US HEMS Accident

[Hedski]

Another one. Still sad. B407 3pob.

https://www.10tv.com/article/3-killed-medical-helicopter-crash-southeast-ohio-identified

[havoc]

https://wwwcache.wral.com/asset/news/national_world/national/2019/01/29/18156156/5c50c011d0bdc-media_9c5bcd8b73524e55a3a9da1551af92c1-DMID1-5hn2j1xt4-640x480.jpg

In this photo provided by the Ohio State Highway Patrol, authorities survey the scene of wreckage where a medical helicopter crashed in a remote wooded area in Brown Township, Ohio, on its way to pick up a patient, Tuesday, Jan. 29, 2019. There had been no reports of anyone else injured in the crash. No names were released immediately. A few crew members were all killed in the crash, authorities said. (Ohio State Highway Patrol via AP

[twinstar_ca]

:sad: condolences to family and friends...

[skadi]

Looks like another night CFIT... :sad: RIP

skadi

[tottigol]

Still getting killed in the same sad useless way.
Shame on the industry, but mostly the blame is firmly on the FAA that is refusing to regulate HEMS.
God bless their young souls.

[SASless]

Extreme cold, snow showers, remote area.....video of the scene shows the aircraft utterly destroyed....just bits and pieces with debris scattered all through the forest.

Such a tragedy.....again.

[chopjock]

Was there an auto pilot fitted?

[TylerMonkey]

Looks like another night CFIT... :sad: RIP

skadi

sunrise approx 7:37 am , reported lost contact 7:20

[skadi]

sunrise approx 7:37 am , reported missing 7:20

So it could have been still dark at the time of the accident....

skadi

[TylerMonkey]

Now seeing ABC news reports crash time as 6:50 am.

https://abcnews.go.com/US/air-ambulance-helicopter-crashes-ohio-board-faa/story?id=60704284

[MightyGem]

Such a tragedy.....again.
So very true. A quote from the Duke of Wellington comes to mind. RIP :(

"They came on in the same old way and we defeated them in the same old way."

[tottigol]

Survivors ought to sue the FAA.

[SASless]

The Pilot was working three jobs....make you question what his sleep deficit was at the time of the crash.

[Robbo Jock]

What on earth are the pay rates if you feel the need to work three jobs?!?!

[Bell_ringer]

The Pilot was working three jobs....make you question what his sleep deficit was at the time of the crash.

Her..
Bit old school assuming all pilots are a he.
Millennials would have you flogged, if they approved of fatal beatings. :E

The crew members have been identified as pilot Jennifer Topper,

https://www.pressdemocrat.com/news/9228418-181/former-santa-rosa-woman-was

[mickjoebill]

“State troopers’ special response team and aviation unit began searching for the wreckage and finally located it around 10:16 a.m., reportedly pinging one of the crew members’ cellphones.”

3 hours to find the wreckage.
No tracking?


Probably wouldn’t have affected the outcome of those onboard had the site been located earlier...

mjb

[SASless]

The initial media report I read got it wrong.....it was the male Flight Nurse that was working three jobs....not the Lady Pilot.

That is what I get assuming the media had their stuff in one sack for a change.



Instrument Proficiency (not just legal currency) will be an issue in this tragedy.






Of course not...why would one want tracking of a EMS Helicopter....that would cost money.

Just like why would you follow a roadway if it takes and extra minute on a night flight when you can fly over dark unlit terrain in snow showers?

Besides....before long folks will want twins and autopilots and effective Instrument Flying Training.

When would it end....this wanting more Gucci kit and training?

[tottigol]

https://cimg0.ibsrv.net/gimg/pprune.org-vbulletin/562x750/fb_img_1548940345298_99e35d7ccda3e48351550fa532008f6f9257ae7 e.jpg
is this a real flyer?
If so someone should go to jail.

[ShyTorque]

"If no-one else will take the risks, call us, we will"

[SASless]

Known in the industry as “Chopper Shopping”.

[HeliHenri]

.
Medflight statment :

"As it relates to MedFlight, we received a request to transport a patient from the Holzer-Meigs Emergency Room in Pomeroy at 6:00 a.m. on Tuesday, Jan. 29. The assigned team’s pilot, working with the Operational Control Center at Metro Aviation, Inc., our aviation operator, determined that weather conditions at the time of request were below our program’s weather minimums. Each helicopter ambulance service has their own protocols for making decisions about whether it is appropriate to fly under given conditions."

http://www.verticalmag.com/press-releases/medflight-releases-statement-on-survival-flight-crash/
.

[112rm]

Why sue??? They didn't make the call to go

[112rm]

There needs to be serious education among the medical community on what it means when a provider turns a flight down due to WX. Sadly, the strive for the all mighty $$$$$ plays a huge factor into these decisions the crews make. based on the age of the pilot she wasn't in the industry several years ago 2004- 2008/09 when everyone was working to stop this type of behavior/risk taking.. Sad so Sad Please let us all do a better job of mentoring young pilots. we are NOT inventing new accidents.. just repeating....and repeating...

can i get an Amen!! sorry preachy I know

[LRP]

“State troopers’ special response team and aviation unit began searching for the wreckage and finally located it around 10:16 a.m., reportedly pinging one of the crew members’ cellphones.”

3 hours to find the wreckage.
No tracking?


Probably wouldn’t have affected the outcome of those onboard had the site been located earlier...

mjb

It was being tracked, when the track stopped they notified the local SAR. The tracking is similar to AFF that USFS uses, you get the last location return, but just like the last radar track, it may not get you close enough to the wreckage in wooded or rugged terrain. BTDT.

[FH1100 Pilot]

No matter what ends up being the actual cause of the accident, the very legitimate question will have to be asked: Why did she accept that flight when *two* other agencies turned it down? Being that close to sunrise, did she optimistically believe that things would get better as it got lighter out? Of course we have no way of knowing what she was thinking. But let us admit that launching at that time was ill-advised. Upon hearing that two other operators had already turned the flight down, most of us old-timers would've said, "Good enough for me!" and then taken off our white knight armor and gone back to sleep.

But we have to understand that women pilots are subject to some amount of increased pressure than their male counterparts. Aviation is a man-dominated industry to be sure and so some women are just going to feel - rightly or wrongly - as though they're infringing in our territory. Could this lead to a bit of, "I'll show 'em! I'll show 'em that I'm just as good as they are." Who knows. But I wouldn't be surprised if she felt some self-imposed pressure to launch, perhaps ignoring that tiny voice in her head saying not to.

