NTSB · Safety Recommendation
Safety Recommendation A-20-021
Recommendation
TO SURVIVAL FLIGHT: Revise its flight risk assessment procedures to incorporate the elements described by Advisory Circular 135-14B, including procedures for determining prior flight refusals by another helicopter air ambulance operator and forecast en route weather.
Safety Issue and Context
On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered Bell 407 helicopter, N191SF, being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio.1 The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135.
Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.
Response History
March 17, 2021 · NTSB Correspondence · Survival Flight
On January 27, 2021, Mr. Windes informed us that, on August 24, 2020, the Federal Aviation Administration (FAA) approved revision 13 of your General Operations Manual (GOM). We note that your updated GOM includes a procedure in the flight risk assessment for determining prior flight refusals by another operator. We believe this additional procedure is responsive to the first part of this recommendation; however, we would also like to know if your GOM includes a procedure for determining forecast and en-route weather, as mentioned in the second part of this recommendation.
Pending our review of this additional information, Safety Recommendation A 20-21 is classified OPEN-- ACCEPTABLE RESPONSE.
July 29, 2020 · Recipient Response · Survival Flight
-From Jack H. Windes, Director of Operations, Viking Aviation, LLC doing business as Survival Flight: We at Survival Flight wanted to provide you with an in progress review of where we are at with addressing the 6 points of recommendation that the board had for us following the release of the final investigation report into our HAA accident in Zaleski, Ohio on January 29, 2019 (NTSB/AAR-20,01).
We have aggressively embraced the need to address these recommendations and we are working diligently everyday to see each and every one to an end. Change has occurred in our organization's management as a first step at addressing these issues.
We want you to know that we care deeply about the safety of our flight crews and the public in which they serve. Your comments on just culture and the role that it needs to play in the safe operation of an HAA company has not been lost on our organization. Every decision we make is with consideration to how we can improve and prevent this from ever happening again.
Although much progress has been made, many of the items that are focus points in your 6 recommendations are not yet fully implemented. We wanted you to know that we are diligently working on completing these items. This in progress review is not meant to be a final report but rather, a conditions check and update to you as to our progress.
I anticipate having fully implemented changes that address all 6 of your recommendations no later than 1 October 2020.