UNITE D STATE S O FAMERIC A DEPARTMEN T O FTRANSPORTATIO N OFFIC EO FHEARING S WASHINGTON , D . C . ../ : ;..,,.., • ' • %^ ^ i% U1'^ ^ ? r

- •>, . '••»-;>•• ' \':>3ies » S Wlane s '%ss0 ' Federa l Aviatio n Administration , Complainant ,

vs . Ai r Charte r Inc. , Respondent . 

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## i/OCKE T FA A Docke t

No . CP09SO000 8 DM S No . FAA-2009-010 0 FA A Cas e No . 2008SO19025 4 Judg e Isaa c D . Benki n

COMPLAINANT' S APPEA LBRIE F Complainant , th e Federa l Aviatio n Administratio n (FAA) , b y an dthroug hth e undersigne dcounsel , pursuan t t o sectio n 13.233(d ) o f

th e Rule s o f

Practic e i n FA A Civi l Penalty Actions , 1 4 C.F.R . § 13.233(d) , hereb y file s thi s brie f i n support

o f it s appea l o f th e ora l initia l decisio n an dorde r serve db y th e Honorabl e Isaa c Benkin , Administrativ e Law Judg e (ALJ) , o n Januar y 8 , 2010 . I n accordanc e withsectio n 13.233(b) , th e FA A Appeal s th e initia l decisio n becaus e th e preponderanc e o f th e reliabl e an dprobativ e evidenc e i n th e recor dshow s materia l error s o f fac t an dconclusion s o f

la w i n th e ALJ' s decision .STATEMEN T O FTH ECAS E O n Ma y 6 , 2009 , th e Federa l Aviatio n Administratio n ("Complainant" ) issue da Notic e o f Propose dCivi l Penalt y (NPCP ) t o Ai r Charte r Inc. , d/b/ aAi r

Flamenc o ("Respondent") . Th e NPC Pallege dtha t Responden t

ha dviolate dthre e Federa l Aviatio n Regulation s (FAR ) a s aresul t o f operation s o n o r

abou t Jun e 8 , 2008 , an dpropose dt o asses s acivi l penalt y o f

$11,000 . O n Ma y 19 , 2009 , after Responden t

receive dth e NPCP , i t requeste dahearing . Responden t di dnot reques t a n informa l conferenc e pursuan t t o 1 4 C.F.R . § 13.16(f)(3) . Complainan t filedit s Complain t

i n thi s May 27 , 2009 . Th e Complain t

allege dth e followin g factual allegations : 1 . A t all time s materia l herei n Ai r Charte r Inc. , d/b/ aAi r

Flamenc o ("Ai r

Charter" ) wa s an di s no w th e holde r o f Ai r Carrie r Certificat e No . UOIA831U . 2 . O n o r abou t Jun e 8 , 2008 , Ai r

Charte r operate dcivi l aircraf

t N906GD , aBritten

Norman , BN-2A-2 6 (seria l no . 3008 ) at Isl aGrande , Puert o Rico . 3 . FA A inspector s observe dagroun dambulanc e i n attendin g t o N906GD . 4 . Th e groun dambulanc e was attende db y peopl e wh o appeare dt o b e paramedics . 5 . A perso n wh o appeare dt o b e apatien t was off-loade dfi-omN906G D ont o a stretcher . 6 . Th e above-mentione dstretche r wa s installe dbackward s o n N906G D (pe r Britten

Norma n Manua l Supplemen t #1 6 t o Chapte r

2.4) . 7 . Th e above-mentione dstretche r ha dan imprope r

numbe r o f safety belt s (four) an d therefor e di dno t

mee t th e standard s o f

th e Technica l Standar dOrde r (TSO-C22f) . Britten-Norma n Maintenanc e Manual , Supplemen t 1 6 t o Chapte r

2.4 . 8 . Ai r Charte r operate dth e above-describe daircraf t withou t aciuren t flight manua l i n th e aircraf

t (FM/2 0 applicabl e (pe r

Britten-Norma n servic e letter , Issu e #9)) . 9 . Th e operation s describe dabove ar e i n violatio n o f Ai r Charter' s approve d operation s specifications .Base do n th e foregoing . Complainan t determine dthat

Responden t

violate dthre e separat e section s o f

th e FAR : 1 4 C.F.R . Sectio n 91.13(a) , Sectio n 119.5(g) , an d 91.9(b)(1). ' O n Jul y 9 , 2009 , th e cas e wa s assigne dt o ALJ Isaa c D . Benkin . O n Jul y 29 , 200 9 Responden t

filedit s Answer . Responden t admitte dth e first

tw o factual allegation s liste d abov e an ddenie dth e remainder . Prio r t o th e hearing , bot hpartie s serve dan danswere d discovery . O n Octobe r

2 3 an d26 , 2009 , ahearing wa s hel do n th e matte r i n San Juan , Puert o Rico . A t

th e reques t

o f Respondent , th e partie s submitte dpost-tria l briefs o f thei r closin g arguments . O n Januar y 8 , 2010 , for reason s w e wil l discus s below , AL J Benki n issue dawritte n decisio n i n th e cas e finding aviolatio n o f 1 4 C.F.R . Sectio n 119.5(g) , bu t not Section s 91.13(a) , o r

91.9(b)(1) . Th e ALJ als o reduce dth e civi l penalt y t o $550 . O n January 9"' , 2001 , Complainan t filedit s Notic e o f

Appea l o f

th e ALJ' s Initia l Decisio n appeal withth e FA A Decisionmaker . STATEMEN T O FTH E FACT S Th e preponderanc e o f

th e reliabl e an dprobativ e evidenc e an dtestimon y o f th e witnes s a t th e hearin g reveale dth e followin g facts . I n Augus t o f 2005 , Respondent' s

