# NTSB CEN09LA388: Beech B100, N4490M, Rapid City, SD, June 15, 2009

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: June 15, 2009, 16:52 local (22:52 UTC)
- Place: Rapid City, SD
- Coordinates: 44.045276, -103.057502 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=44.0453&lon=-103.0575&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-descent: Clear air turbulence encounter](https://openairdocs.org/ntsb-events/362)
- Highest injury: Serious injuries
- Injuries: 1 serious, 4 minor
- Status: Completed, report December 20, 2010
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Federal Aviation Administration - Rapid City FSDO
- NTSB case key (mKey): 74135
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN09LA388
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74135/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74135
- Page: https://openairdocs.org/ntsb/CEN09LA388

## Probable cause

The flight crewmembers’ failure to secure the patient using the available over-the-shoulder restraints and the encounter with clear-air turbulence during cruise descent.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Equipment/furnishings: passenger compartment equip](https://openairdocs.org/ntsb-findings/01022520): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Beech B100, 1 case](https://openairdocs.org/ntsb-findings/01022520/cases.md?model=1152919), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/01022520/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Beech B100, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1152919), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Turbulence: clear air turbulence](https://openairdocs.org/ntsb-findings/03032015): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Beech B100, 1 case](https://openairdocs.org/ntsb-findings/03032015/cases.md?model=1152919), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03032015/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft loading event](https://openairdocs.org/ntsb-events/010); cases with it: [Beech B100, 1 case](https://openairdocs.org/ntsb-events/010/sequence.md?model=1152919), [All aircraft, 84 cases](https://openairdocs.org/ntsb-events/010/sequence.md)
- [Enroute-descent: Clear air turbulence encounter](https://openairdocs.org/ntsb-events/362) (defining event); cases with it: [Beech B100, 1 case](https://openairdocs.org/ntsb-events/362/sequence.md?model=1152919), [All aircraft, 24 cases](https://openairdocs.org/ntsb-events/362/sequence.md)

## Analysis

The air-ambulance flight encountered clear-air turbulence during cruise descent. During the turbulence encounter, the patient’s unrestrained upper-torso fell off the aircraft mounted stretcher assembly. After the turbulence had subsided, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. The stretcher’s available over-the-shoulder restraints were not used because of an interference caused by a flexible lift system that was used to transfer the patient from the ambulance gurney to the aircraft’s stretcher. After the accident the aeromedical transport company discontinued the use of the flexible patient lift system model used during the accident flight and required flight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.

## Factual narrative

On June 15, 2009, about 1652 mountain daylight time (mdt), a Beech B100 (King Air) airplane, N4490M, operated by Air Methods Corporation, encountered clear-air-turbulence while descending through 7,000 feet mean sea level (msl) en route to Rapid City Regional Airport (KRAP), Rapid City, South Dakota. Visual meteorological conditions prevailed during the flight. The air-ambulance flight was conducted in accordance with 14 Code of Federal Regulations (CFR) Part 135 while on an instrument flight plan. The patient was seriously injured as result of the turbulence encounter. The 4 flight crew members sustained minor injuries. The flight departed Gordon Municipal Airport (KGRN), Gordon, Nebraska, at 1619 mdt. Before being loaded onto the airplane, the patient was lying on an ambulance gurney and was already secured to a flexible lift system at the waist and legs. The use of the flexible lift system allowed the easy transfer from the ambulance gurney to the aircraft-mounted stretcher assembly. The lift system comprised of a plasticized sheet and full body length foam pad. The patient was secured to this lift system using the available waist and leg straps. For patient transfers, flight crewmembers grab the edges of the flexible lift system to lift and transfer the patient from the ambulance gurney to the airplane’s stretcher. The airplane’s stretcher also incorporated a full body pad, and its support frame articulated at the waist to elevate the patient’s upper body from a supine position into an inclined position. The airplane’s stretcher had leg, waist, and left and right over-the-shoulder straps. The over-the-shoulder straps combined at the waist strap buckle assembly. The patient, who was already restrained in the flexible lift system by waist and leg straps, was then restrained to the airplane’s stretcher using the stretcher’s available waist and leg straps. The full body pad and plasticized sheet of the flexible lift system completely covered and prevented the use of the over-the-shoulder restraints installed on the airplane’s stretcher. During the flight, the stretcher’s back support was raised into an inclined position for added patient comfort. During cruise descent, the airplane encountered clear-air-turbulence, during which the patient’s upper-torso fell off the stretcher. After the turbulence encounter, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. After the accident, the aeromedical transport company discontinued the use of the flexible patient lift system model utilized during the accident flight and requiredflight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.

## Aircraft

- Registration: [N4490M](https://openairdocs.org/aircraft/N4490M), registered now, S/N BE-64, built 1979 (OpenAirDocs)
- Reported make and model: Beech B100
- Registry model: [Beech B100](https://openairdocs.org/model/beech-b100) (registry code 1152919) (OpenAirDocs)
- Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: BE-64
- Airframe hours: 9898
- Engines: Garrett Airesearch TPE-331 1428 horsepower turbo prop; Garrett Airesearch TPE-331 1428 horsepower turbo prop
- Damage: No damage
- Flight: Part 135
- Operator: Air Methods Corporation, doing business as Black Hills Life Flight
- Registered owner: Vesey Air, LLC.
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, May 12, 2009
- Departed: KGRN, Gordon, NE
- Destination: KRAP, Rapid City, SD
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 34; injuries: minor; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review May 7, 2009; seat: left; flight hours: 3,305 total, 516 in this make and model, 3,150 as pilot in command, 40 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 360° at 10 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 66 °F, dew point 50 °F
- Altimeter: 29.73 inHg
- Observed at: KRAP, 10 nm away

## Docket (8 files)

The files NTSB released with the investigation on August 18, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74135. 1.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335038&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Flight Crewmember Statements (item 2, .PDF, 201 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335037&FileExtension=.PDF&FileName=Flight%20Crewmember%20Statements-Redacted.PDF
- Operator Safety Change Memo (item 3, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335039&FileExtension=.PDF&FileName=Operator%20Safety%20Change%20Memo-Redacted.PDF
- Photo 01 - Aircraft Stretcher Overview (item 4, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335032&FileExtension=.PDF&FileName=Photo%2001%20-%20Aircraft%20Stretcher%20Overview-Master.PDF
- Photo 02 - Stretcher Articulated Back Support (item 5, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335033&FileExtension=.PDF&FileName=Photo%2002%20-%20Stretcher%20Articulated%20Back%20Support-Master.PDF
- Photo 03 - Stretcher Over-The-Shoulder Straps and Waist Buckle (item 6, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335034&FileExtension=.PDF&FileName=Photo%2003%20-%20Stretcher%20Over-The-Shoulder%20Straps%20and%20Waist%20Buckle-Master.PDF
- Photo 04 - Flexible Lift System Overview (item 7, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335035&FileExtension=.PDF&FileName=Photo%2004%20-%20Flexible%20Lift%20System%20Overview-Master.PDF
- Photo 05 - Flexible Lift System Overview (item 8, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335036&FileExtension=.PDF&FileName=Photo%2005%20-%20Flexible%20Lift%20System%20Overview-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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