ePilot ASI Accident Reports - Matters of life and death (ERA12MA122)

By David Jack Kenny

Military flights operate under a different set of standards, but in civilian life pilots are trained not to let the importance of completing a flight affect their assessment of the safety of attempting it. Some EMS programs take this to the extent of not informing the pilot whether the mission is an emergency scene call, routine patient transport, or just a training exercise. The margin of safety should be equally high for each.

That detachment is harder to muster when a pilot knows a life hangs in the balance. Of course, the lives of everyone on board the aircraft are in the balance, too.

About 5:30 a.m. on Dec. 26, 2011, a Bell 206B helicopter landed at the Mayo Clinic Heliport in Jacksonville, Fla., to pick up a transplant surgeon and an organ procurement technician. A donor heart had become available in Gainesville, about 60 nautical miles to the southwest. After being awakened by a phone call from a company dispatcher at 3:35 a.m., the pilot checked weather reports over the Internet, then arrived at the Northeast Florida Regional Airport in St. Augustine about 4:20 a.m. to preflight. The 19-mile hop to Mayo took about 12 minutes.

At the time he checked, the weather wasn’t bad for a VFR helicopter flight; most stations in the area were reporting 10 miles visibility with no ceilings below 1,600 feet. But it was expected to come down—the terminal forecast for Gainesville predicted an 800-foot overcast before 6 a.m., with temporary periods of 400-foot overcast and four miles visibility in mist—and it did. A METAR recorded at St. Augustine eight minutes before his initial takeoff reported 900 feet overcast; at Craig Municipal (now Jacksonville Executive) seven miles northwest of Mayo, the ceiling was down to 700 feet. Visibilities were still 10 miles, but around the region temperature/dew point spreads were one or two degrees and dropping.

The 68-year-old pilot had good reason to be confident of both his ability and his judgment. He was the founder, owner, and operations director of a charter company that operated both helicopters and fixed-wing jets. Its records showed that his 11,343 hours of flight experience included 3,288 hours at night, 3,259 hours of instrument time, and 1,648 in the Bell 206. He’d been flying for more than 50 years, including combat experience in Vietnam that earned him the Bronze Star, the Distinguished Flying Cross, and the Purple Heart. The pilots who flew for him uniformly described a man who clearly loved to fly and didn’t scare easily, but was also careful, prudent, and systematic. When asked to describe his weaknesses as a pilot, several said they couldn’t think of any.

The turnaround at Mayo was quick, perhaps six or seven minutes. There’s no record that he rechecked the weather during the ground stop, which is not surprising: Except for trauma patients, organ transplants are perhaps the most time-critical of all medical flights. In this case, “the transplant team had a maximum of four hours between cross-clamping the heart at the donor hospital and reprofusing it at the recipient hospital,” which left no more than two and a half hours for transportation, and the less time elapsed, the better the chance of a successful outcome.

Radar data indicated that the helicopter flew a little south of the direct line between Mayo and the Shands Cair Hospital Heliport in Gainesville at speeds of 100 to 110 knots and altitudes between 450 and 900 feet agl. At 5:49 a.m., the pilot contacted Jacksonville Approach to confirm that the restricted areas ahead were inactive. The helicopter then turned 45 degrees to the right, placing it on a GPS-direct route to its destination, and descended from 750 feet to 450 feet. The last radar return came three minutes later, showing an airspeed of 81 knots. Eventually Shands Hospital reported the flight overdue. The wreckage was found about 10 a.m. in a dark, swampy, wooded area that other company pilots described as a “black hole,” prone to fog that created instrument conditions at low altitude. The debris field extended 320 feet and suggested a high-speed impact. The pilot, surgeon, and technician were all killed.

While the pilot was more than qualified, the Bell 206 was not certified for instrument flight, and its Garmin 430 GPS had not been upgraded to provide terrain or obstacle warnings. The company’s IFR-capable helicopter, an Agusta 109, had been grounded for maintenance the past four months, in part because declining business during the recession had created cash-flow problems. The supply-chain director for the Mayo Clinic—the charter operator’s single largest customer—told investigators he’d grown sufficiently concerned about the company’s financial viability to begin evaluating alternatives; the owner had arranged a meeting the following month to discuss this.

Company pilots interviewed by investigators agreed that, given the weather information available at the time, they would have accepted the flight, but would also have made alternative arrangements in case it couldn’t be completed. There is no record the owner did that.

The description of him by his staff pilots makes it seem very unlikely that the desire to demonstrate his reliability to an important customer would have led him to take needless risks. Still, it could have been in the back of his mind. He was also known to take particular satisfaction in making transplant flights. Had his equipment matched his skill and dedication, another life might have been saved. Had he recognized the black hole in time to turn around, he and his passengers would have saved others in the future. As it was, the viability of the donor heart expired by the time the wreckage was found.