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Safety Recommendation Details

Safety Recommendation A-07-111
Details
Synopsis: The National Transportation Safety Board has investigated two recent HEMS CFIT accidents that involved low-altitude flight during night visual meteorological conditions (VMC) and that revealed safety issues related to the operability and use of radar altimeters. On January 10, 2005, about 2311 eastern standard time, a Eurocopter EC 135 P2 helicopter, N136LN, operated by LifeNet, Inc., crashed into the Potomac River near Oxon Hill, Maryland, after transporting a patient to a hospital. The certificated commercial pilot and the flight paramedic were killed, and the flight nurse received serious injuries. The VFR positioning flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 during night VMC.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require helicopter emergency medical services (HEMS) operators to install radar altimeters in all helicopters used in HEMS night operations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Oxon Hill, MD, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: NYC05MA039
Accident Reports: Crash into Potomac River, LifeNet, Inc., Eurocopter EC-135 P2, N136LN
Report #: AAB-07-04
Accident Date: 1/10/2005
Issue Date: 12/21/2007
Date Closed: 9/11/2014
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Helicopter Emergency Medical Services,

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/11/2014
Response: We are aware that, in section 135.160, the February 21, 2014, final rule requires operators to install radio altimeters on all helicopters operated under part 135 rules. In addition, section 135.1 requires operators to conduct, under part 135 rules, helicopter air ambulance flights with medical personnel on board. Accordingly, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 8/22/2012
Response: The FAA’s proposed revision to 14 CFR Part 135 to require radar altimeters for all helicopters operated under Part 135, in conjunction with the proposal to require all HEMS operations to be conducted under Part 135, satisfies the intent of this recommendation. Accordingly, pending the expeditious issuance of the final rule as proposed, Safety Recommendation A-07-111 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/23/2012
Response: -From Michael P. Huerta, Acting Administrator: On October 12, 2010, the FAA issued Notice of Proposed Rulemaking (NPRM), Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments. The comment period closed on January 10, 2011. The FAA received the comments submitted by the Board and is reviewing those comments as part of the rulemaking process. The NPRM proposes to add requirements for: • A load manifest for all aircraft operated under part 135 (§ 135.63(c)); • Radio altimeters for all helicopters operated under part 135 (§ 135.160); • Initial and recurrent pilot testing to include procedures for aircraft handling in flat-light, whiteout, and brownout conditions (§ 135.293(a)(9)); • Competency checks that include a demonstration of the pilot's ability to maneuver solely by reference to instruments (§ 135.293(c)); • The use of helicopter terrain awareness and warning systems in helicopter air ambulance operations (§ 135.605); • An FAA-approved procedure for conducting pre-flight risk analyses when conducting helicopter air ambulance operations (§ 135.615); • An operations control center and operations control specialists for helicopter air ambulance operations (§ 135.617); and • A briefing by the pilot in command or designated crewmember to medical personnel prior to each helicopter air ambulance operation (§ 135.619). Additionally, the NPRM defines helicopter air ambulance in § 135.601(b)(l) as operations by a part 135 certificate holder. I will keep the Board informed of the FAA's progress on these recommendations, and provide an updated response by March 31, 2013.

From: NTSB
To: FAA
Date: 3/12/2010
Response: The FAA believes that increased training and evaluation requirements can mitigate the hazards associated with flat light or whiteout conditions; consequently, it revised FAA Order 8900.1, Flight Standards Information Management System, to provide standards and procedures for FAA inspectors to evaluate flat light or whiteout training programs for all helicopter operators. In addition, in April 2009, the FAA began drafting a notice of proposed rulemaking (NPRM) for air ambulance and commercial helicopter operations that will include language addressing the intent of Safety Recommendations A-02-35 and A-07-111 and -112. Although the NTSB agrees that increased training for pilots may be of benefit in avoiding accidents where radio altimeters are needed, issuing guidance and standards for such training is not responsive to these recommendations. The NTSB is pleased to learn that the planned NPRM will include language proposing the recommended requirements for radar altimeters. Pending timely issuance of a final rule to require the installation of radar altimeters in all helicopters conducting commercial, passenger-carrying operations in areas where flat light or whiteout conditions routinely occur, Safety Recommendation A-02-35 is classified Open Acceptable Response. Pending the issuance of a final rule requiring (1) the installation of radar altimeters in all helicopters used in HEMS night operations and (2) the inclusion of a requirement on the MEL that these altimeters be operable on all helicopters during HEMS flights conducted at night, Safety Recommendations A-07-111 and -112 remain classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/17/2009
Response: Letter Mail Controlled 8/31/2009 10:34:54 AM MC# 2090543: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration believes that increased training and evaluation requirements can mitigate the hazards associated with flat light or whiteout conditions. Therefore, the FAA revised FAA Order 8900.1, Flight Standards Information Management System (FSIMS) (enclosures 1 & 2), to provide standards and procedures for the inspector to evaluate flat light or whiteout training programs for all helicopter operators. The FAA also notes that radio altimeters could be beneficial when unique operating conditions exist, such as those operations conducted in Helicopter Emergency Medical Services that routinely take place in remote, off-airport locations. In April 2009, the FAA began drafting a notice of proposed rulemaking (NPRM) for air ambulance and commercial helicopter operations. There will be language in this rulemaking addressing the safety intent of these recommendations. We plan to complete our internal work on the NPRM in January 2010. Publication of the NPRM will occur after clearance from the Department of Transportation (DOT) and the Office of Management and Budget (OMB).

From: NTSB
To: FAA
Date: 11/25/2008
Response: The Safety Board notes that the FAA agrees with the intent of these recommendations and is considering rulemaking that would require all Part 135 HEMS operators conducting night HEMS operations to have an operable radar altimeter installed in the helicopter. The FAA’s rulemaking council will consider these recommendations and will provide the Board with an update. Pending the FAA’s requiring the installation of radar altimeters in all helicopters used in HEMS night operations and ensuring that the minimum equipment lists for these helicopters require that these altimeters be operable during flights conducted at night, Safety Recommendations A-07-111 and A-07-112 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/10/2008
Response: Letter Mail Controlled 4/14/2008 12:20:16 PM MC# 2080199: - From Robert A. Sturgell, Acting Administrator: The Federal Aviation Administration agrees with the intent of these recommendations and is considering rulemaking to require all part 135 HEMS operators, conducting night HEMS operations, to have an operable radar altimeter installed in the helicopter. This project will be considered by the FAA Rulemaking Council in the next few months. We will provide the Board with an update in 180 days.