' a . Sectio n 91.13(a ) i n tha t n o perso n may operat e an aircraf t i n acareles s o r reckles s manne r

s o a s t o endange r

th e Uf e o r propert y o f

another . b . Sectio n 119.5(g ) i n that n o perso n ma y operat e a s adirec t ai r carrie r o r a s acommercia l operato r

without , o r

i n violatio n of

, an appropriat e certificat e an d appropriat e operation s specifications . c . Sectio n 91.9(b)(1 ) i n tha t n o perso n ma y operat e aU.S.-registere dcivi l aircraf t for whic ha n Airplan e o r

Rotorcraf

t FUgh t Manua l i s require db y Sec . 21. 5 o f thi s chapte r unles s ther e i s availabl e i n th e aircraf t acurrent , approve dAirplan e o r Rotorcraf

t FUgh t Manua l o r

th e manua l provide dfor i n Sec . 121.141(b) .aircraft , N906GD , wa s "converte dfor ambulanc e rol e b y th e installatio n o f asingle stretcher..." . Ex . 38 . Afte r that . Responden t

bega n bein g pai d$760 0 pe r mont ht o b e availabl e on-deman dt o transpor t patient s fi-omCulebr at o th e mai n islan do f Puert o Rico . Transcrip t

("Tr") , p . 440 , 441 . O n Jun e 8 , 2008 , Ms . Joa n Blizzar dTod dcam e t o th e Culebr aHealthCente r with ahealthcondition . Ex . 21 . Culebr ai s a n islan dof

f th e eas t coas t o f Puert o Rico . Ibid . Dr . Marangel y Rodrigue z i s an emergenc y roo mphysicia n i n th e Cente r o f Diagnosi s an d treatmen t a t Culebr aHealt hCente r

("CHC") . Tr. , p . 266 . Accordin g t o he r testimony , Ms . Todd , apatien t

th e docto r

knew , was betwee n 6 0 an d7 0 year s old . Tr. , p . 270 . Sh e cam e t o CH C complainin g o f pai n o n on e o f

he r hips . Ibid . Sh e wa s therefor e referre dt o Dr . Rodrigue z for

diagnosis . Ibid . Ms . Tod d"coul dno t stan du p b y herself . Tr. , p . 270

- 271 . Ms . Tod dwa s pu t

o n astretche r

an dtake n t o th e emergenc y room . Dr . Rodrigue z aske dMs . Tod dt o mov e t o awheelchai r t o se e ho w ba dth e pai n was . Tr. , p . 270 . Ms . Tod dtol dDr . Rodrigue z tha t sh e coul dnot

d o that . Ibid . Base do n tha t medica l observation. Dr . Rodrigue z decide dt o sen dhe r t o th e mai n islan dfor

a n X-Ra y i n th e sam e stretche r

i n whic hsh e cam e t o th e emergenc y room . Tr . p . 271 . Dr . Rodrigue z late r confirme dtha t

Ms . Tod dha dafi^acturedfemur , that sh e wa s transferre dt o anothe r hospital , an dtha t

sh e wa s give n surgery for th e fi-acture. Tr . p . 272 . Ms . Todd' s fi-acture wa s aresul t

o f afal l i n he r

apartment . Tr. , p . 273 . Dr . Rodrigue z testifie dtha t whe n Ms . Tod dcam e t o th e emergenc y roo mo n Culebra , sh e wa s accompanie db y afiiend. Tr. , p . 273) . Dr . Rodrigue z testifie dtha t sh e calle dResponden t

i n Culebr at o chec k

th e availability o f

flights. Tr. , p . 273-274 . Sh e trie dt o synchroniz e th e flight withth e arrivalo f

th e terrestria l ambulance . Tr. , p . 274 . Dr . Rodrigue z gav e Responden t "th e nam e o f th e docto r

an dth e institutio n wher e th e patien t i s going" . Ibid . Sh e referre dMs . Tod dt o UPR , Carolin aHospita l becaus e Culebr adidn' t hav e a n X-Ray . Ibid . Ms . Tod dlef t CH C i n an ambulanc e heade dt o Culebr aairport . Tr. , p . 276 . Dr . Rodriguez ' specifi c testimon y was : ". . . 1 call.. . t o th e counte r o f Flamenc o Ai r

i n Culebra , t o se e abou t

th e availabilit y o f

flights at that moment . After

that , I synchroniz e th e hou r i n whic hth e ai r (sic ) i s goin g t o com e here , t o th e mai n island , togethe r withth e terrestria l ambulance , th e ambulance s o n th e roa dhere . An dI tr y t o quantif

y (phonetic ) bot ht o b e at th e same hour . And , firs t o f al l that , th e patien t

ha dt o b e accepte di n a n institutio n here . S o I ha dth e nam e o f

th e docto r

an dth e institutio n wher e th e patien t i s going . And , wit htha t

information , I cal l th e ambulanc e an dtel l the mt o com e here. " Tr. , p . 273

- 74 . Ms . Aid aMaldonado , th e Chie f Administrato r

for CHC , testifie dtha t

Ms . Tod d cam e t o CH C twic e o n Jun e 8 . Tr. , p . 453 . Th e first tim e sh e tol dth e doctors , " I am shaking , an dI nee dassistance" . CH C sen t he r bac k home . Tr. , p . 454 . Maldonad o testifie dtha t