We can dissect accidents six ways from Sunday. We can figure out all of the forensic details...the how and the when. But we can never know a pilot's thought process. When I think about some of the really close-calls I've had in my career, if any one of them had turned into a fatal, the investigators would've been scratching their heads wondering what the hell I was thinking and why I put myself,my passengers and the ship in that position? It is only through God's good fortune that they never had to ask.

We wouldn't be worth a crap as pilots if we didn't think that we could safely complete each flight, right? But how we convince ourselves of that is often complicated and murky and not easily understood.

[SASless]

If I ever learned of a "Turn Down" by another Operator I almost invariably said "No!".

I preferred to start from the default position of "No" then let the weather, etc.....argue me into saying "Yes".

The decision is easy when it is clear cut....good weather or bad weather....it is the in-between stuff that will kill you.

I will bet there were significant presence of snow showers in the area with some reporting sites showing marginal weather.

[tottigol]

Ha! We had several episodes of bad weather at destination and OUR OWN dispatcher was toning every helicopter in the operation to get a GO response.

[LRP]

No matter what ends up being the actual cause of the accident, the very legitimate question will have to be asked: Why did she accept that flight when *two* other agencies turned it down? Being that close to sunrise, did she optimistically believe that things would get better as it got lighter out? Of course we have no way of knowing what she was thinking. But let us admit that launching at that time was ill-advised. Upon hearing that two other operators had already turned the flight down, most of us old-timers would've said, "Good enough for me!" and then taken off our white knight armor and gone back to sleep.

But we have to understand that women pilots are subject to some amount of increased pressure than their male counterparts. Aviation is a man-dominated industry to be sure and so some women are just going to feel - rightly or wrongly - as though they're infringing in our territory. Could this lead to a bit of, "I'll show 'em! I'll show 'em that I'm just as good as they are." Who knows. But I wouldn't be surprised if she felt some self-imposed pressure to launch, perhaps ignoring that tiny voice in her head saying not to.

We can dissect accidents six ways from Sunday. We can figure out all of the forensic details...the how and the when. But we can never know a pilot's thought process. When I think about some of the really close-calls I've had in my career, if any one of them had turned into a fatal, the investigators would've been scratching their heads wondering what the hell I was thinking and why I put myself,my passengers and the ship in that position? It is only through God's good fortune that they never had to ask.

We wouldn't be worth a crap as pilots if we didn't think that we could safely complete each flight, right? But how we convince ourselves of that is often complicated and murky and not easily understood.

She may not have known anyone turned the flight down. The requester is supposed to inform them if they've been turned down, many times when they are shopping they leave that bit out.

[tottigol]

She may not have known anyone turned the flight down. The requester is supposed to inform them if they've been turned down, many times when they are shopping they leave that bit out.

Why couln't she check the WX herself?

[Hot and Hi]

It was being tracked, when the track stopped they notified the local SAR. The tracking is similar to AFF that USFS uses, you get the last location return, but just like the last radar track, it may not get you close enough to the wreckage in wooded or rugged terrain. BTDT.
LPR, do you know the tracking interval?

[LRP]

LPR, do you know the tracking interval?

I do not. But from watching it, the little acft symbol is very "jumpy". If I had to guess I would say around a minute.

[Evil Twin]

She may not have known anyone turned the flight down. The requester is supposed to inform them if they've been turned down, many times when they are shopping they leave that bit out.

So are the dispatch calls recorded? Notwithstanding the fact she should have checked and made a weather decision. Snow showers around also, flight in falling snow anyone?

[Arcal76]

If the flight was turned down by MedFlight, why their dispatch try to get somebody else on the same flight???
This attitude is totally wrong but typical from the US system.
Snow showers at night with a Bell 407 is not a good idea, if MedFlight had those information's, she also had it, why go in this case??
To prove what??
Again and again, same situation, same conditions, same result......

[Brutal]

Could the reason she accepted the flight was because of her lack of experience? I am not talking about her flying hours or instructional....but many guys and girls think that flying a helicopter around the sunny grand canyon, or sight seeing trips in Florida is the same as a job at night up north in foul weather conditions? (or even in the day for that matter)?
Lots of pilots are of the assumption that just because they have their licence and lots of hours they can fly anywhere and do anything? Maybe management should ask the questions in an interview to find out what "real" experience they have ,or think twice when reading one's Resume' before hiring?
B

[SASless]

As the situation stands currently....the Pilot accepted the flight and the aircraft crashed....killing all who were aboard.

It was dark, sparsely populated wooded terrain the aircraft was flying over.

The weather conditions appear to be an issue.

The Investigation will work to determine the most probable cause....be it mechanical or other.

One thing is for sure.....Management will not be held accountable by the FAA or NTSB.

It might very well be taken to task in some civil action....but so will the Pilot.

This as every such tragedy should result in "Lessons Learned" and probably shall.

Also, with absolute certainty we shall read yet another such Accident Report for exactly the same causes set forth in the coming Report.

EMS Helicopter Pilots must not be able to read and comprehend the written word based upon that.

Which makes this tragedy all the worse......daylight was about an hour away.....and we know how a simple factor such as flying in darkness affects the likelihood of a crash can be so pronounced.

Until the EMS Crews all accept they are not in the Life Saving business and are just providing safe, reliable, medical transportation by Helicopter....will the safety stats significantly improve.

Management has a major role to play in achieving that improvement.

Rather than critiquing flights that end in tragedy....perhaps the Industry should critique all of the flights that do not end in tragedy to ensure all of the Industry Best Practices are maintained.

The Crews themselves should be honest when they do their post flight critiques and feel free to accurately report up the chain of command the narrow misses that occurred.

But....I know with absolute certainty that is not something the industry will support.

With the advent of cheap, bare bones, community based EMS operations that must fly in order to pay the Bills.....the pressure is too fly....not reject flights.

Fancy words on slick advertising handouts....does not equate to reality far too often and we all know it.

[tottigol]

Absolutely correct SAS, I could have said the same although with added cursing and swearing.
However there IS a handout with names and phone numbers....

[Devil 49]

As the situation stands currently....the Pilot accepted the flight and the aircraft crashed....killing all who were aboard.

It was dark, sparsely populated wooded terrain the aircraft was flying over.

The weather conditions appear to be an issue.

The Investigation will work to determine the most probable cause....be it mechanical or other.

One thing is for sure.....Management will not be held accountable by the FAA or NTSB.

It might very well be taken to task in some civil action....but so will the Pilot.

This as every such tragedy should result in "Lessons Learned" and probably shall.

Also, with absolute certainty we shall read yet another such Accident Report for exactly the same causes set forth in the coming Report.

EMS Helicopter Pilots must not be able to read and comprehend the written word based upon that.

Which makes this tragedy all the worse......daylight was about an hour away.....and we know how a simple factor such as flying in darkness affects the likelihood of a crash can be so pronounced.

