NTSB Cites Poor Safety Culture in Air Ambulance Accident

[TheGreenGoblin]

On January 29, 2019, a Bell 407 helicopter operating as an air ambulance flight by Batesville, Arkansas-based Survival Flight crashed near Zaleski, Ohio, killing the pilot, the flight nurse and the flight paramedic.

The helicopter impacted heavily forested terrain just before 7 am local time in deteriorating weather while enroute to transfer a patient from one hospital to another. In a synopsis of its final report, the Board explained, “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.”

The NTSB said the probable cause of the accident was “the pilot’s inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain.” The report also cited 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. Contributing to the accident was the FAA’s inadequate oversight of the operator’s risk management program and failure to require [this and other] Part 135 operators to establish safety management system programs.” The Board said, “Although sufficient information was available to the evening shift pilot and the operations control specialist to identify the potential for snow, icing, and reduced visibility along the accident flight route, their failure to obtain complete enroute information precluded them from identifying crucial meteorological risks for the accident flight.” Additionally, the NTSB delivered a dozen specific findings following the accident investigation as well as 14 recommendations to Survival Flight, the FAA and the National Weather Service, some focused on management issues, others on operational topics such as requiring the use of improved weather technology in the helicopter and on the ground.

https://www.flyingmag.com/story/news/su ... dium=email

Type of aircraft, not the accident aircraft...

Final report

[Boac]

"Lessons will be learned" Repeat after me.

[Seenenough]

"Lessons will be learned" Repeat after me.

Did you ever fly EMS in a helicopter Bo?

[Rwy in Sight]

"Lessons will be learned" Repeat after me.

Did you ever fly EMS in a helicopter Bo?

Maybe it is the mentality that counts Seenenough. Numerous cases where an untoward event happened people in authority stated "lessons will be learned" only for the event to be repeated.

[Seenenough]

"Lessons will be learned" Repeat after me.

Did you ever fly EMS in a helicopter Bo?

Maybe it is the mentality that counts Seenenough. Numerous cases where an untoward event happened people in authority stated "lessons will be learned" only for the event to be repeated.

Have you ever flown EMS,at night, in a helicopter?

[Rwy in Sight]

Did you ever fly EMS in a helicopter Bo?

Maybe it is the mentality that counts Seenenough. Numerous cases where an untoward event happened people in authority stated "lessons will be learned" only for the event to be repeated.

Have you ever flown EMS,at night, in a helicopter?

The answer is a no - but kindly treat BOAC's point as a valid one especially in aviation: every accident can provide useful information to avoid another one down the line. Why EMS is so special and should be exempt from this rule? I keep in mind there are lives depending on a flight in a marginal condition but then again as a much respected journalist said after an EMS accident here: we don't need more funerals than necessary. By the way I read the accident report and it clearly shown an incompetence of the operating company. They needed two more accidents before the stop the contract with that company And I need to re-read those reports to see if company had any roles into them.

[TheGreenGoblin]

I guess we should all agree with RiS's point and be united in the understanding that EMS flights, due to their urgency and non-standard nature, need to take additional risk parameters into account. I have never flown same but was in Tingwall to witness the sad aftermath of an EMS flight, fixed wing, that led to tragedy and it still makes me feel uncomfortable for all concerned...

https://assets.publishing.service.gov.u ... 501869.pdf

Another one that springs to mind where clearly SOPS and rules were inadequate to the psychological impetus, of getting a humanitarian job done, was this one...

http://www.caa.co.za/accidents%20and%20 ... v5-nrs.pdf

As a still aspirant helicopter pilot who has flown night instrument approaches in fixed wing aircraft, I would be interested in the comments of the helicopter professionals here as to their views on flying EMS at night in IMC in a helicopter.

[Boac]

A comment from a helicopter 'amateur', but experienced pilot.

their views on flying EMS at night in IMC in a helicopter.

In this particular case, you don't. Whole thing was a cluster f**k and I guess whoever they were trying to 'transport' sadly did not get the service. Let's hope those lessons 'will be learned'.

'Inadvertent IMC' happens to many people but you have to know how to avoid it if possible and handle it if not. I disagree with the NTSB finding 3 "None of the following were factors in the accident: (1) pilot qualifications; " and would consider 1) to be the major cause of the accident. It appears she lost control in IMC for some reason. For the NTSB to blame it mainly on the appalling company approach to operations is, in my opinion, not correct. Many emergency services of all sorts operate in weather conditions that are far from ideal by their very nature. It is down to the operative to handle that. Ring any bells?

[Seenenough]

I have some experience with HEMS operation at night.

The weather can be checked in every way imaginable and meet the take off threashold set out in the Standard Operating Procedures (SOPs) but as we all know weather can and does change.Our SOPs would not have permitted take off in the conditions that the accident report describes.

It is very difficult to see cloudy conditions ahead in the darkness of night especially when away from city lights and out in the country.The pilot work loads are very much higher at night as instrument reference is also being used in conjuntion with the diminished visual reference available at night.

We trained for many hours to learn how to carry out a 180 degree escape turns to get out of sudden and inadvertent flight into IMC.The accident report confirms that the pilot was attempting such a procedure but he lost height in the process and made contact with the ground.The pilot likely lost spacial orientation as a result of work overload and stress.

There was no hospital in South Africa that had published Jepp take off and let down patterns so in effect a HEMS flight could not ever be undertaken under IF Rules regardless of the fact that the helicopter is IF certified and the pilot is IF qualified.HEMS operation can therefore only be undertaken under Night VF Rules which leaves it up to the pilot to determine before and during flight whether to fly or not to fly.

I have aborted a night flight, en-route for a pick up,because I was not happy that I could maintain safe visual reference as a result of deteriorating weather.In this case I landed immediately and waited for sunrise and then returned to base.