Saturday, February 02, 2019

Unknown or Undetermined: Bell 407, N407SF; fatal accident occurred January 29, 2019 in Zaleski, Vinton County, Ohio











Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration; Washington, District of Columbia
Rolls Royce Engines; Indianapolis, Indiana
Viking Aviation LLC; Little Rock, Arkansas
Woodward Inc; Clarita, California 

Investigation Docket - National Transportation Safety Board:


Location: Zaleski, Ohio 
Accident Number: CEN19FA072
Date & Time: January 29, 2019, 06:50 Local
Registration: N191SF
Aircraft: Bell 407 
Aircraft Damage: Destroyed
Defining Event: Unknown or undetermined
Injuries: 3 Fatal
Flight Conducted Under: Part 135: Air taxi & commuter - Non-scheduled - Air Medical (Medical emergency)

Analysis

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.

Probable Cause and Findings

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

Findings

Personnel issues Weather planning - Pilot
Organizational issues Safety - Operator
Organizational issues Standard operating practices - Operator
Organizational issues Adequacy of policy/proc - Operator
Organizational issues Oversight of operation - FAA/Regulator
Organizational issues Operational procedures - FAA/Regulator
Organizational issues Adequacy of safety program - Operator
Organizational issues Adherence to safety program - Operator
Environmental issues Snow - Not specified
Aircraft Altitude - Not attained/maintained
Personnel issues Incorrect action performance - Pilot
Environmental issues (general) - Not specified

Factual Information

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.

History of Flight

Enroute VFR encounter with IMC
Enroute Unknown or undetermined (Defining event)

Pilot Information

Certificate: Commercial; Flight instructor 
Age: 34, Female
Airplane Rating(s): Single-engine land Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: Unknown
Instrument Rating(s): Airplane; Helicopter 
Second Pilot Present: No
Instructor Rating(s): Helicopter; Instrument helicopter 
Toxicology Performed: Yes
Medical Certification: Class 2 Without waivers/limitations
Last FAA Medical Exam: November 18, 2018
Occupational Pilot: Yes
Last Flight Review or Equivalent: April 27, 2018
Flight Time: (Estimated) 1855 hours (Total, all aircraft), 83 hours (Total, this make and model), 1787 hours (Pilot In Command, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: Bell 
Registration: N191SF
Model/Series: 407 No Series 
Aircraft Category: Helicopter
Year of Manufacture: 1996
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 53006
Landing Gear Type: N/A; Skid 
Seats: 4
Date/Type of Last Inspection:
Certified Max Gross Wt.: 5501 lbs
Time Since Last Inspection: 
Engines: 1 Turbo shaft
Airframe Total Time:
Engine Manufacturer: Rolls-Royce
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: 250-C47B
Registered Owner: 
Rated Power:
Operator: 
Operating Certificate(s) Held: On-demand air taxi (135)
Operator Does Business As: Survival Flight Inc Operator Designator Code: KVHG

Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown 
Condition of Light: Night
Observation Facility, Elevation: KUNI,765 ft msl 
Distance from Accident Site: 7 Nautical Miles
Observation Time: 11:55 Local 
Direction from Accident Site: 151°
Lowest Cloud Condition: 
Visibility: 10 miles
Lowest Ceiling: Overcast / 2700 ft AGL
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: Unknown / Unknown
Wind Direction: 280° 
Turbulence Severity Forecast/Actual: Unknown / Unknown
Altimeter Setting: 29.92 inches Hg
Temperature/Dew Point: -6°C / -10°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Grove City, OH 
Type of Flight Plan Filed: Company VFR
Destination: Pomeroy, OH
Type of Clearance: Unknown
Departure Time: 06:28 Local 
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 3 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal 
Latitude, Longitude: 39.323333,-82.309448
======
Location: Zaleski, OH
Accident Number: CEN19FA072
Date & Time: 01/29/2019, 0650 EST
Registration: N191SF
Aircraft: Bell 407
Injuries: 3 Fatal
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Medical Emergency) 

On January 29, 2019, at 0650 Eastern standard time, a single-engine, turbine-powered, Bell 407 helicopter, N191SF, collided with forested, rising terrain about 4 miles northeast of Zaleski, Ohio. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight, Inc., as a visual flight rules helicopter air ambulance flight under the provisions of 14 Code of Federal Regulations Part 135 when the accident occurred. The certificated commercial pilot, flight nurse, and flight paramedic were fatally injured, and the helicopter was destroyed. Visual meteorological conditions existed at the departure location, and company flight following procedures were in effect. The flight departed Mt. Carmel Hospital, Grove City, Ohio at 0628, destined for Holzer Meigs Hospital, Pomeroy, Ohio, about 69 miles southeast.

According to the Survival Flight Operations Control Specialist (OCS) on duty at the time of the accident, the night shift pilot had originally accepted the flight. The OCS said that, while he was on the phone with that pilot reviewing flight details about 0612, he was told that, due to the upcoming shift change, the day pilot would be taking the flight.

