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Safety Recommendation Details

Safety Recommendation A-07-112
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: Ensure that the minimum equipment lists for helicopters used in helicopter emergency medical services operations require that radar altimeters be operable during flights conducted at night.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
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:
Addressee(s) and Addressee Status: FAA (Open Acceptable Alternate Response)
Keyword(s): Checklist

Safety Recommendation History
From: FAA
To: NTSB
Date: 8/9/2019
Response: -From Daniel K. Elwell, Acting Administrator: The Board stated in its letter dated January 11, 2016, the new requirement for helicopter terrain awareness and warning system (HTAWS) as a result of Part 135.179(b), Inoperable instruments and equipment, creates redundancy for terrain avoidance guidance for Principal Operations Inspectors and could address this safety recommendation as stated regarding minimum equipment list (MEL) relief for helicopter air ambulance (HAA) operations. We are in the process of amending rotorcraft Master Minimum Equipment Lists (MMEL) to allow for operations under part 135 with inoperative radar altimeters with certain limitations. Operations with an inoperative radar altimeter prohibits flights utilizing night vision goggles, night off-airport landings or landings at unimproved areas, and flights conducted over water or terrain without surface lights. For flight at night, a requirement for the pilot to evaluate terrain and obstacles along the route and fly at such an altitude to ensure all terrain and obstacles along the route of flight are cleared vertically by no less than 500 feet. Additionally, a Global Change Policy Letter is in draft that would allow for all operators of affected aircraft to amend their MELs before the MMELs are amended. The MMEL Industry Group is currently reviewing the draft Policy Letter; the time frame to complete the updates to the MMELs is one year or more. The FAA's actions listed to amend the MMEL and HAA is specifically addressed in part 135.l 79(b), Inoperable instruments and equipment, and meets the intent of the recommendation. We anticipate providing an update to the Board by June 2020.

From: NTSB
To: FAA
Date: 1/11/2016
Response: We are aware that the February 21, 2014, final rule, titled “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” requires that all helicopters used in helicopter air ambulance (HAA) operations be equipped with an operable FAA-approved radio altimeter and a helicopter terrain awareness and warning system (HTAWS). However, neither the notice of proposed rulemaking nor the final rule addressed minimum equipment lists. We agree that the additional HTAWS requirement for HAA operations creates redundancy for terrain avoidance in the event a HAA aircraft were to be operated with an inoperative radio altimeter for a temporary time interval of up to 10 days. Although we believe that this additional requirement could constitute an acceptable alternate solution to address this recommendation, we would like to know whether you have developed guidance for principle operations inspectors (POI) regarding HTAWS MEL relief for HAA operations. We believe that this guidance should account for the conditions in which HAA operations are conducted and should ensure that alternate procedures are established that reduce the risk of controlled flight into terrain at night if both the HTAWS and radio altimeter are not operating. Pending our review of guidance for POIs regarding HTAWS MEL relief for HAA operations that addresses the concerns described above, Safety Recommendation A-07-112 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) published the final rule titled, "Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations" to the Federal Register on February 21, 2014 (79 FR 9931). As part of this final rule, Title 14, Code of Federal Regulations (14 CFR) Section 135.160, Radio Altimeters for Rotorcraft Operations, was amended to read, in part, "After April 24, 2017, no person may operate a rotorcraft unless that rotorcraft is equipped with an operable FAA-approved radio altimeter, or an FAA-approved device that incorporates a radio altimeter, unless otherwise authorized in the certificate holder's approved Minimum Equipment List (MEL)." The FAA notes that this rule applies to all rotorcraft operations conducted under 14 CFR part 135, not just Helicopter Air Ambulance (HAA) aircraft. In addition, we reviewed rotorcraft Master Minimum Equipment Lists and determined that radio altimeters are a category "C" item, which are granted a 1 0-day period in which repairs must be accomplished. Additionally, 14 CFR Section 135.605, Helicopter Terrain Awareness and Warning System, was amended as part of the final rule, adding "After April 24, 2017, no person may operate a helicopter in HAA operations unless that helicopter is equipped with a helicopter terrain awareness and warning system...." This additional requirement creates redundancy for terrain avoidance in the event a HAA aircraft were to be operated with an inoperative radio altimeter. The FAA believes that having a regulatory requirement precluding HAA aircraft from operating in accordance with an approved MEL could prevent a lifesaving operation from taking place, even when an encounter with adverse meteorological conditions is unlikely. This is especially true for HAA aircraft based in geographical areas with long periods of darkness, in which HAA service is essential and much safer than ground transportation. In areas like northern Alaska, it may take days for equipment to be delivered to repair or replace an inoperative radar altimeter. Additionally, the FAA published Advisory Circular (AC) 135-14B, Helicopter Air Ambulance Operations, on March 26, 2015. The AC provides information and guidance to HAA operations, and addresses operations with an inoperative radio altimeter by stating that, "operators should establish and document procedures to be followed if operations are conducted with an inoperative radio altimeter in accordance with an MEL. Incorporating procedures such as requiring increased ceiling and/or visibility and limiting flights where whiteout, brownout, or encounters with flat-light conditions are possible may mitigate risk. Inoperative equipment should also be addressed as a risk analysis factor...." A copy of this document is available at: http://www.faa.gov/documentLibrary/medialAdvisory_Circular/AC 135-14B.pdf. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/11/2014
Response: We are aware that the February 21, 2014, final rule requires operators to install radio altimeters on air ambulance helicopters that fly with medical personnel on board. Although neither the NPRM nor the final rule addressed minimum equipment lists, you indicated in the final rule that the requirements relating to operations with inoperable radio altimeters would be developed by the FAA’s Flight Standards Service in accordance with its existing master minimum equipment list process. Accordingly, pending our receipt and review of a requirement for the recommended minimum equipment lists, Safety Recommendation A-07-112 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 8/22/2012
Response: The FAA’s proposed revision to 14 CFR Part 135 mandating radar altimeters for all helicopters operated under Part 135, in combination with the definition of helicopter air ambulance operations as those conducted by a Part 135 certificate holder, partially addresses this recommendation. However, the proposed revisions do not address the recommended minimum equipment lists specified in Safety Recommendation A-07-112. Accordingly, pending the expeditious issuance of a final rule including both a requirement for radar altimeters and a requirement for minimum equipment lists as recommended, Safety Recommendation A-07-112 is classified OPEN—UNACCEPTABLE 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: This is in response to Safety Recommendations A-07-1 11 and -1 12 issued by the Board on December 2 1,2007. In those recommendations the Board stated that Helicopter emergency medical services (HEMS) flights typically operate under visual flight rules (VFR) and at low altitudes. When flying during night conditions, HEMS pilots must be especially diligent in avoiding controlled flight into terrain (CFIT) because a lack of visual ground references during night flight can render a pilot susceptible to visual illusions and other conditions that can make it difficult to judge the helicopter’s altitude and actual height above the terrain. Helicopter pilots flying at low altitudes would have little time to recognize and recover from such illusions or other disorienting factors that could place them at risk of CFIT. A pilot’s reliance on cockpit instruments, particularly radar altimeters (also known as radio altimeters), combined with an outside visual scan, is imperative during night flight to ensure the flight’s safe altitude above terrain. A-07-1 1 1. Require helicopter emergency medical services (HEMS) operators to install radar altimeters in all helicopters used in HEMS night operations. A-07- 1 12. Ensure that the minimum equipment lists for helicopters used in helicopter emergency medical services operations require that radar altimeters be operable during flights conducted at night. FAA Comment. 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.