SERVE D JANUAR Y 8 , 201 0 ^ ^ 

# RECEIVE D U.S
. DEPARTMEN T O FTRANSPORTATIO N —• w •- . i ^

OFFIC E O FHEARING S -^A N 1 I 2(N 0 

### WASHINGTON , D C HEARIN G DOCKE T I N TH E MATTE RO F AI RCHARTE RINC. , Respondent
. FA A DOCKE T NO
. CP09SO000 8 (Civi l Penalt y Proceeding ) DM S NO
. FAA-2009-010 0 - " 1

ADMINISTRATIV E LA WJUDGE' S INITIA L DECISIO N

I
. Natur e o f

th e Case
. I n thi s civi l penalt y proceeding , th e Responden t i s charge dwith thre e violation s o f

th e Federa l Aviatio n Regulation s (FAR)
. Th e primar y charg e levele db y th e Complainant , th e Federa l Aviatio n Administration , i s tha t th e Responden t

conducte da n ai r

ambulanc e servic e i n violatio n o f it s Operation s Specifications , whic h di dno t authoriz e i t

t o performthi s service. ' Second , th e FA A say s tha t whe n th e Respondent , whic h own s an d operate s aBritten-Norma n "Islander " aircraft , installe di n tha t aircraf t facilitie s for

transportin g astretcher , i t installe dthos e facilitie s backward s an dwith an imprope r

numbe r o f safet y belt s attache dt o th e stretcher
. This , th e FA A charged , amounte dt o aviolatio n o f § 91.13(a ) o f

th e FAR , whic h prohibit s operatio n o f

a n aircraf

t "i n acareles s o r

reckles s manne r

s o a s t o endange r th e lif e o r propert y o f

another. " Th e thir dcharg e agains t th e Responden t

allege s that , o n th e da y i n question , th e aircraf t di dno t hav e an

' Sectio n 119.5(g ) provides , i

n pertinen t part : "No person ma

y operat e a s adirect

ai r carrie r o r a s a commercia l operato r without , o r i n violation of

, a n appropriat

e certificat e an dappropriat

e Operation s Specifications. " ^ I t i s importan

t to not e tha t the Responden

t was not chargedwit

h violating § 43.13(a) of

the FAR, whic

h require s tha

t aperso n performing maintenanc e o r a n alteratio n o

n a n aircraf t mus t us e the methods , techniques , an

dpractice s prescribe di

n th e curren

t manufacturer' s manua

l or the manufacturer' s instructions , unles s tha

t perso n ha s secure dthe FAA' s approva l fo r adifferen t installation
.FAA-approve dflight manua l aboar di n violatio n o f § 121.141(b ) o f

th e FAR. ^ Th e Responden t

i s an on-deman dai r

carrier , operatin g unde r

th e trad e nam e o f "Ai r Flamenco. " It s principa l plac e o f busines s i s th e Commonwealth o f

Puert o Rico
. Th e FA A lodge dit s charge s i n acomplain t file do n Ma y 27 , 2009 , seekin g acivi l penalt y o f $11,000
. Th e Responden t denie dal l o f

th e charge s an dsough t

an on-the-recor dhearing
. Th e cas e wa s referre dt o th e Department' s Offic e o f Hearings , wher e i t

wa s assigne dt o m e for th e conduc t

o f th e hearin g an dth e issuanc e o f an initia l decision
. A two
da y hearin g wa s hel di n th e Federa l Buildin g i n Hat o Rey , Puert o Ric o o n Octobe r 2 3 an d26 , 2009
. Brief

s hav e bee n filed, an dth e cas e i s no w read y fo r decision
. II
. Complainan t Ha s No t Sustaine dIt s Burde n O f Provin g tha t

Responden t

Performe da n Illega l Ai r

Ambulanc e Service
. Th e Complainant' s evidenc e consiste dentirel y o f th e testimon y o f tw o Ai r Safet y Investigators , on e o f

who mwa s no t

at th e scen e at

th e tim e i n question
. Bot h o f

the mwer e permanentl y assigne dt o th e FAA' s Miam i Fligh t Standard s Distric t

Offic e (FSDO)
. O n Jun e 8 , 2008 , Investigato r Eugen e Jeste r

wa s standin g o n th e tarma c at th e Isl aGrand e airport

i n Puert o Rico , whe n h e notice da n aircraf t bearin g th e Respondent' s trad e nam e bein g offloade dabou t

5 0 t o 10 0 fee t

fro mwher e h e wa s standing
. A n ambulanc e ha dpulledu p nea r

th e aircraft , jm

dastretche r

carryin g wha t

appeare dt o b e an elderly , recumben t

woma n wa s bein g remove dthroug h th e aircraft' s af t door
. Th e woma n wa s the n transferre dt o agume y tha t ha dbee n carrie di n th e ambulance
. Th e gumey , wit h it s occupant , wa s place dint o th e ambulance , whic h the n drov e away . Assistin g with th e transfe r wer e th e aircraft' s pilot , anothe r

passenge r

wh o ha dbee n transporte do n th e aircraft , a perso n wh o Jeste r

recognize da s an airport

employe e an dth e drive r o f th e ambulance
. S o fa

r a s Jeste r coul dtell , th e scen e di dno t includ e an y medica l personne l wh o ha dbee n carrie di n th e aircraft , althoug h th e identity o f th e secon dpassenge r

wa s unknow n t o him
.

