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

The NTSB report on the AirHeart One crash near Santa Rosa Beach, Florida has been published.

Some excerpts from the report.....

History of the Flight

On October 20, 2004, about 0043 central daylight time, a Eurocopter Deutschland BO-105 CBS5, N916SH, call sign Airheart One, registered to and operated by Metro Aviation, Inc., as a Title 14 CFR Part 91 emergency medical services (EMS) positioning flight, from Santa Rosa Beach, Florida, to DeFuniak Springs, Florida, crashed in Choctawhatchee Bay, near Santa Rosa Beach. Instrument meteorological conditions prevailed in the accident area at the time and a company visual flight rules flight plan was filed. The helicopter was destroyed and the commercial-rated pilot, paramedic, and flight nurse were fatally injured. The flight originated from Santa Rosa Beach at 0041.

Personnel from the Walton County, Florida, Emergency Operations Center, stated that at 0021 they received a call from Healthmark Hospital in DeFuniak Springs, requesting the Airheart One helicopter to transport a patient to West Florida Hospital in Pensacola, Florida. The dispatcher then contacted the pilot of Airheart One and advised him of the request. The pilot stated he would have to check the weather and get back to him. At 0035, the pilot called back and stated they would take the flight. At 0041, the paramedic on Airheart One called via radio and reported they were airborne with three persons on board, 2 hours 20 minutes of fuel, and an estimated time en route to Healthmark Hospital of 10 minutes. At 0043, the paramedic reported that due to weather they were returning to base. The dispatcher did not talk with the flight after this. At 0050, the dispatcher cleared the Airheart One call, believing that they were back at base due to the short flight time. At 0610, the relief pilot that was coming on duty called the Emergency Operations Center and advised that Airheart One was not at base. Search and rescue operations were initiated and the wreckage of the helicopter was located in Choctawhatchee Bay about 0820.

A witness, who was fishing on the northwest side of the Highway 331 bridge reported that between 0030 and 0100, he observed a helicopter flying from south to north parallel to the bridge on the east side. The weather was lightning and thunder and it was just starting to drizzle and rain. He observed the helicopter either fly into a big cloud or fly behind the big cloud. He then saw lightning. He then saw the helicopter making a "U Turn" toward the east and then descend at a 45-degree angle to the water. He observed the helicopter by the red light on the belly. He left shortly after this because of the rain.

Recorded radar data from Eglin Air Force Base showed that the flight departed the Walton County Sheriff's Department heliport and was first observed on radar at 0040:37 while at 300 feet, 1/10 of a mile east-southeast of the heliport. The flight climbed to 900 feet, while proceeding north bound, across the bay, flying parallel to Highway 331 Bridge. The flight then descended to between 700 and 800 feet. At 0042:18, the flight initiated a turn to the east and at 0042:49, the last radar contact was recorded when the flight was at 700 feet, flying on an east-southeast heading. This position was about 3/4 mile to the east-northeast of the crash site.


Meteorological Information

A meteorological study was performed by the NTSB Operational Factors Division. The study showed that at 2353 the Destin-Ft. Walton Beach Airport (KDTS), Destin, Florida, automated surface weather observation was winds 220 degrees at 7 knots, 200 degrees to 280 degrees variable, visibility 7 statute miles, ceiling 800 feet broken, temperature 79 degrees F., dew point temperature 75 degrees F., altimeter setting 29.94 inches of Hg., lightning distant north, ceiling 700 variable 1300. The airport is located 16.2 nautical miles west of the accident site. At 0053 the KDTS automated surface weather observation was winds variable at 6 knots, visibility 7 statute miles, ceiling 600 feet broken, 1,500 feet overcast, temperature 79 degrees F., dew point temperature 75 degrees F., altimeter setting 29.93 inches of Hg., lightning distant southeast.

The 2355 surface weather observation taken at the Valparaiso/Okaloosa-Eglin AFB (KVPS) was winds 210 at 5 knots, visibility 7 statute, clouds 800 feet scattered, ceiling 2,000 feet overcast with thunderstorm, temperature 77 degrees F., dew point temperature 77 degrees F., altimeter setting 29.94 inches Hg., thunderstorm northeast and east moving southeast. The airport is located 20 nautical miles west-northwest of the accident site. The 0055 surface weather at KVPS was winds 230 at 5 knots, visibility 7 statute, clouds at 800 feet scattered, ceiling 1,700 feet broken with thunderstorm, overcast at 4,000 feet, temperature 77 degrees F., dew point temperature 77 degrees F., altimeter setting 29.93 inches Hg., thunderstorm northwest and north moving southeast.