Until the EMS Crews all accept they are not in the Life Saving business and are just providing safe, reliable, medical transportation by Helicopter....will the safety stats significantly improve.

Management has a major role to play in achieving that improvement.

Rather than critiquing flights that end in tragedy....perhaps the Industry should critique all of the flights that do not end in tragedy to ensure all of the Industry Best Practices are maintained.

The Crews themselves should be honest when they do their post flight critiques and feel free to accurately report up the chain of command the narrow misses that occurred.

But....I know with absolute certainty that is not something the industry will support.

With the advent of cheap, bare bones, community based EMS operations that must fly in order to pay the Bills.....the pressure is too fly....not reject flights.

Fancy words on slick advertising handouts....does not equate to reality far too often and we all know it.

Why aren't pilots aborting, diverting or landing when issues are encountered????

[Hot and Hi]

Rather than critiquing flights that end in tragedy....perhaps the Industry should critique all of the flights that do not end in tragedy to ensure all of the Industry Best Practices are maintained.
Very good point! The same risky behaviour doesn't become acceptable just because you got a away with it this time.

[SASless]

Looking at the map....the crash site is in the middle of a very dark area.....anyone have the weather reports for the time for one. hour before to one hour after the crash?

[JimEli]

Looking at the map....the crash site is in the middle of a very dark area.....anyone have the weather reports for the time for one. hour before to one hour after the crash?

Archived Wx (https://www.weather.gov/tsa/obs) and Archived Wx (http://www.aviationwxchartsarchive.com/product/metar)

[Arcal76]

Absolutely, SASless !
Our job is to fly a patient from A to B and in this case, it looks like it was a transfer between hospital.
She could have wait one hour and they all will be OK today.
We are doing a job, maybe a special job, but it requires to respect some limits.
There is no hero there, the US has to get out of this stupid thinking.
We are no here to kill everybody on board to save one.
Anybody flying at night knows how difficult it is in reality in those conditions, pushing weather without the proper equipment to help you and having clear limits is just playing "Russian roulette".
Nobody learn, nobody !
It is like a repeat during the last 20 years, same thing again and again.
I believe the US refuse to adopt strict night minimum and still push pilots to fly when they shouldn't be like in the 80's.
And I won't even talk about the FAA..
One hour away from dead or alive !

[tottigol]

Absolutely, SASless !
Our job is to fly a patient from A to B and in this case, it looks like it was a transfer between hospital.
She could have wait one hour and they all will be OK today.
We are doing a job, maybe a special job, but it requires to respect some limits.
There is no hero there, the US has to get out of this stupid thinking.
We are no here to kill everybody on board to save one.
Anybody flying at night knows how difficult it is in reality in those conditions, pushing weather without the proper equipment to help you and having clear limits is just playing "Russian roulette".
Nobody learn, nobody !
It is like a repeat during the last 20 years, same thing again and again.
I believe the US refuse to adopt strict night minimum and still push pilots to fly when they shouldn't be like in the 80's.
And I won't even talk about the FAA..
One hour away from dead or alive !

ARCAL, I would have never thought I could actually get to agree with you on something.
Atta'boy!

[[email protected]]

Brutal Could the reason she accepted the flight was because of her lack of experience? I am not talking about her flying hours or instructional....but many guys and girls think that flying a helicopter around the sunny grand canyon, or sight seeing trips in Florida is the same as a job at night up north in foul weather conditions? (or even in the day for that matter)?
Lots of pilots are of the assumption that just because they have their licence and lots of hours they can fly anywhere and do anything? Maybe management should ask the questions in an interview to find out what "real" experience they have ,or think twice when reading one's Resume' before hiring? I thoroughly agree with your analysis and her judgment was probably skewed further by the fact she used to be a a rescue swimmer involved in real life-saving and may have approached her new job on HEMS with the same attitude.
If this was her first 'proper' job rather than sightseeing and basic instruction and she started in the HEMS business working for what seems like a 'cowboy' operator with a poor attitude to safety and weather limits - the holes in the cheese were lining up against her.

[Nescafe]

I thoroughly agree with your analysis and her judgment was probably skewed further by the fact she used to be a a rescue swimmer involved in real life-saving and may have approached her new job on HEMS with the same attitude.
If this was her first 'proper' job rather than sightseeing and basic instruction and she started in the HEMS business working for what seems like a 'cowboy' operator with a poor attitude to safety and weather limits - the holes in the cheese were lining up against her.

Not exactly definitive.

[[email protected]]

Not exactly definitive. sorry, must have missed the terms and conditions section where it said posts have to be definitive.............

She was a rescue swimmer and in the article her mother implies it was her first job after the sightseeing and instructional jobs and the general comments about the outfit she was working for do strongly suggest they have a poor attitude to safety and weather limits.

So sorry I can't get an affidavit for you........

[SASless]

Keep it simple guys.....one does not have to be inside cloud or fog to encounter the need to control the helicopter by reference to the Instruments.....and it happens very quickly at night over unlit terrain.

Coming from an instructional and tour background....just how much Single Pilot Instrument flight in Actual Instrument flying conditions did this pilot have? How much real IMC flight had she had recently?

We have to remember the US EMS Industry and the US FAA are quite happy if you are "legally" current....no matter that you cannot possibly be proficient and happen to be flying an a helicopter with no stabilization or autopilot at night over dark terrain.....under VFR.

That is a pretty tall order for any Pilot no matter how experienced and well trained.

To be fair....we do. not know if CFIT is the primary cause of this tragedy....but the circumstances sure lend itself to that being the case.

I once flew for a Single Pilot IFR Program where every six months we got an hour or so of Hood Time....immediately followed by an Instrument Check Ride. Upon passing that ride...we were Current and Proficient by Company and FAA Rules.

We were encouraged to do Approaches upon returning to the airfield where we fueled at the end of the EMS flight....but we all know doing Instrument Approaches in the clear blue without restricting your view of the outside is of not much use in maintaining the real skills that need turning up.

Mind you that was in a Sperry equipped Bell 412 that would do a pretty good job of flying itself while you got occupied with the rest of the tasks.

[[email protected]]

Coming from an instructional and tour background....just how much Single Pilot Instrument flight in Actual Instrument flying conditions did this pilot have? How much real IMC flight had she had recently? and how much night flying time?

[SASless]

Did the Pilot have NVG's?

[tottigol]

Keep it simple guys.....one does not have to be inside cloud or fog to encounter the need to control the helicopter by reference to the Instruments.....and it happens very quickly at night over unlit terrain.

Coming from an instructional and tour background....just how much Single Pilot Instrument flight in Actual Instrument flying conditions did this pilot have? How much real IMC flight had she had recently?

