For the first time, the National Transportation Board has cited texting as a contributing factor in a fatal aviation accident, noting that the pilot of a medical helicopter that crashed in 2011 had been texting with friends during the flight minutes before the crash.

Although the agency said several things led to the crash, Chairman Debbie Hersman said the text messages James Freudenbert sent and received clearly distracted him before and during the ill-fated flight, in which four people were killed.

In addition to the texting during flight, the five-member board unanimously agreed Tuesday that the Aug. 26, 2011 crash outside Mosby, Missouri was caused by an overtired pilot who failed to adequately perform the required preflight safety checks that would have revealed his Eurocopter AS350 B2 was low on fuel.

Once the pilot discovered he had insufficient fuel to complete the flight, he decided to press on rather than follow the proper procedure, which would have been to abort the flight and await additional fuel.

“The nation's helicopter emergency medical services perform important work transporting hundreds of patients and organs every day. We all share the same goal: to ensure that lives are saved – not lost – in these vital lifesaving operations,” Hersman said. “But, this investigation highlighted what is a growing concern across transportation – distraction and the myth of multi-tasking. When you are operating heavy machinery, whether it's a personal vehicle or an EMS helicopter, you need to be focused on the task at hand: transportation, safe transportation.”

The pilot was en route to a hospital with one patient, a nurse and a paramedic aboard when he went down in a field as the helicopter approached the airport. Everyone aboard was killed.

At the most basic level, Hersman said, the fatal crash “involved perhaps the most crucial and time-honored aspect of safe flight: aeronautical decision making.”

Aeronautical decision making is a catch-all term for the human factor in flying and refers to the actions and decisions made by pilots and the crew. Perhaps the most famous recent example of aeronautical decision making was Captain Chesley “Sully” Sulenburger’s quick thinking and steady nerves as he landed U.S. Airways Flight 1549 in the Hudson River after losing both engines.

The bad aeronautical decision making that led to the helicopter crash started almost the moment the patient transfer was requested. Freudenbert reported having two hours of fuel when he departed at 5:28 p.m., according to the NTSB, but in reality had just one. He had neglected to refuel before departing, and in the minutes before taking off had been discussing dinner plans with a coworker.

After landing at the hospital at 5:58 p.m. to retrieve the patient, Freudenbert spoke with a dispatcher at Air Methods, the company that employed him, and conceded he had less fuel than previously believed.

Federal Aviation Administration rules dictate helicopters carrying passengers have a fuel reserve of at least 20 minutes. Freudenbert modified the flight plan, deciding to refuel at an airfield in Mosby rather than at the hospital we was enroute to – a difference of just two minutes.

After picking up the patient, Freudenbert departed at 6:11 p.m. and reported having 45 minutes of fuel – although the NTSB says he had just 30, and the airfield was 32 minutes away. During the flight, he received four text messages and sent three others, the last of which was sent 19 minutes before the helicopter went down at 6:41 p.m.

Investigators later discovered the Eurocopter AS350 B2 had just one liter of residual fuel in the system and the engine quit due to fuel exhaustion. Freudenbert ran out of gas.

That in itself would not typically lead to a crash. Helicopters, like airplanes, can glide without engine power, and pilots are thoroughly trained to land in such circumstances. Helicopter pilots must take quick action to initiate an “autorotation.” In a nutshell, the pilot disengages the main rotor from the engine and uses the kinetic energy of the spinning rotor and air flowing over the rotors to provide sufficient lift to slow the rate of descent and make a safe, if firm, landing.

Here, too, Freudenbert failed to take quick action, although it is not known why he did not initiate a successful autorotation. The NTSB notes he was flying at an altitude of less than 500 feet and impacted the ground roughly 10 seconds after losing power.

The NTSB was clear in stating that the text messages did not directly cause the crash, as you might see in cases where a driver goes off the road while sending a text. But the agency believes Freudenbert was distracted by the ongoing conversation and simply did not realize the helicopter was low on fuel. Had he realized his actual fuel levels he could have requested fuel be delivered before deciding to fly again, and once in flight, he could have even landed just about anywhere once he realized he would not have made his destination. Though again, he would have had to wait for fuel.

Air Methods, the company that manages the helicopter service and employed the pilot, prohibits the use of personal electronic devices during flight.

The NTSB found the pilot’s text messaging during critical moments of flight preparation and during the flight itself was a contributing factor along with fatigue and basic pilot errors. With the proliferation of electronic devices in the cockpit, the NTSB investigation into the helicopter crash in Missouri is likely to have far reaching impacts in aviation training and regulations.

In the end, as NTSB Chairman Hersman noted in her introduction, Wilbur Wright was able to cover even unforeseen hazards in the future of flight safety when he said more than a century ago, “greater prudence is needed rather than greater skill.”