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Three Dead....Another Night Bad Weather Flight Over Dark Terrain

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Old 2nd Jan 2006, 21:25
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Some interesting comments and I will reply to SASless's questions in the morning as it is quite late here. Have just returned from a company meeting and had our pilot in Slovakia (we just started a contract there from the 1st Jan) call to tell us he refused a flight this evening due to weather, the operator in the next area accepeted it, and has not been heard from since. An ELT signal has been picked up in the area and they are conducting a ground search now. Weather at the time was 1000ft cloud base, less than 2 kms vis, with the flight taking place in an area of high terrain. I believe the helicopter is a 109 from Bankska Bystrica. Will know more in the morning.
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Old 2nd Jan 2006, 21:42
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

This is sounding a lot like other threads on this subject.
Night VFR in a single engine machine, no SAS or auto pilot and single pilot is safe if you fly night VRF when there are night VFR conditions, it is definately not safe trying to fly night VFR when VFR conditions don't exist.
With a visible horizon and some moon about and recent experience very safe. I know the regulations don't require the horizon or moon, I do.
If you are working EMS you can say NO. If you are doing it privately or airwork, you can say no.
I have done EMS and I did say no on a number of occasions. No it didn't take balls, I was only looking out for myself. I have also been on a job and landed on route home because night VFR conditions were no longer available.
I have also been on a private job and when the boss was late, we stayed overnight because the weather didn't suit night flying. My theory is, if in doubt stay in bed.
I must admit that when doing EMS the Chief Pilot and Management never second guessed or questioned a weather related descision. And now I work for a private operator it is the same, they assume I'm looking out for their safety.
As a lot of experienced people on this forum have stated, the only way to enhance the safety of night VFR is goggles used properly, but with suitable night VFR conditions.
So it nearly always comes down to the fact the the Pilot has made a bad call. On this particular accident, lightening, rain, low cloud, being a coward, I would not have even got out of bed. Please don't take that last cooment as me talking ill of the dead, just my thoughts on the subject.
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Old 2nd Jan 2006, 22:14
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Unhappy Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

"I would much rather learn from your mistakes than my own, particularly if they are fatal ones."

Hear, hear, SASless.

I agree 100%. We owe it to our employers, our passengers, our families and friends to do just that. The most critical thing about this business is knowing when to say no.
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Old 3rd Jan 2006, 02:57
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

While surfing the net tonight....ran across an article put out by AAMS after their Safety Syposium in April of 2000. They spent six hours discussing the safety situation of the US Helicopter EMS industry. I found the summary interesting and wonder how much progress that organization has made on what they proposed as initiatives resulting from that meeting.

One section of their effort was to identify factors that lead to accidents and set a priority on addressing them.

The participants consolidated the factors into the following:

Causal Factors

Organizational Culture/Attitude

Training/Implementation (Pilots, crews, management, mechanics)

External Factors/Pressures/money

Standardization (Ops, FAA, Regional, Industry)

Commitment (money, equipment, time)

Risk Management

Statistics/Survey Industry & line pilots

Decision Making

IFR Competency/Proficiency/Currency

Human Factors

Pilot Error

Zero Accident philosophy

Weather (FAA minimums, Industry minimums, Training, Reporting)

Pilot qualifications

Communications

Flight Ops (VFR/IFR, Day/Night, LZs)

Technology/Equipment

Regulations (& following them)

Monitoring Cockpit actions

Utilizing Lessons Learned



The participants were asked to vote for the 5 areas that were the most important factors affecting industry safety, in order to come up with a group prioritization of these factors.

The results were:

First Priority: Organizational Culture/Attitude

Second Priority: Training/Implementation (Pilots, crews, management, mechanics)-- 40 votes

Third Priority: Standardization (Ops, FAA, Regional, Industry)-- 24 votes

Fourth & Fifth Priorities: (tie, both with 22 votes) Pilot Error and Technology/Equipment

Other factors received these votes:

Decision Making – 21 votes

External Factors/Pressures/money – 20 votes

IFR Competency/Proficiency/Currency – 20 votes

Zero Accident philosophy – 19 votes

Weather (FAA minimums, Industry minimums, Training, Reporting) – 17 votes

Commitment (money, equipment, time) – 11 votes

Human Factors – 11 votes

Statistics/Survey Industry& line pilots – 10 votes

Regulations (& following them) – 10 votes

Utilizing Lessons Learned – 9 votes

Communications – 6 votes

Pilot qualifications – 4 votes

Flight Ops (VFR/IFR, Day/Night, LZs) – 4 votes

Risk Management – 3 votes

Monitoring Cockpit actions – 3 votes

Highlights are mine not the report's.



