A properly run safety management system (SMS) could have prevented the Jan. 29, 2019, fatal crash of a Bell 407 air ambulance, the U.S. National Transportation Safety Board (NTSB) said, citing the operator’s “inadequate management of safety” as the probable cause of the accident.
The crash of Survival Flight’s air ambulance, on a snowy morning 4 mi (6 km) northeast of Zaleski, Ohio, U.S., killed the pilot, flight paramedic and flight nurse, and destroyed the helicopter. [Photo courtesy of The Columbus Dispatch via NTSB]
In its final report, released in May, the NTSB elaborated on the probable cause: the operator’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.”
The report cited as a contributing factor the U.S. Federal Aviation Administration’s (FAA’s) “inadequate oversight” of Survival Flight’s risk management program and the FAA’s failure to require implementation of SMSs at aviation operations conducted under Federal Aviation Regulations Part 135, which governs commuter and on-demand operations.
“This accident was all but invited by the actions and culture of Survival Flight,” NTSB Chairman Robert Sumwalt said. “Unfortunately, we have seen yet another case of how a poor safety culture can lead to tragedy.”
Among the key safety issues cited in the NTSB report were Survival Flight’s preflight risk assessment procedure, which did not require a determination of whether the flight had been refused by another air ambulance operator, and the company’s poor safety culture, which included what the NTSB called “the casual behavior of … management regarding risk assessment and safety programs.”
The morning of the accident, two other helicopter air ambulance (HAA) operators had already refused a request from an emergency room technician at Holzer Meigs Emergency Department in Pomeroy, Ohio, to transport one of her patients to OhioHealth Riverside Methodist Hospital in Columbus; both HAAs cited the poor weather conditions, which included snow showers and areas of instrument meteorological conditions (IMC) along the approximately 85 nm (157 km) flight route.
The technician then contacted an operations control specialist at Survival Flight, who contacted the pilot on duty (the evening shift pilot) to request a weather check before determining if the company should accept the flight.
The pilot accepted “about 28 seconds later,” but he said that since his shift was about to end and since the day shift pilot was expected to arrive for work within minutes, she might take the flight.
When the accident pilot arrived at Mount Carmel Hospital in Grove City, Ohio, one of Survival Flight’s bases, she “proceeded directly to the already-started helicopter and departed” for Pomeroy, about 69 nm (128 km) southeast, the report said. “There was no record of the accident pilot receiving a weather briefing or accessing any imagery on the weather application.”
In addition, neither pilot performed the preflight risk assessment required by U.S. Federal Aviation Regulations Part 135.617, the report said.
The evening shift pilot told accident investigators that the forecast for the route of flight included a 2,400-ft ceiling and 7 mi (11 km) visibility. The report said that he told investigators he had contacted the accident pilot and briefed her on the proposed flight, but because “it was ‘good weather,’” his briefing did not mention weather conditions. After the briefing, the accident pilot said she would take the flight.
The helicopter’s engine was started at 0623 local time, and the accident pilot contacted the operational control specialist twice before 0628, when flight data monitoring (FDM) data showed that the helicopter was lifting off and heading southeast. The last communication was at 0631, when the pilot said she would provide a flight plan.
FDM data showed that, by 0635, the helicopter had climbed to just below 3,000 ft above mean sea level ─ a little more than 100 ft below an overcast. Altitude and airspeed then fluctuated as the helicopter flew through two bands of snow. At 0650, the onboard data ended.
The operational control specialist said that flight tracking software showed that 15 to 20 minutes after departure, the helicopter turned right, then left “as if the helicopter were turning around,” the report said. Then the track stopped, and soon afterward, the “no tracking” alarm sounded, and the specialist initiated the company’s emergency action plan.
The report concluded that the pilot likely encountered IMC and reduced visibility when flying through the second snow band and began a 180-degree turn to escape, but the helicopter did not maintain altitude.
The investigation found no indication that the 1,855-hour pilot’s qualifications or the airworthiness of the helicopter, which had accumulated 1,180 hours total flight time since it was manufactured in 1996, were factors in the accident. In addition, the pilot had no medical condition that would have been a factor, the report said
Although an automated weather observing station 8 mi (13 km) from the accident site reported around the time of the accident that weather conditions were similar to those mentioned by the evening shift pilot ─ visibility of more than 10 mi (16 km) and an overcast ceiling at 2,700 ft above ground level ─ satellite imagery indicated the presence of “low-level cool water clouds,” the report said.
Station models indicated that marginal visual meteorological conditions prevailed around the accident site, with visibility as low as 3 mi (5 km) in light snow, and weather radar showed two bands of snow along the flight path.
The operations control specialist told accident investigators his check of the Helicopter Emergency Medical Services (HEMS) Weather Tool indicated the weather was marginal, with ceilings of at least 1,500 ft and light snow, “but nothing that seemed alarming, the report said.”