Tod dals o ha d"schizophrenia" . Maldonad o state di n alette r provide dt o th e FAA , tha t patient s i n "critica l condition " nee dt o b e transporte db y th e Coast Guar do r Aeromed , whic hhav e th e capabiHtie s o f emergenc y medica l services . Ex . 21 . Whe n aske dt o defin e "critica l condition" , Maldonad o testifie dtha t patient s wit h" abroke n bone " ar e include di n th e definitio n o f critica l condition . Tr. , p . 458 . Whe n Respondent' s aircraf t arrive do n th e mai n island , FA A Inspecto r Eugen e Jeste r wa s ther e performin g surveillanc e wit hagent s firomsevera l othe r Federa l agencies . Tr. , p . 41 . What

dre w hi s attentio n t o Respondent' s aircraf t wa s tha t a n ambulanc e pulle d u p t o th e aircraf

t wit hit s ambulanc e light s on . Ibid . Jeste r observe dth e aircraf

t bein g unloade dan dtoo k

pictures . Tr. , p . 42-43 ; Ex . 3 A an d3B . Th e photo s sho w Ms . Tod d bein g attende dt o b y a s man y a s eigh t peopl e includin g th e pilo t an dambulanc epersonnel . Inspecto r Jeste r askedth e pilo t

for Respondent' s Loa dManifest , hi s flight manual , an dth e operation s manual . Tr. , p . 42 . Th e weigh t an dbalanc e documen t

for N906G D for

th e subjec t

flight fi-omCulebr ashowe dthat ther e wer e peopl e i n Ro w 1 o f th e aircraf t (estimate da s weighin g 25 0 pounds) , aperso n o n th e stretche r (estimate da

t 13 0 pounds) , an daperso n i n Ro w 5 o f th e aircraf

t (estimate da

t 14 0 pounds) . Ex . 6 . Respondent' s witnesse s indicate dtha t th e aircraf

t wa s carryin g four

peopl e - tw o i n Ro w 1 (th e pilo t

an dapassenge r

name dRober t

Emeric) , Ms . Todd , an dafourt hunidentifie d person . Tr. , p . 427-28 ; 328-329 . Inspecto r Jeste r als o state dtha t

h e saw abou t

10 0 peopl e gettin g of

f abou t 3 0 aircraf

t tha t day , bu t h e think s h e saw anothe r femal e passenge r exi t th e aircraft . Tr. , p . 91 , 77 . Th e paramedic s transferre dth e patien t from th e stretche r

t o awheele dgumey , pu t he r i n a n ambulanc e an ddrov e away . Tr. , p . 43,91 . Becaus e th e passenge r

seat s hav e t o b e remove dt o pu t th e stretche r

in , th e onl y othe r availabl e seat

i n th e aircraf

t wa s th e attendan t

seat nex t t o th e stretcher , or , i n th e nex t ro w behin dth e stretche r

(Ro w 5) . Th e flight manua l Responden t

gav e t o Inspecto r

Jeste r at th e airpor t

wa s Fligh t Manua l FM/7 . Ex . 12 . Th e curren t flight manua l applicabl e t o N906G D wa s Fligh t Manua l FM/20 . Ex . 14 , 15 , 3 6 (unde r Equipment , paragrap h4(i)) . Accordin g t o th e Typ e Certificat e Dat aShee t applicabl e t o N906GD , FM/2 0 ha s bee n th e curren t flight manua l for

th e BN-2A-2 6 aircraf

t sinc e Jun e 1 , 1976 . Exhibi t 36 . Respondent' s witnesse s admitte dFM/2 0 wa s th e curren t flight manual . Tr. , p . 353 , 418 , 429 . Inspecto r Jester' s first-handobservatio n was that th e perso n o n th e stretche r was remove dwithhe r

hea dfacin g th e fi"ont

o f th e aircraft . Tr. , p . 53 ; Exhibit s 3 A an d3B . Inspecto r Joe l Roda s late r

determine dtha t

base do n Jester' s observation s an dth e photo sh e took , th e above-mentione dstretche r wa s installe dbackward s o n N906G D (pe r Britten

Norma n Manua l Supplemen t #1 6 t o Chapte r

2.4) . Ex . 5 . Thi s documen t (Ex . 5 ) i s als o describe dspecificall y i n th e Majo r Repai r an dAlteratio n For m(For m337 ) withi n th e Blu e Ribbon Packag e o n aircraf t N90GD . Ex . 38 . Hearin g Exhibi t 5 , figures 1-3 , sho w that th e patient' s headres t

o n th e stretche r

mus t fac e th e rear

(cargo ) sectio n o f

th e aircraft . Th e For m33 7 state s th e stretche r mus t b e "installe dwit hth e headres t lookin g afte r th e baggag e stowag e area... " Ex . 38 . Exhibi t 3 B (specifically , photograp h4 ) show s Ms . Tod dbein g remove dfro mth e aircraf t facin g th e fi-ont

o f th e aircraft . Th e diagram s i n Exhibi t 5 don' t sho w enoug hroo mt o tur n aroun dth e stretche r insid e th e aircraft . Responden t

presente dn o credibl e testimon y o r evidenc e contradictin g th e inspector' s testimon y tha t

th e stretche r

wa s installe dbackward s insid e th e aircraf t befor e bein g unloaded . Inspecto r Jeste r inspecte dth e stretche r

take n ou t o f th e aircraft , foun dtha t

i t had n o TS O (Technica l Standar dOrder ) tag s o n th e stretcher . Tr. , p . 54 , 56-57 ; Ex . 6 , 15 , an d 16 . H e foun dtha t

ther e wer e four

seat s belt s o n th e stretche r instea do f

two . Ex . 3B , photo s 5 an d6 . Th e four-bel t seat belt s wer e horizontall y installe dinstea do f criss

crosse da s th e Britten-Norma n document s require . Ex . 6,15 , an d16 ; Ex . 3B , photo s 5 an d6 . Whe n inspecto r

Joe l Roda s continue dth e investigation , h e verifie dthi s fac t wit h th e manufacturer , Britten-Norman , who , afte r bein g show n photo s o f

