NTSB Identification: CEN09LA388
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Monday, June 15, 2009 in Rapid City, SD
Probable Cause Approval Date: 12/20/2010
Aircraft: Beech B100, registration: N4490M
Injuries: 1 Serious,4 Minor.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The air-ambulance flight encountered clear-air turbulence during cruise descent. During the turbulence encounter, the patient’s unrestrained upper-torso fell off the aircraft mounted stretcher assembly. After the turbulence had subsided, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. The stretcher’s available over-the-shoulder restraints were not used because of an interference caused by a flexible lift system that was used to transfer the patient from the ambulance gurney to the aircraft’s stretcher. After the accident the aeromedical transport company discontinued the use of the flexible patient lift system model used during the accident flight and required flight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The flight crewmembers’ failure to secure the patient using the available over-the-shoulder restraints and the encounter with clear-air turbulence during cruise descent.

Full narrative available

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