# NTSB CEN19FA072: Bell 407, N191SF, Zaleski, OH, January 29, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Field · Final report
- Date: January 29, 2019, 06:50 local (11:50 UTC)
- Place: Zaleski, OH
- Coordinates: 39.323333, -82.309448
- Nearby events: https://openairdocs.org/map.md?lat=39.3233&lon=-82.3094&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000)
- Highest injury: Fatal
- Injuries: 3 fatal
- 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
- NTSB case key (mKey): 98902
- NTSB case page: https://www.ntsb.gov/investigations/Pages/CEN19FA072.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98902/pdf
- Board report AAR2001 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98902
- Page: https://openairdocs.org/ntsb/CEN19FA072

## 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

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

- [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=1182206), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md)
- [Culture: safety](https://openairdocs.org/ntsb-findings/04024010): Organizational issues › Management · Operator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04024010/cases.md?model=1182206), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/04024010/cases.md)
- [Culture: standard operating practices](https://openairdocs.org/ntsb-findings/04024015): Organizational issues › Management · Operator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04024015/cases.md?model=1182206), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/04024015/cases.md)
- [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Operator (probable cause); cases with it: [Bell 407, 3 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=1182206), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md)
- [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=1182206), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md)
- [Enforcement: operational procedures](https://openairdocs.org/ntsb-findings/04034015): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04034015/cases.md?model=1182206), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04034015/cases.md)
- [Safety programs: adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04035015/cases.md?model=1182206), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/04035015/cases.md)
- [Safety programs: adherence to safety program](https://openairdocs.org/ntsb-findings/04035020): Organizational issues › Support/oversight/monitoring · Operator (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/04035020/cases.md?model=1182206), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/04035020/cases.md)
- [Ceiling/visibility/precip: snow](https://openairdocs.org/ntsb-findings/03035045): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/03035045/cases.md?model=1182206), [All aircraft, 43 cases](https://openairdocs.org/ntsb-findings/03035045/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Bell 407, 6 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1182206), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Not specified (probable cause); cases with it: [Bell 407, 2 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=1182206), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md)
- [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=1182206), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell 407, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1182206), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Meteorological services](https://openairdocs.org/ntsb-findings/03013000): Environmental issues › Operating environment · Availability of related info; cases with it: [Bell 407, 2 cases](https://openairdocs.org/ntsb-findings/03013000/cases.md?model=1182206), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/03013000/cases.md)

## Sequence of events

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

- [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Bell 407, 3 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=1182206), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md)
- [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Bell 407, 5 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=1182206), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md)

## 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](https://openairdocs.org/deregistered/N191SF-2021-05-08), registration cancelled 2021-05-08, S/N 53006, built 1996 (OpenAirDocs)
- Reported make and model: Bell 407 (No Series)
- Registry model: [Bell 407](https://openairdocs.org/model/bell-407) (registry code 1182206) (OpenAirDocs)
- Registry engine: [Rolls-Royce 250-C47B](https://openairdocs.org/engine/rolls-royce-250-c47b) (registry code 54585, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 53006