The OCS said that, while watching the helicopter on flight tracking software in the Operations Control Center, he observed that, about 15 minutes after departure, the helicopter made a turn to the right, then "a sharp left turn," which was immediately followed by a "no-tracking alarm." The emergency action plan was then initiated.

The helicopter wreckage was located on a tree-covered hill and exhibited significant fragmentation. The wreckage and debris path extended about 600 ft downslope on a heading of about 345° magnetic. A portion of the front-left skid tube was found at the start of the wreckage path, followed by the main rotor hub and blades, tail boom and tail rotor, cockpit and cabin, and the engine and transmission deck. Tree branches broken about 30 ft above ground level were observed near the front-left skid tube. Additionally, one main rotor blade had separated from the main rotor hub and was embedded in a tree. The elevation of the wreckage area ranged from 850 to 980 ft above mean sea level (msl). There was no evidence of a postcrash fire, but a strong smell of fuel was reported by first responders when the wreckage was first discovered.

The helicopter was equipped with an Outerlink Global Solutions IRIS flight data monitoring system, which provides real-time flight tracking data. The flight tracking information is relayed via satellites to an internet-based storage location in 10-second intervals. According to the IRIS data, the helicopter's last known location was about 4 miles northeast of Zaleski at an altitude of 1,528 ft msl, traveling at 132 knots across the ground, on a course of 072°. In addition to the transmission of data at 10-second intervals, the IRIS stores flight data in 1-second intervals, along with voice and satellite communications. The equipment was removed and sent to the NTSB Vehicle Recorders Laboratory for voice and data extraction.

Aircraft and Owner/Operator Information


Aircraft Make: Bell
Registration: N191SF
Model/Series: 407 No Series
Aircraft Category: Helicopter
Amateur Built: No
Operator: VIKING AVIATION INC
Operating Certificate(s) Held: On-demand Air Taxi (135)
Operator Does Business As: Survival Flight Inc
Operator Designator Code: KVHG 

Meteorological Information and Flight Plan

Conditions at Accident Site: Unknown
Condition of Light: Night
Observation Facility, Elevation: KUNI, 765 ft msl
Observation Time: 1155 UTC
Distance from Accident Site: 7 Nautical Miles
Temperature/Dew Point: -6°C / -10°C
Lowest Cloud Condition:
Wind Speed/Gusts, Direction: 7 knots / , 280°
Lowest Ceiling: Overcast / 2700 ft agl
Visibility:  10 Miles
Altimeter Setting: 29.92 inches Hg
Type of Flight Plan Filed: Company VFR
Departure Point: Grove City, OH
Destination: Pomeroy, OH

Wreckage and Impact Information

Crew Injuries: 3 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude: 39.323333, -82.309444



Jennifer Lynn Topper was born on October 19, 1984 in Santa Rosa, CA. Jennifer tragically left us on January 29, 2019 when her Survival Flight Helicopter went down in Ohio on a mission from Mount Carmel Health to Pomeroy to save a patient's life. Jennifer is preceded in death by her brother Christopher, her Nana Adell, her aunt Carolyn Day, and her beloved step-father, Howard Rader. Jennifer is survived by her mother, Cherie Rader, her fiancé Heath Beecher and her beloved dog Chief, his parents Chuck and Darlene, his sister Jen (Pat) Parento and his nephews Crew and Cy. Her grandparents Joe and Wanda Alarcon, her aunt Cindy and uncle Dan Cardoso, aunt Brenda Alarcon, Cousins Dustin, Tamara, Blaine and Reid Baxter, Jenna, Zach, Jayla and Chloe Brown, aunt Linda Kendrick.
Jennifer attended Biella Elementary, Comstock Jr. High and graduated Piner High in 2002.

Jennifer excelled in many endeavors as a young girl, tap dancing, and SR Neptune's Swim Team. Jennifer also successfully competed with MDM Farms riding jumping horses from age eight through 17 years old. Was on the Piner Swim Team and Girls Basketball Team.
Jennifer joined the United States Navy in 2002 as a Rescue Swimmer and graduated with top honors in 2003 in Pensacola, Florida. She was the 13th female to graduate the Navy SAR program. Jennifer pursued her love of flying by obtaining her private helicopter license. She had a break in her journey, obtained her EMT license, worked at SR Memorial Hospital as CT/Ultrasound and ER Tech.

Jennifer's passion was flying though and soon she was in Helicopter Flight School in Visalia switching to Leading Edge in Bend, Oregon. Jennifer obtained her Commercial Helicopter License and was hired on as an Instructor. Jennifer always set her goals, worked hard to get hours and soon was hired on at Papillon Helicopter Tours in Grand Canyon, Arizona. There she met the "love of her life" Heath Beecher. In May 2018, her dream came true as her and Heath became EMS pilots with Survival Flight. Flying in Oklahoma first, then to their bases in Ohio.

Our beautiful beloved, always smiling "Badass" Jennifer received her Angel Wings and is now flying forever in the heavens above us.
Loved by many and missed terribly by all who had the privilege of knowing and loving her. Her beautiful smile, free spirit, beauty and her everlasting light shines on in each and every one of us every day. Jennifer, beautiful, kind, generous and caring, we love you forever and ever.

