NTSB Cites Safety Culture Failure In Air Ambulance Crash


The National Transportation Safety Board (NTSB) announced on Tuesday that the Jan. 29, 2019, crash of a Bell 407 air ambulance helicopter in Zaleski, Ohio, was caused by the operator’s “inadequate management of safety.” The helicopter, which was only certified to operate in visual flight conditions, collided with trees in a heavily wooded area after failing to maintain altitude following inadvertent flight into instrument meteorological conditions. All three crew members onboard were killed.

As previously reported by AVweb, the aircraft was operated by Survival Flight Inc. and was en route to pick up a patient from Holzer Meigs hospital in Pomeroy, Ohio. According to the NTSB, a thorough preflight weather evaluation had not been conducted prior to the accident flight. The board found (PDF) that pilots and operations staff at the company routinely failed to comply with preflight risk assessment procedures, noting that noncompliance with those procedures had become “normalized by Survival Flight’s deficient safety culture.” Company employees also reported in post-accident interviews that they encountered pressure from management “to operate flights in challenging conditions and to take flights that other helicopter air ambulance services turned down due to inclement weather.”

“This accident was all but invited by the actions and culture of Survival Flight,” said NTSB Chairman Robert Sumwalt. “Unfortunately, we have seen yet another case of how a poor safety culture can lead to tragedy.” The NTSB also cited inadequate FAA oversight of Survival Flight’s risk management program and the FAA’s failure to require helicopter air ambulance operators to have safety management systems as contributing factors in the accident.

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Kate O’Connor works as AVweb's Editor-in-Chief. She is a private pilot, certificated aircraft dispatcher, and graduate of Embry-Riddle Aeronautical University.

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  1. This crash is eerily similar to Kobe Bryant and passengers dying in their chartered helicopter a year later, 1-26-20. Both helicopters certified for vfr only flights and pilots failing to avoid imc……

    • There is a good possibility that the pilot was instrument rated, but the helicopter wasn’t. Most medical helicopter operations require the pilots to be instrument certified even if the aircraft aren’t. I have known of companies that require pilots to stay current even if the aircraft aren’t certified, usually meaning they aren’t flown with 2 pilots or don’t have an autopilot. The company website says instrument rating required.

  2. Someone please help me out. I’m not rotor rated but, why can’t a helicopter stop/hover or turn around, or go straight up when they encounter IMC? Why continue to fly into the rocks/trees/whatever?
    Tom C.

  3. It’s not usually so much an issue of flying “into the rocks/trees” (CFIT) as losing spatial orientation and then crashing, same as in an airplane. Sometimes turning around would solve the problem, but the pressure to keep going is probably just as great as the pressure to take off in such conditions in the first place.