Land & LIVE | An HFI Program


HAI created the Land & LIVE program after a review of the National Transportation Safety Board aviation accident database revealed accident after accident in which a precautionary landing could have broken the accident chain.

Here are six examples:

1. February 16, 2002 – Two fatalities
2. October 16, 2000 – One fatality
3. September 25, 2009 – Three fatalities
4. March 25, 2010 – Three fatalities
5. July 23, 2009 – Four fatalities
6. December 29, 2000 – One fatality

 


Example #1 - February 16, 2002

MCO/ORL to 7FL6 Spruce Creek – 2 fatalities
 

Summary:

It was pre-dawn take-off from Orlando to pick up passenger 41 miles away at a small private airport close to the Atlantic Coast. The weather was VFR at the departure airport, but was low IFR near the destination with 100 foot ceilings, ¼ mile visibility. The pilot received a weather briefing from FSS prior to takeoff.

The aircraft crashed into trees 6 miles southeast of the airport. The route of flight was from the southwest, indicating that the pilot was likely picking through weather in order to reach the destination.   Toxicology indicated that the 17,000+ hour helicopter pilot had a blood alcohol level well in excess of the legal limit for operating an automobile.

Land and LIVE Factors:

Due to this pilot’s state of intoxication, his ability to internalize the weather briefing and the low IFR conditions may have been compromised. His ability to abort or delay the flight may have been compromised by a need to cover up (alcoholism). Land and LIVE may not have been a viable choice for him because he feared being “found out”.  

Thought:

Perhaps this pilot’s reputation was as impaired by alcoholism as his judgment and abilities were by his blood alcohol content.

Read the NTSB probable cause narrative: ATL02FA048


Example #2 - October 16, 2000

Repositioning Flight – 1 fatality

Summary:

About 5 minutes before landing at a hospital to drop off a patient, a transmission oil pressure warning light illuminated. At the hospital, the pilot performed an abbreviated shutdown, eliminating the cool down procedure. The flight nurse reported to the pilot that she smelled burning, but the pilot dismissed this as being a result of the shutdown without cool down. A mechanic was dispatched and disconnected the light and suggested a ground run, hover and night time ferry flight back to the base hospital. The pilot crashed 1 mile from the hospital. 

Land and LIVE Factors:

Landing 5 minutes short of a hospital with a patient on board would not be an easy decision to make, but in this case, it would have been exactly the right thing to do. Following that first bad decision, the pilot elected to follow bad advice and perform a night time ferry flight with a critical indicating system deliberately disabled despite possible convictions otherwise. The pilot clearly understood the urgency of the emergency because of his abbreviated shutdown. “Stay on Land… and Live” is a more fundamental decision that can be seen in many land and live scenarios. Did this pilot rationalize his decision and dismiss gut instincts? Did he smell something? Feel something? KNOW something? 

Thought:

Plan Continuation Bias combined with can do attitudes is a powerful combination that can override good decision making.

Read the NTSB probable cause narrative: MIA01FA006


Example #3 - September 25, 2009

EMS Repositioning Flight – 3 fatalites 

Summary:

After a successful patient transfer, the accident pilot made decision to return to the base of operations despite marginal weather due to thunderstorms and an invitation to remain at the receiving hospital.

For the last 8 minutes of the flight, the aircraft was shown with altitude reports between 650 and 800 feet MSL down from an established cruise altitude of 1000 feet MSL.  Witnesses reported seeing the aircraft in moderate to heavy rain turning landing light on and off immediately before the crash occurred. 

Land and LIVE Factors:

 Plan Continuation Bias and Weather

Thought:

Based on the radar returns showing lowered altitude, there were 8 minutes of flight presumably with visual contact to the ground where the pilot knew things were not going well. There was no patient on board so making a decision to land should have been easy. Was he trying to get to Georgetown Airport just 2 miles away from the crash site?  How many opportunities did he have to Land and Live?  Why didn’t he?  Inconvenience?  Peer pressure?

Read the NTSB probable cause narrative: ERA09FA537

 


Example #4 – March 25, 2010

EMS Repositioning Flight – 3 Fatalities 

Summary:

The accident pilot had delivered a patient to a hospital at end of a night shift. The relieving pilot communicated with the accident pilot about an approaching line of thunderstorms. Estimating that he had 18 minutes to return to the base, the accident pilot advised that he intended to leave the nurses at the hospital in order to expedite. The nurses were able to get on board anyhow. The pilot flew into the leading edge of a line of fast moving (61 knots) thunderstorms and crashed 2.5 miles east of the home base.

Land and LIVE Factors:

Plan Continuation Bias,Weather and possibly fatigue

Thought:

Sometimes things go from bad to unmanageable too quickly to make a decision to land and live – such may be the case flying into the leading edge of a thunderstorm, something the pilot would probably never have done had he not been SO CLOSE to his base. This pilot was probably determined to get back to base, end his shift, get in his own car and drive home.

Read the NTSB probable cause narrative: ERA10MA188 


Example #5 – July 23, 2009

Passenger transportation flight – 4 fatalities 

Summary:

A pilot with 645 hours total experience and 25 hours of night experience was making a short night airport to airport flight with three passengers in known marginal weather conditions. Before take off another company pilot reported to him that the rain had stopped, but that “miserable weather” prevailed and suggested that they could be driven the short distance (43 miles) by one of the passenger’s wives.  While following a highway across a ridgeline, witnesses saw the aircraft make a 180-degree turn as if to escape the bad weather and strike wires.

Land and LIVE Factors:

Weather, night time, aircraft and pilot capabilities, decision making 

Thought: 

This young pilot was likely eager to show the capabilities of the aircraft and get this flight completed.  His passengers had waited already over an hour for the weather to improve (likely at his suggestions).   Numerous alternative offers of transportation were refused by the pilot. 

Read the NTSB probable cause narrative: ERA09FA417

 


Example #6 –December 29, 2000

Off Shore Oil – 1 fatality

Summary:

An off-shore helicopter with the pilot as the sole-occupant crashed into the Gulf of Mexico without any apparent cause. The impact analysis indicated a complete loss of control and there was no evidence of any mechanical failures prior to impact with the water. Autopsy shows significant arterial blockages consistent with possible sudden death or incapacitation.

Land and LIVE Factors:

Possible pilot incapacitation

Thought:

Health and fitness of duty are not mysterious and rarely do people suffer sudden death without knowing of significant risk factors. Sudden death itself generally follows at least one hour of symptoms.

Signs and symptoms

The cardinal symptom of decreased blood flow to the heart is chest pain, experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. This may be associated with diaphoresis (sweating), unrelenting “heartburn", nausea and vomiting, as well as shortness of breath. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with diabetes). Some may report palpitations, anxiety or a sense of impending doom (angor animi) and a feeling of being acutely ill.

Read the NTSB probable cause narrative: FTW01FA043

 

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