Do the priorities arrived at by the operators, managers, FAA, and other non-line pilot persons seem similar to those line pilots might consider important? The Upper echelon of the industry do not seem to rank Risk Management and using Lessons Learned very highly. I wonder why that is?

Am I wrong in thinking a good Risk Management effort combined with learning from past incidents/accidents would go a very long way towards preventing accidents all by themselves?

Last edited by SASless; 3rd Jan 2006 at 03:15.
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Old 3rd Jan 2006, 06:22
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Further to the missing EMS 109 in Slovakia last night, wreck of helicopter found on the side of a mountain with all dead, 3 people, Pilot - Doctor - Paramedic.

We refused it, they throught they could do it.





To answer SASless's questions:

"In your opinion, would that Coordinator have to be physically present for there to be "pressure" felt by a pilot regard turning down flights?"
- Depends on the pilot. Some people are more likely to press on because they are afraid of management than others. Point is, there should have been NO pressure in the first place.

"Do you advocate reducing night VFR weather minima if an operation adopts NVG's?"
- NO WAY. Remember you are still flying VFR...the minimums DO NOT change, things are just a whole lot safer.

"What night weather minima do you use at your operation for Night VFR unaided flights....and Night VFR aided flights?"
- Currently we only fly Night VFR unaided (May be starting a NVG assisted program this year) Weather minimums for this company are: Cloudy conditions-8 kms vis with minimum cloud base of 800ft, No clouds-5 kms vis. Anything less and NO flight.

"What procedures do you use for Goggle Failure during aided night flights in marginal weather? What do you classify "marginal" weather to be at night?"
- We are a 2 pilot operation at night and when we introduce goggles the weather minimums will stay the same. We will NOT be flying nights in marginal weather just because we are on NVG's. With the current generation goggles, the chance of both tubes failing has to be considered pretty remote, but if so you revert back to normal VFR unaided. You were flying VFR weren't you...?
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Old 3rd Jan 2006, 06:40
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

SASless

You say:

"I was not there...thus what I think I would have done is irrelevant. The sad fact is the crew launched and did not survive the flight. Plainly, they got into a situation they could not handle."

I disagree with your first sentence! Sure you were not there, but you have quite rightly commented on other elements of what you would and would not done - eg, launch in the first place. With your experience I think you could have a very valid opinion.

Your last sentence is key: they got into a situation they could not handle. But that's a very generalised comment.

I think it is generally agreed:

That weather was not suitable for a safe VFR operation
That if the job was going to be attempted it should have been with an IFR machine and IR pilot

However, it is indeed important that we learn from these incidents and that means trying to really focus on what specifically caused the accident. It is easy to generalise with very valid comments, eg not VFR should be IFR twin/IR pilot etc. But implementing such changes is (a) costly and (b) takes time. In the meantime, what will save skins is trying to understand what actually caused this helo to crash.

I am sure that amongst the plethora of US EMS ops, VFR singles are on missions every night somewhere in poor VFR conditions. Virtually all are successful, but a tiny % end in a fatal accident. So what was different here? What specific lesson is there to be learnt?

I suspect it comes back to the old issue that one must never, ever lose sight of ground references when flying VFR. That means clinging to them like they're your liferaft alone in the middle of the Atlantic. Always fly defensively - as ground references reduce, descend, and turn to pick up more. If you feel they are reducing dangerously, go still lower and slower, and ultimately land. Almost anywhere.
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Old 3rd Jan 2006, 07:33
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Big Mike

I´m interested in that 109 accident. Were they IFR capable? Certainly a well equipped 109 has no problem flying in IMC.

Is there a english language news site you can link to about the accident.
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Old 3rd Jan 2006, 07:46
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Sad Story Big Mike! They were so proud about their ex-swiss A-109K2.

