Report: Faulty hardware, ‘human error’ led to fatal Flight for Life crash in Frisco
March 28, 2017
A combination of faulty hardware and human error likely led to a tragic Frisco helicopter crash that claimed the life of pilot Patrick Mahany and severely injured two passengers in 2015, according to the National Transportation Safety Board.
The crash was survivable, federal investigators said, but the helicopter was not equipped with a crash-resistant fuel system. That led to the post-impact fire that claimed Mahany's life and severely burned one of the two Flight for Life nurses onboard.
Mahany, who was 64 years old, had been a Flight for Life pilot since 1987 and earned a Bronze Star and a Purple Heart for his service as a pilot in the Vietnam War.
The survivors, David Repsher of Silverthorne and Matthew Bowe of Frisco, have since filed suit against the aircraft's manufacturer, Airbus Helicopters, and Air Methods Corporation, the company that operated it.
“Because the pilot had no alert indication in the cockpit that the switch was not in the correct position, he likely didn’t know why he was having difficulty controlling the helicopter. It’s in these treacherous airborne seconds that pilots need access to the information that a warning indication can provide.”Bella Dinh-ZarrNational Transportation Safety Board chair
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The NTSB hasn't released a final report yet but presented the findings of its investigation during a hearing in Washington on Tuesday morning. According to the investigators, a hydraulic switch that provided pressure to tail rotor flight controls was in the off position when the helicopter took off on July 3, 2015 for a public relations flight.
That caused the aircraft to start spinning counterclockwise while gaining roughly 100 feet of altitude. It then plunged to the ground, crashing into a parked RV at an estimated speed of 40 mph and catching fire a few seconds later.
Investigators concluded that the hydraulic system was likely misconfigured, but they also noted that if Mahany had conducted a standard "hover check" before takeoff, he would have likely noticed the issue and been able to land the craft safely.
Such a check involves flying the aircraft a few feet off the ground to ensure all systems are functioning properly. In a safety alert issued last November, the Federal Aviation Administration recommended always conducting a hover check when conditions and circumstances permit.
"Although adherence to flying procedures could have prevented this crash, we have long known that people make mistakes, which is why we need to take every opportunity to enhance systems that can help mitigate human error," said acting NTSB chair Bella Dinh-Zarr.
The hydraulic pump issue caused a similar crash in 2014 in New Mexico, although no one was killed or seriously injured. That prompted Airbus to issue a safety notice to operators of the helicopter warning them about the issue and recommending they install an alert system.
Air Methods Corporation did not follow through with that recommendation, the NTSB report said.
"Because the pilot had no alert indication in the cockpit that the switch was not in the correct position, he likely didn't know why he was having difficulty controlling the helicopter," Dinh-Zarr said. "It's in these treacherous airborne seconds that pilots need access to the information that a warning indication can provide."
Although investigators concluded that the helicopter was "properly certified, equipped and maintained in accordance with federal regulations," its fuel system was not crash resistant.
That made the otherwise survivable crash fatal, as fuel from the helicopter ignited seconds after impact and quickly grew into an enormous blaze.
Even though the Airbus AS350 B3e was manufactured in 2013, it was not subject to stricter crashworthiness standards adopted by the FAA in 1994 because that model was originally approved in 1977, the NTSB said.
At the time of the incident, no crash-resistant fuel system was available for the AS350 B3e. Since then, investigators said, the company has produced a retrofit designed to address the problem.
In July of 2015, the NTSB asked the FAA to require all newly manufactured helicopters to have crash-resistant fuel systems. The agency is still in the process of developing new rules, officials said.
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