Respondent' s installation, unequivocall y verifie dtha t afour-belt , non-TS O syste mo f belts , suc ha s th e one s use db y Responden t wer e not cleare dfor

use . Ex . 1 5 an d16 .AL J INITIA LDECISIO N

Th e ALJ' s Initia l Decisio n state dth e followin g findings: I . Complainan t

Has 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 . n . Th e Charg e o f

Operatin g an 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 Unprove n III . Responden t

i s Liabl e for

No t Carryin g aCurren t

FAA-Approve dFligh t Manua l IV . A Civi l Penalt y o f $55 0 i s Appropriate . SUMMAR Y O FARGUMEN T I . TH EALJ' S INITIA LDECISIO N CONTAIN S MATERIA LFACTUA L ERROR S THA T AR ENO T SUPPORTE D B Y TH E PREPONDERANC E O FRELIABLE . PROBATIVE , AN D SUBSTANTIA LEVIDENC E

n . TH ECONCLUSION S O FLA WI N TH EALJ' S INITLy; . DECISIO N WER ENO T MAD E I N ACCORDANC E WIT H APPLICABL ELAW . PRECEDENT . AN D PUBLI C POLIC Y ARGUMEN T I . TH EALJ' S INITIA LDECISIO N CONTAIN S MATERIA LFACTUA L ERROR S THA T AR ENO T SUPPORTE D B Y TH EPREPONDERANC E O FRELIABLE . PROBATIVE . AN D SUBSTANTIA LEVIDENC E [Fo r th e purpos e o f

analysis , Complainan t

wil l describ e th e ALJ' s materia l factual error s chronologicall y a s the y appear i n th e initia l decision . Complainan t wil l illustrat e th e materialit y o f

th e error s a s i t

analyze s them . ]A . Ther e Wer e Factua l Error s an dOmission s i n th e ALJ' s Analysi s o f th e Ai r Ambulanc e Issue . I n hi s analysi s o f

th e ai r ambulanc e issue , th e ALJ describe dth e perso n o n th e stretche r capture di n th e photo s i n evidenc e a s a"recumben t woman" , implyin g tha t

th e patien t wa s merel y lyin g down . Initia l Decisio n ("ID" ) at 2 . I n doin g so , th e ALJ di dnot conside r th e evidenc e o f

th e conditio n o f

th e patient . Th e testimon y o f th e emergenc y roo mphysician , Dr . Rodriguez , wa s tha t th e patient , Ms . Todd , "coul dno t stan dup b y herself . Tr. , p . 270-271 , Ms . Tod dwa s put o n astretche r

an dtake n t o th e emergenc y room . Dr . Rodrigue z aske dMs . Tod dt o mov e t o awheelchai r t o se e ho w ba dth e pai n was . Tr. , p . 270 . Ms . Tod dtol dDr . Rodrigue z that sh e coul dnot

d o that . Ibid . Base do n that medica l observation . Dr . Rodrigue z decide dt o sen dhe r t o th e mai n islan dfor

an X

Ra y i n th e sam e stretche r i n whic hsh e cam e t o th e emergenc y room . Tr . p . 271 . Dr . Rodrigue z late r

verifie dtha t

Ms . Tod dha dd

i fracture dfemur , tha t

sh e wa s transferre dt o anothe r hospital , an dtha t

sh e wa s give n surgery for th e fi-acture. Tr . p . 272 . Th e AL J erre db y describin g th e patient' s illnes s a s a"fi-acture dtibia" . I D a t 4 . Objectively , a broke n femur

i s amor e threatenin g conditio n for a n elderl y perso n tha n abroke n tibia . Ms . Tod dals o ha dosteoporosis . Tr . p . 276 . Dr . Rodrigue z gav e Responden t "th e nam e o f th e docto r

an dth e institutio n wher e th e patien t [was ] going" . Tr. , p . 274 . Ms . Tod d lef t CH C i n an ambulanc e heade dt o Culebr aairport . Tr. , p . 276 . Whe n th e patien t

arrive do n th e mai n island , an ambulanc e pulle du p t o th e aircraf t wit hit s ambulanc e light s on . Tr. , p . 42-43 . Inspecto r Jeste r observe dth e aircraf

t bein g unloade dan dtoo k

pictures . Tr. , p . 42-43 ; Ex . 3 A an d3B . Th e photo s sho w Ms . Tod dbein g attende dt o b y a s man y a s eigh t peopl e includin g th e pilo t an dambulanc e1 0

personnel . Th e AL J als o ignore dth e evidenc e tha t ther e wa s anothe r

perso n o n th e aircraf t seate di n th e ro w behin do r nex t t o th e passenger . Th e weigh t an dbalanc e documen t for N906G D fo r

th e subjec t

flight fi-omCulebr ashowe dtha t ther e wer e peopl e i n Ro w 1 o f

th e aircraf

t (estimate da s weighin g 25 0 pounds) , aperso n o n th e stretche r (estimate da

t 13 0 pounds) , an daperso n i n Ro w 5 o f th e aircraf

t (estimate da

t 14 0 pounds) . Ex . 6 . Respondent' s witnesse s indicate dthat th e aircraf

t wa s carryin g four peopl e - tw o i n Ro w 1 (th e pilo t an dapassenge r

name dRober t

Emeric) , Ms . Todd , an da fourt hunidentifie dperson . Tr. , p . 427-28 ; 328-329 . Inspecto r Jeste r als o state dthat

h e though t h e sa w afemal e passenger , othe r tha n th e patient , exi t

th e aircraft . Tr. , p . 91 , 77 . Thes e fact s prov e tha t

th e patien t

wa s seriousl y injure dan dunabl e t o mov e o n he r own . The y d o no t

suppor t th e ALJ' s assertio n that

th e patien t

wa s merel y "recumbent" . B . Ther e Wer e Factua l Error s an dOmission s i n th e ALJ' s Analysi s o f th e "Careles s o r