Weather radar data obtained from the Eglin AFB Doppler Weather Radar System show that weak weather echoes were present in the area of the accident at the time of the accident. Additionally, an intense to extreme weather echo was present about 10 nautical miles north of the accident site.
At the time of the accident Airmet IFR MIAS WA 200145 was in effect for the accident area. The Airmet called for occasional ceiling below 1,000 feet, visibility below 3 miles, precipitation, mist, and fog. The Airmet was issued at 2045 on October 19, 2004, and was valid until 0300 on October 20, 2004.


The General Operations Manual establishes weather minimums for night visual flight rules EMS helicopter operations. The minimums are visual ground light reference, enough to properly control the helicopter, and existing or forecast weather for the duration of the flight should be obtained from a flight service station, weather bureau, automated weather observing system, ect., or the pilot's own observations. For local flights within 30 nautical miles of base the cloud ceiling should be a minimum of 800 feet agl and visibility greater than 2 miles. For preflight planning the cloud ceiling should be 1,000 feet agl and visibility should be 3 miles.
Metro Aviation, Inc. pilots reported to NTSB that on occasion the Sacred Heart Health System, Flight Program Coordinator would question a pilot's decision to not perform a flight because of poor weather conditions. An NTSB Human Performance Investigator and the NTSB Investigator-In-Charge conducted interviews with the Metro Aviation, Inc., Lead Pilot and the 7 pilots based at the Sacred Heart Health Systems operation, the Sacred Heart Health Systems Flight Program Coordinator and Chief Flight Nurse, the Metro Aviation, Inc. Owner, the General Manager, and the Director of Operations, and the accident pilot's wife. The purpose of the interviews was to gather information for evaluating whether the Sacred Heart Health Systems, Flight Program Coordinator's questioning of pilot's decisions might have influenced the accident pilot's decisions on the day of the accident. Most of the pilots interviewed stated that the flight program coordinator had a history of inappropriately involving himself in the weather-related decision making of pilots, and encouraging them to accept and complete more flights. However, the coordinator was not working and on the night of the accident and there is no evidence that he communicated with the accident pilot. Moreover, the lead pilot and most of the other pilots interviewed believed that the accident pilot was experienced, mature, confident in his decisions, and unlikely to have been swayed by the flight program coordinator's actions.


Note: All underlining and bold print is mine and not the NTSB's.

The intense or extreme radar echo would have been pretty much on the track the aircraft would have had to make to get to DeFuniak Springs from Santa Rosa Beach. Could the weather check have missed the large thunderstorm on the proposed route? Could the crew not see the lightning ahead of them? Why would the pilot turn to the East when flying on the East side of the only highway that runs north-south over the bay?

Any wonder why the US EMS fatal accident rate is as high as it is?

75% of the fatalities occur at night....usually from VFR flight into IMC conditions.

Anyone care to begin an "accident chain" on this one....or perhaps do a safety case review and comment on factors that "pressured" a pilot to make the decision he did?

Three people died in this one....we ought to mitigate that loss by learning from it.

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

Another strident call for helicopter specific instrument procedures....
Here is a Power Point discussion that is now only 6 years old that discusses a cure for the problem:
View:
http://webpages.charter.net/nlappos/DGPS.pdf

Download (166K)
http://webpages.charter.net/nlappos/DGPS.ppt

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

Interesting presentation Nick, It would be great if this becomes a reality.

Right now though, people continue to die needlessly. How do we stop this?
The big killer is flight into IMC at night, when operating VFR.
I know I have harped on about this, but I will continue to do so. NVG's are available now, and for a relatively small cost, and some training, could be making a huge difference. It would enable VFR flights to REMAIN VFR. There is NO justifiable argument for not having them.

"flight program coordinator had a history of inappropriately involving himself in the weather-related decision making of pilots" This is where management need to have a hard look at themselves. The pilot has to have the backing of his employer when it comes to decisions regarding the flight.
The pilot also has to be totally removed from outside influences, ie, pressure from company, being told the condition of the patient, etc. Decisions to fly must be based on whether the pilot thinks the flight can be carried out safely or not.

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

BigMike,

The NTSB report stated after interviews with the unit pilots, each felt the pilot killed was beyond being pressured by the improper involvement of the Flight Program Coordinator previously.

In your opinion, would that Coordinator have to be physically present for there to be "pressure" felt by a pilot regard turning down flights?

Do you advocate reducing night VFR weather minima if an operation adopts NVG's?

What night weather minima do you use at your operation for Night VFR unaided flights....and Night VFR aided flights?

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?