We have to remember the US EMS Industry and the US FAA are quite happy if you are "legally" current....no matter that you cannot possibly be proficient and happen to be flying an a helicopter with no stabilization or autopilot at night over dark terrain.....under VFR.

That is a pretty tall order for any Pilot no matter how experienced and well trained.

To be fair....we do. not know if CFIT is the primary cause of this tragedy....but the circumstances sure lend itself to that being the case.

I once flew for a Single Pilot IFR Program where every six months we got an hour or so of Hood Time....immediately followed by an Instrument Check Ride. Upon passing that ride...we were Current and Proficient by Company and FAA Rules.

We were encouraged to do Approaches upon returning to the airfield where we fueled at the end of the EMS flight....but we all know doing Instrument Approaches in the clear blue without restricting your view of the outside is of not much use in maintaining the real skills that need turning up.

Mind you that was in a Sperry equipped Bell 412 that would do a pretty good job of flying itself while you got occupied with the rest of the tasks.
Amen to that, and actually more actual than you may remember SAS, enough so to acually be proficient, at least by the time I got there.
And night time was a good 30% of total.
You are however correct on the whole post.

[BigMike]

What is the percentage of EMS operators using NVG in the US currently?

[LRP]

What is the percentage of EMS operators using NVG in the US currently?

Probably 100%

[SASless]

Probably.....is not an accurate response.

Either she did.....or did not.

Which was it?

[Arcal76]

If she had NVG's, she probably wouldn't crash because one the big advantage is, you see the weather
So, if there is a shower, you see it, you see the size, the intensity. It is easy in this case to go around and avoid it.
If you don't have them, well you only know when you are in and it is to late.
Now, if you try to scud in low weather with NVG's with snow showers, it is the perfect tool to get disoriented.

[Shawn Coyle]

Except over a built up area.
Did she have an IFR rating?

[chopjock]

Did the Pilot have NVG's?

Or more importantly perhaps, was there an AP?

[LRP]

Probably.....is not an accurate response.

Either she did.....or did not.

Which was it?

I am not on the accident board, I can't give you an absolute answer. The question was the percentage of HEMS are using NVG's. I don't know of any that are not, that's the best I can do. Whether this girl had them mounted and down would require forensics at the accident site.

[SASless]

Shawn.....under the FAA Rules....Part 135 Ops require surface light reference.....but then we also know that Rule is ignored nightly by far too many Operators.

What the rules are for NVG's and surface light reference....I am not knowing.

In some parts of the United States it can be along way between farm houses, ranch houses, and automobiles at night.....then throw in steep hills and mountains....a bit of haze....and there is lots of DARK.

[MightyGem]

If she had NVG's, she probably wouldn't crash because one the big advantage is, you see the weather
So, if there is a shower, you see it, you see the size, the intensity. It is easy in this case to go around and avoid it.
Looking at the map....the crash site is in the middle of a very dark area
Only if there is some ambient light. NVGs take in ambient light and magnify it. An overcast night, no moon, no streetlights/houselights to reflect off the clouds equals no light, so nothing too magnify, so you can see nothing.

[Arcal76]

"Only if there is some ambient light. NVGs take in ambient light and magnify it. An overcast night, no moon, no streetlights/houselights to reflect off the clouds equals no light, so nothing too magnify, so you can see nothing"


What is that ???
We see well at night every night. The intensity and clarity are different if it is cover or clear sky, but we still see all around us with NVG's.
There is no problem to fly with cover sky, it is just not so bright.

[Hedski]

One of the points raised re hours and actual experience strikes a chord. It seems common in US EMS that you need lots of hours (ca. 2000) but nobody cares to examine what quality of hours. So as in this scenario the pilot had very repetitive types of
day VFR experience, likely much of it on piston singles. But because the total number was big enough then it’s all ok. Yet I see on another form of social media military medevac experienced twin engine IFR pilots with 1000 hours of such unable to get a job. Especially in EMS where 2000 seems
to be required. So a box was ticked but actual experience totally inappropriate for the role etc. Again FAA not doing their job. Where’s the oversight....?

Not the company’s first rodeo either with 407: https://www.swoknews.com/local/air-scare

[SASless]

Gem,

I would politely differ with you.

I have flown on pitch dark overcast nights in the middle of southern pine forests doing confined area operations with no lights of any kind.....and had no problem.

Yes....some celestial light...stars...Moon....make it a whole lot better but even on the worst night for NVG's...it beat hell out of a good night with no NVG's!

Flying at night in snow without NVG's....without any real lighting...the snow was invisible....then click on the Landing Light and what an impressive sight that becomes!

[Arcal76]

I agree with you SASless,

If you fly manually at night in snow showers and turn the landing light ON, the result is more than disturbing and is the best way to loose everything. If you are coupled, just turn the light off and continue as long as it is a brief shower.
I will be very, very surprised if those machine had any sort of autopilot / flight director.
And I also agree than your experience can be vastly different from what the job requires, even if you have the 2000 hrs required, but in any case, you have to start somewhere on a new job.
Nobody had night time until you start flying at night, I mean real night flying, not around a town.
Nobody has HEMS time until you start flying HEMS.
It is important in this case to get all information's, advises, experiences from other crew to reduce any possibility to get caught in a stupid way because you were not aware of those problems.
In aviation, you don't know what you don't know.
We still have this mentality of keeping information's for ourselves just because we hire a pilot with 2000 / 3000 hrs.
Well, every time you change job, you will have to discover something...something you did not know.....and sometimes, you will be very surprised....
Was she aware of those situations?

[DOUBLE BOGEY]

Err, I am correct in believing there is no confirmed cause yet for this accident? Whilst it may carry the DNA of another CFIT at night it could also be something mechanical.

[SASless]

DB....welcome to the party....bit late old fella....that point has been made several times already.

[JimEli]

Shawn.....under the FAA Rules....Part 135 Ops require surface light reference.....but then we also know that Rule is ignored nightly by far too many Operators.
What the rules are for NVG's and surface light reference....I am not knowing.


NVGs are used as an aid to night flight during visual meteorological conditions (VMC), and operators are not to use NVGs during inadvertent instrument meteorological conditions (IIMC). This means that operators must comply with visual flight rules (VFR) weather minimums during a flight. For air carrier operations, these weather minimums are prescribed in the air carrier’s OpSpecs. The use of NVGs will not change or modify any of the existing regulations.

