History of Flight
On April 27, 2015, about 2150 central daylight time, a helicopter rescue specialist fell during an external hoist rescue operation. The rescuer received fatal injuries; the pilot, flight paramedic, and patient were not injured. The Eurocopter MBB BK 117 helicopter, N392TC, was not damaged. The helicopter was registered to the Travis County Purchasing office and operated by STAR Flight, Austin, Texas, as a public aircraft operation. Night visual meteorological conditions prevailed.
STAR Flight operations were contacted for an injured individual on the greenbelt of Barton Creek. Ground first responders determined that an air rescue was necessary due to the patient's condition and difficult terrain. The pilot, hoist operator (paramedic), and helicopter rescue specialist gathered equipment and completed normal checks before departure and en route. After arriving at the patient's location, the rescuer and medical equipment were hoisted to the ground. The hoist operator later deployed a backboard.
While the rescuer prepared the patient for hoist, the flight crew selected a running track near a school as a landing zone. After securing the patient in a Bauman bag, the rescuer radioed the helicopter. The helicopter moved into position and extended the hook. After receiving "ready for extraction," the hoist operator initiated lift. Once the rescuer and patient cleared the trees, they began a steady spin. The pilot moved the helicopter forward to arrest the spin; the spin slowed and nearly stopped as they were hoisted upward. As they neared the helicopter, the rescuer fell away from the patient and hoist.
The flight crew continued with the patient to the rendezvous location, where the patient was transferred via ambulance. After disconnecting the patient, the helicopter landed. The pilot and hoist operator then departed to search for the rescuer, landing back at the landing zone shortly afterward.
Witness interviews: The pilot reported wind from 350 degrees at 5 knots, with possible turbulence in the rescue area. They approached from the north. After deploying the rescuer and backboard, they loitered until the rescuer's call for extraction. Upon hearing "axis clear," the pilot transitioned to forward flight at about 100-120 feet AGL. The hoist operator then stated the rescuer had fallen from the hook.
The hoist operator reported completing safety checks before launch. During deployment from 100 feet AGL, incidental contact with tree branches occurred. While retracting the hoist, a small branch wedged on the hoist bumper; he removed it and inspected the hook and cable, finding no damage. They lowered a backboard via rope. For extraction, they chose to lift 50 feet higher to minimize rotor wash. During lift, the rescuer and patient made light contact with tree branches. After clearing trees, they started spinning; at the hoist operator's request, the pilot added forward airspeed after "axis clear." The spin slowed. The hoist operator noticed the rescuer riding lower than normal, and then she fell from the rigging, leaving the patient and medical bag attached to the hoist hook.
Fire department emergency personnel on scene reported the rescuer was inserted below their location and had to climb uphill. One person noted adequate lighting but did not recall headlamp use. After the rescuer said she was about to call the helicopter, she requested a catch hook. The hook was handed to her, and she gave a thumbs up. The rescuer and patient departed; they moved into a small tree, appearing controlled, then departed skyward. Another firefighter asked if she needed safety gear, but she responded she was fine. The patient's left foot briefly entered trees, then they cleared above the tree line. Another firefighter saw the rescuer hook up the Bauman bag and backpack, gave a thumbs up, and they took off; during lift, they entered a tree, stopped, possibly lowered, then moved and departed. One witness reported the rescuer had the HRV, called the helicopter, hooked into a bull ring quickly, gave a thumbs up, and lifted; they slightly entered a tree, then cleared and were gone. At the landing zone, personnel initially did not approach the hovering helicopter; after radio contact, a fireman disconnected the patient. The crew chief asked for the medical bag and said they needed to search for their rescuer. The patient stated she did not know the rescuer was with her at any point.
A citizen discovered the fallen rescuer and called 911. The rescuer's helmet was off; the vest was zipped up, leg straps on, and the triangle (Tri-link) closed. Emergency personnel opened the triangle, vest, and cut belts and leg straps to provide medical care.
Personnel Information
The pilot held a commercial pilot certificate with helicopter, airplane single- and multi-engine land ratings, and instrument ratings for airplane and helicopter. He held a first-class medical certificate issued November 11, 2014. He had 5,512 total flight hours, with 5,197 in helicopters and 315 in the Eurocopter BK 117. He had Army and Coast Guard experience and had been employed by STAR Flight since August 2012.
The hoist operator (paramedic) had been employed by STAR Flight since March 2010 and was qualified as both a hoist operator and helicopter rescue specialist (HRS).
The rescuer (flight nurse) was qualified as both a hoist operator and HRS. She held a registered nurse license and paramedic certificates. She had been employed by STAR Flight since October 2008.