Reckless " Allegatio n Th e AL J materiall y erre db y stating , "th e complain t allege dtha t

th e stretche r

wa s installe dwit honl y tw o safety belts , wherea s fou r safet y belt s wer e required" , an dtha t Complainan t

allege dth e stretche r

installe di n Complainant' s aircraf t ha d"a n insufficient numbe r o f safety belts" . Thi s wa s no t th e allegatio n i n th e Complaint . Th e allegatio n i n th e Complain t

was : Th e above-mentione dstretche r ha da n imprope r

numbe r o f safety belt s (four ) an d therefor e di dno t

mee t th e standard s o f

th e Technica l Standar dOrde r (TSO-C22f) . Britten-Norma n Maintenanc e Manual , Supplemen t 1 6 t o Chapte r

2.4 . Th e ALJ als o di dnot

mentio n th e evidenc e i n th e recor dsupplie db y th e manufacture r

after inspecto r

Roda s showe dth e manufacture r aphot o o f Respondent' s 4-bel t

seat bel t installation . Ex . 15 . I n thi s evidence , th e1 1

manufacture r

state dthat

havin g four

non-TS O horizonta l belt s instea do f tw o crisscrosse dbelt s di dno t mee t th e requirement s o f

th e TSO . Ibid . ("Unfortunately , w e d o not hav e amodificatio n for

four belt s directl y traversin g th e body , therefor e w e d o not hav e clearanc e for

afour-bel t

non-TS O system , an d w e hav e t o advis e yo u tha t the y ar e currentl y imacceptable." ) Inspecto r Jeste r als o testifie dtha t

th e seat belt s ha dn o TS O tag s o n the mat al l t o identif

y thei r complianc e wit han y appHcabl e TSO . Tr. , p . 54-59 . Th e AL J agai n materiall y erre db y ignorin g Inspecto r Jester' s testimon y that h e actuall y sa w th e stretche r bein g remove dfi-omth e aircraf t headfirst . Tr. , p . 53 . Non e o f

Respondent' s witnesse s actuall y testifie dtha t th e stretche r

wa s not installe dbackward s insid e th e aircraft . The y simpl y testifie dtha t i t didn' t matter . Tr.,p . 412 . In it s Brie f

o f Closin g Argument , Complainan t describe dth e patien t

o n Respondent' s aircraf

t a s "a n immobilize dallegedl y schizophreni c huma n passenge r wit hamedica l condition" . Th e ALJ materiall y erre db y describin g thi s descriptio n a s "outrageous " whe n i t i s completel y supporte db y th e record . Respondent' s ow n witnesse s testifie dt o thes e facts . Rober t Emeri c testifie dtha t th e patien t

unbelte dhersel f

fi-omth e stretche r

after th e flight

whic hsh e coul dnot hav e don e i f

sh e wer e no t

belte dt o th e stretche r

durin g th e flight. Tr . p . 325 . Ms . Aid aMaldonado , th e Chie f Administrato r

fo r CH C testifie dtha t

th e patient , Mrs . Tod dwas schizophreni c an dtha t sh e ha dbee n treate dman y time s a t CH C for th e condition . Tr . p . 455-56 . Sinc e th e patien t ha dabroke n femur , sh e ha dbee n admitte dt o a n emergenc y roo mi n Culebr aan dahospita l o n th e mai n island , sh e1 2

clearl y ha damedica l condition . Respondent' s witness , Francisc o Torres , als o testifie dtha t

Responden t

does n ' t as k an y question s abou t

th e patient s i t

transport s i n it s aircraft . Tr. , p . 424-434 . Emeri c testifie dtha t n o on e tende dt o th e patien t durin g th e flight. Tr. , p . 316 . Therefore , th e recor dsupport s everythin g i n th e Complainant' s descriptio n o f th e operation . Th e ALJ materiall y erre db y statin g ther e wer e n o fact s t o support th e Complainant' s statement . C . Ther e Wer e Factua l Error s an dOmission s i n th e AU' s Civi l Penalt y Analysis . Th e ALJ erre dwhe n h e stated , "ther e wa s n o evidenc e place di n th e recor d bearin 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 aircraf t i n it s inventor y o r

th e numbe r

o f employee s o n it s staff . Respondent' s O p Spec s wer e on e o f Complainant' s primar y exhibits . Ex . 4 . Accordin g t o Respondent' s O p Specs , i t ha s a t leas t 8 aircraf t o n it s certificate . Ex . 4 , paragrap hD485-1 , Tabl e 1 . Th e O p Spec s als o Uste dthre e Par t 13 5 managemen t

employees . Ex . 4 , p . A006-1 . Als o i n evidenc e wer e pertinen t section s o f

FA A Orde r

2150.3 B includin g th e FAA' s sanctio n guidanc e an d Respondent' s Ai r

Carrie r Certificate . Ex . 1 8 an d3 . Therefore , th e evidenc e supporte dth e categorizin g o f Responden t

a s asmal l busines s i n Grou p m , an d prescribe s aminimu mcivi l penalt y o f at leas t $82 5 for eac hregulator y violation . Ex . 18 , p . B-3 , B-4 . Th e AL J materiall y erre db y failin g t o acknowledg e th e existenc e o f

thes e exhibits , especiall y after bein g reminde do f

thei r relevanc e t o th e sanctio n i n Complainant' s writte n closin g argument .1 3 Th e judg e als o materiall y erre db y failin g t o conside r Respondent' s violatio n history . Inspecto r Roda s testifie dtha t

Responden t

pai da$650 0 civi l penalty recentl y i n 200 5 for violatio n o f

th e FARs . Tr. , p . 132-133 , 240-243 . Contrary t o FA A Orde r

2150.3B . Respondent' s violatio n histor y wa s not part o f th e ALJ' s analysi s at

all .

n . TH ECONCLUSION S O FLA WI N TH EALJ' S INITIA LDECISIO N WER ENO T MAD EI N ACCORDANC EWIT H APPLICABL ELAW . PRECEDENT . AN D PUBLI C POLIC Y A . Th e ALJ' s Analysi s o f Respondent' s Ai r