8900.1 VOLUME 4 AIRCRAFT EQUIPMENT AND OPERATIONAL AUTHORIZATION, CHAPTER 7 ROTORCRAFT AUTHORIZATIONS AND LIMITATIONS, Section 4 Safety Assurance System: Night Vision Imaging Systems (http://fsims.faa.gov/wdocs/8900.1/v04%20ac%20equip%20&%20auth/chapter%2007/04_007_004.htm)

[evil7]

Just for me to understand - in the US you take tour pilots used to nice bright sunshine tours, put them on a SE „HEMS“ Helicopter and let them fly in sh...ty weather, at night because you can stick a NVG on them and then all is good? Well, congratulations to that bright idea!

[[email protected]]

Anyone know what the company's published VFR limits are?

[MightyGem]

What is that ???
Just saying that on an overcast night, no moon, no cultural lighting, out in the desert, we couldn't see the ground if we went above 100 feet.

[Arcal76]

I agree Gem.
Desert or lake with cover sky are different because you do not see any texture, looks like a uniform surface and it becomes hard to know how high you are.
But it was not the case there, hills , trees..... a lot of texture in this case to get reference.

[SLFMS]

If she had NVG's, she probably wouldn't crash because one the big advantage is, you see the weather
So, if there is a shower, you see it, you see the size, the intensity. It is easy in this case to go around and avoid it.
If you don't have them, well you only know when you are in and it is to late.
Now, if you try to scud in low weather with NVG's with snow showers, it is the perfect tool to get disoriented.


Arcal76 I have to respectfully disagree at least in part with your comment about seeing the weather while using NVG's. Most of the time seeing the weather is the case but not always. In my part of the world when you have an overcast sky with multiple squalls of bad weather moving through on some nights it is very easy to fly into rain or cloud without seeing either. My operation is IFR so if at safe height it is really not an issue and those conditions certainly are not conducive for VFR, my point though is if a crew is pushing it VFR in marginal weather even with goggles they may not see rain or cloud until in it, even then it is possible an inexperienced crew are not aware they are in fact IMC. NVG's while awesome also have there limitations and are not a silver bullet especially if mixed with bad crew decision making.


I do not have any NVG experience in snow or sleet so perhaps the squall lines are more obvious in those conditions?

[Shawn Coyle]

Seems impossible to know what the vis is without lights on the ground at night when t's overcast...

[Jack Carson]

I apologize if this issue has been previously addressed. My experiences include flying single engine B-206L and AS-350 machines at night, unaided, in the deserts surrounding Globe, AZ and operating more advanced machines at night with NVGs and autopilots in the Carolinas. The believe that decision to mandate the use NVGs over the basic autopilots was flawed. Standardized training that would require the engagement of an autopilot for all but departure and arrival phases of flight and would reduce workload allowing for better overall management of the flight. Encountering a significant change in weather, in route, could be handled by simply allowing the autopilot to reverse course. I believe that there is also a place for NVGs. A night emergency requiring an immediate landing in a remote would be just such an instance where NVGs would be invaluable. Given a choice, I would select an autopilot over NVGs.

[SASless]

The Rule!


§ 135.207 VFR: Helicopter (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=7dc120721ef47a2c4dc17c9948799e0e&term_occur=1&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207) surface reference requirements.No person (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=24a80ca42ed148d527b7ddad982da95a&term_occur=1&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207) may operate a helicopter (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=7dc120721ef47a2c4dc17c9948799e0e&term_occur=2&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207) under VFR (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=89ef57ffe626edb2df5bf10d8ab4f876&term_occur=1&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207) unless that person (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=24a80ca42ed148d527b7ddad982da95a&term_occur=2&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207) has visual surface reference or, at night (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=eafc41de53e33571dffcb7bf5791ab80&term_occur=1&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207), visual surface light reference, sufficient to safely control the helicopter (https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=7dc120721ef47a2c4dc17c9948799e0e&term_occur=3&term_src=Title:14:Chapter:I:Subchapter:G:Part:135:Subpart:D: 135.207).

Notice the emphasis upon "Person" and "That Person" in the Regulation.

So...while you are out risking life and limb of yourself and the Med Crew....you reach an area that has no surface lighting within sight....and it is an overcast night....and there are no headlights, tail lights or hunters out spot lighting deer for you see.......what do you do?

[[email protected]]

MG - same in the Falklands but being able to discern the ground from the sky is possible even on the darkest nights (except maybe over the sea) and combined with the good use of the rad alt and some flight planning is at least enough to stop you spanking in. Even seeing the ground suddenly appear in the last 100 ft would be enough to take avoiding action.

Jack - agreed, autopilot first, then NVG.

[Devil 49]

The Rule!

Notice the emphasis upon "Person" and "That Person" in the Regulation.

So...while you are out risking life and limb of yourself and the Med Crew....you reach an area that has no surface lighting within sight....and it is an overcast night....and there are no headlights, tail lights or hunters out spot lighting deer for you see.......what do you do?



You divert to a route that allows keeping the required surface reference. I routinely planned to follow routes that maximized the possibility of surface lighting and avoided areas where it was more likely to be difficult. If the plan is in place from takeoff, considerable diversions, say a 20 mile diversion mid-leg on a 100 mile route requires a mere 4 minute penalty (117 kn cruise) making 0:51 into 0:55. I've spent more time waiting for the hospital to get the pad cleared, not to mention performing high recons on a remote lz while the ground people get stuff organized.

Or you abort- just like ceilings and vis, that light is a required minimum. "If you wouldn't go for a box of rocks...' was the cliche used in company orientation.

NVGs make maintaining that single light contact much, much easier in that the smallest light is visible and from much farther away. I have flown nights in which I NVGs showed lights on the ground that were not visible with the naked eye, recent 'controlled burns' of managed forests with remaining embers spring to mind. I believe I could also see personal electronics, watch and cell phone faces from miles away as well with NVGs, there were certainly more lights visible aided than unaided.

Descending to maintain visual reference in adverse weather is a trap. It is an especially dangerous practice for VFR nights. One needs other parameters in the decision before you even consider 'down'. How low will you allow yourself to descend? How quickly do you want to descend? Wanting down quickly is a very, very bad sign. Are there likely to be surface references after the descent? Are you 100% certain that the issue is temporary? Are you slowing from maximum cruise to deal with vis? Another big, BIG indicator that it's really time to quit.

[JimEli]

§ 135.207 VFR: Helicopter surface reference requirements. No person may operate a helicopter under VFR unless that person has visual surface reference or, at night, visual surface light reference, sufficient to safely control the helicopter.

“sufficient” meaning being what is necessary or desirable, or that which is required for meeting a need.

Is it possible, that NO “visual surface light reference” is sufficient (required to meet the need) to “safely control the helicopter”? Think in terms of a high illumination, starry, cloudless night in a highly defined but remote environment devoid of surface lights. Just asking.

[SASless]

visual surface light reference is the immediate issue.