To me a well known situation. I refuse a flight at night in difficult weather and an other operator will probably accept. On the next morning i have to declare my decision to the boss who is allways max interested in flights . "How can this be? The others have flown!" And all the base pilots have heard from him in the past "Other pilots fly also!". There is allways a pressure to the pilot. Sneeking and unverifiably. Because there are no papers. There are phone calls in the morning, "How many hours we have flown in the night? None? Please explain your decision." or also very popular - statistics! "We are 10 hours behind the same month last year. We have to fly more!" or "This year is going really bad, all prices have increased. We need more hours!" All the base pilots are highly experienced, more than 5000h, years in the business and in the area. But because we are so "difficult" (means carefully) we need urgently "new blood". New guys, lucky to have a job, without type ratings, without experience in the business (EMS), without experience in the flight area (mountains, heavy winters). AND they do the flights! Understand, we do single pilots ops at night, in a VFR twin without AP, without wxRadar.

That's the situation and i'm pissed about the "Safety Syposiums" (my boss is seating in one of the first rows i bet), about the authorities, only preparing dump papers and i'm pissed about me and my collegues. Because if i refuse the flight, absolutely sure an other pilot will accept.
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Old 3rd Jan 2006, 08:26
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Sad story to hear of yet another pilot who by the sound of it should have stayed alive on the ground. The relatives of these three are now having a very poor start to the new year..

A couple of points. In UK VFR for normal operations by night is not allowed.

Police aircraft have a dispensation to fly under Visual Contact Flight (VCF) rules, which essentially lay down the minimum cloud and vis and distance/altitude from obstructions. An important rider to those limits is the requirement for the pilot to have sufficient lighting on the ground to judge the aircraft attitude. In order words, flight over a totally dark area with poor lighting (e.g. a large expanse of water or unpopulated area) is NOT allowed, irrespective of cloud and visibility.

EMS aircraft fly iaw IFR, there is no dispensation.

UK military night flights are not required to fly iaw the IFR rules (not governed by the CAA) but normal flight is done using NVG. The wx limits are NOT reduced because NVG are used.

As long as pilots are pushed to fly "VFR" at night in marginal wx, especially without IFR competency or capability (the latter is madness in my book), accidents will continue. Take "pushed" to mean whatever you think it does, pressure can come in all directions. That's the bottom line.
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Old 3rd Jan 2006, 08:44
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

ShyTorque

Agree with you, though presumably the Slovakia A109K2 was IFR with IR pilot so ability to fly with visual reference still the crucial element here, assuming it did not crash on intended IFR sector in IMC.

BikeMike - do you know if 109 pilot/helo was IR/IFR? Where was pilot from/trained?

How sad that that yet another EMS accident should occur - this time in Europe - as we're debating lessons of another.

What sort of % hull insurance rates do EMS ops get, for goodness sake?
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Old 3rd Jan 2006, 10:22
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Mike

Sorry to hear the news.

It has happened to all of us. You declining and someone down the road accepting.

If the job is knocked back once - that should be the end of it. Take the patient by road.

Quichotte: Tell your boss to go get . It makes my blood boil getting the screws put on for making a decision based on safety.

I think I need a cuppa and a lie down!
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Old 3rd Jan 2006, 11:34
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

It happens, this pressure to go. A few years ago I flew a police aircraft, which was a "floppy stick" unstabilised twin. I didn't have a UK IR, most of us didn't, although I had quite a lot of military instrument flying experience.

One night, we had just returned from one local job, scrubbed due to the weather deteriorating due to low cloud and rain turning into snow.

A short time later, a call came to search for a man and his son, not returned from a day in the hills. They were known to be experienced walkers and well equipped for the terrain and weather. There was no known start point so they wanted us to search a huge area in bad weather. I declined, explaining that the weather was too bad even for a local job; this one was further away in hills 2000 feet high. The Chief Inspector rang back - he wanted to speak to me on the phone. He tried to tell me how to do my job and how he knew the capabilities of the aircraft (yes, he was convinced that we had radar, that well known supposed answer to a pilot's prayers - we didn't), which irritated me just a little. I still declined to go and asked him if he had a weather report for the search area. He said that a traffic car had reported heavy snow and fog. I asked how he thought we were going to search in that weather. He "advised" me that I should launch, fly around the back of the hills and try to gain access to the area from the other side, using radar.

I told him that he was trying to press me into risking the aircraft and three lives to save two lives that may or may not need saving. He didn't like that and told me he would be making an adverse report about me. He said he was going to call out the neighbouring police unit's aircraft instead ,who were actually closer to the job than we were. I said go ahead, we're not launching. He did, they also refused to launch.

