ASN Wikibase Occurrence # 221281
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| Date: | Tuesday 29 January 2019 |
| Time: | 06:50 |
| Type: |  Bell 407 |
| Owner/operator: | Survival Flight Inc |
| Registration: | N191SF |
| MSN: | 53006 |
| Year of manufacture: | 1996 |
| Engine model: | Rolls Royce 250-C47B |
| Fatalities: | Fatalities: 3 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | 4 miles NE of Zaleski, OH -
 United States of America
|
| Phase: | En route |
| Nature: | Ambulance |
| Departure airport: | Grove City, OH |
| Pomeroy, OH | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
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.
Accident investigation:
 |
|
Sources:
NTSB
FAA register: https://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=191SF
http://aerossurance.com/helicopters/survival-flight-safety-culture/
Location
Media:
The Ohio State Highway Patrol has released new details on a medical helicopter crash that killed 3 people Tuesday near Lake Hope State Park in Vinton County. Click here to see the latest information. https://t.co/BMSx7E07PL
— WTAP Television (@wtaptelevision) 29 janvier 2019
Survival Flight Fatal Accident in #Ohio :
— Aerossurance (@Aerossurance) May 19, 2020
Air ambulance operator's poor #safetyculture influential say #NTSB. Poor #FAA oversight was contributory.https://t.co/skfmy6ZXmS #helicopter #accident #flightsafety #aviationsafety #safetymanagement pic.twitter.com/PHJPMAPtJW
Countdown of our most popular articles of 2020 – at 20: Survival Flight Fatal Accident: #AirAmbulance Operator's Poor Safety Culture. Poor #FAA oversight contributory say #NTSB. https://t.co/xRUesxqviu #helicopter #hems #safetyculture #accident #flightsafety #aviationsafety pic.twitter.com/ycDceIaYIv
— Aerossurance (@Aerossurance) January 9, 2021
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 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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