The pilot of an emergency medical helicopter was text messaging before and during the flight that ended in disaster near an airport in Mosby, Mo. 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, a 58-year-old grandmother, was being transferred from a hospital in Bethany, Mo. 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 in 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, wouldas, 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 Aug. 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.