Introduction
Flying is indeed one of the safest forms of transportation. However, when they do occur, aircraft accidents frequently have devastating outcomes. Although many unlucky elements might cause aviation accidents, weather-related situations are one of the most significant hazards to an aircraft. Natural forces can be unpredictable, intense, difficult to comprehend, and physically challenging to regulate or avoid. Consequently, compared to most other types of accidents, weather-related incidents are disproportionately devastating (Brotak, 2018). Historically, more than two-thirds of all general aviation (GA) accidents in IMC result in fatalities, significantly higher than the mortality rate for GA incidents (Long, 2022). To recognize and respond appropriately to dangerous weather events, all pilots must have a certain level of expertise. Giving GA pilots more direction on where to get preflight weather information. The ability to collect detailed weather data while flying has significantly enhanced thanks to the increased availability of inflight meteorological equipment. Yet weather-related incidents still happen. This paper is a case analysis of a case study of an aviation accident whose probable cause was poor weather conditions.
At 6:50 a.m. Eastern Standard Time on January 29, 2019, a single-engine, turbine-powered Bell 407 helicopter, N191SF, was being used as a helicopter air ambulance (HAA) flight crashed into a forest about 4 miles northeast of Zaleski, Ohio. The commercially licensed pilot, the flight nurse, and the paramedic died, and the helicopter was ruined. Under Title 14 Code of Federal Regulations Part 135, the helicopter was registered to and run by Viking Aviation, LLC, which did business as Survival Flight Inc. The visual flight rules (VFR) flight left Mount Carmel Hospital in Grove City, Ohio, at 6:28 a.m. and was going to Holzer Meigs Emergency Department in Pomeroy, Ohio, about 69 nautical miles to the southeast, to pick up a patient. At the point of departure, it was dark enough to see, but weather reports showed snow showers and areas of “instrument meteorological conditions” (IMC) along the flight route.
National Transportation Safety Board (NTSB) is an independent body founded in 1967 that promotes aviation, highway, railroad, and pipeline safety. The 1974 Independent Safety Board Act requires it to investigate transportation accidents (Marcus & Rosekind, 2017). Through this, the National Transportation Safety Board (NTSB) is supposed to determine accident causes, issue safety recommendations, conduct safety studies, and evaluate the safety effectiveness of all transportation-related government agencies.
Synopsis
N191SF, a Bell 407 helicopter registered and operated as a helicopter air ambulance (HAA) flight under Title 14 Code of Federal Regulations Part 135, collided with forested terrain in Zalenski, Ohio. The pilot, a flight nurse, and a flight paramedic were among those killed in the crash. The helicopter was also damaged (NTSB, 2020). On the morning of January 29, 2019, an ERT at Holxer Meigs emergency department in Pomeroy, Ohio, called two other HAA operators to request transport of a patient from her facility, OhioHealth Riverside Methodist Hospital in Columbus, Ohio. The two operators declined the technician report due to adverse weather conditions (Levin, 2020). The ERT discussed the request with the operations control specialist, who called the Survival Flight pilot on duty during the evening shift. The operation control officer requested the weather check to decide whether the mission could be accepted. Even though the nighttime shift was ending, the pilot took a 69-mile flight between two hospitals, notifying operations control that the day shift pilot, Jennifer L. Topper, 34, of Sunbury, also the accident pilot, was five minutes away and could take the flight.
Jennifer L. Topper arrived at Base 14 and immediately boarded the awaiting helicopter. Bradley J. Haynes, 48, from London, and Rachel L. Cunningham, 33, from Columbus, were the other two individuals on board. There was no record that the pilot received a weather briefing or viewed weather imagery. Both pilots skipped a preflight risk assessment; the evening shift pilot anticipated the accident pilot to complete the check when she returned. He informed accident investigators the flight path forecast included a 2,400-ft ceiling and 11 km visibility; therefore, it was “excellent weather” (Werfelman, 2020). On the morning of the accident, station models at the accident site suggested marginal visual conditions, including gusty west wind of 10 to 20 kts. At the time of the accident, the temperature in Viton County was 15 degrees with light snow showers and west winds of 15 mph with gusts of 21 mph. Snow reduced visibility to 3 kilometers; 30 to 60 percent likelihood of light snow. Low-level cool water clouds were spotted by satellite (Werfelman, 2020). Therefore, the Federal Aviation Administration issued moderate turbulence below 10,000 feet and moderate icing below 8,000 feet airmen’s meteorological intelligence advisories.