Ambulanc e Operation s I s No t In Accor dWit hPubli c Policy . Th e ALJ' s first finding wa s tha t Complainan t

di dnot prov e Responden t performe dan illega l ai r

ambulanc e operation . Complainan t allege daviolatio n o f

1 4 C.F.R . § 119.5(g ) whic hread s a s follows : "N o perso n may operat e a s adirec t ai r carrie r o r a s acommercia l operato r without , o r

i n violatio n of

, a n appropriat e certificat e an dappropriat e operation s specifications . N o perso n ma y operat e a s adirec t ai r carrie r o r a s acommercia l operato r i n violatio n o f

an y deviatio n o r

exemptio n authority , i f

issue dt o tha t

perso n o r

tha t person' s representative. " Th e cite dregulatio n i s intende dt o proscrib e al l operation s conducte di n violatio n o f th e appropriat e Operation s Specifications . Th e Administrator , throug hth e FAA' s flight standard s divisio n issue s Operation s Specifications , o r "O p Specs" , t o ai r

carrier s wh o hav e bee n authorize dt o hol dai r carrie r certificates . O p Spec s contain , "th e authorizations , limitations , an dcertai n procedure s unde r whic heac hkin do f

operation , i f applicable , i s t o b e conducted" . 1 4 C.F.R . §119.7(a ) (1) . B y citin g § 119.5(g) , Complainant , th e FAA , allege dtha t Responden t

was operatin g i n violatio n o f

it s O p Specs , no t

tha t Responden t

actuall y wa s aproperl y1 4

operatin g a

n ai r ambulance . Th e O p Spec s preven t Responden t

fi-omth e conduc t o f an y ai r ambulanc e operation s unde r 1 4 C.F.R . Part

135 . Unde r th e ALJ' s analysis , th e onl y way an aircraf t ca n b e a

n "ai r ambulanc e aircraft " i s b y havin g every piec e o f equipmen t

a n ai r ambulanc e i s require dt o have . An dth e onl y thin g tha t woul dmak e an operatio n an "ai r ambulanc e operation " woul db e t o hav e an danurs e attendin g t o th e passenge r o n th e flight. Thi s i s no t

th e inten t

o f th e O p Spec s restrictio n agains t operatin g a s a

n air ambulance . Th e practica l definitio n o f "ai r ambulance " doe s not

compl y with th e ALJ' s limite dvision . Th e docto r i n thi s matte r

decide dtha t

th e patien t require dmor e medica l attentio n tha n sh e coul dprovid e i n he r emergenc y room . Th e patien t

wa s transporte dvi aregular , fiilly equippe dgroun dambulance s t o an d firomRespondent' s aircraft . Therefore , ther e wa s neve r an y tim e th e patien t

di d no t nee dth e sam e medica l attentio n tha t th e groun dtw o ambulance s coul d provide . Th e docto r

i s no t require dt o kno w what

equipmen t

th e ai r carrie r ha s o n board . Bu t

th e ai r carrie r should . A stretche r

i s on e o f

th e primar y piece s o f

medica l equipmen t

necessary for prope r ai r ambulanc e operations . FA A Orde r 8900.1 , Chang e 22 , Vol . 4 , Chapte r 5 , paragrap h4-91 8 (B) . Th e stretche r i n thi s cas e wa s primaril y use dfor th e patient' s safety durin g th e flight, not for he r comfort . Obviously , th e docto r di dno t wan t th e patient , who msh e suspecte dt o hav e abroke n bone , t o fiirther injure hersel f

b y fallin g ou t

o f th e stretche r

durin g groun do r

ai r transportation . T o avoi dliability , b y havin g th e pilo t o r apassenge r

considere dt o b e anurs e o r attendant . Respondent' s witnesse s testifie dthat n o on e sai dawor do r

tende dt o1 5

th e patien t

durin g th e flight. Ironically , Respondent' s ver y lac k o f car e o f th e patien t i s wha t th e AL J use dt o findn o violatio n o f th e regulation . Thi s kin do f operatio n i s no t

saf e fo r patient s i n th e conditio n o f Mrs . Todd , no r

i s i t saf e o r advisabl e fo r

improperl y equippe dai r carrier s t o carr y patient s i n suc ha condition. ^ Th e regulatio n i s intende dt o prohibi t thi s kin do f

operatio n withou t th e FA A havin g oversigh t throug hth e O p Spec s issue dt o th e ai r carrier . I n effect . Responden t

use dit s aircraf

t a s an ai r ambulance . I n Augus t

o f 2005 , Respondent' s aircraft , N906GD , wa s "converte dfo r ambulanc e rol e b y th e installatio n o f

asingl e stretcher..." . Ex . 38 . Sometim e after that . Responden t bega n bein g pai d$760 0 amont ht o b e availabl e on-deman dt o transport patient s firomCulebr at o th e mai n islan do f Puert o Rico . Tr. , p.440 , 441 . Th e Administrator' s interpretatio n o f what constitute s "ai r

ambulanc e operations " i s clarifie di n FA A Orde r

8900.1 , Chang e 22 , Chapte r 5 ("Ai r Ambulanc e Operations") . Ex . 22 . A fiilly-equippedai r ambulanc e need s t o hav e "medica l oxygen , suction , an dastretcher , isolett e [for infants] , o r

othe r approve dpatien t restraint/containmen t

device" . Ex . 22 , paragrap h4-917(B) . Thi s doe s no t mea n however , tha t

tha t aaircraf t operate dwit ha

n infan t i n a n isolett e i s no t

an ai r ambulance . I t

simpl y mean s i t

i s a n ai r ambulanc e flight

tha t i s bein g operate d withou t al l th e prope r

medica l equipment . Tha t i s th e cas e here . Further , th e orde r states,". . . aschedule dai r carrie r wh o transport s aperso n o r person s requirin g medica l persoime l and/o r equipmen t

o n an imschedule dflight (charter ) i s engage di n ai r

ambulanc e operations. " Ex . 2 2 (at paragrap h4-92 1 (A)(1)) .

