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  3. NTSB A-20-023
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NTSB · Safety Recommendation

Safety Recommendation A-20-023

Recommendation

TO SURVIVAL FLIGHT: Develop a procedure for tracking actual pilot duty times in compliance with Title 14 Code of Federal Regulations 135.267.

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

We note that, for each day that your pilots are on shift, they are required to complete and update their duty times in Survival Flight’s Pilot Flight and Duty Tracker form, which tracks pilots’ total days worked and flight hours accrued. We also note that this information is reviewed by the chief pilot and lead pilot at each base. Although we believe your actions thus far are responsive to this recommendation, we would also like to know if you have a procedure in place to ensure that actual—not just scheduled—duty time is tracked. Pending confirmation from you that such a procedure exists, Safety Recommendation A-20-23 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.

Attached is a document entitled "NTSB update". In this document you will find all 6 of your recommendations in italics along with a corresponding update as to our progress in addressing each one. There are also additional Exhibits attached so that you can see the corresponding company policy/procedure as supporting documentation as to how we are addressing these recommendations.

In addition to the updates on addressing your recommendations, I wanted you to know that we have other parallel efforts ongoing in an attempt to mitigate risk and improve our culture beyond the 6 recommendations that you have. I am proud to tell you that Survival Flight has begun the process for CAMTS accreditation. We have also partnered with ECHO (Every Coast Helicopter Operators). ECHO is an organization made up of industry professionals who promote safety and cross talk between HAA companies. They have been a strong critic of ours in the past. We reached out to them and invited them to conduct an external evaluation as to our policies and our climate.

June 8, 2020 · NTSB Correspondence · Survival Flight

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters.

The attached letter from the NTSB Chairman provides information about the NTSB’s May 19, 2020, report Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019, NTSB/AAR-20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-20-18 through -20). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this/these recommendation(s). Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters.

Read Recommendation

Recommendation Facts

Status
Open - Acceptable Response
Issued
June 8, 2020
Priority
CLASS II
Recipient
Survival Flight
Adopted
May 19, 2020
Related Investigation
CEN19FA072
Related Report
AAR-20-01

This evaluation is currently ongoing. We anticipate ECHO bringing even more recommendations as to how we can even further foster a climate of just culture, safety, and dignity for the first responder family members that make up our company.

Please feel free to contact me if you have any questions or if there is anything additional I can provide regarding our update to you. I look forward to providing you with a final summary as to our full implementation of all 6 recommendations in the coming weeks.

A-20-23 Develop a procedure for tracking actual pilot duty times in compliance with Title 14 Code of Federal Regulations 135.267.

We currently require all pilots to complete and update VA Form 128 (Pilot Flight and Duty Tracker) each day that they are on shift. This form keeps a running total of days worked and flight hours accrued. This tracker is submitted monthly to the Chief Pilot for review and oversight. As a matter of change, we have added to the list of duties and responsibilities to the Lead Pilot at each base to review this tracker for each of the pilots assigned to their base. The intent behind this is to provide an additional layer of oversight in preventing anyone from exceeding duty and flight time limitations as well as to ensure that each pilot is receiving their required amount of days off.

We are continuing to evaluate ways in which this data can be made available to the OCS so as to provide an additional layer of oversight and safety. Many of the digital risk assessments that we are looking at link duty time into the assessment of risk as well as making this data visible to the OCS.

The VA Form 128 is attached as “Exhibit C”.

We are providing the following information to urge the National Weather Service to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary.

This letter also includes information about our May 19, 2020, report Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019, NTSB/AAR-20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

As a result of this investigation, we identified the following safety issues:

• Survival Flight’s lack of comprehensive and effective flight risk assessment and risk management procedures. • The lack of a positive safety culture endorsed by Survival Flight management and the lack of a comprehensive safety management system. • Need for flight data monitoring programs for helicopter air ambulance (HAA) operators. • Lack of HAA experience for principal operations inspectors assigned to HAA operations. • Lack of accurate terminal doppler weather radar (TDWR) data available on the HEMS (helicopter emergency medical services) Weather Tool. • Lack of a flight recorder.

Accordingly, the NTSB makes the following safety recommendations to the National Weather Service. Additional information regarding these recommendations can be found in the noted sections of the report.

• Distribute Level II TDWR data to all of your users (as recommended in Safety Recommendation A-20-15 to the Federal Aviation Administration) so they will have access to the most accurate precipitation information. (A-20-18) (See section 2.4) • Add TDWR data to the HEMS Weather Tool overlay (as recommended in Safety Recommendation A-20-16 to the Federal Aviation Administration). (A-20-19) (See section 2.4) • Provide capability in the HEMS Weather Tool to graphically display areas of weather radar limitations, including areas where beams may lack low-altitude coverage, areas that lack radar coverage, and areas of beam blockages (as recommended in Safety Recommendation A-20-17 to the FAA).

(A-20-20) (See section 2.4) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A-20-18 through -20). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents.

Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations are stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to these recommendations. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. In the likely event that your company uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.