^ Sectio n 121.141(a

) require s eac

h certificat e holde r to kee p " acurren

t approvedairplane fligh

t manua l fo r eac h typ e of airplane tha

t i t operate s ... " Paiagraph (b ) of §121.14 1 state s tha

t acopy of the fligh t manua l must b e carried"[i] n eac

h airplane require dto have a n airplane fligh

t manua l i n paragraph (a) of

thi s section. "Fro mhi s vantag e point
. Jeste r too k aserie s o f

photograph s o n th e variou s step s i n th e transfer , startin g with th e tim e th e stretche r ha dbee n remove dfi-omth e aircraft
. H e testifie dtha t h e ha dlooke dint o th e interio r o f th e aircraft , after

th e recumben t

passenge r

ha dbee n drive n away . Inspector * Jeste r als o spok e wit h th e pilot , askin g t o se e hi s loa dmanifes t (containin g hi s weight-and-balanc e calculation ) an dth e Fligh t Manua l tha t

ha dbee n carrie do n th e flight. Excep t for tha t brie f conversation , i t

doe s no t appear tha t Jeste r interviewe danyon e els e wh o wa s o n th e flight. I n particular , h e di dno t speak wit h eithe r

o f th e passenger s o r

with anyon e els e wh o wa s involve di n th e transfe r

o f th e elderl y patient
. Th e flight ha doriginate do n Culebra , asmal l islan dof f th e eas t coast o f Puert o Rico
. Unde r

loca l law , Culebr ai s amunicipalit y with it s ow n local government . Ther e i s aferr y servic e betwee n th e tw o islands , althoug h i t i s slo w an dsubjec t

t o th e vagarie s o f

th e weather
. Th e municipa l authoritie s o f

Culebr aha dentere dint o acontract with th e Responden t

t o provid e ai r

servic e betwee n Culebr aan dth e mai n islan dfor resident s o f Culebr awh o wer e considere dto o fi-ail o r elderl y t o suffer

th e rigor s an d discomfort

o f an ocea n crossin g i n orde r t o obtai n medica l services , e.g. . appointment s with specialis t physician s whos e servic e wer e no t availabl e o n Culebra
. Culebr aha s asmal l clini c bu t lack s man y elementar y medica l facilitie s suc h a s X-ra y machines
. Th e contrac t doe s no t cal l for th e Responden t

t o provid e ai r

ambulanc e services
. I n cas e o f agenuin e medica l emergenc y requirin g suc h services , ther e ar e othe r provider s (Aeromed , Aviane , Critica l Care ) a s wel l a s th e U.S
. Coast Guar dwh o ar e availabl e t o transfe r patient s t o hospital s o n th e large r island
. I n addition , th e contract , whic h i s Exhibi t

2 0 i n th e record , provide s for th e Responden t

t o fiimish ai r transportatio n t o municipa l official s o f Culebra. Th e Responden t als o provide s an on-deman dservic e betwee n th e tw o island s for traveler s wh o pay thei r ow n way . A t som e point , Inspecto r

Jeste r sough t th e counse l o f

Joe l Rodas , th e Principa l Maintenanc e Inspecto r at th e Miam i FSDO
. Jeste r showe dth e photograph s t o Rodas
. After viewin g th e picture s an dperformin g som e researc h int o th e aviatio n literatur e pertainin g t o th e Britten-Norma n "Islander " aircraft
. Inspecto r Roda s concurre di n hi s colleague' s vie w tha t Respondent' s aircraf

t ha dbee n use dt o conduc t an illega l ai r

ambulanc e operation
. Inspecto r

Roda s wa s als o responsibl e for th e conclusio n tha t

th e flight manua l tha t

th e pilo t ha dshowe dt o Jeste r

wa s no t th e prope r

manua lt o b e carrie di n th e aircraft ; althoug h i t ha dbee n prepare db y th e Britis h firm tha t buil t th e aircraft , th e manua l carrie db y th e pilo t wa s no t th e on e tha t wa s currentl y approve db y th e FA A for us e i n domesti c operations
. Finally , Roda s conclude dtha t

th e stretche r

ha dbee n improperl y installe dan dwa s no t equippe dwit h th e appropriat e numbe r o f safet y belts , aconclusio n h e reache do n th e basi s o f

viewin g th e photograph s tha t Jeste r ha dtaken
. Lik e Jester , Roda s di dno t

intervie w an y o f

th e individual s involve di n th e transfe r o f th e patient ; no r

di dh e speak

with th e pilot , th e patien t o r th e othe r passenge r o n th e aircraft
. Th e Complainant' s cas e wa s close dafter th e testimon y o f

th e tw o inspectors
. Respondent' s evidenc e opene dwith th e testimon y o f Dr
. Manangel y Rodriguez , th e physicia n wh o ha dsee n th e patien t tha t Inspecto r Jeste r later observe dleavin g th e aircraf t o n Jun e 8 , 200 8 at

th e Isl aGrand e airfield
. Dr
. Rodrigue z i s agenera l practitione r i n Culebra. Sh e wa s o n clini c duty tha t Sunday , whe n a n elderl y lad y wa s presente dt o her , sufferin g fro mpai n i n he r hi p after afal l at home
. Suspectin g abroke n hi p o r broke n leg
. Dr
. Rodrigue z mad e arrangement s fa r he r patien t t o b e flown t o th e mai n islan d fo r an X-ray
. Sh e als o mad e arrangement s for th e airplan e t o b e me t

b y an ambulanc e t o tak e th e patien t t o th e X-ra y facility
. I t

wa s Dr
. Rodriguez' s unequivoca l testimon y tha t th e conditio n o f

he r patien t di dno t requir e medical personne l t o atten dt o he r durin g th e flight, an dth e arrangement s for he r transportatio n di dno t

includ e th e attendanc e o f amedicall y traine d perso n o r person s durin g th e flight. Dr
. Rodrigue z testifie dthat , afte r th e flight too k place , sh e learne dtha t

th e patien t

ha dsuffere dafi'acturedtibia , althoug h sh e di dno t

kno w tha t

a t th e time
. Durin g th e hearing , th e Responden t als o sponsore dth e testimon y o f Aid aMaldonado , th e Manage r o f th e Culebr aHealth Center , wher e Dr
. Rodrigue z ha dsee n th e patient
. O n th e witnes s stand , Ms
. Maldonad o confirme dastatemen t

sh e ha dmad e earlie r

an dtha t i s i n evidenc e a s Exhibi t 21
. Accordin g t o th e statement , th e patien t wa s stabl e whe n sh e lef

t th e Health Cente r

an dwa s no t

accompanie db y paramedics
. Ms
. Maldonad o als o testifie dtha t

an ai r ambulanc e wa s no t

require dt o performth e transportation , an dtha t

i f on e ha dbee n required , th e Health Cente r would hav e calle do n adifferen t provide r tha n th e Respondent
.Anothe r o f th e Respondent' s witnesse s wa s Rober t Emerick , th e othe r passenge r o n th e flight