^ Responden

t di dfollow it s ow

n Operation s Manual , whic

hstates , "only the person wh o need s the stretche

r and/o r relative s of

himwill b e allowedo

n thi s flight." Ex . 28 . Emeric an dTorre s testifiedtha

t Emeric did not kno w th e patient an dwa s no t relate dt o her . Tr. , p . 323.427 .1 6

Finally , th e orde r

state s that , "Operator s holdin g par t 13 5 O p Spec s withou t paragraph s A02 1 o r

A02 4 ma y transpor t

medica l personne l a s passenger s wh o ar e accompanyin g asic k

o r injure dperson , bu t

mus t mee t th e followin g requirements:. . .(2 ) An y in-fligh t patien t car e equipmen t

an dmedica l personne l tha t accompan y th e passenge r mus t b e provide dsolel y fo r

th e patient' s comfort . Ex . 22 , paragrap h4-921(C)(2) . Th e Administrato r

ha s clearl y proven , an dpubli c polic y dictate s tha t th e medica l operatio n conducte db y Responden t shoul dnot

b e conducte dwithout

prope r O p Spec s issue db y th e Administrator . B . Th e ALJ' s Analysi s O f FA R91.1 3 Wa s Contrary T o Applicabl e Law , Preceden t An dPubli c Policy . A n "independent " violatio n o f §91.3(a ) i s prove n b y ashowin g o f actua l o r potentia l endangerment . Administrato r v . Seyb , NTS B Orde r

No . EA-502 4 at

2 , Administrato r

v . Nix , NTS B Orde r

No . EA-500 0 (2002 ) a

t 3 , Administrato r

v . Pierce , NTS B Orde r

No . EA-496 5 (2002 ) a

t n . 2 . Complainan t

thoroughl y explaine dth e potentia l medica l danger s o f transportatio n o f

an elderl y patien t wit habroke n femur , osteoporosis , an dunapprove dseat belt s i n it s Brie f

o f Closin g Argument . Th e fact s sho w that , at th e very least , potentia l danger s t o a n elderl y passenge r

i n suc haconditio n existed . Potentia l dange r exist s for

patient s flown withou t

approve dseat

belt s a s well . Seat

belt s o n aircraf

t exis t onl y for th e purpos e o f

preventin g injurie s t o passenger s durin g transportation . A Technica l Standar dOrde r

i s aminimu mperformanc e standar dissue db y th e Administrato r for specifie darticle s use do n acivi l aircraft . See , Legal Interpretation , 200 9 W L1 7

2421799 , Jul y 31 , 2009 . Th e apphcabl e ai r carrie r operatin g rule s prohibi t

th e operatio n o f

a n airplan e unles s eac hperso n ha s asafet y bel t properl y secure d abou t hi mo r he r at appropriat e times . 1 4 C.F.R . § 135.128(a) . Th e airworthines s standard s for

transpor t categor y airplane s als o requir e that eac hseat an dseat bel t "mus t b e designe ds o tha t

aperso n makin g prope r

us e o f [them ] wil l no t

suffer seriou s injur

y i n an emergenc y landin g a s aresul t of. . .interti aforces" . See , 2 5 C.F.R . § 785(b) . Shoulde r sea t belt s wer e adde dt o car s t o increas e th e safety o f th e seat bel t system . I t

stand s t o reaso n tha t

tw o seat belt s criss-crossin g th e uppe r tors o o f abod y o n astretche r

i s mor e stabl e tha t

afour-bel t

syste mo f

horizonta l belts . Thi s wa s certainl y th e positio n o f th e manufacture r

wh o di dnot

approv e th e four

bel t syste mResponden t

used . Clearly , th e ai r

transportatio n o f

th e elderl y patien t withabroke n femu r

an dunapprove dbelt s wa s not safe . Despit e th e actua l danger s describe dabove , i t i s not necessar y for

th e Complainan t

t o establis hactua l dange r o r aflight suddenl y i n peri l i n orde r t o prevai l i n provin g tha t

aresponden t

ha s operate da

n aircraf t i n acareles s o r reckles s manner . Osmus , Actin g Administrato r v . Martz , NTS B Orde r

No . EA

544 7 (2008) ; Administrato r v . Lorenz , NTS B Orde r

No . EA-5205 , at

2- 3 (2006) ; Roac hV . Nat' l Transp . Safet

y Bd , 80 4 F.2 d1147 , 115 7 (10 * Cir. , 1986 ) (findin g that it i s not necessar y t o prov e actua l endangermen t i n orde r t o sustai n a carelessnes s charge) ; Haine s v . Dept . o f Transp. , 44 9 F.2 d1073 , 1076 , n . 1 0 (D.C . Cir . 1971) : Administrato r v . Szabo , NTS B Orde r

No . EA-426 5 a

t 4 , (1994 ) (statin g that

"innumerabl e Boar dcase s mak e clear that n o mor e tha n potentia l1 8

endangermen t

i s required " i n orde r

t o find aviolatio n o f

§91.13) . Therefore , basedo n th e prove n facts , th e Respondent' s operatio n wa s clearl y careless . Dr . Rodrigue z gav e Responden t "th e nam e o f

th e docto r

an dth e institutio n wher e th e patien t [was ] going" . Tr. , p . 274 . Responden t kne w th e patien t

wa s bein g transporte dfor

fiirther medica l evaluation . Tr . 440-41 . Th e patien t neede da n ambulanc e t o trave l t o an dfi:omRespondent' s aircraft . Whe n thi s informatio n was give n t o them , alon g wit himmobiUze delderl y patient . Responden t chos e t o operat e th e aircraf

t withou t an y car e abou t

whethe r the y wer e properl y equippe d to performloading , car e durin g flight, an dunloadin g o f th e patient/passenger . I f th e docto r didn' t kno w better , Respondent , th e ai r carrier , shoul dhave . I f

th e patien t wen t int o shoc k

o r cardia c arrest , o r

i f sh e was improperl y loaded , secured , o r unloaded , ther e woul dhav e bee n nothin g Responden t coul dd o abou t

i t becaus e i t ha dnon e o f

th e basi c equipmen t

o r persoime l necessary t o tak e o f car e o f suc ha patient . Accordin g t o th e testimon y o f i t witnesses . Respondent' s employee s ha d n o medica l trainin g an dpai dn o specia l attentio n whatsoeve r t o th e patien t

o n th e stretcher . Thes e action s d o no t demonstrat e th e leve l o f car e require do f

a n on demand , passenge r

ai r carrier . C . Th e AL J Improperl y Analyze dTh e Sanctio n Issue . Perhap s th e mos t

egregiou s erro r

i n thi s cas e involve dth e ALJ' s calculatio n o f

th e civi l penalty . A s describe dabov e i n th e materia l error s o f fact , th e ALJ faile dt o recogniz e th e evidenc e i n th e recor dtha t supporte dth e Complainant' s recommende dsanction . Additionally , non e o f th e reason s give n1 9

for reducin g th e civi l penalt y t o aminimu mar e supporte db y th e record , agenc y poUcy , o r cas e law . Pursuan t

t o 4 9 C.F.R . §46301(a)(5)(a ) th e maximu msanctio n for eac ho f th e pleade dviolation s i s $11,000 . Therefor e th e maximu msanctio n i n thi s matte r

coul dhav e bee n $33,000 . That i s wher e th e sanctio n analysi s shoul d hav e begun . A s state dabove , th e O p Specs , whic hare i n evidence , provide dal l th e evidenc e th e AL J foun dt o b e missin g includin g th e siz e o f Respondent , numbe r o f aircraf t an dnumbe r

o f pilot s Responden t

had . Additionally , th e ALJ' s reason s for reducin g th e C Par e insufficien t t o reduc e th e CP . Inten t i s no t an elemen t

o f th e cite dviolations . Th e fac t tha t th e violatio n was not

intentiona l i s not mitigating . Th e regulatio n require s th e flight manua l t o b e curren t

no t jus t "serviceable" . Th e evidenc e ma y no t sho w fiill exten t

o f th e potentia l safet

y o f flight issue s presente db y Respondent' s us e o f th e wron g manual . However , Respondent' s expert

witnes s di dtestif

y that th e maximu mweigh t

limitation s i n th e manual s wer e differen t b y at leas t on e hundre dpounds . Tha t amoun t i s no t insignificant . Th e AL J completel y ignore dRespondent' s violatio n history . Tha t omissio n i s contrary t o th e sanctio n guidance . A violatio n histor y can justif y imposin g asanctio n a

t th e highe r en do f th e norma l rang e o r

asanctio n beyon dth e norma l range . FA A Orde r 2150.3B , p . 7-7 . Th e Administrato r ha s bothth e authorit y an ddut y t o impos e th e agency' s polic y o n appeal . I n th e Matte r o f Warbelo w ' s Ai r

Ventures , FA A Orde r

No . 2000-3 , Docke t

No . CP97AL001 2 (2000) . Th e ALJ' s penalt y o f $55 0 i s belo w th e minimu mamoun t

i n th e sanctio n guidanc e for on e violatio n ($850) . Th e propose d2 0

penalt y o f

$11,00 0 wa s nowher e nea r th e statutory maximu mpenalt y o f $33,00 0 Complainan t

coul dhav e propose dfor eac ho f th e regulation s cite di n th e complaint . Finally , Complainan t

i s not require dt o presen t

evidenc e o f

Respondent' s abilit y t o pa y th e propose dcivi l penalty . Folso m' s Ai r Service , Inc. , FA A Orde r No . 2008-1 1 (2008) ; I n th e Matte r

o f Conques t

Helicopters , FA A Orde r No . 1994-2 0 at

3 (1994) . Respondent' s abilit y t o pa y th e propose dcivi l i s i n th e natur e o f a n affirmativ e defense . ToyotaMoto r

Sales , US

A Inc. , FA A Orde r

No . 1994-2 8 at

1 0 (1994) . Fo r

th e above reasons , th e propose dpenalt y o f $11,00 0 shoul db e reinstated . CONCLUSIO N Th e preponderanc e o f

reliable , probative , an dsubstantia l evidenc e i n th e recor d prove dth e Complainant' s allegation s discusse dabove an dsupporte dth e Complainant' s propose dcivi l penalty . WHEREFORE , fo r

th e reason s se t

fort habove , Complainan t

request s th e FA A Decisionmake r

issu e an Orde r

reversin g th e decisio n o f th e AL J an dasses s apenalt y o f $11,00 0 agains t

Respondent . Respectfull y submitte dthi s -^Z)/ ? da y o f March , 201 0 

### Ao/ f d ;

GERAL D A . ELLI S Attorne y Offic e o f th e Regiona l Counse l2 1 CERTIFICAT EO FSERVIC E I hereb y certif

y tha t th e foregoin g COMPLAINANT' S APPEA LBRIE Fha s bee n sen t b y Federa l Expres s to : Attention : Hearin g Docke t Clerk , AG C 430 , Wilbu r

Wrigh t Buildin g - Suit e 2W100 0 Federal Aviatio n Administratio n 80 0 Independenc e Avenu e Washington , D C 2059 1 FAX : 202-493-225 1 Gabrie l I . Penagaricano , Esq . PMB23 9 40 5 Ave. , Esmeralda , Ste . 10 2 Guaynabo , Puert o Ric o 0096 9 TEL : 787-287-902 4 FAX : (787 ) 731-067 9 OMJ L 

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