[[email protected]]

And one or two lights really doesn't provide the spatial information required - anyone who has been disorientated by trying to use a single point light reference will know that.

[nomorehelosforme]

https://www.10tv.com/article/ntsb-sharp-left-turn-fatal-survival-flight-helicopter-crash-southeast-ohio

The National Transportation Safety Board has released its preliminary report on the Survival Flight medical helicopter crash in southeast Ohio last month (https://www.10tv.com/article/3-killed-medical-helicopter-crash-southeast-ohio-identified).

The flight was traveling from Mount Carmel Grove City hospital to Holzer Meigs hospital in Pomeroy for a patient transfer back to Columbus on January 29

[LRP]

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20190129X14921&AKey=1&RType=Prelim&IType=FA

[Arcal76]

Well, it looks like a typical CFIT......

I don't know how people fly at night but this idea to be in contact with the ground all time is....impossible.
You have to stay around urban area or town to be able to do that.
How would you fly EMS doing that?
The fact is, the FAA and Transport Canada have regulation who make no sense, are not appropriate to any operation, and of course, refuse to change it because they perfectly know the consequences.
In many places, you go for a night flight and a big part of this flight is done in complete darkness. In reality, a night flight is an instrument flight and nothing else.
We go to many places where it does not matter looking outside because you won't see anything. Of course, now we have NVG"s, so we see everything.
But, I flown for a very long time without them and what you do, is an instrument flight.
Looking at one lonely light somewhere won't help you anyway, it is the best way to get disoriented.
The FAA and TC know that perfectly well, they know what everybody is doing, but do they change anything??

[chopjock]

So no AP then...

[SASless]

Arcal.....the VFR minimums are determined by weather data....ceiling and visibility.....not whether you can see anything or not.

[tottigol]

Arcal.....the VFR minimums are determined by weather data....ceiling and visibility.....not whether you can see anything or not.

Remember though, THEIR WX minimums are different.....they can do things when others cannot....

[helonorth]

Remember though, THEIR WX minimums are different.....they can do things when others cannot....

Yes and no. Their minimums are the FAA EMS minimums of 800 and three day and 1,000 and three at night, aided. These are the same minimums as where I work (a very a safe and reputable company that I'll leave out). Their primary competitor's minimums are higher and very often decline flights with very good weather. I can't really blame them if they want to capitalize on this. So if you have a problem with Survival Flight's minimums, you really need to take it up with the FAA. As far as this accident, it's starting to look like CFIT, probably from spacial disorientation. If that is the case, the pilot (ahem) probably didn't quite meet the minimums on the accident flight. Now you will probably want bring up pressure to fly. I worked there and I was never pressured to fly (ever) and I never heard another pilot say anything to that effect, either. You've got a bit of a nothing burger going on.

[[email protected]]

So if the weather minima are fine and there is no pressure to go flying - how come we keep seeing HEMS helicopters spread all over the hillsides?

[SASless]

Crab....you know as well as anyone....there are "pressures" applied that are even sub-conscious pressures.

Even at a 1000 foot ceiling and 3sm Vis....on an overcast night....there are more than a few times there is n nothing to be seen outside the aircraft in remote areas.

Could it have simply been as easy as merely losing control of the aircraft due to vertigo?

That can happen with zero overt pressure to fly being applied by anyone.

[helonorth]

So if the weather minima are fine and there is no pressure to go flying - how come we keep seeing HEMS helicopters spread all over the hillsides?

Have you ever taken a flight that you wish you hadn't? Ever made a dumb mistake that could have gotten yourself killed but got lucky? That's how. Helicopter flying is inherently dangerous.

[NRDK]

HELONORTH

Of course Crab has. All SAR pilots have and they have the most demanding pressure of all aviators to get airborne. Decisions never come easy. The difference being this is as a highly trained team of 4 crew. You get what you pay for, equipment, crew training and logistical support...

Sadly, cheap options are going to be spread out across the ground for years to come as a result.

[helonorth]

HELONORTH

Of course Crab has. All SAR pilots have and they have the most demanding pressure of all aviators to get airborne. Decisions never come easy. The difference being this is as a highly trained team of 4 crew. You get what you pay for, equipment, crew training and logistical support...

Sadly, cheap options are going to be spread out across the ground for years to come as a result.

Okay, change the minimums and require IFR aircraft and two pilots. Since that's never going to happen, why even bring it up. A flight like this is done hundreds of times a day. It should be no different that flying some tourists around the Grand Canyon (oh yeah, they crash, too). If you can do the flight safely, do it. If you can't, don't go. If you do go and it goes south, turn around or land. It's really no different than any other VFR operation and I think the accident rates, across all segments, back me up.

[Devil 49]

Have you ever taken a flight that you wish you hadn't? Ever made a dumb mistake that could have gotten yourself killed but got lucky? That's how. Helicopter flying is inherently dangerous.

Divert. Abort and go home. Land. Fly to survive, survive to fly. I can get another job, it's harder to get another ticket, and impossible if you're dead- and careless, lazy aviation will kill you.

There are several reasons US HEMS has 'so many accidents.' There is more of it, covering more area with minimal support and regulation built around operator's interest.
Beyond being told landing was 'an acceptable option' if I could not proceed safely, nothing in the company culture or structure encouraged that decision easy. It was never trained in initial or recurrent, and seldom even mentioned in discussion. Weather minimums are secondary to decision making, forecasts are guesses, observations are history, the weather is what you see from the cockpit, you have to deal with what exists. The vis, ceilings may be officially acceptable but if you're working hard to just control and fly the aircraft safely, you are behind the aircraft and it is flying you. A competent PIC's job is to evaluate and plan to complete the leg if possible, but definitely maximize survival and perhaps, just perhaps not break the aircraft. Approaching each flight prepared to abort, divert, land somewhere uncomfortable to survive or minimize the chance that you sacrifice an aircraft to merely survive would, I think, go a long way to reducing all accidents.

When I flew Gulf of Mexico, our training emphasized the fact that a power on ditching was much, much safer than an autorotative ditching. How many pilots would put a running helicopter on the water, or in the trees, merely because he wasn't certain he could extend the fuel to a safe, undamaged landing? Extending the glide kills crews regularly, avoiding the decision that you have to land now does too. I found it much more comfortable and easy to avoid the possibility at every opportunity, because I knew with certainty that better pilots than I had died pushing it. Been to a lot of funerals over the years.

[SASless]

I never regretted landing when I did because of deteriorating weather....on the other hand I have rued deciding to push on.

I very much was into the "Chicken out early....mode of thinking!".

If you think Taxi Fare is expensive....try adding up the cost of an accident.

[Heliringer]

I never regretted landing when I did because of deteriorating weather....on the other hand I have rued deciding to push on.