- Year built: 1996
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 34; injuries: fatal; 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 files)

The files NTSB released with the investigation on November 19, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98902. 526 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 12 pages, 507 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8302929&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf
- Occ recorded line transcript (item 2, PDF, 5 pages, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9268274&FileExtension=pdf&FileName=Transcribed%20Phone%20Conversations_Redacted-Rel.pdf
- Operational factors/human performance factual report (item 3, PDF, 53 pages, 923 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8668223&FileExtension=pdf&FileName=OPSHPFactual_Formatted_9-Rel.pdf
- Operational factors/human performance factual report - errata 1 (item 4, PDF, 2 pages, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9265951&FileExtension=pdf&FileName=Ops%20Errata%201-Rel.pdf
- Operations/human performance attachment 1 company interviews (item 5, PDF, 1,025 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8676288&FileExtension=pdf&FileName=Attach1%20Interviews_Redacted-Rel.pdf
- Operations/human performance attachment 2 FAA interviews (item 6, PDF, 99 pages, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8676297&FileExtension=pdf&FileName=CEN19FA072_Attachment%202_Redacted-Rel.pdf
- Operations/human performance attachment 3 requesting facility interivews (item 7, PDF, 6 pages, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8626850&FileExtension=pdf&FileName=CEN19FA072_Attachment%203-Rel.pdf
- Operations/human performance attachment 4 accident nurse letter to human resources (item 8, PDF, 6 pages, 561 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8628246&FileExtension=pdf&FileName=CEN19FA072_Attachment%204_Redacted-Rel.pdf
- Operations/human performance attachment 5 shift briefing/debriefing forms (item 9, PDF, 60 pages, 137 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8698833&FileExtension=pdf&FileName=CEN19FA072_Attachment%205_Redacted-Rel.pdf
- Operations/human performance attachment 6 company forms (item 10, PDF, 18 pages, 458 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627474&FileExtension=pdf&FileName=CEN19FA072_Attachment%206-Rel.pdf
- Operations/human performance attachment 7 regulatory preamble (item 11, PDF, 2 pages, 570 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627691&FileExtension=pdf&FileName=CEN19FA072_Attachment%207-Rel.pdf
- Operations/human performance attachment 8 fsb report (item 12, PDF, 5 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627971&FileExtension=pdf&FileName=CEN19FA072_Attachment%208_Redacted-Rel.pdf
- Operations/human performance attachment 9 FAA legal interpretation (item 13, PDF, 3 pages, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627398&FileExtension=pdf&FileName=CEN19FA072_Attachment%209_Redacted-Rel.pdf
- Operations/human performance attachment 10 dot ig report (item 14, PDF, 24 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8624747&FileExtension=pdf&FileName=CEN19FA072_Attachment%2010-Rel.pdf
- Operations/human performance attachment 11 pilot training records (item 15, PDF, 21 pages, 13.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8625573&FileExtension=pdf&FileName=CEN19FA072_Attachment%2011_Redacted-Rel.pdf
- Operations/human performance attachment 12 company flight release records (item 16, PDF, 27 pages, 8.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627144&FileExtension=pdf&FileName=CEN19FA072_Attachment%2012_Redacted-Rel.pdf
- Operations/human performance attachment 13 pilot flight/duty records (item 17, PDF, 9 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627020&FileExtension=pdf&FileName=CEN19FA072_Attachment%2013_Redacted-Rel.pdf
- Operations/human performance attachment 14 company occ shift change checklists (item 18, PDF, 8 pages, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8628011&FileExtension=pdf&FileName=CEN19FA072_Attachment%2014_Redacted-Rel.pdf
- Operations/human performance attachment 15 base 14 flight records (item 19, PDF, 22 pages, 745 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8626758&FileExtension=pdf&FileName=CEN19FA072_Attachment%2015-Rel.pdf
- Operations/human performance attachment 16 FAA surveillance activity (item 20, PDF, 5 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627162&FileExtension=pdf&FileName=CEN19FA072_Attachment%2016_Redacted-Rel.pdf