The weather eventually cleared at base and we were informed that the men's car had been found in a lay-by so they now had a start point. I agreed to go for a look see and we launched, some time after midnight. We didn't get far because the area in question still had total blizzard conditions so we turned back. We advised the control room that the only real option was to go back at first light if the weather was suitable.

The Chief Inspector then rang the RAF SAR boys. They declined the job too, saying that they couldn't fly in that weather either. By this time he was almost incandescent but at least the pressure was off me as an individual...

The following morning, the two men, having safely camped out overnight in their tent walked back to their car and drove home. They rang the police when the lady of the household told them about the search...

RISK ASSESSMENT
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Old 3rd Jan 2006, 11:41
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Report this morning from Slovakia says the weather was ok where the crew departed from?

"Three people die in rescue service helicopter crash in Slovakia
BANSKA BYSTRICA- Three crew members perished in a helicopter of the Air Transport Europe (ATE) rescue service that crashed near Janova Lehota, central Slovakia, at about 8:00 p.m. CET on Monday, ATE spokesman Pavol Sveton has told.
The helicopter flew from the airport in Sliac, east Slovakia, for Zilina, central Slovakia, from where it was to transfer a patient to Banska Bystrica, Sveton explained.

A pilot, a doctor and a rescuer were aboard the helicopter. None of them survived the accident.

Two dead bodies were found near the crashed helicopter, while rescuers are searching for the third victim in the surroundings.

The Air Transport Office is investigating the cause of the accident. However, Sveton ruled out that it could have been caused by bad weather.

The ATE bought the Italian made-helicopter Agusta A 109 K2 from Swiss rescuers. It has been already the fourth plane of this kind that the ATE has used.

Author: ČTK"

Link here: http://www.ceskenoviny.cz/news/index_view.php?id=165478
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Old 3rd Jan 2006, 12:47
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Rotorspeed,

Why is my "generalized" comment "they encountered a situation they could not handle" off base?

They encountered weather bad enough for them to cancel the mission "after" takeoff and enroute to the destination. They did not succeed in getting back to the takeoff pad.

The physical examination of the aircraft determined no mechanical cause for the crash. That does not rule out a mechanical malfunction but commonsense would suggest some other cause is the most likely reason for the crash.

What might that be?


BigMike,

Sad news about the Slovakian crew. Your responses go straight to the heart of the NVG issue. I agree the latest versions are absolutely magic....and failures are rare but they do happen. Usually it is something simple like a faulty wire from the battery pack or a bad connection on the helmet mount but these things do occur.

My point there is....should that happen....and you are flying in a region where there is no surface reference visible to the un-aided eye....then you have a very quick onset of having to fly on instruments alone. Combine that with being in a mountain valley or in an area surrounded by hills that are obscured by cloud and you have a most interesting dilemna. That is where CRM techniques and crew coordination become paramount. Lets throw in another thought...it is the flight sector with the patient aboard....and both the crew are needed to care for the patient....think of the decision making that has to take place in a hurry. Does one of the med crew ignore the patient and start looking out front and steering the pilot visually?
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Old 3rd Jan 2006, 13:54
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

On night VFR flights especially in the winter there is always the danger to find suddenly and unreported bad weather. In the most cases the local pilots are able to make a better weather forecast than the hundreds of miles away coffee-drinking meteorologists. Because they have the weather from the computer who is modelling and counting the forecast and didn't know the local weather problems like forrests with low stratus or sudden fog over water. Weather reporting stations are sometimes more than 50 miles away from the next. In our area is no ATC radar help available in our common flight altitudes.
As i wrote we fly single pilot with VFR Twins without AP. This means there is no way to check the FM/emergency checklist in case of an emergency because i have only two hands or to hold a flight chart. You have to know the area and the FM by heart. The written weather report gives 4-5 reporting stations (reports only any full hour) in an area greater than 10.000 square miles. Flights are often more than 3h with the risk of a complete weather change. The (non flying) boss is only interested in flight hours and volume. His boss, the big big boss, promised years ago an adequate ship full IFR with flight director. But now both bosses seem to be really lucky with the simple old ship and his low operating costs.
This kind of equipment and flight ops are fully certified by the authority. The officers aren't interested in pilots talks. Could make problems! Forget QM!!! The QM is only interested to hold his job.

