September 25, 2009 – Three Fatalities

SuperUser Account LAND & LIVE Case Studies

EMS Repositioning Flight – 3 fatalities


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


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

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