After the Accident: The Story Behind the Story
My first major investigation was as an operator party member for a crash involving a single air medical AS350B2 helicopter that resulted in the death of the pilot, two medical crewmembers and a patient in Mosby, Missouri in August 2011. The scene was within a short distance of an intermediate destination airport where the pilot was planning to get fuel. They never made it to the airport because the engine flamed out due to fuel starvation and the pilot failed to successfully autorotate to a safe landing. This accident was chosen for a public “sunshine meeting” by the NTSB due to several circumstances including pilot distraction. (Links to the NTSB accident report & public docket for this accident included below if you want to learn more.)
Through the course of the on-scene investigation and following months of interactions with the NTSB and FAA I shaped my approach to future accident investigations. In the future I avoided the approaches that increased conflict and focused my efforts on what had proven successful. I was involved in varying capacities in several more major helicopter investigations over the next four years and each one taught me new lessons from an operator’s perspective.
Several years and accidents later we had refined our approach and our investigation team was highly respected by the NTSB.
Wreckage of N352LN at the accident scene in Mosby, Missouri (NTSB CEN11FA599)
I started VyClimb in 2015, and no longer being affiliated with a single operator I was free to share what I had learned with others without any conflicts of interest. Through my investigator contacts at the FAA, NTSB, and OEMs I promoted the idea of sharing these lessons with others. Consolidating my own lessons learned and opinions together with input from my network I built a briefing: After the Accident: Working with the NTSB.
I asked my NTSB, FAA and OEM investigator contacts what items they wish all operators knew before participating as party members.
As a result of my reputation and these efforts, I was invited to teach at the NTSB Training Center as part of their Helicopter Accident Investigation course. Additionally, I have presented these concepts at HAI’s Heli-Expo Rotorcraft Safety Challenge and various safety events.
Now that I have this blog, I felt like this was one more way to spread some of this experience and share with more people. I plan to break down my presentation into smaller sections and share them here as a series of posts. While this information will not prevent an incident or accident, my sincere hope is that it will better prepare you and your organization in the event of a tragedy.
It surprised me how many operator employees with “accident investigator” somewhere in their job description have never been trained or even been a part of a major accident.
The topic of accident investigations is too complex for a simple blog or briefing so if you want to learn the technical aspects there are courses from the NTSB and third-parties available and some are linked below.
If you enjoy these posts, be sure to share this blog with others in your network.
More Reading:
NTSB Accident Report: CEN11FA599 - N352LN - Mosby, MO
NTSB Public Docket: CEN11FA599 - N352LN - Mosby, MO
NTSB Training Center
USC Aviation Safety & Security Training
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