The flight data monitoring (FDM) showed that the Survival Flight helicopter began to climb around 06:28 and reached its highest point at about 3,000 feet. The aircraft flew for 22 minutes in a southeast direction to get to the Holxer Meigs emergency room, its final destination. The weather radar data showed that the helicopter flew through two snow showers (Aerossurance, 2020). During the second band of snow, the pilot probably ran into “instrument weather conditions” because it was hard to see in the snow. The helicopter flew past the two snow bands and followed a path the same as a 180-degree left turn down. This likely indicates that the pilot tried an escape maneuver to escape the unexpected IMC (Aerossurance, 2020). Still, the pilot could not command the helicopter to go up, so it kept falling until it hit the hilly, forested terrain (Parsons, 2020). The trees were hit in the same direction as the plane’s flight path.
Causation
The NTSB determined that Survival Flight’s poor safety management, which normalized pilots’ and operations control experts’ noncompliance with risk analysis protocols, caused this tragedy. The flight took off without a comprehensive preflight weather evaluation. This led to the pilot’s unintentional encounter with instrument meteorological conditions, inability to maintain altitude, and the resultant collision with tertiary objects. The Federal Aviation Administration poorly supervised the operator’s risk management program, and operators covered by Title 14 of the Code of Federal Regulations Part 135 were not required to implement safety management system programs, which impacted the accident.
The pilot and operation control specialist made human errors due to a lack of a suitable safety culture and a robust safety management program or system. These errors lead the pilot to fly without a preflight risk assessment, weather briefing, or VMC (Werfelman, 2020). According to the NTSB (2020), pilots and operations control specialists ignored risk analysis processes due to weak safety management. Ineffective safety and management methods caused the operation control specialist to hunt for a Survival Flight pilot after two others declined (Aerossurance, 2020). Evening shift and accident pilots did not examine the weather and other risk variables to ensure flight safety.
The pilot involved in the crash was not documented as having received weather briefings or imagery before the incident. Due to the 2,400-foot ceiling and 11 km of visibility, the evening shift pilot rated the weather as “excellent” (Werfelman, 2020). The NTSB discovered snow showers reduced surface visibility to three miles (Parsons, 2020). Weather reports suggested a 30-60% likelihood of light snow the morning of the disaster (NTSB, 2020), while satellite imagery showed “low-level cool water clouds” (Werfelman, 2020). Two airmen’s meteorological advisory warned of moderate turbulence and icing below 10,000 ft MSL.
Decision Criteria
The investigators determined that the FAA should require principal operators operating in ambulatory helicopter rescue health services to have HAA experience. This condition was rooted in the fact that the operations control expert assigned to the Survival Flight lacked sufficient knowledge and authorized the flight to take off despite two operators’ prior refusals due to weather-related difficulties. It also proposed that the FAA mandate that all helicopter ambulatory programs conduct flight risk assessments before takeoff (Parsons, 2020). This entails adhering to Advisory Circular 135-14B and Title 14 Code of Federal Regulations 135.617, which includes filling out a paper worksheet with all the safety-related information, such as meteorological information (NTSB, 2020). This advice would aid in addressing all deficiencies in safety and security before the start of a flight. With data management and tracking features to the HEMS weather tool, helicopter systems could provide weather radar coverage, like graphically presented areas. The mandate that all mobile helicopter health services adopt the most recent weather radar software arose from the Survival Flight’s lack of a meteorological data system at the time of the tragedy.
