NTSB · Safety Recommendation
Safety Recommendation A-20-024
Recommendation
TO SURVIVAL FLIGHT: Develop a process to ensure shift change briefings are performed, to include comprehensive preflight risk assessments, before the acceptance of any flight requests.
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 your shift-change briefing is incorporated into the preflight risk assessment and must be completed within 60 minutes of when the pilot-in-command assumes duty. However, we would also like to know if your policy requires briefings to be completed prior to accepting flight requests. Pending confirmation from you that your policy addresses this concern, Safety Recommendation A-20-24 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.