Pilot Debrief

Bell 407 near Zaleski, OH — 2019-01-29

Final reportCEN19FA072
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Date
2019-01-29
Location
Zaleski, OH, USA
Aircraft
Bell 407
Registration
N191SF
Category
Helicopter
Highest injury
Fatal
Fatalities
3
Phase of flight
Climb

Probable cause

The NTSB 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.

Contributing factors

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.

NTSB narrative

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered Bell 407 helicopter, N191SF, 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.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have aborted the flight due to worsening weather conditions.

NTSB coding

Evidence available

  • Video
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  • 88 docket documents
View NTSB final reportView NTSB docket

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