fro mCulebra
. H e testifie dtha t ther e wa s n o on e o n th e flight wh o wa s attendin g t o th e patient
. H e himsel f i s an automobil e mechanic , an dh e purchase dhi s passag e o n th e flight t o Isl aGrand e becaus e ther e wa s a n empt y sea t

o n th e aircraf

t an dh e ha dsom e privat e busines s on ^ th e mai n island
. Mr
. Emeric k als o testifie dtha t

ther e wa s n o medica l equipment , suc h a s oxygen , o n th e aircraft , an dtha t th e patien t

di dno t nee d o r receiv e medica l attentio n durin g th e flight. Whe n th e aircraf t landed , h e an dother s assiste di n removin g th e patien t an dtransferrin g he r

t o th e ambulance
. Th e definitio n o f

"ai r ambulance, " a s use di n th e Operation s Specification s for

th e Respondent' s Islande r (Exhibi t 4 ) turn s o n th e servic e actuall y performe da s wel l a s th e configuratio n o f th e aircraft
. Th e fac t

tha t th e aircraf t ha s bee n modifie dt o carr y apassenge r i n arecumben t

positio n o n astretche r

i s no t dispositive
. Th e ter m"Ai r Ambulanc e Operations " i s define da s follows : (a ) Ai r transportatio n o f

aperso n with ahealth conditio n tha t require s medica l personne l a s determine db y ahealth car e provider ; o r (b ) Holdin g ou t

t o th e publi c a s willin g t o provid e ai r transportatio n t o aperso n with ahealt h conditio n tha t require s medica l personne l a s determine db y ahealt h car e provide r including , bu t

no t limite dto , advertisement , solicitation , associatio n with ahospita l o r medica l car e provider ; an d (c ) Use s an ai r

ambulanc e aircraft , eithe r fixedwin g o r

helicopter
. Th e term"Ai r

Ambulanc e Aircraft " i s define das : A n aircraf

t use di n ai r

ambulanc e operations
. Th e aircraf t mus t b e equippe dwith at

leas t medica l oxygen , suction , an dastretcher , isolette , o r

othe r appropriat e patien t

restraint/containmen t

device
. Th e aircraf t nee dno t b e use dexclusivel y a s an ai r ambulanc e aircraf

t an d th e equipmen t

nee dno t b e permanentl y installed
. A n ai r ambulanc e i s b y definitio n a n aircraf t tha t i s use dfor

th e transportatio n o f

person s whos e medica l conditio n i s suc h tha t the y mus t

b e accompanie db y medica l personne l a s determine db y ahealt h car e provider
. I t i s no t simpl y a n aircraf

t tha t i s equippe dt o carry apassenge r wh o i s confine dt o astretche r

o r litter
. Th e aircraf

t mus t b e equippe dwith oxyge nan dsuctio n for us e b y th e patient , alon g with th e stretcher , i n orde r t o qualif y a s an "ai r

ambulanc e aircraft. " Th e passenge r mus t b e attende db y someon e with medica l training , an dth e presenc e o f th e attendan t

mus t hav e bee n require db y ahealt h car e provider
. I f th e aircraf

t doe s no t qualif y a s an "ai r ambulanc e aircraft, " th e servic e provide db y tha t aircraf t canno t b e deeme dai r

ambulanc e service
. Hence , i n orde r

th e prov e tha t

an ai r ambulanc e servic e wa s bein g performed , th e Complainan t mus t at aminimu mpresen t

evidenc e tha t

eithe r (a ) th e aircraf

t transporte daperso n who , becaus e o f il l health , wa s accompanie dby , e.g. , adoctor , nurse , paramedi c o r othe r medicall y traine d individual ; an d(b ) th e physicia n o r othe r perso n wh o treate dth e patien t determine dtha t

i t wa s necessar} ' t o hav e amedicall y traine dindividua l accompan y th e patien t

o n th e flight. I n thi s case , th e Complainan t ha s no t sustaine dit s burde n o f

proo f wit h respec t

t o th e charg e o f

unlawfiill y performin g ai r

ambulanc e service
. Ther e i s n o evidenc e i n th e recor dt o prov e tha t

th e patien t

who mInspecto r

Jeste r saw bein g remove dfrom Respondent' s aircraf

t wa s eithe r

accompanie db y medicall y traine d personne l o r

wa s th e subjec t

o f arecommendatio n b y he r docto r o r an y othe r perso n a t Culebr aMedica l Cente r

tha t sh e mus t b e s o accompanied
. I n fact , th e physicia n wh o treate dhe r a s wel l a s th e hea do f

th e Medica l Cente r wher e sh e wa s see n both testifie dtha t ther e wa s n o recommendatio n for a medicall y traine dperso n t o accompan y th e patien t o n th e flight. Th e issu e i s no t

eve n close
. Inspector s Jeste r an dRoda s coul dhav e ascertaine dtha t

thi s wa s no t

an ai r ambulanc e servic e simpl y b y makin g a few telephon e call s t o Culebra
. Th e fac t tha t the y neglecte dt o d o s o an d instea dreliedo n erroneou s inference s from afew distan t photograph s doe s no t redoun dt o th e credi t

o f the mo r th e Complainant
. Fo r thes e reasons , I findan ddetermin e that th e charg e o f

conductin g an ai r ambulanc e servic e i n violatio n o f Respondent' s Operation s Specification s canno t

stand
. I t mus t be , an dwil l be , dismisse dwit h prejudice
. III
. Th e Charg e o f

