NTSB CAROL · Event
Event CEN11FA599
Aircraft involved
Probable cause & findings
The pilot's failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion. Contributing to the accident were (1) the pilot's distracted attention due to personal texting during safety-critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator's lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot's autorotation training in the accident make and model helicopter.
Factual narrative
The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/02. On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH. The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/02. On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Task performance-Planning/preparation-Fuel planning-Pilot
- C Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot
- C Personnel issues-Action/decision-Action-Incorrect action performance-Pilot
- F Organizational issues-Support/oversight/monitoring-Oversight-Oversight of operation-Operator
- F Organizational issues-Support/oversight/monitoring-Training-(general)-Operator
- F Personnel issues-Psychological-Attention/monitoring-Attention-Pilot
- — Aircraft-Aircraft systems-Indicating/recording systems-Data recorders (flight/maint)-Not installed/available
Verbatim from NTSB's published report. Source file
NTSB_2011_CEN11FA599.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (fuel exhaustion, engine failure). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- arXiv 2022 · arXiv preprint
Multi-level Adaptation for Automatic Landing with Engine Failure under Turbulent Weather
This paper addresses efficient feasibility evaluation of possible emergency landing sites, online navigation, and path following for automatic landing under engine-out failure subject to turbulent wea…
- NASA NTRS 2019 · Conference Paper
Simulation of Liquid Rocket Engine Failure Propagation Using Self-Evolving Scenarios
Traditional probabilistic risk assessment approaches often require failure scenarios to be explicitly defined through event sequences that are then quantified as part of the integrated analysis.
- NASA NTRS 2019 · Conference Paper
Rocket engine failure detection using system identification techiques
The theoretical foundation and application of two univariate failure detection algorithms to Space Shuttle Main Engine (SSME) test firing data is presented.
- NASA NTRS 2019 · Conference Paper
Rocket engine failure detection using system identification techniques
The theoretical foundation and application of two univariate failure detection algorithms to Space Shuttle Main Engine (SSME) test firing data is presented.
- NASA NTRS 2019 · Technical Memorandum (TM)
A simulator investigation of engine failure compensation for powered-lift STOL aircraft
A piloted simulator investigation of various engine failure compensation concepts for powered-lift STOL aircraft was carried out at the Ames Research Center.
- Semantic Scholar 2019 · Article (AIAA Scitech 2019 Forum)
Impact of Engine Failure Constraints on the Initial Sizing of Hybrid-Electric GA Aircraft
Potential advantages of hybrid-electric aircraft are fuel savings, lower emissions, and reduced noise. Since these aircraft generally apply multiple power sources, they can also be designed to sustain…
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