- Operations/human performance attachment 17 FAA order 8900.1 excerpt (item 21, PDF, 8 pages, 348 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8628571&FileExtension=pdf&FileName=CEN19FA072_Attachment%2017-Rel.pdf
- Operations/human performance attachment 18 interivews with medflight and healthnet (item 22, PDF, 5 pages, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8628625&FileExtension=pdf&FileName=CEN19FA072_Attachment%2018-Rel.pdf
- Operations/human performance attachment 19 NTSB calculated weight and balance (item 23, PDF, 3 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8629026&FileExtension=pdf&FileName=CEN19FA072_Attachment%2019_Redacted-Rel.pdf
- Operations/human performance attachment 20 flight into known icing FAA legal interpretation (item 24, PDF, 5 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8628793&FileExtension=pdf&FileName=CEN19FA072_Attachment%2020_Redacted-Rel.pdf
- Statement from metro aviation pilot regarding flight refusal (item 25, PDF, 1 page, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9598443&FileExtension=pdf&FileName=Metro%20Aviation%20Pilot%20Statement_redacted-Rel.pdf
- November 15, 2019 survival flight training policy change (item 26, PDF, 1 page, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9598589&FileExtension=pdf&FileName=Bell%20407%20Training%20Policy%20Change_Redacted-Rel.pdf
- Additional record of conversation with night shift pilot (item 27, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9598077&FileExtension=pdf&FileName=ROC-Rel.pdf
- Operational factors/human performance factual report - addendum 1 (item 28, PDF, 10 pages, 339 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8696129&FileExtension=pdf&FileName=Ops%20addendum%201_Redacted-Rel.pdf
- Operations/human performance - addendum 1 (item 29, PDF, 1 page, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9292237&FileExtension=pdf&FileName=Ops%20Addendum%201-Rel.pdf
- Operations/human performance - addendum 1 - attachement 1 (item 30, PDF, 1 page, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9292700&FileExtension=pdf&FileName=Bell%20407%20Training%20Policy%20Change_Redacted-Rel.pdf
- Flight data monitoring (fdm) - data - group chairman's factual report (item 31, PDF, 17 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8335237&FileExtension=pdf&FileName=CEN19FA072%20Zaleski%20Outerlink%20Iris%20Data%20Report-Rel.pdf
- Attachment 1 to flight data monitoring (fdm) - data - group chairman's factual report (item 32, CSV, 976 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8335016&FileExtension=csv&FileName=Attachment1_CEN19FA072_rev2-Rel.csv
- Flight data monitoring (fdm) - audio transcript - group chairman's factual report (item 33, PDF, 14 pages, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8713943&FileExtension=pdf&FileName=CEN19FA072%20Zaleski%20Outerlink%20Iris%20AUDIO%20Report_2withOCCadded-Rel.pdf
- Addendum - flight data monitoring (fdm) - audio transcript - group chairman's factual report (item 34, PDF, 1 page, 557 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9567111&FileExtension=pdf&FileName=ADDENDUM%20-%20CEN19FA072%20-%20Sound%20Spectrum%20Study-Rel.pdf
- Personal electronic devices - specialist's factual report (item 35, PDF, 7 pages, 304 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8405178&FileExtension=pdf&FileName=Personal%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf
- Attachment 1 to personal electronic devices - specialist's factual report (item 36, XLSX, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8711946&FileExtension=xlsx&FileName=Attachment%201%20to%20Personal%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.xlsx
- Attachment 2 to personal electronic devices - specialist's factual report (item 37, XLSX, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8712237&FileExtension=xlsx&FileName=Attachment%202%20to%20Personal%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.xlsx
- Airworthiness group chairman's factual report (item 38, PDF, 27 pages, 15 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8402330&FileExtension=pdf&FileName=Airworthiness%20Group%20Chairman%27s%20Factual%20Report%20(CEN19FA072)%20FINAL-Rel.pdf
- Airworthiness group chairman's factual report - attachment 1 (item 39, PDF, 11 pages, 351 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8402454&FileExtension=pdf&FileName=Airworthiness%20(CEN19FA072)%20-%20Attachment%201%20-%20CAE-847007%20ECU%20Download%20Results-Rel.pdf
- Airworthiness group chairman's factual report - attachment 2 (item 40, PDF, 6 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8401769&FileExtension=pdf&FileName=Airworthiness%20(CEN19FA072)%20-%20Atttachment%202%20-%20N191SF%20Mx%20Records_Redacted-Rel.pdf