Nick,

I endorse your concept to the extent it would be much better than what we have now. However, I see insurmountable problems for such a concept.

Sheer costs alone would defeat the concept. How does an EMS operator zipping around the countryside at night in marginal weather using A-stars and Jetrangers find the financial resources and pilots to convert to such a program you advocate?

How do you formulate a "point in space" approach then proceed VFR and remain VMC to a scene location in weather that requires the use of your system.....and do all this with just a few minutes response time from call to launch?

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

Nick,

I like the presentation; I'm sure one day it'll become a reality.

However, I agree with BigMike. The pertinent point in question is being missed in this thread.

Surely the problem was the fact that it was a single pilot VFR flight, who was in marginal weather. (My point is in darkenss, with scattered clouds at his altitude, thunder, lightning and rain, it may as well have been an IMC flight.) The workload must be immense. Couple that with ADM concerns (diversion), the pilot work-load overloading must become a factor. Did this aircraft have 4-axis autopilot?

Either the minimums must be raised, or there must be more stringent requirements for fully IMC capable flight (both equipment and crew requirements).

cl12pv2s

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

News Article posted 7/17/05...

Since 2000, 60 people have died in 84 crashes — more than double the number of crashes during the previous five years. During that period, more than 10% of the U.S. air ambulance helicopter fleet crashed. If commercial airlines lost the same proportion of large passenger jets as air ambulance companies lost helicopters, 90 airliners would crash each year.
Despite the surge in the number of crashes, however, air ambulance companies and the federal agency that oversees them failed time and again to take steps that might have averted tragedy and saved lives, a USA TODAY investigation shows.

The newspaper reviewed hundreds of pages of documents and interviewed dozens of pilots, aviation experts, federal officials, and executives with the companies that operate the flights. Because government statistics on air ambulance crashes are sparse, USA TODAY also created its own database of 275 accidents since 1978.

The full article with links to other feature stories regarding their research:

http://www.usatoday.com/news/nation/...-crashes_x.htm

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

NVG isn't the answer to this type of accident!

NVG allow a pilot to operate in lower light conditions, but they should definitely NOT be used as a means of pressing on further in bad wx.

The weather limits should NEVER be lowered to accommodate NVG Ops.

More relevant, for this type of operation, IS there a suitable bad weather plan (IFR/IMC) - are the crew competent and current to carry it out and is the aircraft suitably equipped and carrying sufficient fuel?

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

I disagree with SASless about cost as the issue with real IFR capability, since the industry now has the cost of the accidents added to its bill, at 100X the cost to do it right.

The autopilots in most helos, if 4 que, can do the auto approach, and these are not oppressively expensive.

To BigMIke's point, the problem is flying VRF when it is really IMC, and the answer is to stop flying unless properly equipped. But stopping operations is not realistic, unless we all agree to get out of the market. For every accident, there are 100 guys who get away with it, so we continue. The problem is EXACTLY like the problem intersection in town where car wrecks happen regularly, until a traffic light is put in. The human factors of why pilots push is complex, and you will get NOWHERE when you simply try to more tightly regulate the human judgement. The answer is to add technical capability to perform safe operations in instruments to do the missions required, and to supplant visionics (like NVG's) for night ops.

The wrong answer is to stand on the ramp with more safety posters and hold them up higher.

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

From the info given above seems we are still not really sure what happened here, though IMC LOC is the understandable presumption. From the various weather reports, I wouldn't have thought even BKN 600ft and 3 miles vis over the water with reasonable (I assume) ground lighting nearby should have been too marginal for even a good VFR pilot. Of course we don't know what very local conditions were, but if the witness saw the helo go behind/into a cloud it must have been clearish around that, not complete murk.

Can't see that NVGs are a big issue in this case and that they would have made the difference.

What we don't know was whether the pilot was IR - we presume not. Was the heli IFR equipped - again, I assume not. 4 axis autopilot on a 105? Surely no way. Even so with presumably sea below why would he have not stayed low enough and around enough lighting to maintain visual contact? Maybe someone who know more about the exact area can comment. Maybe extreme turbulence from CB activity contributed to LOC?

Yes, an IR pilot with an IFR equipped helo would have made resuming ground contact reasonably straightforward but I still wonder if good practice even with a VFR pilot and helo could have avoided this accident.

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

I have driven across that causeway at night. The bay is just over three miles wide at that point with some lights on either shore. At that time of night....it would have been very dark on the water. I cannot recall if there are lights along the causeway but I would assume so, at least at the bridge(s) under which the water traffic can pass.

My reading of the accident report seemed to say he was east of the road heading south back to the base, and made a left turn to the east which would have taken him away from any lights.