Operatin g a n Aircraf

t I n aCareles s o r

Reckles s Manne r S o A s t o Endange r

Lif e o r Propert y wa s Unproven
. I n it s complaint , th e FA A allege dtha t th e Responden t

operate dth e Islande r aircraf t o n th e Jun e 8 , 200 8 flight i n acareles s o r

reckles s manner .Th e gravame n o f thi s charg e i s th e clai mtha t whe n th e Responden t

modifie d th e aircraf t b y removin g tw o seat s an dinstallin g aframe t o hol dth e removabl e stretcher , i t

performe dth e installatio n s o tha t th e stretche r

wa s carrie dbackwards , i^ , wit h th e patient' s hea dtoward s th e front o f th e aircraf t rathe r tha n wit h th e hea do f

th e patien t

toward s th e rear

o f th e ^ aircraft
. Th e complain t

als o allege s tha t

th e stretche r

wa s installe dwith onl y tw o safet y belts , wherea s four

safet y belt s wer e required
. I n it s post-hearin g briefs , th e Complainan t ha s attempte dt o transmut e it s initia l clai mo f

violatin g § 91.13(a ) o f

th e FA Rint o abroa dattac k o n whethe r th e Responden t

too k prope r car e o f th e patien t

durin g th e flight fromCulebr at o Isl aVerde
. Th e proble mtha t Complainan t

canno t overcome , however , i s tha t i t di dno t mak e thi s clai mi n it s complain t o r i n any othe r pleadin g precedin g th e hearing
. Elementar y principle s o f du e proces s requir e tha t

th e Complainan t

must , a t an earl y stag e o f

th e proceeding , giv e th e Responden t clear notic e o f th e claim s th e Responden t mus t meet . I t i s beyon dquestio n that , at th e tim e thi s cas e wen t

t o hearing , th e Complainant' s cas e for aviolatio n o f

§ 91.13(a ) wa s founde do n th e manne r i n whic h th e stretche r

wa s installe dan dth e numbe r o f safet y belt s attache dt o it
. Th e Complainan t simpl y cannot , at

th e post-hearin g briefin g stage , shif t it s focu s an dassert

tha t atotall y differen t

theor y o f

liabilit y wa s establishe db y th e evidence
. It s cas e mus t res t o n th e validit y o f

it s origina l contentio n tha t

th e aircraf

t wa s operate d"i n acareles s o r reckles s manne r

s o a s t o endange r

th e lif e o r propert y o f

another " becaus e th e stretche r wa s installe dimproperl y an dha dan insufficien t numbe r o f safety belts
. Th e principa l witnes s for th e Complainan t

o n thi s issu e wa s Maintenanc e Inspecto r

Rodas
. Inspecto r

Roda s wa s no t

at th e Isl aGrand e fieldo n th e dat e i n questio n and , therefore , coul dno t hav e examine dth e aircraf t t o ascertai n ho w th e framework tha t hel dth e stretche r

wa s installed
. Instead , hi s primar y evidenc e for hi s conclusio n tha t

i t ha dbee n installe d backward s wa s th e photograph s take n b y hi s colleague
. Inspecto r Jester
. Inspecto r Jeste r testifie dtha t

h e examine dth e interio r o f th e aircraft
. H e di d so , however , onl y after

th e stretche r

wit h th e patien t

o n i t ha dbee n removed
. Hence , hi s examinatio n di dno t permi t hi mt o ascertai n th e configuratio n o f th e stretche r

uni t durin g th e flight fromCulebra
. Th e earlies t o f hi s photo s i n th e recor dappear s t o sho w th e stretche r after i t ha dbee n remove dfrom th e aircraft
. Ther e wer e n o photo s showin g th e interio r o f th e aircraf

t whil e th e patien t

wa s o n board
. I t

i s clear , therefore , tha t

Inspecto r

Jeste r reache d hi s conclusio n abou t

th e so-calle d"backwards " installation o f th e stretcher

-holdin g mechanis mb y inferrin g tha t conclusio n from aphotograp h o f th e stretche r (an dagrou p o f

peopl e surroundin g it ) a s i t wa s hel do n th e tarma c outsid e o f th e aircraft
. Thi s wa s arathe r strang e inferenc e t o draw , sinc e ther e i s n o indicatio n i n th e photograph s (at leas t thos e tha t

wer e offere di n evidenc e b y th e FAA ) a s t o ho w th e stretche r ha dbee n remove dfromth e " ^ aircraf t - fee t first o r hea dfirst - o r

ho w i t ha dbee n move dwithi n th e aircraf t befor e i t cam e ou t th e rear door
. Th e evidenc e proffere db y th e FA A als o include dth e installation instruction s tha t

accompanie dth e aircraf

t manufacturer' s "kit " for th e remova l o f

tw o passenge r

seat s an dthei r

replacemen t

b y th e stretche r

unit
. Th e instruction s wil l b e foun di n Exhibi t 5
. I t i s tru e tha t

thos e instruction s teac h that th e uni t shoul db e installe ds o tha t th e occupan t

o f th e stretche r ha s hi s o r he r hea dfacin g th e reia

r o f th e aircraft
. I t

i s als o noteworthy , however , tha t

th e Responden t

i s no t charge dwith failure t o follo w thos e instructions ; i t

i s charge dwith operatin g i n acareles s o r reckles s manner . Thi s mean s tha t

th e Complainant , i n orde r t o mak e it s case , mus t

d o mor e tha n merel y demonstrat e tha t th e stretche r

uni t may hav e bee n installe di n a manne r inconsisten t

wit h th e manufacturer' s directions
. Th e FA A wa s require dals o t o prov e tha t th e failure t o follo w thos e direction s produce da palpabl e dange r

t o huma n lif

e o r property . This , th e Complainan t faile dt o do
. I n it s initia l brief

, th e Complainan t

charge s Ai r

Charte r wit h a"breac h o f th e duty o f

car e t o trea t

an immobilized , allegedl y schizophreni c huma n passenge r wit h amedica l conditio n th e sam e a s acarrie r woul dtrea t

carg o (i.e
. loade di n th e bac k

o f an aircraf

t with n o attentio n unti l unloaded.) " Comp
. Init
. Br
. A t

1-2
. Th e troubl e with thi s outrageou s charg e i s tha t ther e i s n o evidenc e (medica l o r other^^ise ) t o support

it
. Th e onl y physicia n wh o testifie dstate dcategoricall y tha t th e patient' s medica l conditio n di dno t requir e he r

t o b e attende ddurin g th e flight. I n addition , th e FAA' s complain t i n thi s cas e di dno t