- Airworthiness group chairman's factual report - addendum 1 (item 41, PDF, 3 pages, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8657521&FileExtension=pdf&FileName=Airworthiness%20Group%20Factual%20Report%20Addendum%20(CEN19FA072)%20FINAL-Rel.pdf
- Electronic devices - specialist's factual report (item 42, PDF, 5 pages, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8511977&FileExtension=pdf&FileName=Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf
- Sound spectrum study (item 43, PDF, 10 pages, 545 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20433804&FileExtension=pdf&FileName=CEN19FA072%20Zaleski%20Sound%20Spectrum%20Study-Rel_Redacted-Rel.pdf
- Weather factual report (item 44, PDF, 69 pages, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8672293&FileExtension=pdf&FileName=CEN19FA072_weatherfactualSuffernfinal-Rel.pdf
- Weather attachment 1 (item 45, XLSX, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447190&FileExtension=xlsx&FileName=attachment1_flightrackwitheights10seconds-Rel.xlsx
- Weather attachment 2 (item 46, PDF, 2 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447362&FileExtension=pdf&FileName=attachment2_QuickGuide_NtMicro_GOESR_NASA_SPoRT_20170914-Rel.pdf
- Weather attachment 3 (item 47, GIF, 21.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447199&FileExtension=gif&FileName=attachment3_animationfrom1032_1232utc_CODNEXLAB-GOES16-subregional-Virginias-ntmicro-12_32Z-20190129_map_-25-1n-10-100-Rel.gif
- Weather attachment 4 (item 48, GIF, 30.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447208&FileExtension=gif&FileName=attachment4_animationwxradarTDWR_1002utcto1209utc-Rel.gif
- Weather attachment 5 (item 49, PDF, 7 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447371&FileExtension=pdf&FileName=attachment5_GFAimagedata-Rel.pdf
- Weather attachment 6 (requires gunzip or winzip software to view) (item 50, GZ, 12.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446825&FileExtension=gz&FileName=attachment6_20190129OH_CIP_FIP_imagery.tar-Rel.gz
- Weather attachment 7 (item 51, PDF, 1 page, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446934&FileExtension=pdf&FileName=attachment7_foreflightwaypointselected_Redacted-Rel.pdf
- Weather attachment 8 (item 52, PDF, 2 pages, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446834&FileExtension=pdf&FileName=attachment8_HEMS_PDD-Rel.pdf
- Weather attachment 9 (item 53, PDF, 2 pages, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446410&FileExtension=pdf&FileName=attachment9_scn15-20hems_cca-Rel.pdf
- Weather attachment 10 (item 54, PDF, 3 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446843&FileExtension=pdf&FileName=attachment10_HEMScorrespondencewithNWS_Redacted-Rel.pdf
- Weather attachment 11 (item 55, PDF, 2 pages, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446943&FileExtension=pdf&FileName=attachment11_noTDWRonMRMS_Redacted-Rel.pdf
- Weather attachment 12 (item 56, PDF, 3 pages, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446852&FileExtension=pdf&FileName=attachment12_ROC_FPAWmeeting_4_17_2019_final-Rel.pdf
- Weather attachment 13 (item 57, PDF, 206 pages, 10.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446861&FileExtension=pdf&FileName=attachment13_14.%20OCC%20Meteorology%20101-Rel.pdf
- Weather attachment 14 (item 58, PDF, 43 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447463&FileExtension=pdf&FileName=attachment14_15.%20OCC%20Radar%20and%20Satellite-Rel.pdf
- Weather attachment 15 (item 59, PDF, 210 pages, 15.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447606&FileExtension=pdf&FileName=attachment15_16.%20OCC%20Aviation%20Weather-Rel.pdf
- Weather attachment 16 (item 60, PDF, 33 pages, 714 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8445941&FileExtension=pdf&FileName=attachment16_HEMS_SRMD_V1%2004JC-Rel.pdf
- Weather attachment 17 (item 61, PDF, 34 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8690440&FileExtension=pdf&FileName=attachment17_HEMS%20SRMD%200408154JC_Redacted-Rel.pdf
- Weather attachment 18 (item 62, PDF, 5 pages, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447248&FileExtension=pdf&FileName=attachment18_N_8000.333%20-%20HEMS%20use%20of%20the%20Experimental%20HEMS%20tool-Rel.pdf
- Weather attachment 19 (item 63, PDF, 4 pages, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447615&FileExtension=pdf&FileName=attachment19_hemshistorydocument_Redacted-Rel.pdf
- Weather attachment 20 (item 64, PDF, 36 pages, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447380&FileExtension=pdf&FileName=attachment20_metars_FlightonJanuary14th_2019-Rel.pdf
- Weather attachment 21 (item 65, GIF, 890 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8447624&FileExtension=gif&FileName=attachment21_animationlowcloudsfrom2130to2345utc-Rel.gif
