- Date
- January 29, 2019, 06:50 local (11:50 UTC)
- Place
- Zaleski, OH
- Injuries
- 3 fatal
- Damage
- Destroyed
- Phase of flight
- Enroute
- Aircraft
- N191SFBell 407
- Defining event
- Enroute: Unknown or undetermined
- Weather
- Night
- Status
- Completed · report June 10, 2020
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Central Region
- Parties
- FAA, Rolls Royce Engines, Woodward, Viking Aviation LLC
- Safety recommendations
- Yes
- Case key
- 98902
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The NTSB determines that the probable cause of this accident was Survival Flight's inadequate management of safety, which normalized pilots' and operations control specialists' noncompliance with risk analysis procedures and 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 Federal Aviation Administration'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.
Findings · 14
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered Bell 407 helicopter, N191SF, being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.
Factual narrative
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered Bell 407 helicopter, N191SF, being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.
Aircraft
- Registration
- N191SF
- Reported as
- Bell 407 (No Series)
- Category
- Helicopter
- Serial number
- 53006
- Built
- 1996
- Engine
- Rolls-Royc 250-C47B, turbo shaft
- Damage
- Destroyed
- Flight
- Part 135
- Operator
- Viking Aviation Inc, doing business as Survival Flight Inc
- Registered owner
- N191sf LLC
- Airworthiness certificate
- Standard, Normal
- Departed
- Grove City, OH
- Destination
- Pomeroy, OH
- Flight plan
- Company VFR
- Equipment
- Electronic flight bag or handheld device, Onboard weather, Satellite tracking device, ADS-B, Auto-pilot, Data recorder
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 34
- Injuries
- Fatal
- Certificates
- Commercial, Flight instructor
- Airplane ratings
- Single-engine land
- Instrument ratings
- Helicopter, Airplane
- Medical
- Class 2, Without waivers/limitations
- Last flight review
- April 27, 2018
- Seat
- Right
- Toxicology
- Performed
- Flight hours
- 1,855 total · 83 in this make and model · 1,787 as pilot in command
Weather
- Conditions
- Night
- Wind
- 280° at 7 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- 2,700 ft overcast
- Temperature
- 21 °F, dew point 14 °F
- Altimeter
- 29.92 inHg
- Icing
- Unknown
- Turbulence
- Unknown
- Observed at
- KUNI, 7 nm away
Docket · 89
The files NTSB released with the investigation on November 19, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 526 MB in all.
