Saturday, January 09, 2021

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

34-year-old pilot Jennifer Topper, flight nurses Bradley Hayes, 48, and Rachel Cunningham, 33.











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





1 comment:

  1. I worked for Survival Flight, I was 'let go' because I refused to fly in bad weather, thunderstorms. I hope this company gets a huge fine, loses their certificate or gets sued for everything they own. If you read the report for this 'accident' you will agree.

    ReplyDelete