Accident at Zaleski, Ohio, 29 Jan 2019 (N191SF)

Accident narrative

On January 29, 2019, about 0650 eastern standard time, a Bell 407 helicopter, registration N191SF, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The helicopter was operated by Viking Aviation, LLC, doing business as Survival Flight Inc., as a Title 14 Code of Federal Regulations Part 135 helicopter air ambulance flight. The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed.

**The flight request**

About 0609 on the morning of the accident, an emergency room technician at Holzer Meigs Emergency Department in Pomeroy, Ohio, contacted the Survival Flight operations control center to request a patient transport to Columbus, Ohio. Before calling Survival Flight, the technician had contacted two other helicopter air ambulance operators, MedFlight and HealthNet Aeromedical Services. Both operators declined the request due to weather conditions, which included low cloud ceilings, icing probabilities, and snow squalls.

About two minutes after the technician contacted Survival Flight, the operations control specialist contacted the Survival Flight evening shift pilot at Base 14 in Grove City, Ohio, for a weather check. About 28 seconds later, the evening shift pilot accepted the flight. He informed the operations control specialist that the day shift pilot, who was the accident pilot, was five minutes away and might take the flight.

The evening shift pilot contacted the accident pilot while she was en route to the base and briefed her on the mission. He stated he did not brief her on the weather because he considered it to be "good weather." When the accident pilot arrived at the base, she proceeded directly to the helicopter, which the evening shift pilot had already started.

Neither pilot completed a preflight risk assessment for the flight, as required by federal regulations. The evening shift pilot stated he expected the accident pilot to complete the assessment after she returned. There was no record of the accident pilot receiving a weather briefing or accessing weather imagery before departure.

**The flight sequence**

The helicopter departed Mount Carmel Hospital in Grove City about 0628. Night visual meteorological conditions existed at the departure location. At 0629, the operations control specialist requested flight release information, and the pilot replied that she was "green in all categories."

Flight data monitoring data showed the helicopter climbed to a maximum altitude just below 3,000 feet mean sea level and traveled southeast at groundspeeds between 120 and 140 knots. Between 0635 and 0643, the helicopter descended about 1,000 feet before climbing back to 2,600 feet. During this time, recorded weather data indicated the helicopter encountered the first of two snow bands.

By 0647, the helicopter had descended to 2,400 feet and encountered a second, higher-intensity snow band. The Board concluded the pilot likely encountered instrument meteorological conditions inadvertently due to decreased visibility in the snow. The helicopter continued to descend to about 1,975 feet, briefly climbed, and then descended at a rate of about 900 feet per minute.

At 0649:45, the helicopter descended to 1,300 feet and began a final climb. Onboard data ended at 0650:08 as the helicopter climbed through 1,500 feet at 100 knots. Satellite data and the wreckage location indicated the helicopter flew a path consistent with a 180-degree descending left turn. The Survival Flight manual instructed pilots encountering inadvertent instrument meteorological conditions to execute a climbing 180-degree turn to return to visual conditions. The Board found the pilot may have begun the turn in an attempt to perform an escape maneuver but did not maintain altitude and allowed the helicopter to descend until it impacted terrain.

**What the investigation found**

The 34-year-old pilot had accumulated 1,855 hours of total flight experience, including 83.3 hours in the Bell 407. The Board found no evidence that pilot qualifications or medical conditions were factors in the accident.

The helicopter initially collided with a tree about 30 feet above the ground on a heading opposite to its initial flightpath. Examination of the airframe and flight controls revealed no anomalies that would have precluded normal operation. The engine control unit recorded two overtorque events about 8 and 3 seconds before the end of recorded data. These events correlated with increases in collective position, consistent with the pilot attempting to climb. The Board found no evidence of inflight mechanical failure.

Forecasts and station models for the area indicated marginal visual flight rules conditions, with visibilities as low as 3 miles in light snow. Two airmen’s meteorological information advisories warned of moderate turbulence and moderate icing conditions. The operations control specialist and the evening shift pilot used the HEMS Weather Tool to check conditions. The tool's default setting displayed weather radar information that did not incorporate terminal doppler weather radar data. Consequently, precipitation detected by terminal doppler weather radar along the route was not displayed on the tool. The Board noted that the availability of this data would have provided awareness of the potential for snow.

The Board found Survival Flight's risk assessment process was inadequate. The company's worksheet did not require evaluation of en route weather or a procedure to determine if another operator had refused the flight request. When the accident flight's criteria were entered into an exemplar worksheet containing all federally recommended components, the flight scored two levels higher, which would have required management approval.

Interviews with current and former employees revealed a poor safety culture at Survival Flight. Personnel reported pressure to accept flights, punitive repercussions for safety decisions, and management interference with maintenance decisions. The company advertised that it would fly in weather that other operators would not, and rewarded bases with a massage chair for reaching 30 flights in a month. Pilots were expected to depart within 7 minutes of receiving a call, which did not allow sufficient time for a comprehensive preflight risk assessment. The Board concluded this poor safety culture likely influenced the accident pilot's decision to conduct the flight without a shift change briefing or adequate risk assessment.

Survival Flight did not have a safety management system in place, nor did it have a flight data monitoring program to analyze the data recorded by its helicopters. The Board noted that an active flight data monitoring program could have identified previous flights that encountered snow or instrument conditions.

The Federal Aviation Administration principal operations inspector assigned to Survival Flight had limited helicopter experience, no rotorcraft rating, and no experience with helicopter air ambulance operations. The inspector was unaware that Survival Flight's flight risk assessment did not meet regulatory requirements. The Board concluded that the Federal Aviation Administration's oversight was inadequate.

The helicopter was not equipped, and was not required to be equipped, with a crash-resistant flight recorder system. The Board noted that a recorder capturing cockpit audio, images, and parametric data would have enabled investigators to determine why the pilot did not maintain altitude.

**Probable cause**

The National Transportation Safety Board determines that the probable cause of this accident was 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, leading to the pilot’s inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain. Contributing to the accident was the Federal Aviation Administration’s inadequate oversight of the operator’s risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.