But this isn't an isolated "boss problem". We, the pilots, are the problem. We are ready to swallow this conditions. We are ready to accept a flight an other pilot refused. We are ready to make the job as pilot, as QM, as Chief Pilot. Awaring that others have refused this jobs. There are so many pilots out there in this world ready to take my job. I'm sure also here on PPRUNE we have a lot of pilots ready to sell her grandma for a Twin rating. (As could be seen on some threads ) Only to have a job or to make more money than today. On a nearby base (other operator) the crews get more money in case of flying at night. They try really to make any flight because they seem to need money, money, money...

And i forgot, the last EMS accident at night in bad weather in our area was only two years ago... 2 guys died...

I'm tired from talks like this. This things will never changed in the future, also if the authority will make 1000 new regulations.

Last edited by Quichotte; 3rd Jan 2006 at 19:51.
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Old 3rd Jan 2006, 15:17
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

SASless, to answer your point, we would have 2 pilots BOTH on NVG's. We always fly with 2 pilots at night. Under our company rules, you would already be breaking night weather minimums if you had no reference to the ground unaided.

This is really the problem isn't it. Guys pushing on when things start to turn bad. If you are not maintaining minimums, then you need to be turning back, or if that option has disapeared, then thinking about landing. Sure, everyone wants to get the patient to the hospital (little kid who's critical...) but you have to be able to say NO, and boy that is sometimes a very tough call...
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Old 3rd Jan 2006, 15:21
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Thumbs up Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Well said SASless. Pilots are an easy target when they are no longer in a position to respond or defend their actions. The system should take a good long introspective look at itself. The FAA refuses to address the real issue, weather minimums. Presently, the ceiling and visibility requirements for day/night VFR remote area EMS missions are much lower than common sense would call for. In many instances the weather observations utilized for go no-go decisions are not located sufficiently close to be meaningful with respect to the mission. As a result, EMS crews accept missions with little or no information specific to the actual flight. This information becomes available in real time during the flight. 99.9% of the time, flight crews get away with this, completing the mission with only a scary tale to tell. It is the other 0.1% that gets all the press and discussion time on this and other sites. We operate a SPIFR Bell 230UT. This machine gives us true IFR capability for inter-facility flights and a bailout capability should we back ourselves into a dark low visibility corner in the middle of the night. This capability comes at a significant cost above that of the typical single pilot VFR EMS operation. A cost that many would say is difficult to justify. IFR scene flights are at least one technology leap into the future. This task is achievable but at what expense. In the meantime, each crew has the responsibly to make prudent decisions with respect to go/no-go. No-go should always be the decision and than line up the elements that lead to a GO. Management pressure is never one of the elements.
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Old 3rd Jan 2006, 15:27
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

Thomas Coupling,
Hate to burst your bubble but I (like many others) have flown with excellent pilots from all backgrounds and I have also flown with lemons from ALL backgrounds on both sides of the atlantic.

I have to agree with Quichotte... It is in part up to us as pilots to stop accepting this poor equipment and pressure etc. I have always thought I would love to fly EMS in the states but the rules would be simple.... Interview the program. Get a sense of the culture.....after that its Twin, IFR, NVG and super super cautious until VERY familiar with the local area.
Otherwise its back to the north Sea or the middle east or where ever will have me....
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Old 3rd Jan 2006, 16:57
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain



So tragic and sad.

News link, only in Slovak: http://www.tasr.sk/

More from RADIO SLOVAKIA INTERNATIONAL > NEWS : "Helicopter Crash Pilot Had 20 Years of Experience
An Air Transport Europe medical rescue service helicopter that crashed on Monday evening killing all three crew members on-board was en-route to a call in Zilina. The crew, made up of the pilot, a doctor and a rescue worker was to have ferried a patient from a Zilina hospital to Banska Bystrica. "The pilot had 20 years of experience, and was trained to fly at night... the helicopter was equipped with state-of-the art instruments, and the weather on January 2 was not considered too severe for flying," an ATE spokesperson informed. An eye-witness saw flames coming out of the low-flying helicopter, and two subsequent explosions. Police and the Aviation Authority are looking into the causes of the crash."

Last edited by BigMike; 4th Jan 2006 at 15:18.
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Old 4th Jan 2006, 15:17
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Re: Three Dead....Another Night Bad Weather Flight Over Dark Terrain

This is a further link to Slovak news which has several stories on the accident, including a photo gallery. Anyone who has been pushing there luck recently should have a long hard look at these photos.

http://www.bleskovky.sk/cl/10/97994/...ik_traja_mrtvi
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