chiarg e th e Responden t

with a"breac h o f

it s duty o f care. " Th e charg e wa s imprope r installatio n o f

astretche r

equippe d wit h an insufficien t

numbe r o f safet y belts
. Whe n askedwha t

dange r t o lif e o r propert y may hav e resulte dfrom th e manne r

i n whic h th e stretche r

ki t wa s installed
. Inspecto r

Roda s

• * Th e instruction s als o includ

e direction s fo

r remova l of fou r seat s an dthe installatio n of

tw o stretcher s i

n thei r place
. S o fa

r a s the recor

dshows , the two-stretche

r option was neve

r used
.mentioned , i n avagu e way , tha t th e installation ma y hav e adversel y affecte d th e pilot' s weigh t

an dbalanc e calculation
. Bu t h e coul dno t

adequatel y explai n wh y tha t

migh t b e so . I askedhi mdirectl y whethe r h e wa s assumin g tha t th e patient' s hea dweighe dmor e tha n he r feet o r vic e vers aan dI di dno t receiv e asatisfactory answer . Inspecto r Roda s concede dtha t

h e di dno t kno w whethe r

th e patien t

wa s lyin g dow n o r

sittin g u p durin g he r

journey
. A s w e hav e noted
. Inspecto r Roda s di dno t

intervie w anyon e wh o wa s aboar dth e aircraf

t durin g th e fiight, no r

wa s h e abl e t o describ e ho w th e calculatio n o f

th e aircraft' s cente r

o f gravit y migh t

chang e dependin g o n th e locatio n o f

th e patient' s hea drelativ e t o he r feet, ^ Durin g hi s testimony
. Inspecto r Roda s wa s compelle dt o retrac t th e charge , foun di n th e FAA' s complaint , tha t th e stretche r

uni t use db y Responden t

lacke dasufficien t

numbe r o f safet y belts
. H e di ds o afte r

bein g show n th e Britten-Norma n instruction s for equippin g th e aircraf

t wit h a stretche r unit ; thos e instruction s showe dtha t th e stretche r

wa s t o b e equippe dwith tw o safety belt s crossin g over th e uppe r

tors o o f th e patient
. I f Inspecto r Roda s ha ddon e hi s homework sufficiently , h e woul dhav e learne dtha t

th e stretche r

uni t wa s par t o f aki t supplie db y amanufacture r wh o worke dwith Britten-Norman , th e builde r o f th e aircraft ; th e safet

y belt s wer e part o f th e ki t tha t ha dbee n installe do n th e aircraft
. Hence , i n th e absenc e o f

evidenc e tha t

Responden t

ha dremove don e o r

mor e belt s (an d ther e wa s n o suc h evidence) , th e numbe r o f belt s see n i n th e photograph s coul dno t hav e bee n insufficient, ^ Th e fac t remain s tha t

neithe r Roda s no r hi s colleagu e ha dperforme dathoroug h investigatio n o n thi s issue
. Muc h o f th e testimon y durin g th e hearin g concerne dth e Respondent' s installatio n o f

th e stretche r

ki t withou t first securin g th e approva l o f th e FAA
. Unde r

Par t 43 , Appendi x B , sectio n (a ) o f th e FAR , aperso n performin g amajo r

alteratio n o r

repai r t o an aircraf

t mus t obtai n th e prio r approva l o f

th e FA A for

th e wor k b y submittin g aFor m33 7 t o th e loca l FSDO
. I n Apri l 2009 , th e FA A learne dtha t th e Responden t

ha dinstalle d th e stretche r

uni t i n it s aircraf

t withou t submittin g aFor m33 7 t o authoriz e th e installation
. A s aresult , th e Miam i FSD O sen t th e Responden t

a warnin g notic e abou t

thi s allege dviolatio n o f

th e Regulations
. Se e Exhibi t

' I n fact, Rodas' s testimon

y o n cross-examination demonstratedtha t h e di dnot know how to calculat

e the cente r o f gravity
. H

e i s not apilot
. * Th e person wh

o strappe dthe patien

t to the stretche

r fo r he r remova l fromthe aircraf

t erroneously locked th e two uppe r belt s parallel to eac

h other , rathe

r tha n criss-crossing the

move r he r torso . Th e Respondent , however, was not

chargedwit

h locking the belt s improperly ; i t wa s chargedwit

h having a n insufficien

t numbe r of belts , acharg e tha

t was palpabl

y false
.23
. Th e Responden t the n filed aForm337 , an dth e FA A close dth e case , notifyin g th e Responden t tha t "thi s matte r

doe s no t warran t lega l enforcemen t

action. " Durin g th e hearing , th e FLesponden t maintaine dtha t

th e Complainant' s decisio n t o terminat e th e cas e withou t enforcemen t

actio n barre dth e agenc y fromno w assertin g aclai mtha t th e stretche r

uni t ha dbee n improperl y installe dan dlacke dth e requisit e numbe r o f safet y belts
. A grea t deal o f testimony , includin g th e testimon y o f Hernand o Otero , Respondent' s expert witness , wa s devote dt o th e questio n whethe r th e FA A ha dbee n correc t i n insistin g o n th e submissio n o f aFor m337. ^ Th e issu e o f

whethe r th e remova l o f

tw o seat s an dth e installation o f th e stretche r

uni t i n thei r plac e constitute s amajo r alteratio n requirin g FA A approva l i s no t

relevan t t o thi s case , however
. Ther e may b e agrea t dea l t o b e sai dfor

th e Respondent' s contentio n tha t th e FA A may no t

prosecut e a civi l penalt y clai mafte r

notifyin g th e putativ e Responden t that i t i s closin g th e book s o n th e matte r

withou t formal enforcemen t

action
. Th e sam e principle s o f

repos e tha t

underli e th e doctrine s of

^ re s judicat aan ddoubl e jeopard y woul dsee mt o dictat e tha t th e agenc y mus t

b e hel dt o it s initia l decisio n i n suc h cases . Nevertheless , tha t issu e i s no t

rip e for decisio n here
. Th e Responden t

ha s no t bee n charge di n thi s cas e with causin g amajo r modificatio n o f

it s aircraf

t withou t FAA' s prio r

approval
. I t

ha s bee n charge dwith operatio n o f an aircraf

t i n acareles s o r

reckles s manner . Tha t charg e relate s t o th e manne r i n whic h th e stretche r