- Weather attachment 22 (item 66, PDF, 59 pages, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446952&FileExtension=pdf&FileName=attachment22_metars_FlightonJanuary24th_2019-Rel.pdf
- Weather attachment 23 (item 67, PDF, 34 pages, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446961&FileExtension=pdf&FileName=attachment23_metars_FlightonDecember6th_2018-Rel.pdf
- Weather attachment 24 (item 68, GIF, 12.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8446419&FileExtension=gif&FileName=attachment24_animationwxradar0306to0416utc-Rel.gif
- Weather addendum 1 (item 69, PDF, 5 pages, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798772&FileExtension=pdf&FileName=CEN19FA072_weatheraddendum1_Suffernfinal-Rel.pdf
- Weather addendum 1 attachment 1 (item 70, PDF, 1 page, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798872&FileExtension=pdf&FileName=attachment1_wet-dry%20snow_Redacted-Rel.pdf
- Weather addendum 1 attachment 2 (item 71, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798227&FileExtension=pdf&FileName=attachment2_Redacted-Rel.pdf
- Weather addendum 1 attachment 3 (item 72, PDF, 3 pages, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798368&FileExtension=pdf&FileName=attachment3HCA_discussionwetsnow_Redacted-Rel.pdf
- Weather addendum 1 attachment 4 (item 73, PDF, 45 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798672&FileExtension=pdf&FileName=attachment4_faa_ar98_76_tablec1isgood-Rel.pdf
- Weather addendum 1 attachment 5 (item 74, PDF, 3 pages, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798998&FileExtension=pdf&FileName=attachment5_DanAcorrespondance_cip_fipstuff_Redacted-Rel.pdf
- Weather addendum 1 attachment 6 (item 75, PDF, 99 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798790&FileExtension=pdf&FileName=attachment6_snowratio1-Rel.pdf
- Weather addendum 1 attachment 7 (item 76, PDF, 127 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8798410&FileExtension=pdf&FileName=attachment7_snowratio2-Rel.pdf
- Aircraft performance study (item 77, PDF, 16 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182046&FileExtension=pdf&FileName=CEN19FA072_Performance_Study-Rel.pdf
- Weather addendum report 2 (item 78, PDF, 3 pages, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9250308&FileExtension=pdf&FileName=CEN19FA072_weatheraddendum2_Suffernfinal-Rel.pdf
- Weather addendum 2 attachment 1 (item 79, PDF, 1 page, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9250560&FileExtension=pdf&FileName=addendum2_attachment1_Archer%20Followup-Rel.pdf
- Weather addendum 2 attachment 2 (item 80, ZIP, 159 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9250317&FileExtension=zip&FileName=addendum2_attachment2_FIS_Bdata_cen19fa072-Rel.zip
- Weather addendum 2 attachment 3 (item 81, PDF, 44 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9249650&FileExtension=pdf&FileName=addendum2_attachment3_freeman-fis-b-newproducts-fpaw-2018jul17-1_forCEN19FA072addendumpart2-Rel.pdf
- Weather addendum 2 attachment 4 (item 82, PDF, 2 pages, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9250600&FileExtension=pdf&FileName=addendum2_attachment4_wetdrysnowresponse_jan_2020_Redacted-Rel.pdf
- Toxicological report (item 83, PDF, 1 page, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8705997&FileExtension=pdf&FileName=PIC%20Toxicology_Redacted-Rel.pdf
- Sound spectrum study - addendum (item 84, PDF, 3 pages, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=20434882&FileExtension=pdf&FileName=ADDENDUM%20-%20CEN19FA072%20-%20Sound%20Spectrum%20Study-Rel_Redacted-Rel.pdf
- Addendum - flight data monitoring (fdm) - audio transcript - group chairman's factual report V2 (item 85, PDF, 1 page, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9583099&FileExtension=pdf&FileName=ADDEDNDUM%20CEN19FA072%20Zaleski%20Outerlink%20Iris%20AUDIO%20Report_2withOCCadded-Rel.pdf
- Party submission (item 86, PDF, 6 pages, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9662118&FileExtension=pdf&FileName=SF%20Party%20Submission_Redacted-Rel.pdf
- Photo array (item 87, PDF, 9 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9663110&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf
- Record of conversation (jonathan Robinson) (item 88, PDF, 3 pages, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9678364&FileExtension=pdf&FileName=Jonathan%20Robinson%20ROC-Rel.pdf
- NTSB and survival flight correspondence (item 89, PDF, 50 pages, 11.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9690706&FileExtension=pdf&FileName=Correspondence_SurvivalFlight_Redacted-Rel.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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