NTSB addresses volunteer pilot decision making

June 17, 2010

Volunteer pilots provide a ray of hope for many medical patients by providing transportation to much-needed treatment. But good intentions without sound aeronautical decision making can have grave consequences. The NTSB issued recommendations June 9 for improving the safety of charitable medical transportation flights.

In response to four fatal accidents in a one-year period involving volunteer pilots on medical transport flights, the board recommends that the Air Care Alliance (ACA), an umbrella organization for charitable flying groups, take action to address concerns over the 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 flights.

“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 recommendations state. “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.”

A myriad of public benefit flying organizations operate under Part 91. The Air Care Alliance unites many of these organizations so that they may learn from one another, work together on national policy and safety issues, and connect those in need with resources in their area. ACA President Lindy Kirkland said the alliance works with all volunteer pilot organizations, not just members of the ACA, to help improve the culture of safety and share best practices.

“We’re in the process of communicating with various groups that are out there to get a sense of their best practices so that we can turn that back around and provide that to all the groups,” he said. “… Many of the groups are already doing over and above what the NTSB recommendations were.”

The NTSB recommends that the alliance work with its affiliate organizations and other charitable medical transport organizations to develop, disseminate, and require all voluntary pilot organizations to implement written safety guidance, best practices, and training material for volunteer pilots, as well as require the groups to verify pilot currency before each flight and inform passengers that Part 91 charitable medical flights do not operate under the same standards as commercial flights.

The alliance cannot require volunteer pilot organizations to take certain actions, but it has been working to establish best practices. The group has discussed the accidents cited in the NTSB recommendations, along with improved safety guidelines, in its last two national conferences and has solicited input from all known volunteer pilot groups, the ACA said in a press release. The alliance has also been working with the AOPA Air Safety Foundation to develop an interactive online course that would address many of the NTSB’s recommendations.

“Volunteer pilots perform a vital service, but many don't have guidelines to use during preflight planning,” said AOPA Air Safety Foundation President Bruce Landsberg. “Our online course will provide that guidance to help pilots as they consider factors such as weather, passenger safety, and personal minimums.  Additionally, the foundation has many other risk management tools online in the form of courses and safety advisors to provide guidance.”

The recommendations are in response to the NTSB’s investigation of four fatal accidents involving volunteer pilots transporting patients between Sept. 26, 2007, and Aug. 12, 2008: A Beech G35 crashed into a shopping plaza parking lot when the pilot, who had no record of instrument currency, failed to maintain control of the airplane during an instrument approach in IMC; a Beech A36 collided with an airport glideslope antenna during takeoff when the pilot took off with a tailwind and failed to maintain runway alignment during the climb; a Socata TBM 700 crashed during initial climbout after taking off with a tailwind and failing to abort the takeoff; and a Piper PA-32R-301T crashed after the pilot encountered convective turbulence and became spatially disoriented. The NTSB said the pilots were experienced and likely should have been aware of the risks associated with their flights.

“Although the NTSB could not determine why these experienced pilots made the inappropriate decisions that led to the accidents, the pilots may have been subjected to self-induced pressure to start or complete the flight because of their passengers’ serious medical conditions,” the NTSB said. If pilots are consciously aware of the self-induced pressure associated with this type of mission and have mechanisms to deal with it, the risk can be reduced, the board added.

Kirkland said the AOPA Air Safety Foundation course will help volunteer pilots recognize real and perceived pressures and address them properly. In addition, the alliance will continue to emphasize to pilots that Part 91 medical transportation flights are not emergency flights. In most cases, the patients have flexibility in their plans, Kirkland said.

The AOPA Air Safety Foundation currently provides recommendations to help individual volunteer pilots improve their levels of performance and the safety of their flying—including enhanced personal minimum tips, recommended practices, and a discussion of the pressures a pilot may feel when transporting sick patients.