I very much was into the "Chicken out early....mode of thinking!".

If you think Taxi Fare is expensive....try adding up the cost of an accident.

Autopilot and NVIS should be mandatory for this type of 24/7 flying. I doubt they are though. One thing I have found as I get more experienced, I find it much easier to refuse to fly in marginal conditions.

[bryancobb]

The Temperature/Dewpoint was 6C/10C ( 42.8 DegF/50.0 DegF).

The current Temperature/Dewpoint SPREAD was 7.2 Deg in the NEGATIVE direction, well B E L O W the temperature at which the air would become
saturated and fog would form! Then...if there were flat valleys or streams, HEAVY fog would have formed faster than the wind could sweep away.

[LRP]

The Temperature/Dewpoint was 6C/10C ( 42.8 DegF/50.0 DegF).

The current Temperature/Dewpoint SPREAD was 7.2 Deg in the NEGATIVE direction, well B E L O W the temperature at which the air would become
saturated and fog would form! Then...if there were flat valleys or streams, HEAVY fog would have formed faster than the wind could sweep away.

The NTSB prelim says -6C/-10C.

[bryancobb]

The NTSB prelim says -6C/-10C.

That wouldn't make any sense for foggy conditions. It must be a typo. If it was 21 DegF outside, all moisture would have fallen as
frost already and the humidity would be ZERO. If the temperature dropped from 21 DegF to 14 DegF, I'm pretty sure the air would
not become saturated.

[LRP]

That wouldn't make any sense for foggy conditions. It must be a typo. If it was 21 DegF outside, all moisture would have fallen as
frost already and the humidity would be ZERO. If the temperature dropped from 21 DegF to 14 DegF, I'm pretty sure the air would
not become saturated.


https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1177x473/nome_46712e6eae3123753e00697c27631eed9f3b04e8.jpg
No offense intended, but you might want to research that theory.

[megan]

Water can remain liquid down to -40°C. Then you can have ice fog which only forms under specific conditions; the humidity has to be near 100% as the air temperature drops to well below 0 °C (32 °F), allowing ice crystals to form in the air.

[Outwest]

"Water can remain liquid down to -40°C"

Really??? I guess I better go back to school, I would like to see that trick :}

Megan, I'm sure you meant " water can remain VISIBLE down to -40C" as in ICE fog......

[Outwest]

That wouldn't make any sense for foggy conditions. It must be a typo. If it was 21 DegF outside, all moisture would have fallen as
frost already and the humidity would be ZERO. If the temperature dropped from 21 DegF to 14 DegF, I'm pretty sure the air would
not become saturated.

Don't let anyone ever tell you you can't have fog (ice fog) at -40C I have iced up badly at -40C, ice fog rising off the open sea in the Canadian arctic

[SASless]

Memory serves me we removed the Water Filters from the Barrel Pumps in the Winter up in Alaska.....two reasons....water becomes ice and jet fuel gets awfully thick and hard to pump by hand.

We are talking Temps of 0 degrees F and colder....down to like -45F.

I went South after I saw -50F on any OAT Gauge as I was a fair weather pilot.....and not a real Sourdough.

[Old Dogs]

Don't let anyone ever tell you you can't have fog (ice fog) at -40C I have iced up badly at -40C, ice fog rising off the open sea in the Canadian arctic

Very true.

Strong winds = open leads = ice fog. Often you will see a "Moon Dog" associated with these conditions.

I have picked up heavy clear at -45C in the Lougheed Island area in November/December/January.

I experienced the same icing conditions in the Beaufort Sea on 212/61/76's every winter I flew there (8 years).

[bryancobb]

Water can remain liquid down to -40°C. Then you can have ice fog which only forms under specific conditions; the humidity has to be near 100% as the air temperature drops to well below 0 °C (32 °F), allowing ice crystals to form in the air.
Well... I guess I'm just allowing my ignorance to shine brightly. ;) Just a very lower-48 kind of guy.

[[email protected]]

Most aviation meteorology books with a section on icing will tell you about supercooled water droplets - ie those existing below 0 degrees C which can be found in temperatures as low as -40 degrees C, normally in cloud with lots of vertical movement.

However, it requires the absence of appropriate freezing nuclei in the atmosphere for the water to freeze onto.

[bryancobb]

Most aviation meteorology books with a section on icing will tell you about supercooled water droplets - ie those existing below 0 degrees C which can be found in temperatures as low as -40 degrees C, normally in cloud with lots of vertical movement.

However, it requires the absence of appropriate freezing nuclei in the atmosphere for the water to freeze onto.

I remember the "supercooled water droplets" and "condensation nuclei" questions but have never had any experiences related to it.
It was wayyy back in my head-noodle. I would guess it's pretty hard to find modern day sky that is not packed with condensation nuclei.
I was just searching for weather related reasons this HEMS crash could have happened. I know fast-forming fog could put a pilot in a
situation with no "out."

[Airbubba]

Radar and other data sources showed the helicopter, which was only certified to operate in visual flight conditions, flying mostly between 900 and 1,700 feet above ground level as it traversed the first of two bands of snow showers. During a second encounter with snow several minutes later, which would have significantly reduced visibility, the pilot made a left 180° turn in what investigators said was likely an effort to reverse course to an area of better visibility. For unknown reasons, the pilot failed to maintain altitude while making the turn and the helicopter collided with trees and then terrain in a heavily wooded area

A VFR helo trying to make a 180-degree turn in reduced visibility has a CFIT. Seems like I've heard that one before... :(

Helicopter Air Ambulance Operator’s Poor Safety Management, Inadequate Oversight Led to Fatal Crash5/19/2020 WASHINGTON (May 19, 2020) — An air ambulance helicopter crash that killed three crew members was caused by the operator’s “inadequate management of safety,” which led to a pilot departing on a flight without a thorough preflight weather evaluation, the National Transportation Safety Board announced in a public meeting Tuesday.

The Bell 407 helicopter air ambulance, operated by Survival Flight, crashed in Zaleski, Ohio, Jan. 29, 2019, in deteriorating weather while enroute to pick up a patient for transport from one hospital to another. All three occupants – the pilot, flight nurse and flight paramedic – were killed in the accident.

“This accident was all but invited by the actions and culture of Survival Flight,” said NTSB Chairman Robert L. Sumwalt. “Unfortunately, we have seen yet another case of how a poor safety culture can lead to tragedy.”

