Bell 407VIKING AVIATION INC
Zaleski, OH, USA · 2019-01-29·N191SF
What happened
NTSB summary, verbatimNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered 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 certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.
Probable cause
the Board's determinationThe 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.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · EnrouteVFR encounter with IMC
- 2 · EnrouteUnknown or undetermineddefining event
Findings
12 causal · 2 contributing- CAUSEPersonnel issues › Task performance › Planning/preparation › Weather planning — Pilot
- CAUSEOrganizational issues › Management › Culture › Safety — Operator
- CAUSEOrganizational issues › Management › Culture › Standard operating practices — Operator
- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Enforcement › Operational procedures — FAA/Regulator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adherence to safety program — Operator
- CAUSEEnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Snow — Not specified
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude — Not attained/maintained
- CAUSEEnvironmental issues › Physical environment › Terrain — Not specified
- CAUSEPersonnel issues › Task performance › Use of equip/info › Use of equip/system — Pilot
- FACTOREnvironmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima — Effect on operation
- FACTOREnvironmental issues › Operating environment › Meteorological services — Availability of related info
Safety recommendations
14 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Require that principal operations inspectors (POI) assigned to helicopter air ambulance (HAA) operations possess helicopter and either HAA experience or experience as an assistant POI under a POI with HAA experience.
TO THE FEDERAL AVIATION ADMINISTRATION: Review the flight risk assessments for all helicopter air ambulance operators for compliance with Title 14 Code of Federal Regulations 135.617 and Advisory Circular 135-14B and require operators to address any deficiencies that are identified.
TO THE FEDERAL AVIATION ADMINISTRATION: Install the latest software on your terminal doppler weather radars (TDWR) and require the National Weather Service (NWS) to distribute Level II TDWR data to all of its users (as recommended in Safety Recommendation A-20-18 to the NWS) so they will have access to the most accurate precipitation information.
TO THE FEDERAL AVIATION ADMINISTRATION: Require the National Weather Service (NWS) to add terminal doppler weather radar data to the HEMS Weather Tool overlay (as recommended in Safety Recommendation A-20-19 to the NWS).
TO THE FEDERAL AVIATION ADMINISTRATION: Require the National Weather Service (NWS) to provide capability in the HEMS Weather Tool to graphically display areas of weather radar limitations, including areas where beams may lack low-altitude coverage, areas that lack radar coverage, and areas of beam blockages (as recommended in Safety Recommendation A-20-20 to the NWS).
TO THE NATIONAL WEATHER SERVICE: Distribute Level II terminal doppler weather radar data to all of its users (as recommended in Safety Recommendation A-20-15 to the Federal Aviation Administration) so they will have access to the most accurate precipitation information.
TO THE NATIONAL WEATHER SERVICE: Add terminal doppler weather radar data to the HEMS Weather Tool overlay (as recommended in Safety Recommendation A-20-16 to the Federal Aviation Administration).
TO THE NATIONAL WEATHER SERVICE: Provide capability in the HEMS Weather Tool to graphically display areas of weather radar limitations, including areas where beams may lack low-altitude coverage, areas that lack radar coverage, and areas of beam blockages (as recommended in Safety Recommendation A-20-17 to the FAA).
TO SURVIVAL FLIGHT: Revise its flight risk assessment procedures to incorporate the elements described by Advisory Circular 135-14B, including procedures for determining prior flight refusals by another helicopter air ambulance operator and forecast en route weather.
TO SURVIVAL FLIGHT: Require pilots to complete a comprehensive risk assessment before each flight and complete the appropriate paperwork to reflect their assessment as required by Title 14 Code of Federal Regulations 135.617.
TO SURVIVAL FLIGHT: Develop a procedure for tracking actual pilot duty times in compliance with Title 14 Code of Federal Regulations 135.267.
TO SURVIVAL FLIGHT: Develop a process to ensure shift change briefings are performed, to include comprehensive preflight risk assessments, before the acceptance of any flight requests.
TO SURVIVAL FLIGHT: Establish a safety management system (SMS) program under the Federal Aviation Administration SMS Voluntary Program that includes compliance with Advisory Circular 120-92B, “Safety Management Systems for Aviation Service Providers.”
TO SURVIVAL FLIGHT: Develop and implement a flight data monitoring program independent of a Federal Aviation Administration requirement.
NTSB analysis
from the final reportNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered 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 certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.