Further, a review of helicopter training resources
suggested that the accident pilot may not have been
aware of the specific control inputs needed to
successfully enter an autorotation at cruise speed. The
NTSB concluded that because of a lack of specific
guidance in Federal Aviation Administration training
materials, many other helicopter pilots may also be
unaware of the specific actions required within seconds
of losing engine power and recommended that FAA revise
its training materials to convey this information.
An
examination of cell phone records showed that the pilot
had made and received multiple personal calls and text
messages throughout the afternoon while the helicopter
was being inspected and prepared for flight, during the
flight to the first hospital, while he was on the
helipad at the hospital making mission-critical
decisions about continuing or delaying the flight due to
the fuel situation, and during the accident flight.
While there was no evidence that the pilot was using his
cell phone when the flameout occurred, the NTSB said
that the texting and calls, including those that
occurred before and between flights, were a source of
distraction that likely contributed to errors and poor
decision-making.
"This investigation highlighted what is a growing
concern across transportation distraction and the myth
of multi-tasking," said Hersman. "When operating heavy
machinery, whether it's a personal vehicle or an
emergency medical services helicopter, the focus must be
on the task at hand: safe transportation."
The NTSB cited four factors as contributing to the
accident: distracted attention due to texting, fatigue,
the operator's lack of policy requiring that a flight
operations specialist be notified of abnormal fuel
situations, and the lack of realistic training for
entering an autorotation at cruise airspeed. The
NTSB made a nine safety recommendations to the FAA and
Air Methods Corporation and reiterated three previously
issued recommendations to the FAA.
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