NTSB faults pilot, missing equipment in Wis. air medical crash
The crash killed pilot Steve Lipperer, nurse Mark Coyne and doctor Darren Bean
By Doug Erickson
Wisconsin State Journal
MADISON, Wis. — The 2008 crash of a University of Wisconsin Hospital Med Flight helicopter that killed three people near La Crosse was due to pilot error and the lack of an on-flight instrument that could have provided an audible alert of upcoming trees, according to a final determination by the National Transportation Safety Board.
The board's report, released Friday, lists the probable cause as the following: "The pilot's failure to maintain clearance from trees along the top of a ridgeline due to inadequate preflight planning, insufficient altitude and the lack of a helicopter terrain awareness and warning system."
However, one of the five board members dissented, saying more blame should be placed on a lack of training resources available to the pilot by the helicopter's owner, Denver-based Air Methods. Med Flight leased the helicopter from Air Methods.
An Air Methods spokesperson could not immediately be reached for comment.
The May 10, 2008, crash killed Dr. Darren Bean, nurse Mark Coyne and pilot Steve Lipperer. The helicopter left the La Crosse airport at 10:34 p.m. and was reported missing 30 minutes later. The next morning, a search team found the helicopter wreckage at the top of a wooded ridge about 4 1/2 miles southeast of the La Crosse airport.
Concerns about fog have lingered. The NTSB report said the weather in the area at the time was "marginal," but "it was above the minimums required by the Federal Aviation Administration (FAA) regulations and the operator's procedures."
Furthermore, "there were no identified weather risks that would have warranted classifying the flight" in the risk assessment category for "caution," the report states. The pilot's assessment that night placed the level of risk in the "normal operations" category, according to the report.
The report says that during preflight planning, "the pilot should have identified any obstacles along the route of flight, including the tree-covered ridgeline."
The terrain awareness and warning system is not required on medical helicopters, although the NTSB has asked the FAA to require them, according to the report.
The FAA so far has not done so, the report said.
Lisa Brunette, spokeswoman for UW Hospital, said hospital officials were reading the report Friday and not yet prepared to comment.
The five-member NTSB voted 4-1 to adopt the probable cause report. In a dissenting opinion, member Robert Sumwalt said the report should be expanded to include the "failure of Air Methods" to ensure that the pilot was current with his training on "instrument flight rules," or IFR, that could have helped him navigate through questionable weather.
Lipperer had been certified to use IFR during bad weather before his company was acquired by Air Methods in October 2007. But Air Methods didn't recertify Lipperer, "due to a lack of Air Methods training resources," Sumwalt wrote.
This "resulted in the pilot being restricted" to visual flight rules, or VFR, and could explain why Lipperer was flying below 500 feet that night, Sumwalt wrote.
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