ki t wa s installe d- no t

t o th e installatio n o f

th e ki t pe r se . Hence , th e Respondent' s clai mtha t th e FAA' s prio r

no-enforcemen t

decisio n exonerate s i t

fromth e charg e i s incorrect
. Nevertheless , I findtha t

ther e i s n o validity t o th e Complainant' s allegatio n tha t

operatio n o f

th e aircraf

t with th e stretche r

installatio n a s i t wa s constitute dacareles s o r reckles s ac t

tha t endangere dhuma n lif

e o r property . Th e ineluctabl e fac t i s tha t neithe r o f th e Complainant' s witnesse s appear s t o hav e actuall y examine dth e manne r o f th e stretcher' s installatio n durin g th e flight; i f

the y did , neithe r

testifie dt o th e result s o f tha t

^ Th e warnin g notic e spok

e abou t the failur e to submi t "approveddata " to suppor

t the modification
. I

t i s clear , however , tha

t the aircraf t manufacturer' s specific instruction s fo r installation of

the stretche

r kit constitutedsufficien

t "approve ddata. " * Oter o testifiedtha

t a33 7 was imnecessar

y becaus e the installation of the stretche

r kit , utilizing the sam

e anchorage hardwar

e a s ha dbeen use dfo

r the passenge

r seat s tha t the ki t replace , was no t

a"majo r repai r o r alteration. " 1 0installation
. Al l tha t th e recor dcontain s o n th e poin t i s Inspecto r

Jester' s photograph s showin g th e stretche r with apatien t

upo n i t afte r i t ha dbee n remove dfromth e aircraft , couple dwith Inspecto r Rodas' s inferenc e tha t

th e stretche r ha dt o hav e bee n installe dbackwards
. Tha t inferenc e i s faulty , a s w e hav e seen , o r

a t leas t completel y unsupported
. T o lea mwhethe r th e - * stretche r wa s properl y installed , on e woul deithe r hav e ha dt o examin e i t whil e i t wa s i n th e aircraf

t o r interrogat e someon e wh o wa s o n th e aircraf t whil e th e stretche r

wa s carryin g apatient
. Neithe r o f th e tw o investigator s di dthis
. No r

wa s ther e an y persuasiv e testimon y tha t th e manne r

i n whic h th e uni t wa s installe dpresente dan unreasonabl e ris k o f harmt o it s occupan t o r t o th e aircraf

t a s awhol e durin g th e flight fromCulebr at o th e mai n islan d o f Puert o Rico
. I n short , th e Complainan t ha s faile dt o sustai n it s burde n o f persuasio n a s t o thi s charge
. A s aresult , th e controvers y over whethe r Form33 7 o r

it s approva l b y th e FSD O wa s necessar y i s moot . IV
. Responden t

i s Liabl e fo r

No t Carryin g aCurren t FAA-Approve dFligh t

Manual
. Ther e doe s no t

appea r t o b e muc h disput e concernin g th e fact s tha t gav e ris e t o Complainant' s thir dcharge : failure t o hav e o n boar dth e aircraf t acop y o f th e current , approve dflight manual
. A s w e hav e note dabove , § 121.141(a ) o f

th e FA Rrequire s acertificat e holde r t o kee p " acurren t approve dairplan e flight

manua l for

eac h typ e o f

aircraf t tha t i t operates " an d § 121.141(b ) state s tha t

acop y o f

th e manua l mus t

b e carrie d"[i] n eac h airplan e require dt o hav e an airplan e flight manua l i n paragrap h (a ) o f thi s section. " Whe n Inspecto r Jeste r askedth e pilo t

o f Respondent' s aircraf

t t o exhibi t acop y o f

hi s flight manual , th e pilo t

produce dacop y o f

wha t i s calle dFM-20
. FM-2 0 i s th e flight manua l issue db y th e manufacture r o f th e aircraft , Britten-Norman , Ltd. , aBritis h compan y with headquarter s o n th e Isl e o f Wight. ' Th e manua l ha dbee n approve dfor us e with th e "Islander " b y th e Britis h government' s counterpar t o f th e FAA , th e Civi l Aviatio n Authority
. I t

cam e wit h th e aircraf

t whe n th e Responden t

acquire di t

froma compan y base do n Tortola , on e o f Grea t Britain' s Caribbea n islands
. A t som e point , however , th e Britten-Norma n compan y issuedaversio n o f th e Fligh t Manua l vali dfor

operatio n o f

th e aircraf

t i n th e Unite dStates
. Thi s versio n i s calle dFM-7
. Th e FA A approve dth e FM- 7 versio n an drequire d

' A copy o f

FM- 7 will b e foun

di n Exhibit 37
. 1 1operator s t o us e i t for domesti c operations
. S o fa r a s th e recor dshows , th e tw o version s ar e practicall y identical , excep t perhap s for

change s i n th e spellin g o f

som e terms . Th e witnesse s coul dpoin t t o onl y on e substantiv e • difference : th e fac t

tha t th e gros s weigh t

figure i n th e U.S
. versio n i s 100 pound s lighte r

tha n th e figure tha t

appear s i n FM-20.' ^ Whe n th e "Islander " wa s acquire db y th e Respondent , i n Jul y 2005 , th e FA A issue dan Airworthines s Certificat e for th e aircraft
. Se e Exhibi t