Nick is quite correct....more safety posters, no matter how many you display or how high you hold them...will not change things.

Training, equipment, procedures, risk management techniques, CRM, and instrument currency and proficiency can all be undone by bad judgement.

Are we designing our systems upon "getting the job done" or are we designing our systems to "doing the job safely" seems to be the issue.

Why is it....the hardest word to say in aviation speak is "NO"?

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

As a parallel universe here in the UK, I'd say the glaring differences I've picked up between you and us (our accident rate in the EMS world is negligible), is:

1. EMS in this country doesnt get revenue for patients It's a charitable organisation and I believe because of this a magic ingredient is missing in UK Ops: PRESS ON ITIS. If U.S. ops managers run the unit on a profit basis, there will certainly be gross danger of this press on itis appearing in the equation.

2. CRM. This subject (even CRM for single pilot ops) is becoming a religion over here. ALL trng captains have to be CRM instructors soon. CRM is compulsory for all pilots.

3. Training. Most (not all) EMS pilots are ex mil which brings with it a wealth of guaranteed quality flying ability.

4. Most EMS operations are VFR only, day only. Those who do fly at night [must be twin pilot full IFR and IR pilots] utilise some or all of the onboard IFR suite.

I think you in the USA have reached the "tipping point" in EMS accidents listening to what your industry is doing about it lately...Hopefully this 'trend' is a thing of the past.

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

SASless

Thanks for the insight into the area.

Seems strange - and hazardous - to turn away (East) from all ground lighting, doesn't it?

If you had launched up to do that flight, in that aircraft, given the info we have, what do you think the chances would have been of you having a fatal accident that night? Do you think he was doomed on launch? I would say no, and suspect that a bad judgement call during the flight caused the accident. And none of us are immune from that. Nor should we be too quick to shift blame.

Having said that, I must reiterate, I do not know many facts here and this is just speculative - healthily though, because it focuses on our responsibilities and vulnerability as pilots.

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

Do we dare to dream of a day when we can launch, single-pilot on a bad-weather night in our twin-engine, IFR-equipped helicopter with a four-axis autopilot and fly to a scene in the clouds, then make a coupled approach to a stabilized hover 100' above the highest surrounding obstacle?

I do!

And why not? That program Nick was involved in proved that it *is* possible. And it *was* possible back when the study was done which, if memory serves, was some years ago. It is we pilots (especially those of us who've risen into management positions) who aren't pushing hard enough. We keep accepting this paradigm of day/night VFR EMS operations. And helicopters keep crashing into the ground in preventable and predictable accidents.

The future is here, folks. We have the technology, and it needn't be prohibitively expensive. The Chelton Synthetic Vision system is awesome and will only get better. Nick's proposal might seem unrealistic right now, but let's think outside the box. Let's ask ourselves why we can't have such a system? Yes, it might put an end to all of the 206's and 350's running around VFR after dark, but maybe that time has come anyway.

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

We can only read the information available to us and form our own thoughts about what might have happened.

I can see several issues that jump out at me thus far. This accident like so many others we read about seem to have some very common threads that tie them together.

Dark night, bad weather, dark area, VFR only machine, no STAB(SAS) machine, limited recent IFR flight and training beyond some very quick practice on an annual checkride, and crash scene in very close proximity to a base, destination, or place of takeoff, and with no patient aboard.

The base had a source for obtaining graphic radar reports to determine precipitation locations along the planned route, and good access to trend data and airmets and sigmets. The investigation showed some sort of weather check had been done thus we can assume the "pilot" knew of the extent of the bad weather in the area. How did the pilot miss....or fail to determine (or decide) the intense/extreme weather return that was ten miles north of the accident location was a factor (or not a factor)for his flight? Did that information appear on his source of weather.

Did the dispatch center have access to aviation weather? Are they trained to read Metars and TAFS as a backstop to a pilot making an unwise decision?

Did the base television have the weather channel available for the crews to monitor weather trends and radar data and serve as an additional source of information? Did the base have internet service for hitting commerical web sites for up to date radar data?


We also know that base and operator allowed interference in weather decisions by others than the pilot concerned. That fact alone throws up a huge RED FLAG! That one part of the accident report tells me there was a poor Safety Environment at that location. That is compounded by the Comm center not confirming the aircraft had landed either by radio or by telephone. That shows a failure of the flight following system that had been normal practice over a period of time.

