Crash Unveils Safety Culture Clash, Part 3
This is the last of a three-part article series on analyzing a Bell 407 crash. The first part outlined the conditions before takeoff and the fatal flight. The second part analyzes the accident investigation.
An operational factors/human performance group was formed to examine and document the pilot’s background, company policies, training and supervision, and other operational details. As part of their work, they interviewed 28 people associated with the company, including OCC staff, medical crew, pilots and management. They also talked to people at the hospital and took written statements from other persons of interest. In all, they accumulated 1,146 pages of interviews and statements.
The results showed a marked contrast between the company’s stated policies and its actual practices.
The evening duty pilot at Grove City on the morning of the accident had rated conditions as amber for weather, and later replaced it with green. When the NTSB graded conditions using the methods in AC 135-14B, “Helicopter Air Ambulance Operations,” including the turndowns by other operators, it resulted in a score that would have cancelled the flight.
Why did the flight depart in unsafe conditions? Comments made by the staff help to explain why the two pilots failed to do the flight’s risk analysis.
Of 23 current or former employees interviewed, 11 said pilots were pressured to take flights. Three of the eight pilots interviewed said they were not able to make a “red” risk assessment. When one pilot said his base was “red” for maintenance, the director of operations (DO) called and said “why are you red...that’s not the way we do things.” When a helicopter had a hot start, management refused to allow an engine inspection until the mechanic threatened to quit. The engine was damaged.
Pilots were reprimanded or criticized for declining a flight. A medical crew member said when pilots turned down flights for weather, “the chief pilot of the company...would call within about 10 minutes and would cuss out our pilots and belittle them...saying...we need to take these flights...he would yell so loud on the phone that you could hear it...just standing within earshot.”
A pilot turned down a flight due to 35-50 kt. winds and low ceilings. Both the DO and chief pilot called the pilot to question his decision. A pilot who turned down a flight for low ceilings was told by a manager, “get that helicopter flown back to the [hospital]” because she “wanted [it] back on the helipad for the visual effect.”
Company management expected pilots to depart from the helipad within 7 minutes of receiving a call. One pilot said he was criticized for waiting beyond that time to allow the engine temperatures to move into the green range.
Two former employees reported they were terminated shortly after voicing safety concerns and turning down flights, and one current employee was demoted after voicing his safety concerns.
Investigators obtained a poignant letter written by the flight nurse who died in the accident. The letter detailed many examples of harassment and intimidation of crews by one pilot in the base. She described flying in conditions that were “only black and a ton of clouds and precipitation.” The letter was written to company human resources officials about six weeks before the accident.
Even though the company had a safety reporting system, the safety director admitted he had only received one incident report in a year and a half.
When helicopter air ambulance companies check the weather turndown website for possible charters, it’s called “reverse helicopter shopping.” Several current and former Survival Flight staff said it was a common company practice to use the weather turndown site to find flight requests.
Survival Flight distributed a quick reference guide to hospitals that said, in part, “Our weather minimums are different, if other companies turn down the flight for weather–CALL US. If we can fly to you safely and take the patient safely to another facility...WE WILL.”
Survival Flight’s Response
The NTSB released its docket of factual reports to the public in November 2019. According to a letter from an attorney working for Viking Aviation (dba Survival Flight), immediately after the docket was released, customers In Ohio terminated contracts with the company and a client hospital in Oklahoma City decided not to refer patients to the company anymore. He also said the company was now unable to find employees who were willing to work for the company.
The company publicly released arguments about the docket factual material, including the interviews, and proposed the cause of the accident was “an object, presumably like a bird” striking the airplane.
On Dec. 4, 2019, the NTSB’s director of aviation safety wrote a letter to Survival Flight’s party representative reminding him that he and his company had agreed to the NTSB’s party agreement, which says parties may not comment publicly about the ongoing investigation or make analytical comments about the cause of the accident. The letter was a final warning before removing the company from party status.
In January 2020 the company’s attorney accused the NTSB of using the investigation to “advance a dispute with the FAA” and complained that their management personnel were not allowed to be on investigative groups. He complained of factual errors even though three of the company’s employees were full members of investigative groups and all concurred with the facts in the NTSB’s technical review. The attorney’s letter was sent to officials all over Washington, D.C., including the FAA administrator and the Department of Transportation secretary.
Management personnel are routinely excluded from investigative groups as a matter of long standing NTSB policy.
Conclusions and Recommendations
When the NTSB analyzes all the information gathered by investigators, it takes into account the possibility that some people interviewed might not be entirely candid and that some people may have a grudge against a company. In the winnowing of the data, it’s a consistent pattern of data and remarks that leads to sound conclusions. In the Survival Flight investigation, the pattern of poor safety practices stood out.
The Board described safety culture as “the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.” The company’s safety director described the company’s culture as “pretty good,” but the evidence showed otherwise.
The NTSB’s probable cause for the accident was “Survival Flight’s inadequate management of safety, which normalized pilots’ and operations control specialists’ noncompliance with risk analysis procedures resulted in the initiation of the flight without a comprehensive preflight weather evaluation, leading to the pilot’s inadvertent encounter with instrument meteorological conditions, failure to maintain altitude and subsequent collision with terrain. Contributing to the accident was the FAA’s inadequate oversight of the operator’s risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.”
In a board member statement appended to the report, Chairman Robert Sumwalt remarked that “denial is the enemy of change.” The other board members joined in his statement. The company CEO, chief pilot and attorney had attacked the credibility of the witnesses and, speaking of the board’s findings about their culture, said “That’s not who we are. That’s not us.” The NTSB chairman said the only ones who could fix the problems was the company’s management.
The Board made recommendations to the FAA, the National Weather Service and Survival Flight. The recommendations to the company included improving flight risk assessment procedures, tracking pilot duty times, improving shift change briefings, establishing a safety management system (SMS) and developing a flight data monitoring system.
In a July 2020 response to one of the recommendations, the company’s DO said they were aggressively embracing the need to address the recommendations and expected to fully comply with all of them by October 2020. As of Dec. 1, 2021, two of the six were closed acceptably and the others were ongoing. They had implemented an FDM program and were implementing an SMS program.