35
. Th e certificat e covere dth e aircraf t an dit s associate dequipment
. Th e Respondent' s contentio n i s tha t th e FAA' s airworthines s certificat e include s approva l o f

th e Fligh t

Manua l tha t

accompanie dth e aircraf

t an dtha t wa s show n t o th e FA A representativ e wh o signe dth e certificate
. Hence , say s th e Respondent , ther e wa s n o violatio n o f th e FA Rprovision s tha t

requir e a "curren t approved " flight

manua l t o b e carrie do n an aircraft
. Th e proble m wit h th e Respondent' s positio n i s that th e wor d"current " canno t b e stretche d t o mea n "curren t

at th e tim e th e initia l airworthines s certificat e wa s issued. " Th e term"current " mean s "curren t at th e tim e th e FA A inspect s th e aircraft. " A t

som e point , th e FA A i n it s wisdo mdecide dtha t FM- 7 shoul d b e adopte dan dshoul dsupersed e FM-20
. T o d o s o wa s wel l withi n th e discretio n o f

th e agency . Onc e tha t

decisio n wa s mad e an ddul y published , partie s wh o operate dth e Britten-Norma n "Islander " wer e duty-boun dt o replac e thei r

ol dflight manual s with th e on e tha t th e FA A ha dblessed
. Th e Responden t

di dno t d o so . Thereby , i t

violate d§ 121.14 1 o f

th e FAR
. Th e Responden t

als o stresse s th e fac t

tha t th e aircraf

t i n questio n wa s ramp-inspecte do n anumbe r o f occasions , an dn o FA A inspecto r objecte dt o th e FM-2 0 manua l tha t

i t carried
. Thi s i s irrelevant
. Th e failur e o f law

enforcemen t

personne l t o detec t

aviolatio n o n on e o r

mor e occasion s doe s no t transmut e th e violatio n int o complianc e with th e la w whe n i t finally come s t o light
. Th e FAA' s lac k o f enforcemen t

actio n with respec t

t o th e flight manua l durin g prio r

ram p inspection s di dno t creat e an immunity from prosecutio n o n thi s particula r occasion
. Th e Responden t

als o argue s tha t

th e Agreemen t

betwee n th e Unite d State s an dth e Unite dKingdo mo n Certificate s o f Airworthines s for Importe dAircraft , signe da t Londo n o n Decembe r

28 , 1971 , 2 3 U.S.T
. 4309 , conferre do n i t

th e righ t t o continu e t o us e th e sam e flight manua l tha t

ha d bee n supplie db y th e aircraf t manufacturer
. Paragrap h 2(b ) o f th e

1 0 Se e Tr
. 416-17
. 1 2Agreemen t provide s tha t

i f th e exportin g country' s aeronautica l authoritie s hav e certifie dtha n an aircraf t i s airworthy , "th e importin g Stat e shal l giv e th e sam e validit y t o suc h certificatio n a s i f th e certificatio n ha dbee n mad e b y it s ow n competen t

aeronautica l authoritie s . .."
. Tha t i s exactl y wha t happene dwhe n th e FA A issuedan airworthines s certificat e for Respondent' s aircraf

t i n Jul y 2005
. Bu t

tha t i s no t th e en do f

th e matter . Fo r paragraph 4 o f

th e Agreemen t

als o give s th e "competen t aeronautica l authoritie s o f

th e importin g State, " Le. , th e FAA , th e righ t t o prescrib e "additiona l requirement s whic h th e importin g Stat e finds necessar y t o ensur e tha t th e produc t

meet s aleve l o f

safety equivalen t

t o tha t provide db y it s applicabl e laws , regulation s an drequirement s . . ."
. Thi s latte r claus e vindicate s th e FAA' s righ t t o chang e it s min dan dt o direc t tha t th e FM-2 0 manua l mus t

b e replace db y th e FM- 7 manual
. Tha t i s exactl y wha t

seem s t o hav e happene dhere
. Consequently , th e internationa l agreemen t doe s no t absolv e th e Responden t

fro mit s duty t o adop t

th e lates t FAA-approve d flight manua l for

us e i n it s aircraft
. Fo r thes e reasons , I findaji ddetermin e tha t th e Complainan t

shoul d prevai l o n th e thir do f

it s charge s agains t

th e Responden t

- failure t o carry th e current , approve dflight manua l o n it s aircraft
. V
. A Civi l Penalt y o f

$55 0 i s Appropriate
. Th e charg e for

whic h th e Responden t

ha s bee n foun dliabl e - failure t o hav e acurren t

flight manua l aboar dth e aircraf t - i s on e that , standin g alone , woul dno t

hav e merite dthi s length y an dcomple x prosecutio n t o whic h th e Responden t

ha s bee n subjected
. Inspecto r Roda s admitte da s muc h whil e o n th e witnes s stand ; i n th e absenc e o f th e first charg e - operatin g an unauthorize dai r ambulanc e servic e - thi s cas e woul dhav e resulte di n awarnin g letter
. Nevertheless , th e Complainan t ha s established , after atrial-typ e hearin g i n accordanc e with th e Administrativ e Procedur e Act , tha t th e Responden t

wa s i n violatio n o f

aprovisio n o f

th e FAR
. Th e Responden t

mus t therefor e pa y th e price
. I n determinin g wha t

tha t pric e shoul dbe , agoo dplac e t o start i s with th e Tabl e o f

Sanctions , Appendi x B t o FA A Orde r No
. 2150.3B
. I t

i s i n evidenc e a s Exhibi t

16
. Th e Tabl e o f

Sanction s list s differen t

level s o f penaltie s for

violation s b y ai r

caiTiers , dependin g o n th e siz e o f th e carrier. Ther e was , however , n o evidenc e place di n th e recor dbearin g o n th e siz e o f th e Respondent , eithe r

i n term s o f

it s gros s annua l revenue s o r th e numbe r

o f 1 3aircraf

t i n it s inventor y o r

th e numbe r

o f employee s o n it s staf

f Sinc e th e burde n o f proo f wit h respec t

t o thos e issue s o f

fac t reste do n th e Complainant , w e mus t

assum e tha t

tha t th e resul t mos t favorabl e t o th e Responden t

i s true . Hence , I conclud e that th e Responden t

woul db e considere da"GROU P IV " ai r carrie r unde r Orde r No
. 2150.3B , i^ , asmal l busines s concern . Th e orde r als o provides , i n Figur e B-1 1 foun do n pag e B

