approach and was not current for instrument flight. In these
accidents, the pilots demonstrated shortcomings in sound aeronautical
decision-making by failing to adequately assess the weather and their
inability to operate the airplane in those conditions.
The NTSB is
concerned that these pilots did not provide the passengers with the
basic level of safety that passengers in these circumstances have a
right to expect. Furthermore, the voluntary pilot organization arranging
or fostering the flights made no attempt to verify the pilots? currency.
Because each of
these flights was operated under Part 91, the passengers on board
received only the level of safety that the individual pilot provided to
them; no additional oversight, training, verification, or guidance was
provided to these pilots beyond the basic Part 91 requirements imposed
on the pilots themselves.
There is no
evidence that Angel Flight Northeast checked the pilot?s qualifications
before the flight. The NTSB concludes that the pilot?s lack of currency
in conducting the flight in instrument conditions placed the passengers
at higher risk for an accident. Therefore, the NTSB recommends that ACA
require voluntary pilot organizations to verify pilot currency before
patient seeking a charitable medical flight is not likely aware of the
significant differences in pilot training, pilot qualifications, or FAA
oversight for a charitable medical flight operated under Part 91
compared to commercial flights operated under 14 CFR Parts 121 or 135.
The NTSB is
concerned that members of the public who accept charitable medical
flights likely have no meaningful awareness of the resulting increased
potential for exposure to the risks that may be associated with these
flights. In most instances, passengers flying on such charitable medical
flights are unaware of the pilot?s experience level or the airworthiness
of the aircraft.
The NTSB concludes
that a more meaningful awareness of the less rigorous oversight provided
for such Part 91 charitable medical flights would provide passengers
with a basis for making an informed decision about the standards of
safety that apply to these operations before accepting the flight.
The NTSB recommends that ACA require that voluntary pilot organizations inform passengers, at the time of inquiry about a flight, that the charitable medical flight would not be conducted under the same standards that apply to a commercial flight (such as under Part 121 or Part 135).
Although many of
the volunteer pilots who provide charitable medical transportation are
highly skilled, proficient in operating their aircraft, and prepared to
execute an appropriate response to changing flight conditions or
emergencies, others may not be.
The NTSB is
concerned that the pilots flying charitable medical flights receive no
guidance, additional training, or oversight regarding aeronautical
decision-making, proper preflight planning, or the risk of self-induced
pressure. Since the failures in aeronautical decision-making and
improper preflight planning were major factors in the accidents
reviewed, it is evident that stronger guidance, training, or oversight
that ensures pilot and aircraft safety is needed for the volunteer
pilots who provide charitable medical flights.
The NTSB notes
that the pilots in these accidents were experienced and likely should
have been aware of the risks associated with taking off with excessive
tail or crosswinds or flying into deteriorating weather. Although the
NTSB could not determine why these experienced pilots made the
inappropriate decisions that led to the accidents, the pilots may have
been subject to self-induced pressure to start or complete the flight
because of their passengers? serious medical conditions.
The NTSB?s study
of helicopter emergency medical services (HEMS) accidents6 cited time
pressures as a risk factor in HEMS flights, and a similar risk can exist
for charitable medical flights: the desire to get a patient to medical
treatment quickly. The NTSB believes that if pilots are consciously
aware of the self-induced pressure associated with charitable medical
flights and have mechanisms for appropriately dealing with this
pressure, the risk associated with these flights can be reduced.
A review of the
pilot requirements for some ACA members revealed that the organizations
differed widely in the minimum standards for volunteer pilots who
participate in charitable medical flights and most require only basic
pilot and airplane documentation before assigning patient flights,
sometimes without actually meeting the volunteer pilot.
In addition, most
of the organizations do not provide the volunteer pilots with guidance
or training materials on such topics as aeronautical decision-making,
preflight planning, and techniques for avoiding self-imposed time
pressures that may result in poor decisions. The NTSB concludes that
guidance and training on aeronautical decision-making and best practices
would make the volunteer pilots more aware of aeronautical risks and how
to address them, thus improving the level of safety that volunteer
pilots who operate charitable medical transport flights provide to their
Therefore, the NTSB recommends that ACA, in conjunction with its affiliate organizations and other charitable medical transport organizations, develop, disseminate, and require all voluntary pilot organizations to implement written safety guidance, best practices, and training material for volunteer pilots who operate charitable patient transport flights under 14 CFR Part 91. The information should address, at a minimum, aeronautical decision-making; proper preflight planning; pilot qualification, training, and currency; and self-induced pressure.
National Transportation Safety Board recommends that The Air Care
Require voluntary pilot organizations to verify pilot currency before every flight. (A-10-102) Require that voluntary pilot organizations inform passengers, at the time of inquiry about a flight, that the charitable medical flight would not be conducted under the same standards that apply to a commercial flight (such as under 14 Code of Federal Regulations Part 121 or Part 135). (A-10-103)In conjunction with your affiliate organizations and other charitable medical transport organizations, develop, disseminate, and require all voluntary pilot organizations to implement written safety guidance, best practices, and training material for volunteer pilots who operate charitable patient transport flights under 14 Code of Federal Regulations Part 91. The information should address, at a minimum, aeronautical decision-making; proper preflight planning; pilot qualification, training, and currency; and self-induced pressure. (A-10-104)
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