NTSB calls out poor safety management in Survival Flight crash
By Elan Head | May 20, 2020
Estimated reading time 9 minutes, 41 seconds.
The fatal crash of a Survival Flight helicopter air ambulance in January 2019 was caused by the operator’s “inadequate management of safety,” the National Transportation Safety Board (NTSB) has determined.
In a virtual public hearing on May 19, the NTSB found that the Bell 407 — which was en route to pick up a patient in Pomeroy, Ohio — likely encountered instrument meteorological conditions (IMC) while flying through a snow band, resulting in decreased visibility.
In a probable attempt to recover from the encounter, pilot Jennifer Topper began a 180-degree turn, but failed to maintain altitude for unknown reasons, the NTSB said. The helicopter collided with terrain a short time later, killing Topper and both medical crewmembers on board, Bradley Haynes and Rachel Cunningham.
The accident occurred at around 6:50 a.m. local time on Jan. 29, 2019. Although Topper, the day shift pilot at the Survival Flight base, was at the controls, the flight request had been accepted by the night shift pilot, who had done so after a weather check lasting no more than 28 seconds. Two other helicopter air ambulance operators in the area had declined the same transport request due to weather.
The night shift pilot already had the helicopter running by the time Topper arrived at the base to take over. There was no record of Topper conducting an independent weather check, and neither pilot completed the required pre-flight risk assessment, with the night shift pilot telling investigators that he expected Topper to complete the assessment after she returned.
This non-compliance with risk assessment procedures wasn’t unusual at Survival Flight, investigators found. NTSB personnel described a “poor safety culture” in which Survival Flight management not only failed to enforce standard operating procedures, but pressured pilots to complete flights and punished employees for raising safety concerns.
Details of that poor safety culture first emerged when the NTSB opened its docket for the crash in November 2019, provoking shock and widespread condemnation of the company within the helicopter air ambulance industry.
According to the NTSB, Survival Flight’s poor safety culture “likely influenced the accident pilot’s decision to conduct the accident flight without a shift change briefing, including an adequate pre-flight risk assessment.”
The NTSB contends that a safety management system — which Survival Flight did not have at the time of the accident — would have provided the company with a foundation to develop a positive safety culture and identify poor risk management practices. The board is reiterating a previous recommendation that the Federal Aviation Administration (FAA) require all part 135 operators to establish safety management systems.
The NTSB also wants to see all part 135 operators implement flight data monitoring programs, which in Survival Flight’s case could have identified and addressed previous instances of pilots flying into IMC while under visual flight rules.
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The board also criticized the FAA for its inadequate oversight of the operator, finding that Survival Flight’s principal operations inspector (POI) — a fixed-wing pilot — had only two or three hours of helicopter flight time and no experience with helicopter air ambulance operations. Prior to the accident, the POI had not identified any deficiencies with Survival Flight’s operations, even though multiple problems were discovered after the crash.
The NTSB is recommending that the FAA require its POIs assigned to helicopter air ambulance operators to have relevant experience with these operations. The board also wants the FAA to review the flight risk assessments for all helicopter air ambulance operators, and address any deficiencies that are identified.
The NTSB determined that sufficient information was available for the night shift pilot and Survival Flight’s operations control specialist (OCS) to identify the potential for snow, icing, and reduced visibility along the accident flight route. (The OCS is supposed to monitor the progress of each flight and confirm and verify all entries on the pilot’s pre-flight risk analysis worksheet.)
However, its investigation found that terminal doppler weather radar data was missing from the HEMS Weather Tool that was consulted by the OCS. Had that data been available on the HEMS Weather Tool at the time of the accident flight, the potential for snow along the flight route would have been more readily apparent.
The National Weather Service should provide this data to the HEMS Weather Tool and other users, and the HEMS Weather Tool should be updated to graphically display areas of weather radar limitations, the NTSB says.
Maybe it was timber thieves?
In a “Thanksgiving message” to employees last year, Survival Flight CEO Chris Millard promised that “the cause of the crash will be nothing related to weather or anything else that they have speculated on to date, and all of this noise that is out there regarding our operations will all be proven to be untrue and unrelated to the cause.”
With the publication of additional material from Survival Flight parent company Viking Aviation, we now know the putative cause that Millard was hinting at: the damage of a window due to a bird or drone strike — or even a gunshot.
Viking Aviation’s party submission points to an unidentified whistling sound that was recorded towards the end of the accident flight on the helicopter’s flight data monitoring device (which was set up in this aircraft to record only audio, not video.) The NTSB was unable to identify the source of the sound, but a sound spectrum analysis suggested it was consistent with air blowing into a window opening.
In a hostile 12-page letter to the NTSB dated Jan. 21, 2020, a Viking Aviation attorney asserted that “the only factual evidence available indicates that the accident was caused by a foreign object (e.g. a drone or a bird) striking a perfectly functioning and maintained aircraft.”
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Viking Aviation’s party submission, published to the NTSB docket on May 18, builds on this theory, contending that impact damage to a window somehow incapacitated Topper. The submission even suggests that the damage might have been caused by criminals on the ground firing at the helicopter, and includes a link to a local TV news story about timber thieves stealing trees from Ohio state parks.
The NTSB did not find any evidence to support these possibilities. Millard and a Survival Flight spokesperson did not respond to a question from Vertical as to whether the sound might also have been caused by a sliding window being open, and/or the aircraft being out of trim in the 180-degree turn.
In emotional remarks for which he later apologized during the hearing, NTSB Chairman Robert Sumwalt said that Survival Flight appeared to be “in denial — as evidenced by their lawyer’s 12-page letter to us to tell us how we were wrong. . . . My biggest fear is that we’re going to slap this gavel down at the end of the meeting, and Survival Flight/Viking is going to say the NTSB doesn’t know what they’re doing. They got it all wrong.”
The NTSB has made six recommendations to Survival Flight, including revising its flight risk assessment procedures, ensuring that shift change briefings are performed before the acceptance of any flight requests, and establishing safety management system and flight data monitoring programs independent of an FAA requirement.
“The other thing I want to say for Survival Flight . . . is that even if you don’t like the report, even if you disagree with it, we’ve done our best to come up with recommendations that can help you to improve the safety of your operation,” Sumwalt emphasized.
A Survival Flight spokesperson told Vertical, “We’re learning from this tragedy and have already completed five of the NTSB’s six recommendations with ongoing work on the final recommendation. Survival Flight will continue to learn, improve, and adapt as a company in order to better serve our communities and save lives.”