Because of the accident, the National Weather Service is now required to give all users accurate rain information from the terminal Doppler weather radar. These systems would also ensure that helicopter pilots can see their radar coverage and limits on their geographical displays. The proposal also called for Survival Flight operators and pilots to change their risk assessment procedures to ensure they were in line with Advisory Circular 135-14B. This meant evaluating all risks in detail, like determining if other operators had turned down flights before and predicting the weather along the route (NTSB, 2020). Tracking the pilot’s duty time per Title 14 Code of Federal Regulations 135.267 would ensure that pilots work under less pressure and stop rushed flight missions like the one in the Survival Flight case. Safety management systems, like flight data surveillance systems for aviation service providers in line with Advisory Circular 120-92B, were put in place because the accident pilot had to deal with “instrument meteorological conditions ” (Ellis et al., 2022). Therefore, the incident prompted new regulations requiring the National Weather Service to provide precise precipitation forecasts via the terminal Doppler weather radar to all customers.
Analysis
Most likely, she ran into unexpected meteorological conditions because she was flying through two snow bands, which made it harder for her to see. The pilot’s 180-degree turn was probably an attempt to escape the bad weather, but she could not keep the altitude, so she went down towards the forest. The accident had nothing to do with the pilot’s skills, health, use of drugs or alcohol, or the helicopter’s ability to fly (NTSB, 2020). The crash happened because the plane did not have a complete flight management and safety system that followed the rules in Title 14 Code of Federal Regulations Part 5. (NTSB, 2020). This could mean that operational staff for Survival Flight have to fill out a risk assessment worksheet that includes weather risks on their route and questions about why the last two flight requests were turned down. In this scenario, it would have elevated a culture of safety and made it less likely that the pilot who caused the accident would be in a hurry to take over the flight without a shift change briefing.
The fact that the principal operations inspector had not been trained or had no experience with risk assessment and safety management methods is also a significant factor in this case. Standard operating procedures and rules are needed to ensure that operators are taught flight safety programs. This means that essential weather risks for the flight must be found, such as the chance of snow showers and low visibility along the route of the accident flight. Weather radar data systems are essential because they let operations control experts and accident pilots know if there might be snow on the way to the hospital (NTSB, 2020). Suppose an accident-resistant flight recorder had been installed in the cockpit. In that case, it could have given images, audio, and parameter data that could have helped figure out the real cause of the Survival Flight accident, such as why the pilot could not maintain altitude or deal with the unexpected weather conditions.
Implications
The National Transportation Safety Board issued 14 recommendations regarding the Survival Flight crash. These included proposals that principal operating inspectors allocated to ambulatory helicopter services have the necessary experience and undertake a risk assessment per Title 14 Code of Federal Regulations 135 principles (NTSB, 2020). Such policies are crucial because they oblige operators to examine risk and safety flaws before taking off. Without such rules, the primary operation inspectors may repeat such errors, as seen in the case of the Survival Flight (Parsons, 2020). The accident flight investigator also advocated installing software that supports terminal Doppler weather radars and the HEMS Weather Tool overlay. These devices would allow operation auditors and pilots to access precipitation data and successfully regulate their helicopters using graphically displayed techniques.
The thorough risk assessment processes outlined in Advisory Circular 135-14B require flight controllers and pilots to assess potential hazards, such as procedures to establish why two previous planes refused to take the mission. Finishing the risk assessment document, which comprises the shift change briefings, is also required. Title 14 of the Code of Federal Regulations 135 also included methods for tracking pilot duty hours (NTSB, 2020). This provision is needed to guarantee that flight decisions are not rushed and that arriving shift pilots have access to risk and weather briefings. Without such risk assessment techniques, pilots may engage in perilous trips and encounter weather challenges, like in the case of the Survival Flight (Werfelman, 2020). The suggestions further enhanced the FAA’s requirement that helicopters include data monitoring devices, which are essential because they can give risk and weather information that can help avert possible flight accidents.
Recommendations
Procedures for evaluating all risk factors, including low visibility, must be included in the flight risk assessment. There was a 30% to 60% chance of light snow on the fateful morning of the Survival Flight crash. At the surface, the snow decreased the pilot’s sight to as little as 3 miles (Parsons, 2020). These conditions put any flight, especially emergency ambulatory helicopters, at risk. Before taking each flight, pilots should inquire about the weather conditions on their route and complete the safety assessment worksheets, as the National Transportation Safety Board recommended.