Radar and other data sources showed the helicopter, which was only certified to operate in visual flight conditions, flying mostly between 900 and 1,700 feet above ground level as it traversed the first of two bands of snow showers. During a second encounter with snow several minutes later, which would have significantly reduced visibility, the pilot made a left 180° turn in what investigators said was likely an effort to reverse course to an area of better visibility. For unknown reasons, the pilot failed to maintain altitude while making the turn and the helicopter collided with trees and then terrain in a heavily wooded area.


https://www.ntsb.gov/news/press-releases/PublishingImages/NR20200519-img.png

(In this photo taken Aug. 7, 2018, the accident helicopter is positioned on the helipad at Mount Carmel East Hospital, Columbus, Ohio. Photo courtesy of The Columbus Dispatch.)

In post-accident interviews, current and former Survival Flight employees said there was pressure from management to operate flights in challenging conditions and to take flights that other helicopter air ambulance services turned down due to inclement weather.

The NTSB found pilots and operations staff of Survival Flight routinely failed to comply with preflight risk assessment procedures because such noncompliance had become “normalized” by Survival Flight’s deficient safety culture.

The NTSB also said the Federal Aviation Administration’s inadequate oversight of Survival Flight’s risk management program and the FAA’s failure to require helicopter air ambulance operators to have safety management systems contributed to the accident.

Investigators said the safety risks that existed at Survival Flight would likely have been identified and mitigated by a properly run safety management system, which could have prevented this crash.

In 2009 the NTSB recommended the FAA require all helicopter air ambulance operators to have safety management systems. The FAA didn’t adopt the recommendation – and the NTSB subsequently identified the lack of safety management systems as a factor in a string of additional fatal crashes. In 2016 the NTSB recommended that all on-demand aircraft operators, including helicopter air ambulances, be required to have safety management systems. That recommendation, which was reiterated three times between 2016 and 2020, was reiterated for a fourth time Tuesday.

“We keep asking that safety management systems be required of Part 135 operators because we keep seeing crashes the systems are designed to prevent,” said Sumwalt. “This has to change, and it is past time for the FAA to implement our recommendation.”

Improving the safety of Part 135 operations is on the NTSB’s Most Wanted List.

As a result of the investigation the NTSB made 14 new recommendations to the FAA, the National Weather Service and Survival Flight. The NTSB also reiterated four other recommendations previously issued to the FAA.

An abstract of the NTSB report, which includes the findings, probable cause and safety recommendations, is available at https://go.usa.gov/xvJ8A.

The complete text of the final report is expected to be published in the next few weeks. The accident docket, containing more than 2,600 pages of factual materials was opened Nov. 19, 2019; it is available at https://go.usa.gov/xvsha.


https://www.ntsb.gov/news/press-releases/Pages/NR20200519.aspx

[MightyGem]

Seems like I've heard that one before..
...and before that and before that ad nauseam. :ugh:

[[email protected]]

Maybe 'Survival Flight' should change their name:ugh:

[JimEli]

Seems like an accident waiting to happen. Does the FAA perform any oversight of HEMS operators? This accident comes down to this:

1. The information that 2 previous operators declined this flight was never passed to the accident operator/pilots.

2. Unacceptable behavior:

“When the accident pilot arrived at Base 14, she proceeded directly to the already-started helicopter and departed.”

“There was no record of the accident pilot receiving a weather briefing or 2 accessing any imagery on the weather application (Foreflight).”

“Additionally, neither pilot completed a preflight risk assessment for the flight, as required by Title 14 Code of Federal Regulations Part 135.617, and the evening shift pilot stated he expected the accident pilot to complete the assessment after she returned.” My italics.

[Two's in]

As much as the threat to a regular paycheck is always a major consideration, there are very few HEMS accidents that can't be root caused back to poor airmanship. Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable risk. If (as a Captain) you are unable to do that, commercial flying may not be for you.

[megan]

Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable riskTrue in a perfect world Ti, but when normalisation of deviance is the SOP, and it's the company ethos, else you are subject to the highlighted part of the NTSB report below.Survival Flight’s inconsistent compliance with standard operating procedures and regulations, combined with management’s procedural gaps in risk management, advertising of flights in lower weather minimums, pressure to complete flights, and punitive repercussions for safety decisions, were indicative of a poor safety culture at the company.

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.Even the FAA gets a slap. Remember the two Shuttles were br ought down by normalisation of deviance, so it's not confined to the low end of GA. It's very rare that an accident is the result of a single cause, like the pilot not standing up to organisational pressure, the NTSB has told us why the pilot in this case possibly didn't - punitive repercussions.

[[email protected]]

The management of Survival Flight should be in court and, very shortly afterwards, in jail.

[JimEli]

It seems that the culture of total disregard for policy and regulation in this HEMS organization was extreme. Does anyone believe this is the norm in the HEMS industry or is this just an example of a rogue operator?

[MightyGem]

Still operating.
https://www.survivalflightinc.com/about-us/

[megan]

is the norm in the HEMS industry or is this just an example of a rogue operatorIt's a feature that exists all over the place, even in Fortune 500 companies. One company had its pilots on staff and they were subject to a yearly appraisal as to what, if any, yearly salary increase may be received, made sure things were done the company way, not what ops manual or regs said.

[Torquetalk]

The 407 is pretty much a Longranger with 4 blades and lots more power. Easy to slip into a turn if banking more than standard rate and not adding enough collective. Perilously easy if in IMC or pitch darkness and not tight on the instruments.

[Torquetalk]

As much as the threat to a regular paycheck is always a major consideration, there are very few HEMS accidents that can't be root caused back to poor airmanship. Good Captaincy decisions start with resisting organizational pressure to operate beyond acceptable risk. If (as a Captain) you are unable to do that, commercial flying may not be for you.

True but culture and context are powerful. Otherwise we are still stuck at blaming pilots for making decisions which are wrong in hindsight. Yet they are rewarded and good pilots who get on when it doesn’t go wrong... Insidious and implicitly dangerous.

Reminds me of the old joke about the aborted take-off due to unusual engine noise. Took the company an hour to find a replacement crew that wasn’t bothered by the noise.

[Airbubba]

NTSB Final Accident Repost issued: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf

[grumpytroll]

NTSB Final Accident Repost issued: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf

If I walked in to work and the aircraft was already running..To the pilot on duty, "go out and shut that damn thing off". One of us might be leaving the company permanently depending on what happens next. So many things wrong with this entire situation but that one really struck me as outrageous. I can assure you that at the EMS program where I work, a running aircraft awaiting my arrival and immediate departure would NEVER happen.

[LRP]

If I walked in to work and the aircraft was already running..To the pilot on duty, "go out and shut that damn thing off". One of us might be leaving the company permanently depending on what happens next. So many things wrong with this entire situation but that one really struck me as outrageous. I can assure you that at the EMS program where I work, a running aircraft awaiting my arrival and immediate departure would NEVER happen.
and there in is the actual cause of the accident.