NTSB Cites Poor Safety Culture in Air Ambulance Accident

Board also called the FAA a contributing factor.

This story originally featured on Flying Mag.

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.

Coincidental to the release of the NTSB’s report, the Flight Safety Foundation published a white paper called Commercial Passenger-Carrying Helicopter Safety. Foundation President and CEO Hassan Shahidi said, “Statistics show that for-hire and air taxi helicopter operations have a higher fatal accident rate than the industry has as a whole. It is clear that more needs to be done to drive down helicopter accident rates, improve crash survivability and develop industry-wide improvements in managing aviation risk. It also is clear that there is no single solution. Instead, a mix and of short- and longer-term strategies involving operators, manufacturers, regulators and consumers is required to improve the industry’s safety performance. And there needs to be a sense of urgency.”

What We Know About the Flight

In the pre-dawn hours of January 29, a nurse at Holzer Meigs Emergency Department contacted two other helicopter air ambulance operators requesting transport for her patient to OhioHealth Riverside Methodist Hospital in Columbus, Ohio. Both companies turned down the request citing poor weather conditions. When Survival Flight was contacted, the dispatcher contacted the evening pilot on call to check the weather and decide if he could accept the trip which he did a minute later. Since the evening pilot was about to go off duty, he suggested the dispatcher reach out to the day pilot who was reportedly just five minutes away from the base. She arrived and climbed into the helicopter that was already running.

The Board said, “There was no record of the accident pilot receiving a weather briefing or accessing any imagery on the weather application (Foreflight). Additionally, neither pilot completed a preflight risk assessment for the flight, as required by Part 135.617.” The evening shift pilot said he expected the accident flight pilot to complete the assessment after she returned. The weather was marginal VFR when the helicopter departed the Survival Flight base with gusty surface winds from the west and visibilities down to three miles in light snow. The forecast called for a 30- to 60-percent chance of light snow while two airmets warned of possible moderate turbulence below 10,000 and moderate icing below 8,000 feet.

Recorded weather radar and flight data monitoring (FDM) information indicate the helicopter departed about 6:28 am local and climbed southeastward to about 3,000 feet. During the next 22 minutes, the helicopter flew through two snow bands on the way to the destination hospital. The Board believes the pilot ran into IMC in the second band shortly after which the helicopter began a 180-degree descending left turn. Investigators believe the pilot might have been attempting to escape from the inadvertent IMC. However, the helicopter continued descending until it impacted trees. The report did say however that neither the pilot’s qualifications, medical conditions or impairment by alcohol or other drugs or the airworthiness of the helicopter were issues in the accident. There were no facts mentioned to indicate why the pilot was unable to complete the escape turn while maintaining altitude.

In the synopsis of the final report, the NTSB specifically pointed to a number of additional safety issues including the lack of a positive safety culture endorsed by Survival Flight management, the lack of helicopter air ambulance (HAA) experience for principal operations inspectors assigned to HAA operations; the lack of accurate terminal doppler weather radar data available on the HEMS (helicopter emergency medical services) weather tool and the lack of a flight recorder.

The Board’s called Survival Flight’s risk assessment process inadequate as illustrated by consistent failure by the company’s operational personnel completing a risk assessment worksheet before every flight, including the accident flight, as well as the accident pilot’s decision to conduct the flight without a shift change briefing, including an adequate preflight risk assessment. The Board added, “If a recorder system to capture cockpit audio, images, and parametric data had been installed, it would have enabled NTSB investigators to reconstruct the final moments of the accident flight and determine why the accident pilot did not maintain the helicopter’s altitude and successfully exit the encounter with inadvertent instrument meteorological conditions.” The report also took the FAA’s principal operations inspector to task for not knowing Survival Flight’s flight risk assessment (FRA) was inadequate and that it failed to meet the requirements of Part 135.617 or comply with the guidance in Advisory Circular 135-14B. The Board believes POIs assigned to helicopter air ambulance would benefit from helicopter experience or specific experience with HAAs.

The Helicopter Association International responded to the NTSB’s report on May 20, 2020, saying it “supports many of the NTSB’s recommendations and suggestions but believes that the NTSB overstated some solutions while overlooking other potentially valuable programs.” James A. Viola, president and CEO of HAI said, “We agree that flight-data monitoring equipment can be valuable. But, as indicated in the hearing, industry follow-through with programs that use the data to improve operational safety may be inadequate. We believe this data should be shared with programs like the government-industry Aviation Safety Information Analysis & Sharing (ASIAS), which anonymously compiles information from participating operators’ flights to provide a snapshot of how our industry is doing and where improvements are needed.

Viola added, “HAI also agrees that safety management systems (SMS) have a place in business operations. However, we also recognize that voluntary SMS while supported by the FAA, is not being fully optimized and implemented because of limited resources.” HAI said it believes that requiring the FAA to hire and train helicopter-specific POIs will not adequately address the issues identified during the NTSB hearing, and may instead lead to delays in implementing safety initiatives. “The safety issues attributed to the POI during the hearing were irrelevant to their specific aircraft training or expertise. Helicopter-specific experience does not significantly improve a safety professional’s ability to monitor the use of a risk assessment or SMS program,” according to Viola. “HAI’s concern is that rotorcraft operators will end up waiting for their specific rotorcraft POI, who is suddenly backlogged or otherwise unavailable, and safety initiatives will lag as a result.”