The FAR's are quite plain....they call for "postive" control of all flights under part 135. The CP is required to know of the status of all flights all the time (or establish a system to ensure that happens). The non-patient leg might be legally a FAR part 91 flight but it was dispatched to retrieve a patient which was part 135. The practice of reverting to Part 91 weather standards when without patient is a troublesome practice as well. They are not anywhere as strict as Part 135 is.

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

SASless

Disappointed you've not answered my questions!

From your last post, suppose there was no weather info at all - though seems in fact they had quite a lot. Surely for a 10 mile distance presumably flattish terrain task you fly as you find, don't you - as indeed you always, ultimately should? If you launch up and encounter cloud at 300ft you almost certainly RTB and land. Presumably too EMS helo landing lights are good enough to pick out alternative en route landing sites in an emergency - weather or otherwise?

I really don't see that the ultimate quality of the weather reporting was fundamentally causal here.

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

While the US EMS system is a money making venture, I believe that the accidents will unfortunately continue.

These are the reasons for the accidents:

• Night or marginal weather
• Non-IR pilots
• Lack of SUITABLE stability system (call it autopilot if you want)
• Prees-on-itis
• And finally........... $$$$$$$$$$$$

The twin-engine debate (I believe) has no relevance here.:hmm:

We all hear that the companies have minimums so why does this continue to happen.:confused:

Make it mandatory IFR for night ops.

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

TC, UK and European EMS operators indeed have an enviable safety record compared to the US, but that's at least partly a function of volume. If you don't fly as much, and as much at night, as we do here then you won't have as many accidents. If you did, you would.

The charitable nature of an EMS operation may help to reduce pressure to fly but doesn't completely eliminate it. Once you load up a badly injured patient there may be pressure to fly regardless, and indeed many accidents happen with a patient on board on the way to the hospital. By the very nature of the job, pilots are going to feel the need to fly. As you pointed out, CRM training is a great tool and can be used to train pilots to manage the inevitable pressures of the job.

At the risk of enraging every ex-military US pilot on this board I would also like to point out that -in the US at least- military experience is not always a benefit. US military pilots almost always share flying duties as part of a two-pilot crew. Many have never flown solo ('solo' during military training is often flown with a 'stick buddy') and are not used to managing a flight single handedly. I don't mean to imply that they don't make fine EMS pilots, only that a military background is not neccessarily a seamless fit with a subsequent career in EMS.

I think it's easy to pinpoint what must be done: to reduce the US accident rate, EMS operators must increase the ability of pilots and aircraft to fly at night and in marginal conditions, through increased training and upgraded equipment. The difficult part is to restructure the healthcare system in such a way that it becomes financially attractive for operators to do so.

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

How about starting with the correct machines for the job.......SPIFR, then the correct drivers for the machine.......IFR, and maybe then and only then NVG's.

Shooting off through the night as a VFR driver with googles doesn't sound to fantistic an idea.....

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

"Shooting off through the night as a VFR driver with googles doesn't sound to fantistic an idea...."

It certainly ISN'T a good idea! It's extremely dangerous because when the goggles finally clamp down when they have reached their limits due to to cloud the pilot has possibly no other escape - he's left behind his option for naked eye / visual contact flight. This is a long known risk, which is why the weather limits musn't be lowered for NVG ops at night and the pilot / aircraft combination MUST be able to safely fly IFR if required.

Those of us teaching this banged on long and hard about this to our RAF hierarchy; finally they saw sense and night wx limits were aligned, even though all of our pilots were instrument qualified. It worries me greatly that other organisations might like to think they know better, or are reluctant to learn from the mistakes of others, even though their pilots are possibly less experienced........ :(

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

Rotorspeed,

If your questions (plural) you want answered are....

My response is this.....

I would not have launched based upon the weather information given....compounded with the radar image of the thunderstorm giving off intense/extreme returns ten miles north of the accident. When the lightning is cracking and the thunder is booming....as it was...combined with the weather that must have shown on the radar.....it would be red tag time...get out the popcorn and put on a good movie until the weather improved drastically.

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.

Was the crew doomed no matter what.....absolutely not. At some point they ran out of options and as always...a crash occurred. At what point that happened....and exactly why that happened we will never know. However we can play a game of what if....and see how many ways there are to break the accident chain that led to these three fine folks dying.

The point of posting this report and encouraging a professional discussion of the circumstances surrounding it is not to demean the dead but rather to try to provoke what hopefully will be some constructive dialogue about how to prevent another one of these.

If I ever snuff it in a crash, I sure hope my friends and co-workers will use it as an opportunity to learn from it. We all take that risk when we go flying....every time thus it should be a topic we take some professional interest in. I would much rather learn from your mistakes than my own, particularly if they are fatal ones.