Flight controllers and pilots should not be forced to fly. In the Survival Flight case, the nighttime shift pilot accepted the task of transporting the patient to the Holxer Meigs emergency department in Pomeroy, Ohio. Regardless, the accident pilot was also not present at Mount Carmel Hospital in Grove City, Ohio, where the flight was scheduled to depart (Parsons, 2019). She discovered an already running emergency ambulatory helicopter and took off, despite the risk and weather conditions.
All flights must adhere to the risk assessment methods outlined in Title 14 of the Code of Federal Regulations and Advisory Circular 135. All aircraft must incorporate the appropriate information technology systems or programs into their flight (NTSB, 2020). Data monitoring systems for weather conditions are included. To ensure that the data system technology satisfies the standard standards, it must be updated and certified by local and federal flight stakeholders. The lack of cutting-edge computer technology in the Survival flight, which began operations in the 1980s, contributed to the catastrophe (NTSB, 2020). Before and during the trip, data monitoring devices would allow the flight to deliver essential information regarding safety and weather-related threats. Pilots must be instructed on preparing for flying obstacles such as engine or flight system failures and those that may arise en route to the destination. After the unexpected instrument meteorological conditions, the pilot of Survival Flight made a steady 360-degree left turn (NTSB, 2020). As a result, previous planning must include recommendations on dealing with limited visibility due to adverse weather conditions.
More investigation needs to be conducted into what constitutes “onboard weather equipment.” According to Long (2022), such technologies have evolved in recent years, creating more alternatives. Before 2010, most technologies delivered textual information, frequently in audio formats, such as flight service reports or ATIS, AWOS, or ASOS transmissions, or in-panel radar systems, such as onboard radar or storm scope systems. Recent innovations include third-party radar. The reported use of onboard weather equipment is unrelated to the flight phase or final cause decision. Such findings require more examination into how to include and document onboard weather equipment in accident investigations properly. With increasingly affordable onboard weather equipment technologies, it was projected that the number of reports carrying a narrative about their use would increase, especially for weather-related accounts.
Conclusion
On January 29, 2019, Survival Flight crashed near Zalenski, Ohio. The Bell 407 helicopter, N191SF, killed the pilot, a flight nurse, and a paramedic. Accident investigators blamed weather conditions. The pilot couldn’t gain altitude due to two snow bands. This case study shows that flights are always dangerous. The evening pilot accepted the mission minutes before the accident parent’s shift. She located a starting chopper and took off without a risk appraisal, including weather analysis and inquiry into two previous mission refusals. The accident led to 14 suggestions for flying compliance with Title 14 CFR and Advisory Circular. Methods for calculating the likelihood of a flight and controlling risks were among them. Positive changes in safety culture, administration, and oversight resulted. The NTSB recommended Doppler weather radar data for use by all EMS helicopters. It also suggested using a crash-proof flight recorder to analyze the flight’s path and any issues that may arise. To prevent tragedies and preserve lives, pilots must undergo emergency training.
References
Aerossurance. (2020). Survival Flight Fatal Accident: Air Ambulance Operator’s Poor Safety Culture – Aerossurance. Aerossurance. Web.
Brotak. (2022). Weather Concerns for General Aviation – Flight Safety Foundation. Flight Safety Foundation. Web.
Long. (2022). View of Analysis of Weather-Related Accident and Incident Data Associated with Section 14 CFR Part 91 Operations. View of Analysis of Weather-Related Accident and Incident Data Associated With Section 14 CFR Part 91 Operations. Web.
Marcus, J. H., & Rosekind, M. R. (n.d.). Fatigue in transportation: NTSB investigations and safety recommendations. Fatigue in Transportation: NTSB Investigations and Safety Recommendations. Web.
National Transportation Safety Board. (2020). Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, Web.
Parsons. (2019). NTSB: Survival Flight pilots and crew pressured to take risky flights. Vertical Mag. Retrieved December 15, 2022, from https://verticalmag.com/news/ntsb-survival-flight-pilots-and-crew-pressured-to-take-risky-flights/
Werfelman. (2022). NTSB: ‘Inadequate’ Safety Management Probable Cause of 2019 Bell 407 Helicopter Crash – Flight Safety Foundation. Flight Safety Foundation. Web.