NTSB: Fatal air ambulance crash caused by safety shortfalls

The NTSB said "inadequate management of safety" led to the crash that killed two flight nurses and the pilot


Megan Henry
The Columbus Dispatch, Ohio

VINTON COUNTY, Ohio — A Survival Flight medical helicopter crash last year in southeast Ohio that killed three crew members was caused by the operator's "inadequate management of safety," the National Transportation Safety Board announced during a public meeting Tuesday.

"This accident was all but invited by the actions and culture of Survival Flight," said NTSB Chairman Robert L. Sumwalt. "Unfortunately, we have seen yet another case of how a poor safety culture can lead to tragedy."

A pilot and two flight nurses aboard a Survival Flight air ambulance traveling from Mount Carmel Grove City hospital to pick up a patient at Holzer Meigs hospital in Pomeroy crashed into trees in a state forest near Zaleski in Vinton County, southeast Ohio, at 6:55 a.m. on Jan. 29, 2019. Pronounced dead at the scene were: pilot Jennifer L. Topper, 34, of Sunbury; and flight nurses Bradley J. Haynes, 48, of London and Rachel L. Cunningham, 33, of Galloway. (Photo/Ohio State Highway Patrol)
A pilot and two flight nurses aboard a Survival Flight air ambulance traveling from Mount Carmel Grove City hospital to pick up a patient at Holzer Meigs hospital in Pomeroy crashed into trees in a state forest near Zaleski in Vinton County, southeast Ohio, at 6:55 a.m. on Jan. 29, 2019. Pronounced dead at the scene were: pilot Jennifer L. Topper, 34, of Sunbury; and flight nurses Bradley J. Haynes, 48, of London and Rachel L. Cunningham, 33, of Galloway. (Photo/Ohio State Highway Patrol)

The Bell 407 helicopter operated by Survival Flight was on its way from Mount Carmel Grove City hospital to pick up a patient at Holzer Meigs hospital in Pomeroy on Jan. 29, 2019.

The NTSB said the pilot took off without first conducting a thorough preflight weather evaluation and was unable to maintain altitude while making a left 180-degree turn.

The air ambulance crashed into trees at 6:55 a.m. in Zaleski State Forest, part of Lake Hope State Park in Vinton County.

Killed in the crash were pilot Jennifer L. Topper, 34, of Sunbury, and flight nurses Bradley J. Haynes, 48, of London, and Rachel L. Cunningham, 33, of Columbus.

"This accident was a tragedy that took the lives of three brave people who'd dedicated themselves to saving others and Survival Flight will always mourn their loss," Ryan Stubenrauch, spokesperson for Survival Flight, said in a statement.

NTSB investigators found pilots and operations staff of Survival Flight regularly failed to comply with preflight risk assessment procedures.

Current and former Survival Flight employees said there was pressure to operate flights in difficult weather conditions and take flights other helicopter air ambulances turned down because of inclement weather, NTSB said.

A MedFlight pilot received a request to transport the patient on Jan. 29, 2019, but the pilot determined the weather was too bad to fly.

At the time of the crash, Vinton County had light snow showers and winds blowing steadily from the west at 15 mph and gusting to 21 mph . It was 25 degrees, with wind chills in the single digits.

The Federal Aviation Administration's poor oversight of Survival Flight's risk management program and the FAA's failure to mandate helicopter air ambulance operators to have safety management systems also contributed to the accident, NTSB said.

The safety risks at Survival Flight would have probably been identified and mitigated by a properly run safety management system, which would have prevented the crash.

NTSB made a total 14 new recommendations to Survival Flight, the FAA and the National Weather Service and Survival Flight as a result of the Survival Flight investigation.

Survival Flight has already implemented five of its six recommendations from the NTSB, including revised procedures for determining prior flight refusals by another helicopter air ambulance operator, requiring pilots complete a comprehensive risk assessment before each flight, developed a procedure for tracking pilot duty times, developed a process to make sure comprehensive preflight risk assessments happen before accepting any flight requests and implementing a flight data monitoring program independent of a FAA requirement.

Survival Flight is working on the last recommendations, establishing a safety management system program through the FAA's Safety Management System Voluntary Program. The FAA program is a voluntary safety program designed to improve aviation safety.

"We're learning from this tragedy...," Stubenrauch said in the statement. "Survival Flight will continue to learn, improve and adapt as a company in order to better serve our communities and save lives."

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©2020 The Columbus Dispatch (Columbus, Ohio)

McClatchy-Tribune News Service

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