12 , tha t "failur e t o maintai n acurren t manual " warrant s a"minimum"-leve l civi l penalty
. (Th e orde r addresse s maintenanc e manuals , no t flight manuals
. I als o recogniz e tha t "failur e t o maintain " i s no t th e sam e a s failure t o hav e th e manua l o n board
. This , however , i s a s clos e a s w e ca n come , sinc e th e orde r

doe s no t specificall y addres s th e latte r violation. ) Orde r

No
. 2150.3 B say s tha t

th e rang e o f

th e minimu mpenalt y for asmal l busines s concern woul db e $550-$2,199
. I n thi s case , I conclud e tha t apenalt y at

th e lowe r

en do f th e rang e i s appropriate , for

severa l reasons . First , th e fac t i s tha t th e Respondent' s aircraf t wa s equippe dwit h aserviceabl e flight manual ; th e troubl e wa s that i t wa s ou t o f date
. Th e secon di s tha t ther e i s n o evidenc e tha t th e Responden t

committe dth e violatio n intentionally. Thir di s th e fac t tha t n o advers e effec t

o n th e safety o f

flight wa s show n t o hav e take n plac e a s a resul t o f th e violation
. I n th e onl y reporte dcas e m y researc h ha s uncovere d wher e a n airma n wa s subjecte dt o acivi l penalty for no t havin g acurren t flight manual , Eri c W
. Hereth , FA A Orde r No
. 95-26 , 199 5 W.L
. 85389 6 (1995) , a$3,00 0 civi l penalt y wa s deeme dappropriat e i n acas e wher e th e pilo t ha dconsulte dth e wron g flight manua l and , a s aresult , ra n ou t o f fue l an dcrashed-lande dth e airplane
. Wha t happene di n th e instan t

cas e wa s no t nearl y a s egregiou s an ddemonstrates , i n m y view , tha t

apenalt y a t

th e lowe r en do f th e rang e i s appropriate
. V L Order
. I n consideratio n o f

th e foregoing , an dsubjec t t o revie w b y th e Administrato r

o f th e Federa l Aviatio n Administratio n o n appea l o r o n th e Administrator' s ov mmotion , I T I S ORDERE D THA T - 1
. Th e Respondent , Ai r

Charter , Inc. , i s liabl e t o th e Unite dState s o f America , a s represente db y th e Federa l Aviatio n Administration , for acivi l penalt y i n th e amoun t o f five hundre dfifty dollar s ($550.00) ;

142
. Th e amoun t o f th e civi l penalt y fo

r whic h th e Responden t

ha s bee n hel dliabl e herei n shal l b e pai dt o th e Federa l Aviatio n Administratio n forthwith ; an d 3
. Th e charge s agains t

th e sai dResponden t

se t fort h i n Paragrap h III
. 1
. a . an db
. o f

th e Complain t

ar e dismisse dwit h prejudice
.

Isaa c D
. Benki n Administrativ e La w Judg e

[Note : Thi s decisio n ma y b e appeale dt o th e Administrato r o f th e FAA
. Th e Notic e o f

Appea l mus t

b e file dno t

late r tha n 1 0 day s afte r

servic e o f thi s decisio n (plu s fiv e additiona l days , i f thi s decisio n i s serve db y mail)
. 1 4 C.F.R
. § § 13.233(a) , 13.211(e)
. Th e appea l mus t b e perfecte d wit h awritte n brie f

o r memorandu mno t

late r tha n 5 0 day s afte r

servic e o f thi s decisio n (plu s five additiona l days , i f thi s decisio n i s serve db y mail)
. 14C.F.R.§ § 13.233(c) , 13.211(e)
. Th e Notic e o f Appea l an dbrie f o r memorandu mmus t

b e eithe r

(a ) maile dt o th e Federa l Aviatio n Administration , 80 0 Independenc e Avenue , S.W. , Washington , D C 20591 ; Attention : Hearin g Docke t Clerk , AGC-430 , Wilbu r Wrigh t Building—Suit e 2W1000 , o r (b ) delivere dpersonall y o r vi aexpedite d courie r servic e t o th e Federa l Aviatio n Administration , 60 0 Independenc e Ave. , S.W. , Wilbu r Wrigh t Building—Suit e 2W1000 , Washington , D C 20591 , Attention : Hearin g Docke t Clerk , AGC-430
. 1 4 C.F.R
. § § 13.233(a) , 13.210(a)(2) , (1)
. A cop y o f th e Notic e o f

Appea l an dbrie f o r memorandu mshoul dals o b e sen t t o counse l fo r

th e FA A i n thi s proceeding
. 1 4 C.F.R
. § 13.233(a). ]

1 5FA A Docke t No
. CP09SO000 8 (Civi l Penalty Action ) ORIGINA L & ON E COP Y Federal Aviatio n Administratio n 80 0 Independenc e Avenue , S.W
. Washington , D C 2059 1 Attention : Hearin g Docke t Clerk , AGC-430 , Wilbu r Wrigh t Building—Suit e 2W1000 '

ON E COP Y Gabrie l I
. Penagaricano , Respondent' s Counse l PM B 23 9 40 5 Ave
. Esmerald aSte
. 10 2 Guaynabo , P R0096 9 TEL : 787-287-902 4 Francisc o Torres , Chie f

Executiv e Officer Ai r Charte r Inc. , Responden t P.O
. Bo x 81035 2 Carolina , P R00981-032 5 TEL : 787-405-159 2 Geral dA
. Ellis , Complainant' s Counse l Attorney , Offic e o f

th e Regiona l Counsel. , ASO- 7 Southern Regio n Federal Aviatio n Administratio n P.O
. Bo x 2063 6 Atlanta , GA 3032 0 TEL : 404-305-520 0 FAX : 404-305-522 3 Th e Honorabl e Isaa c D
. Benkin , Administrativ e La w Judg e Offic e o f Hearings , M-2 0 U.S
. Departmen t

o f Transportatio n 1200 Ne w Jerse y Avenue , S.E
. Eas t Buildin g Groun dFloor , Roo mEl2-32 0 Washington , D C 2059 0 TEL : Attorne y 202-366-043 7 Legal Assistan t

202-366-213 2 FAX : 202-366-753 6

' Service wa

s b y U.S
. Mail
. Fo

r servic e i n person o r by, expeditedcourier , us e th e followin g address : Federa

l Aviatio n Administration , 600 Independenc e Avenue , S.W. , Wilbu r Wrigh t Building—Suit

e 2W1000 , Washington , D C 20591 ; Attention : Hearin g Docke t Clerk , AGC-430
.