On January 29, 2019, a single-engine, turbine-powered Bell 407 helicopter being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. 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 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.
Safety issues identified in this report include Survival Flight’s lack of comprehensive and effective flight risk assessment and risk management procedures, the lack of a positive safety culture endorsed by Survival Flight management and the lack of a comprehensive safety management system, the need for flight data monitoring programs for HAA operators, the lack of 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.
As a result of this investigation, the National Transportation Safety Board makes five new safety recommendations to the Federal Aviation Administration, three new safety recommendations to the National Weather Service, and six new recommendations to Survival Flight.