STAR Flight staffs one helicopter at the University Medical Center at Brackenridge 24 hours per day and one helicopter at STAR Flight's facilities or Dell Children's Medical Center 12 hours per day. Crews are normally scheduled for three 12-hour shifts followed by three to four consecutive days off. The rescuer was on the third night (1900-0700) of her scheduled shift. STAR Flight reported compliance with FAA pilot duty day and rest requirements for flight nurses and paramedics.
Aircraft and Equipment Information
The MBB BK117 is a twin-engine medium utility transport helicopter powered by two Turbomeca Arriel 1E2 engines. It was modified by Metro Aviation, Inc., and equipped with a Goodrich external mount hoist system with a D-LOK rescue hook. The helicopter had a North Flight Data Systems Outerlink cockpit video and voice recorder and an Avalex AVR-8240 DVR recorder on the hoist system. A post-accident examination of the hoist and helicopter by the operator, NTSB, FAA, and a technical representative from Airbus Helicopters, Inc., did not reveal any abnormalities that contributed to the accident.
Crew equipment included flight suits, Tac-Air Rappel vests with two chest hoisting positions and one mid-scapular back position, adjustable leg straps, and cobra buckles. The vest had pockets for a Motorola APX 7000 multi-band radio with a remote push-to-talk switch. The Bauman bag provided single-point suspension for patient lifting. Tri-link (10 mm Maillon Rapide Delta Link) quick links were used on the vest's insertion-extraction loops. The HRV (Helicopter-Rescuer-Victim) consisted of a steel O-ring and blue and red webbing with carabineers; the O-ring attached to the hoist hook, blue for patient/equipment, red for rescuer connection to the Tri-link. Helmets were Gentex Corporation HGU-56 with headphones, visors, and a detachable maxillofacial shield. Night vision goggles (NVG) were ITT Model F4949F, AN/AVS-9. Equipment was either personalized or common; HRV and Bauman bag were not personalized. Personalized equipment was inspected by the member and replaced on condition; common equipment was inspected before/after each use and annually.
Meteorological Information
At 2151, Camp Mabry/Austin recorded wind from 360 degrees at 4 knots, 10 miles visibility, clear sky, temperature 73°F, dew point 54°F, barometric pressure 29.78 inHg. At 2153, Austin-Bergstrom International recorded wind calm, 10 miles visibility, scattered clouds at 9500 feet, temperature 66°F, dew point 62°F, pressure 29.77 inHg. Sunset was at 2006, end of civil twilight at 2031. The moon was waxing gibbous with 66% visible disk. The flight and rescue were conducted at night; crew members wore NVGs, but the rescuer was not hoisted while wearing NVGs.
Scene Information
Barton Creek Greenbelt is a recreational area in Austin, Texas, with about 809 acres. It includes sheer cliff walls, dense vegetation, swimming, hiking, and climbing areas, with several access points.
Medical and Pathological Information
The Travis County Office of the Medical Examiner conducted an autopsy on the rescuer, determining the cause of death as blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory conducted toxicological testing; specimens were negative for tested drugs and alcohol.
Examination of Equipment
The rescuer's Tac-Air vest insertion/extraction loops showed no evidence of failure or suspicious marks. Belt buckles and leg straps were absent evidence that might have contributed to the fall. The HRV and Tri-link were visually inspected on site and later at the NTSB laboratory under a high power microscope, finding no evidence of witness marks or abnormalities indicating failure. Hoist and cockpit video data cards were sent to the NTSB Vehicle Recorder Laboratory. A video group reviewed the hoist camera footage. Based on accident details, only part of the cockpit video was viewed, determined not to contain relevant information.
Organizational and Management Information
STAR Flight (Shock Trauma Air Rescue) is a public safety, government-based air rescue program provided by Travis County. Based in Austin, Texas, the program operates under 14 CFR Part 135 and public aircraft operations depending on the mission. Services include transport, emergency assistance, inter-facility transfers, firefighting, search and rescue, and law enforcement support. Normal service area covers nineteen central Texas counties. The STAR Flight Public Mission Committee (PMC) is responsible for developing policies, procedures, and the Aircrew Standards Manual (ASM). The PMC includes a Chief Medical Supervisor, Director of Operations or Chief Pilot, two Line Crew Chiefs/Hoist Operators, two Line HRS, and two Line Pilots. The committee uses cockpit and hoist recordings and formalized debrief forms to evaluate public mission events for compliance and improvement. The committee meets monthly or as required. The committee did not review the video recording for this accident.