15 Bases in 6 States
At the time of the accident, Survival Flight operated 15 bases in six states, including the Grove City, Ohio base. Of the company’s 70 pilots, four were assigned to Grove City.
The company established weather minimums for its operations that included a ceiling of 800 ft and visibility of 3 mi in non-mountainous areas during the day; at night, a ceiling of at least 1,000 ft and visibility of 5 mi (8 km) were required.
Because the company’s helicopters were not certified for flight under instrument flight rules, any inadvertent encounter with IMC was considered an emergency, and Survival Flight’s General Operations Manual (GOM) instructed pilots to “exit the conditions.”
The GOM also contained the company’s preflight risk analysis, which called for consideration of environmental factors, aircraft status, personnel and human factors, and “flight type, the job, what we do.” The procedure did not call for conducting the assessment before every flight or for identifying whether an individual flight had been refused by another operator, the report said.
When the criteria for the accident flight were entered into a worksheet that included all components identified by FAA Advisory Circular 135-14B, “Helicopter Air Ambulance Operations,” the score would have placed the risk level of the accident flight two levels greater than Survival Flight’s risk assessment the report said.
“Because of the ineffective flight risk assessment used at Survival Flight, the accident flight was allowed to depart, and the pilot had no knowledge of other operators’ previous refusals of the flight or the potential weather along the route of flight,” the report added.
‘Multiple Safety-Related Deficiencies’
The report said that the accident investigation revealed “multiple safety-related deficiencies at Survival Flight, including the failure to record accurate duty times, noncompliance with regulations and procedures, the pressure to complete flights, punitive repercussions for safety decisions and the lack of operational oversight.”
The document also noted management’s “casual behavior … regarding risk management and safety programs,” and said that the safety culture ─ combined with what employees described as a management expectation that a flight depart within seven minutes of receiving a call ─ probably explained why neither the evening shift pilot nor the accident pilot performed a comprehensive weather evaluation or preflight risk assessment.
Survival Flight’s chief pilot told accident investigators that the safety culture was good and that safety concerns could be discussed anytime. The company’s director of safety and training told them he considered the safety culture “pretty good,” although he was aware that some pilots were uncomfortable reporting safety problems.
However, the report quoted one Survival Flight pilot as saying, “I like my job. I like the people I work with. But you get the sense that you’re going to be blackballed, you know, if you go against them.”
A former company paramedic called the safety culture “so damaging and so toxic,” and other current and past employees told investigators that pilots often felt they were being pressured to accept flights.
The report cited a “quick reference guide” that Survival Flight distributed to hospitals and fire department that said, “Our weather minimums are different, if other companies turn down the flight for weather ─ CALL US. If we can fly to you safely and take the patient safely to another facility … WE WILL.”
Pilots and medical crewmembers told accident investigators of “incidents in which they were reprimanded or challenged by senior management, or witnessed similar treatment of a pilot, for declining a flight.”
For example, the report noted a letter submitted by the accident flight nurse to the Survival Flight human resources department that said multiple crewmembers had experienced “unsafe flights” with a company lead pilot, “and when we have to abort a flight with (the lead pilot), we get talked to by management, questioned, and we are always made to look like we are just lazy and don’t want to do it.”
Another medical crewmember told investigators that when pilots refused flights because of poor weather, “the chief pilot of the company … would call within about 10 minutes and would cuss out our pilots and belittle them, … saying, … we need to take these flights, … he would yell so loud on the phone that you could hear it, … just standing within earshot.”
Two former employees told investigators their employment was terminated after they expressed concerns about safety, and a third said he was demoted.
No SMS Documentation
Although the Survival Flight director of operations said the company had an SMS, accident investigators found no documentation of such a program, and operations were “not consistent with defined and industry-recognized components of an SMS,” the report said.
Because the company did not have a culture for reporting safety concerns, it lacked the structure for managing safety in accordance with an SMS, the report said.
Establishment of an SMS under an FAA program that calls for compliance with Advisory Circular 120-92B, “Safety Management Systems for Aviation Service Providers,” was one of the report’s 14 safety recommendations, including six recommendations to Survival Flight, three to the U.S. National Weather Service (NWS) and five to the FAA.
Other recommendations to Survival Flight called for changes in several areas, including in the company’s risk assessment procedures, and for new requirements that pilots complete the risk assessments before all flights.
The recommendations to the FAA included calls for the agency’s principal operations inspectors for HAA operations to have experience involving helicopters and HAAs, and for operators to address deficiencies in their risk assessment procedures.
Other recommendations said the NWS should add terminal doppler weather radar data to the HEMS Weather Tool overlay and provide capability for the Weather Tool to graphically display certain areas of weather radar limitations.
This article is based on NTSB Accident Report NTSB/AAR-20/01, “Helicopter Air Ambulance Collision With Terrain; Survival Flight Inc.; Bell 407 Helicopter, N191SF; Near Zaleski, Ohio; January 29, 2019.” Adopted May 19, 2020. https://ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf