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ASN Wikibase Occurrence # 221281
Last updated: 10 September 2021
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Date:29-JAN-2019
Time:06:50
Type:Silhouette image of generic B407 model; specific model in this crash may look slightly different
Bell 407
Owner/operator:Survival Flight Inc
Registration: N191SF
MSN: 53006
Fatalities:Fatalities: 3 / Occupants: 3
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:4 miles NE of Zaleski, OH -   United States of America
Phase: En route
Nature:Ambulance
Departure airport:Grove City, OH
Destination airport:Pomeroy, OH
Investigating agency: NTSB
Narrative:
The Bell 407 helicopter, N191SF, being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed.
On the morning of the accident, before contacting Survival Flight, an emergency room technician at Holzer Meigs Emergency Department contacted two other HAA operators with a request to transport a patient from her facility to OhioHealth Riverside Methodist Hospital, Columbus, Ohio; both operators ultimately turned down the flight request due to poor weather conditions. After speaking with the ERT about the details of the request, the operations control specialist at Survival Flight contacted the Survival Flight pilot on duty (the evening shift pilot) at Base 14 and requested a weather check to determine if the mission could be accepted. The evening shift pilot accepted the flight. Because the request was received around the time the evening shift pilot’s shift was ending, he informed the operations control specialist that the day shift pilot (the accident pilot) was 5 minutes away from the base and may take the flight.
When the accident pilot arrived at Base 14, she proceeded directly to the already-started helicopter and departed. There was no record of the accident pilot receiving a weather briefing or accessing any imagery on the weather application. Additionally, neither pilot completed a preflight risk assessment for the flight as required and the evening shift pilot stated he expected the accident pilot to complete the assessment after she returned.
On the morning of the accident, station models around the accident site indicated marginal visual meteorological conditions with gusty surface wind from the west between 10 to 20 kts.
Visibilities were reported as low as 3 miles at the surface in light snow conditions. There was a 30% to 60% chance of light snow and two airmen’s meteorological information advisories had been issued: one for moderate turbulence below 10,000 ft mean sea level (msl) and one for moderate icing conditions below 8,000 ft msl.
Recorded weather radar and flight data monitoring (FDM) data indicate that, about 06:28, the helicopter began to gain altitude, reaching a maximum altitude of about 3,000 ft, and traveled in a southeast direction for about 22 minutes, flying through two snow bands en route to the destination hospital. During the encounter with the second snow band, the pilot likely encountered instrument meteorological conditions (IMC) due to reduced visibility in snow. Shortly after the encounter with the second snow band, the helicopter flew a path consistent with a 180° descending left turn, which may have indicated the pilot was attempting to perform an escape maneuver to exit inadvertent IMC. However, she did not command the helicopter to climb, and it continued to descend until the last moments of the flight. The helicopter impacted trees on the reciprocal heading of the flightpath.


Probable Cause: The NTSB determines that the probable cause of this accident was Survival Flight's inadequate management of safety, which normalized pilots' and operations control specialists' noncompliance with risk analysis procedures and resulted in the initiation of the flight without a comprehensive preflight weather evaluation, leading to the pilot's inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of the operator's risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.

Sources:

NTSB
FAA register: https://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=191SF
http://aerossurance.com/helicopters/survival-flight-safety-culture/

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration: 1 year and 3 months
Download report: Final report
Location

Media:


Revision history:

Date/timeContributorUpdates
29-Jan-2019 18:21 gerard57 Added
29-Jan-2019 18:24 harro Updated [Operator, Total fatalities, Location, Source]
29-Jan-2019 19:44 Captain Adam Updated [Source, Damage, Narrative]
29-Jan-2019 21:00 Iceman 29 Updated [Source, Embed code, Narrative]
29-Jan-2019 21:02 Iceman 29 Updated [Time, Embed code, Narrative]
29-Jan-2019 21:39 Aerossurance Updated [Location, Source, Narrative]
29-Jan-2019 21:41 Aerossurance Updated [Departure airport, Destination airport, Narrative]
30-Jan-2019 02:44 RobertMB Updated [Source]
30-Jan-2019 04:03 Geno Updated [Operator, Departure airport]
30-Jan-2019 09:32 SANMJN Updated [Registration, Cn, Source]
30-Jan-2019 15:46 RobertMB Updated [Registration, Location, Narrative]
30-Jan-2019 15:50 RobertMB Updated [Source]
30-Jan-2019 16:07 A.J. Scholten Updated [Registration]
30-Jan-2019 16:56 harro Updated [Registration, Cn, Source]
31-Jan-2019 11:49 RobertMB Updated [Source, Narrative]
12-Feb-2019 20:29 Aerossurance Updated [Time, Operator, Location, Phase, Destination airport, Source, Narrative]
16-Dec-2019 08:54 Aerossurance Updated [Location, Source]
19-May-2020 19:30 harro Updated [Narrative]
19-May-2020 21:54 Aerossurance Updated [Source]
16-Jun-2020 18:58 ASN Update Bot Updated [Time, Operator, Departure airport, Destination airport, Source, Embed code, Narrative, Accident report, ]
29-Jul-2020 07:55 harro Updated [Location, Source, Embed code, Narrative, Accident report, ]
01-Nov-2020 10:50 Aerossurance Updated [Location, Source, Embed code, Accident report]
09-Jan-2021 11:15 Aerossurance Updated [Embed code, Accident report]

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