Tuesday, April 9, 2013

Air Ambulance Pilot Demonstrates How Deadly Distraction Can Be

The pilot of an emergency medical helicopter was text messaging before and during the flight that ended in disaster near an airport in Mosby, Missouri in 2011. His actions and his distraction were cited as contributing factors in the crash that killed four people on board an Air Methods helicopter in August 2011, the National Transportation Safety Board said today. 

During a hearing into the cause of the crash, Bill Bramble, a human performance specialist with the NTSB said, "A lot of texting was going on." And while the information that a stream of text messages were received and sent by the pilot during the day was startling, it was only one of several factors that led to the crash. 

Terry Tacoronte on her wedding day
Terry Tacoronte, a 58 year old grandmother was being transferred from a hospital in Bethany, Missouri to Liberty, 62 miles away. Before lifting off, the pilot, James Freudenberg, was concerned he might not have enough fuel to make the 30 minute trip. Nevertheless, the pilot opted to fly and one mile short of the destination, the engine on the Eurocopter AS350 quit for lack of fuel. The helicopter hit the ground just a few seconds later. 

If ever there was a case that seemed to rate the characterization "pilot error" it is this one. We have a pilot who knows and disregards information that his aircraft may not have sufficient fuel to reach his destination, who fails to conduct a pre flight check, who does not reset cockpit instrument lights from a night vision goggle setting, who allows his personal after work plans with a friend to add a stressful component to his day and who, when all this catches up with him and he is faced with an engine flameout, fails to put the aircraft in an auto-rotation above a level field absent of obstructions. 

In bringing this considerable list of lapses to the public, investigators note the judgment call that may have impacted so many of Freudenberg's other decisions is the one that is being made day in and day out; the use of portable electronic devices by operators of all kinds of transportation. 

"We have to re-ignite a debate in the community about what is acceptable behavior," Hersman told me after the hearing. "It’s a problem with these portable electronic devices, it is an addiction and we've got to figure out how to keep them out of the environment where there are safety critical things happening." 

So far, policies that prohibit the use of electronic gadgets for non flight-related activities are prohibited by many transportation companies, including Air Methods. In an email he sent me after the hearing, Mike Allen, the president of Air Methods confirmed his company didn't allow them during flight and that since the accident, the company has upped the restriction a notch to institute "a zero tolerance policy."  The former Northwest Airlines had a no-personal-electronic-device-use-in-the-cockpit-policy, back when two pilots working on their laptops overflew their destination on October 2009.  

So did Metrolink, the operator of the train in Los Angeles that blew through a red signal and crashed killing 25 people in 2008. The engineer was text messaging despite the prohibition. And the co-pilot on the Colgan Air plane that crashed in Buffalo in 2009 was also texting while the plane was taxiing for takeoff, though there's no suggestion that it played a role in the accident in which 50 people died. Still, it is no wonder Hersman wants to re-ignite the conversation about distraction's deadly consequences. 

After a hearing that seemed at times to be an unrelenting barrage of shoulda', coulda' woulda's, members of the board made nine safety recommendations, some reiterations of previous pleas to the FAA to improve the dismal safety record of helicopter ambulances.  

The board also voted to issue a Safety Alert, urging pilots to recognize the threat electronic devices pose and turn them off, not just during flight, but during the critical time before takeoff, when decisions as basic and as important as go/no go, are made. 

For all the mental energy Freudenberg spent on August 26, 2011, trying to coordinate his after work plans, the degraded decisions that resulted made it so that he would never meet up with his dinner date. For pilots, boat captains, train operators, bus drivers and all the rest of us, it should be noted this Safety Alert is a product of that tragic irony. 

Read my previous story on this accident by clicking here


Nikos said...

Text messaging has also been mentioned in a report that I read about the recent tragic accident in London: The pilot of an air taxi Agusta 109 was reported to have been texting his client about weather conditions at the pick up point whilst operating at low altitude over central London in misty conditions.

Frank Van Haste said...

Hi, Christine...

For the most part I agree with the tenor of your post and with the urgency of the message from Deb Hersman and her folks at NTSB. May I, however, offer a small caution.

I will give you an example where use of a mobile phone during aircraft operations improves safety. When I am departing Potomac Airfield on an IFR morning, Potomac Approach has to coordinate my departure with the traffic at DCA a few miles away. The way we do this is that they issue my clearance over the telephone and add, "Hold for release". I then return to my airplane, start it, run my checklists deliberate way, taxi to the runway, then call Potomac Approach again on my mobile phone to obtain my IFR release. That done, I then turn off the phone, and depart. Safe, orderly and expeditious.

Without the mobile telephone, Approach would have to give me a void time with my clearance. I'd have to hustle. Run my checklists with an eye on my watch. Maybe taxi a bit faster than normal. All opportunities for error, all increases in risk. I'm happy that I don't need to do that.

My point is that mobile phones offer a communication channel that can reduce operational risk when used correctly. Obviously it can also increase risk when mis-used. We need policies that combat mis-use but avoid reactive broad-brush prohibitions that discard both beneficial and detrimental applications.

Best regards,


Christine Negroni said...

You are absolutely correct and I should have been more clear that the Special Alert is focused specifically on non flight related activities. Evolving technology is always a two edged sword, as I have written in the past. http://christinenegroni.blogspot.com/2011/09/day-of-simple-flying-time-of-complex.html

Jim Blaszczak said...

In safety analysis we get into trouble when we “personify” objects. Whether it is a hammer, a gun, a cellphone, or a box cutter, an inanimate object has no control of its use.

The object cannot control itself or the user. There are still people getting their fingers cut off by lawnmower blades in spite of all the “idiot proofing”.

How the object is used rests solely with the user. Sometimes the misuse is intentional as in the case of 9/11. Sometimes the misuse is unintentional as in the case of the crashed helicopter. I say unintentional because I assume the pilot was not intending on a dual homicide/suicide.

We need to expand Threat and Error Management training so that we reduce the unintentional misuse of inanimate objects. Intentional misuse is a totally different discussion.

If the pilot actually understood the threats associated with his behavior, or recognized his errors before they became consequential, I doubt if there would have been a crash. It’s not easy, but the process is simple. That’s the difference with humans, they can control what they do. The discussion of all the human factors associated with this topic is too extensive to cover here.

IT’S NOT ABOUT THE CELLPHONE, it’s about how the cellphone is used. The human is always the most effective and the most error prone element in any cockpit. That goes for UAV’s as well.

david said...

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Air Ambulance said...

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