Alpine Texas Air Ambulance Crash the Latest in a Legacy of Unsafe Practices

The fatal crash of a medical evacuation airplane is certain to be investigated with an eye to unrequited recommendation to improve aerial ambulance operations.

Shortly after midnight on 4 July, in clear weather, an O’Hara Flying Service-operated twin-engine Cessna 421 aerial ambulance took off from Alpine-Casparis Municipal Airport, Texas, for a flight to Midland International Airport, Texas. The airplane was carrying patient Mary Folger, 73, who had broken her hip. She was accompanied by her husband, Guy Folger 78. Two flight nurses were aboard, Sharon Falkener and Tracy Chambers. Piloting the aircraft was Ted Caffarel, 59.

Crash scene at Alpine, Texas, of an O’Hara Flying Service air ambulance, killing all 5 aboard.

Crash scene at Alpine, Texas, of an O’Hara Flying Service air ambulance, killing all 5 aboard.

After an uneventful takeoff, the airplane experienced some sort of problem, perhaps engine related, and Caffarel was attempting a return to the departure airfield. About a mile short of the runway, a main landing gear wheel hit a rut in an open, muddy field. The airplane overturned at least once and burst into flames. There were no survivors.

In May 2009, another O’Hara Flying Service aircraft, also a Cessna 421, was substantially damaged during a forced landing following the loss of engine power shortly after takeoff near Alpine. The pilot was the sole occupant of this positioning flight and received minor injuries in the incident. It is not known if this earlier event involved the same Cessna 421 or one of its engines.

Between December 2007 and February 2010 a total of 41 patients and flight crew have been killed in EMS fixed-wing and helicopter accidents. Generally, EMS flight safety is about 30 times lower than it is for commercial airline operations.

The National Transportation Safety Board (NTSB) will be investigating this accident. The NTSB has a long record of concern about the safety of Emergency Medical Service (EMS) flights. A special investigation report was produced in 2006 that examined about 40 EMS accidents. In 2008 helicopter EMS accidents hit an all-time high, with 29 fatalities, prompting the NTSB to hold a public hearing on HEMS safety in February 2009. In addition to the four safety recommendations issued as part of the 2006 study, the 2009 forum produced an additional, and whopping, 21 recommendations. None have been fully implemented.

In February of this year, the NTSB increased the pressure to act on the Federal Aviation Administration (FAA) by adding the improved safety of EMS flights to its “Most Wanted” list of still-to-be-enacted improvements. On that “Most Wanted” list was the recommendation to install Terrain Awareness Warning Systems (TAWS) on all EMS flying machines. A technical standard order (TSO) was released by the FAA for TAWS in December 2008, but the FAA has yet to take action requiring such a system to be installed on EMS aircraft and helicopters. The NTSB has characterized its moribund TAWS recommendation as “Open – Unacceptable Response.”

It is not known at this time if O’Hara Flying Service voluntarily installed TAWS on its EMS air ambulances. Since there was no FAA requirement to do so, there is reasonable suspicion that the accident airplane was not equipped with TAWS.

TAWS might have prevented this night time crash. TAWS may have alerted the pilot to his low altitude, preventing the premature contact with the ground as pilot Caffarel was returning to the runway.

The NTSB investigation will doubtless discuss the legacy of FAA-ignored recommendations as part of its investigation of this accident.

Of interest, the NTSB has never recommended two pilots in the cockpit. Single pilots like Caffarel frequently rely on a flight nurse in the co-pilot’s seat to manage part of the radio communications and to maintain a look out the cockpit for other aircraft or terrain.

In Canada, which has not suffered a single fatal EMS accident, two-pilot operation is required.

No commercial airline flights would be undertaken by a single pilot. Yet here is an EMS flight, with passengers, being flown by one pilot, who had an emergency such that he was attempting to return to the departure airfield.

Any number of NTSB reports on EMS accidents have served to justify its recommendation for TAWS, but TAWS is best employed with two pilots. TAWS alerts require one pilot to be looking out the windscreen while the other pilot tracks the dangerous rising terrain on the cockpit display.

And if he had an engine problem, Caffarel could certainly have used a co-pilot to manage the overall situation. With the resources of two pilots’ trouble shooting, and TAWS to avoid premature ground contact, the fiery crash just may have been avoided.