History of Flight
On February 14, 2013, at approximately 1221 eastern standard time, a Eurocopter MBB-BK-117 C-2, registration N481LF, operated by Geisinger Medical Center d.b.a. Life Flight, was substantially damaged when the main rotor contacted a flag marker mounted on a construction crane during approach to Geisinger Rooftop Heliport (79PN) in Danville, Pennsylvania. The pilot, flight nurse, flight paramedic, and patient were uninjured. Visual meteorological conditions prevailed for the Title 14 Code of Federal Regulations Part 135 helicopter emergency medical services flight, which originated from Muncy Valley Hospital Heliport (7PS5) in Muncy, Pennsylvania at 1210.
According to the pilot, the flight departed from Primrose Heliport (25PS) in Minersville, Pennsylvania to 7PS5 to pick up a patient for an interfacility transfer. After arriving at 7PS5 at 1142, the patient was loaded, and they departed for 79PN at 1212. The patient was "doing poorly," and there was initial consideration about whether the patient was alive and whether to fly him. After departure, the pilot climbed to 2000 feet above mean sea level and flew on an approximate 160-degree magnetic heading direct to 79PN.
As the helicopter approached the mountains near Danville, the pilot turned slightly right to pass through a gap in the ridgeline and continued direct to the heliport. The pilot radioed that he was "3 minutes out." Around this time, the medical team intubated the patient. The pilot was advised by the communications center that there were two people on the roof to assist. He then observed two individuals on the rooftop landing pad, which "while not abnormal" was "not routine." He was "a bit concerned" and wanted to ensure the personnel were clear of the helipad before getting closer.
The pilot recalled being somewhat more attuned to the patient's condition as the medical crew worked to keep the patient alive and moved about the cabin unrestrained. He continued descending and commenced final approach to the rooftop helipad. About 100 yards from touchdown, he noticed something "orange" out of the left window. Almost simultaneously, the flight paramedic mentioned seeing something orange. The pilot then felt a "slight low frequency vibration," also noticed by the flight nurse. About six seconds later, he landed on the pad, executed an emergency shutdown, and cleared the crew to exit.
Contractors operating a construction crane near the heliport reported that they were lowering equipment onto a roof when one observed a helicopter approaching. Another contractor saw "all of a sudden" one of the blades hit the safety flag (flag marker) mounted on the crane boom, with "pieces of wood and flag flying all over the place." The contractors then stopped crane operations to confirm personnel were uninjured and that the boom and cable were undamaged.
Personnel Information
The pilot held an airline transport pilot certificate with ratings for rotorcraft-helicopter, commercial privileges for airplane single-engine land, airplane multiengine-land, and instrument airplane, and held type ratings for SK-64 and SK-65. He also held a flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA first-class medical certificate was issued on September 11, 2012. He reported 3,035 total flight hours, including 12 hours in the accident helicopter make and model.
Aircraft Information
The accident aircraft was a twin-engine medium utility–transport helicopter configured for emergency medical use. It featured a four-bladed main rotor with a hingeless rotor system, fiber-reinforced plastic blades, and a semi-rigid two-bladed tail rotor. It was powered by two turboshaft engines, each producing 708 shaft horsepower. The helicopter was manufactured in 2010. The most recent continuous airworthiness inspection was completed on January 10, 2013, at which time the helicopter had accrued 635.6 total flight hours.
Meteorological Information
The reported weather at Penn Valley Airport (SEG) in Selinsgrove, Pennsylvania, located 15 nautical miles southwest of the accident site, at 1253 included calm winds, 10 miles visibility, clear skies, temperature 4°C, dewpoint -3°C, and an altimeter setting of 29.96 inches of mercury.
Wreckage and Impact Information
Examination of the construction crane revealed that the metal pole holding the flag marker was damaged and the wooden pole attaching the flag marker was missing. Examination of the helicopter confirmed that the main rotor had contacted the flag marker. Two of the four main rotor blades were damaged: the Green Blade incurred minor tip damage, and the Blue Blade was substantially damaged and required replacement. The pilot reported that neither he, the flight nurse, nor the flight paramedic had seen the construction crane prior to contact.
Additional Information
To improve safety, Geisinger Medical Center took multiple actions: acquiring multiple images of cranes from different angles to confirm location and height; temporarily closing the helipad if a crane was in the direct flight path and diverting to a secondary helipad; requiring email confirmation that flight crews received and understood notices; emphasizing shift change briefings; ensuring full staffing of the communications center and preventing Communications Technicians from off-loading patients on the rooftop; having Communications Technicians announce advisory hazards for both takeoffs and approaches over a program-wide frequency; requiring all relevant personnel to participate in Air Medical Resource Management training; and creating a Safety Manager position.
Tests and Research
Review of accident photographs revealed that the helicopter's final approach passed over the construction crane's location near the "Annex" building, where the crane was being used to remove condensers from the roof. Interviews with the crane operator indicated that at the time, the crane's boom was inclined upward at 66 degrees, extended 133 feet, and aligned with the helicopter's flight path during final approach. Flight crews had been notified of the crane's position on February 12, 2013. The pilot believed he had briefed the crew about the crane before departure from 25PS. The notification stated the crane would be in position from about 0700 to approximately 1000 and would have a beacon on top; however, no beacon was installed, and the crane was still in use 2 hours and 21 minutes after the scheduled completion of work.
According to the Geisinger Medical Center General Operations Manual, maximum use of radio facilities was required on all departures and arrivals. During the investigation, it was determined that one of the individuals observed by the pilot on the rooftop was the Communications Technician who normally manned the radio in the "Glass House" next to the helipad.
The pilot approached the heliport from the north, which was not the usual direction (south). Witness statements indicated that despite 10 miles visibility, the helicopter's straight-in flight path would have restricted the pilot's ability to see the crane due to sun glare; the crane would have been below the pilot at his 11 o'clock position as he approached the helipad. Examination of the cockpit layout showed that the crane would not have been in the pilot's direct line of sight, as the instrument panel obstructed the view of the crane and portions of the Annex roof.
Per the Geisinger Medical Center GOM (12.9.6 VFR Approach Procedures), visual flight reference approaches required great caution: a high orbiting reconnaissance was required before beginning the approach; pilots were required to use continued vigilance searching for obstacles and debris; maximum use of prevailing wind was required while maintaining a safe distance from obstacles; and all published helicopter procedures were to be observed.
Organizational and Management Information
Life Flight began in 1981 as a helicopter emergency medical services (HEMS) operation, providing critically ill or injured patients rapid access to advanced life support and transportation to critical care facilities. It operated 24 hours a day from 5 bases, averaging 2,600 flights per year. Initially operating under contracted air carrier certificates, Life Flight was issued its own Title 14 CFR Part 135 air carrier certificate in 2012. At the time of the accident, the program operated 6 helicopters, each equipped with night vision systems, traffic collision avoidance systems, and terrain avoidance systems, operating in both visual and instrument meteorological conditions. Normal cruising altitude was between 3,000 and 5,000 feet above mean sea level. In addition to emergency response, Life Flight transported premature newborns, cardiac patients, critical care, and organ transplant patients. Crews consisted of a pilot, flight nurse, flight paramedic, and occasionally a flight physician or specialty nurse. All pilots were airline transport rated and instrument current. Communications specialists were emergency medical technicians experienced in EMS and medical communications, credentialed by the National Association of Air Medical Communications Specialists. Communications between helicopters and hospitals used a wide range of radio frequencies and satellite telephones. Flight following was monitored via real-time satellite tracking by a dispatch and operations center staffed by two Communications Technicians.