Crash Unveils Safety Culture Clash, Part 1

This is the first of a three-part article series on analyzing a Bell 407 crash. 

Many words have been written about safety culture, but attaining that culture remains a somewhat elusive goal. CEOs, managers, chief pilots and even pilots tell themselves they’ve done everything they can do to achieve a good safety culture, and then an accident happens. The leaders are shocked, and then they begin to find out that not everyone in the organization believed the safety culture was good. That can lead to some hard feelings.

Safety culture was at the heart of the investigation into the crash of a Bell 407 helicopter air ambulance flight in 2019. When the NTSB released the docket of factual information halfway through the investigation, over a thousand pages of interviews with current and former employees revealed that many of them felt pressured into flying in marginal or unsafe conditions, and that the management wasn’t listening to them. The company’s immediate response was anger and disbelief.

The investigation may be an object lesson in not taking your safety culture for granted. There also may be some lessons in how not to handle an investigation if one comes your way.

The accident flight, which took place on Jan. 29, 2019, was a Part 135 helicopter air ambulance flight from Mount Carmel Hospital, Grove City, Ohio to Holzer Meigs Emergency Department in Pomeroy, Ohio, about 69 nm away. The purpose of the flight was to pick up a patient, and onboard were the pilot, a flight nurse and a paramedic. The operator of the flight was Viking Aviation, doing business as Survival Flight. 

Another pilot, who had been on duty during the evening shift, started the helicopter at 06:23. The accident pilot boarded the helicopter and, using an onboard satellite radio, contacted the company’s operations control center (OCC) at 06:25. She confirmed the flight’s destination and obtained the geographical coordinates for Holzer Meigs. 

It was still dark when the helicopter took off at 06:28 Eastern Standard Time. Typical Ohio wintertime weather conditions prevailed, with overcast skies, freezing temperatures, and about 7 miles visibility. Marginal visual flight rules (MVFR) conditions were forecast for the area along the route, with an overcast between 2,200 and 2,800 ft AGL, a 30-60% chance of light snow and surface winds of 10-15 kt. from the west. 

There was a winter weather advisory for rapidly falling temperatures, flash freeze conditions, scattered snow showers, and up to an inch of snow accumulations possible. Three nearby airports reported gusty winds of 10-20 kt. and visibilities as low as 3 miles. Two AIRMET’s were valid for the area warning of moderate turbulence and moderate icing.

Shortly after takeoff the company OCC specialist called the pilot to request her risk assessment for the flight, and she replied “I’m green in all categories.” She got information about the patient who was to be picked up and promised to provide the OCC with a flight plan.

The company’s preflight risk analysis scored four factors: environmental factors, aircraft status, human factors and flight type. Colors were used to rate each factor--green for normal, amber for intermediate risk and red for out of limits. An amber-critical rating was used for factors approaching out of limits conditions.

The helicopter climbed to and leveled off at 3,000 ft. MSL, just below an overcast deck, and proceeded southeast at 120-140 kt. Three minutes after leveling off, the pilot noticed snow beginning to fall and started a descent. After reaching 2,000 MSL, she again climbed, and again encountered snow. From 06:47 to 06:50 she continued her descent, and at 06:50 she began a 180-deg. turn to the left.

The helicopter continued to descend and struck a tree about 30 ft. above the ground. The elevation of the wreckage area was from 850-980 ft. and the wreckage was aligned along a northwesterly heading. One of the main rotor blades was embedded in a tree. The other three blades stayed attached to the rotor hub and were found about halfway down the 600 ft. wreckage path. There was no fire and no evidence of engine failure. There were no survivors.

The next part of the article series will cover the investigation.