Service and Celebration of Life to be held on Saturday, February 23, 2019 at 1:00 p.m. at Sonoma Country Day School, 4400 Day School Place, Santa Rosa, CA. 95403.

Authorities say three people aboard a medical helicopter have died in a crash in southeastern Ohio.


According to the Ohio State Highway Patrol, they were notified by Survival Flight that communications was lost with one of their helicopters around at 7:20 a.m. Tuesday.

The helicopter departed Mount Carmel Grove City hospital and was flying to Holzer Meigs hospital in Pomeroy.

Troopers located the wreckage of a Bell 407 helicopter east of State Route 278 and south of King Hollow Trail in Vinton County.

The flight crew has been identified as 34-year-old Jennifer L. Topper, 48-year-old Bradley J. Haynes and 33-year-old Rachel L. Cunningham. Topper was the pilot and Haynes and Cunningham were flight nurses.

The Federal Aviation Administration and National Transportation Safety Board are investigating the crash.

Mount Carmel Health issued the following statement on behalf of Andrew Arthurs, VP of EMS Operations, Survival Flight:

I am deeply saddened to share with you news of a heartbreaking event that occurred earlier this morning. A Survival Flight helicopter was involved in an accident in southeastern Ohio. Law enforcement confirmed that all three crew members on-board the helicopter did not survive. There were not any patients on-board. The Federal Aviation Administration is investigating. We will share more information with you as it becomes available.


Story and video:  https://www.10tv.com


COLUMBUS, Ohio (AP) — A newspaper reports two air-medical companies opted not to accept an assignment to transport a patient over concerns about the weather before a helicopter owned by a third medevac company crashed in southern Ohio, killing the pilot and two flight nurses.

The Columbus Dispatch reports West Virginia-based HealthNet Aeromedical Services and Columbus-based MedFlight were contacted Tuesday morning to transport a patient from a medical center in Pomeroy to a Columbus hospital.

A Survival Flight helicopter crashed around 7 a.m. Tuesday in state forestland in Vinton County.

MedFlight’s president and CEO told the newspaper that conditions on Tuesday didn’t meet the company’s minimum standards to fly. HealthNet Aeromedical said atmospheric conditions fell below “published operational weather minimums.”

The crash killed pilot Jennifer Topper and nurses Bradley Haynes and Rachel Cunningham.



VINTON COUNTY, Ohio (WSAZ) --   The names of the flight crew killed Tuesday morning in a medical helicopter crash have been released.


According to the Ohio State High Patrol, the victims were the pilot, Jennifer L. Topper, 34, of Sunbury, Ohio; and flight nurses, Bradley J. Haynes, 48, of London, Ohio, and Rachel L. Cunningham, 33, of Galloway, Ohio.


No passengers were onboard the helicopter.


Around 7:20 a.m., OSHP troopers were notified by Survival Flight that communication was lost with one of their helicopters. The helicopter left Mount Carmel Grove City Hospital in Grove City, Ohio, and was flying to Holzer Meigs hospital in Pomeroy.


Around 10:15 a.m., the OSHP found the wreckage of a Bell 407 helicopter east of state Route 278 and south of King Hollow Trail in Brown Township.


There were no reported injuries to anyone on the ground in the area.


The Ohio State Highway Patrol was assisted by Vinton, Meigs and Jackson counties sheriffs’ offices; Vinton County Emergency Management Agency; Ohio Department of Natural Resources; and the Vinton County Coroner’s Office.


Story and video:  https://www.wsaz.com






MCARTHUR, Ohio (WSYX/WTTE) — Ohio authorities are investigating a deadly medical helicopter crash in the southeastern part of the state.

The Federal Aviation Administration reports that a medical flight on its way to Pomeroy crashed Tuesday morning near the community of Zaleski. That's about 75 miles southeast of Columbus. Ohio State Highway patrol said three people were on board. The three killed were employees of Survival Flight, partners with Mount Carmel. 

Authorities have identified the victims as 34-year-old pilot Jennifer Topper, of Sunbury, and flight nurses Bradley Hayes, 48, of London, and Rachel Cunningham, 33, of Galloway.

Highway patrol troopers said they were able to locate the crash site by pinging one of the victims' phones. The wreckage was found shortly after 10 a.m. Highway patrol said there was "a lot of debris."

The crash was reported around 7:20 a.m. by Survival Flight. The helicopter was heading to Holzer Meigs hospital in Pomeroy to pickup a patient. It departed from Mount Carmel Grove City.

"Our prayers are with the families of the crew members and Survival Flight team as we grieve this devastating loss," said Michael Wilkins, president and COO of Mount Carmel East.

The FAA and National Transportation Safety Board sent investigators to the scene.

Mount Carmel Health announced the Survival Flight partnership last June. The program was launched to help those with serious injuries in rural areas around Ohio. 

https://myfox28columbus.com

1 comment:

  1. The scathing Final Report is out -
    https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=63015&CFID=3022903&CFTOKEN=70eb7b1c00894263-932BA7FC-E8F3-E7B8-F3A00FCD8070BFD7

    ReplyDelete