Lifeguard Emergency Medical Services (EMS) Crash Near Riverwoods, Illinois
At nearly 9:00 in the evening on November 28th, 2011, a Piper PA-31-350, registration N59773, operating as a Lifeguard emergency medical services (EMS) flight, crashed near Riverwoods, Illinois, after the pilot declared an emergency and reported that the airplane was out of fuel.
According to the NTSB preliminary report, after declaring an emergency, the pilot reported that he was unable to get to Chicago Executive Airport, out of fuel, and that the airplane was “coasting.” The pilot initially reported he did not see Chicago Executive Airport, but later indicated he had the field in sight. The aircraft crashed about three miles from the airfield. Tragically, the pilot and two passengers were killed. Another passenger and medical crew member were seriously injured. According to FAA records, the aircraft was registered to Trans North Aviation LTD of Wisconsin.
The flight departed from the Jesup-Wayne County Airport (JES), near Jesup, Georgia, about 7:00. The aircraft, known as a Piper Navajo Chieftain, was equipped with twin Lycoming IO 540 engines. Fueling records show the airplane was fueled at JES with 165 gallons of aviation gasoline (avgas). Notably, the NTSB found only about 1.5 ounces of avgas within the airplane fuel system after the crash, so the question is whether the pilots mismanaged their fuel or whether there was a mechanical problem that caused or contributed to the low fuel state.
While we never like to jump to conclusions, this preliminary evidence certainly suggests that fuel exhaustion is a possibility, which raises an issue we have encountered before in EMS flight accidents: flight crews who will sacrifice safety and overlook normal procedures in order to accomplish the mission.
As an Army helicopter pilot who has performed medical evacuation (medevac) missions in the Washington DC area, I can identify with this innate sense of urgency to save a life. I vividly recall several missions where the weather was poor and, “normally,” we would have stayed on the ground, but the critical nature of the medevac flight compelled us to launch. It is that same impulse all pilots feel which might cause a pilot to push his fuel calculations beyond reality. For these reasons, it is critical for EMS operators to supervise and train their flight crews to stick to established procedures and take no safety risks just because it is an important life saving mission.
For those operators who do not heed this call the result will be more lives lost.
Kreindler’s Medevac Experience
The firm has had significant experience in investigating and litigating claims arising out of EMS helicopter and fixed wing flights accidents. Just last year the firm successfully resolved claims arising from the crash of a Cessna Citation in Lake Michigan. The primary cause of that fixed wing “Survival Flight” crash was piloting errors by the flight crew.
In addition to reconstructing the accident flight and dissecting the pilot actions in the cockpit, our investigation scrutinized the training and hiring practices of the operator and found them to be wanting. As a result of the investigation, several important safety recommendations have been proposed to the FAA which will hopefully prevent accidents of this kind in the future for all charter and EMS operators. The recommendations include, among others, a requirement that all Part 135 operators incorporate upset recovery training (similar to that used by many major carriers) and related checklists and procedures into their training programs.
Also noteworthy in this case, following the accident the FAA was called upon to conduct a detailed review of the oversight provided to the operator to determine why the system failed to detect (before the accident) and correct the operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures.
It was also recommended that operators notify the assigned FAA principal operations inspectors of specific adverse financial events, such as bankruptcy, court judgments related to nonpayment of recurring expenses, or termination of a credit agreement or contract by a vendor for reasons of late payment or nonpayment. Upon receipt of such information, inspectors should increase their oversight of operators who appear to be in financial distress. This is a point we have made time and time again in our lawsuits. When financial pressure increases, airlines and charter operators cut corners, so signs of financial distress are a harbinger of disaster.
As for EMS operators, a recommendation was presented to the American Hospital Association asking them to inform its members of the FAA’s role in aviation safety with respect to medical/air ambulance services and provide FAA contact information. Further, the American Hospital Association should urge its members to communicate any safety concerns related to medical/air ambulance services to the FAA.
Kreindler partner Justin Green has been active with numerous EMS cases and recently published an article entitled “When Rescue is Too Risky” for Trial Magazine.
Photo Credit: Piper-PA-31-350 plane, ta_dzik