ZALESKI — A National Transportation Safety Board (NTSB) investigation found the medical flight company associated with the 2019 helicopter crash in Zaleski, which resulted in the death or three people, to be at fault for the crash.
The NTSB said the operator, Survival Flight, showed “inadequate management of safety,” which led to a pilot leaving on a flight without a thorough evaluation of the weather for that day. The NTSB issued a recent report detailing findings from the investigation.
“The pilot likely encountered instrument meteorological conditions inadvertently when the helicopter flew through a snow band, which resulted in decreased visibility,” the report stated. “In an attempt to recover from the inadvertent instrument meteorological conditions (IIMC) encounter, the pilot began a 180° turn as part of an IIMC escape maneuver, in keeping 4 with standard operating procedures but did not maintain altitude and allowed the helicopter to descend until it impacted terrain.”
The NTSB also reported that the crash was not a result of the qualifications of the pilot, Jennifer L. Topper, or the airworthiness of the helicopter. In addition, the investigation found that Survival Flight’s risk assessment process was “inadequate for identifying weather risks for the accident flight,” the report states. The NTSB investigation noted Survival Flight operational personnel failed to complete risk assessment worksheets before every flight, including the flight that resulted in the 2019 crash.
In addition, the absence of required elements on the worksheet, “including en route weather risks and refusals of previous requests for a flight,” according to the report.
“Survival Flight’s lack of a procedure to track pilots’ actual duty time contributed to the ineffectiveness of the company’s risk management,” the report stated.
In all, the NTSB identified several safety issues in the report, issued in mid-May. Survival Flight’s lack of comprehensive and effective flight risk assessment and risk management procedures; a “positive safety culture” and a “comprehensive safety management system (SMS)”; ”accurate terminal doppler weather radar data available on the HEMS (helicopter emergency medical services) Weather Tool”; a flight recorder and the need for certain kinds of programming geared toward helicopter air ambulance operations.
The NTSB requested certain actions from SurvivalFlight: revising its flight risk assessment procedures, requiring pilots to perform a flight risk assessment before each flight, developing a procedure for tracking pilot duty times, developing a process to ensure shift change briefings are performed and implementing a flight data monitoring program.
Several former Survival Flight employees have voiced concerns about the company before the 2019 crash, according to a 2019 report by the National Transportation Safety Board.
All three people aboard the Survival Flight helicopter were killed on impact when it crashed in Zaleski State Forest on Tuesday, Jan. 29. The crew was headed to pick up a patient in Meigs County when it crashed early that morning amid poor weather conditions.
Those killed were pilot Topper, 34, of Sunbury and flight nurses Bradley J. Haynes, 48, of London, and Rachel L. Cunningham, 33, of Galloway.
The NTSB Group Chairman’s Factual Report was released in November of 2019. The report contains details about the crash and those deceased, but it also contains multiple anecdotes from several former employees who reportedly witnessed people in management, including the chief pilot, pressuring pilots to accept flights.
One pilot described a situation where another pilot had reported to the OCM that he was concerned he was too fatigued to take another flight after flying three already. In this case, the chief pilot reportedly convinced the pilot to accept the flight.
The pilot who was interviewed by the NTSB expressed concern about pressure from management, stating a pilot had already reported that he was tired “ but they try to talk you through it and say hey,…maybe drink a cup of coffee before you go …and try to get it done.”
Numerous pilots and medical crew indicated incidents in the NTSB report where they were the recipient of or witnessed a pilot being reprimanded or challenged for declining a flight.
One medical crewmember said, “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.”
He reportedly told the NTSB that the chief pilot told the pilot that “if the base failed,” it would be “his fault” because he was “turning down flights.”
The director of safety and training stated that several pilots informed him that they were getting reprimands from an operational control manager, specifically the chief pilot. The director of safety and training said that “we don’t need to be pushing people past their comfort level. If they assessed that, and they’re the pilot, they need to have the final say.”
One of the nurses killed in the January crash, Rachel Cunningham, submitted a letter in December of 2018 to her human resources department following up from a conversation she had with that department, detailing incidents where crews were forced to take flights in unsafe conditions.
“... each individual have multiple stories of unsafe flights… and getting yelled at or talked to when you’re unable to make a flight,” she wrote. She recounted one of her own experiences, where she, other medics and a pilot were flying to an unnamed location.
“... It was pitch black, no lights and a ton of high terrain,” she wrote. “The medic was nervous because he could only see out his side, a small portion of my window on the nurse’s side and a small area straight in front of him.”
An initial NTSB report on the January crash said the Survival Flight helicopter, a Bell 407, made a turn to the right about 15 minutes after takeoff in suburban Columbus Jan. 29, followed by the left turn.
Two other air ambulance companies, MedFlight and HealthNet, were contacted before Survival Flight that day. In a statement released a day after the crash, MedFlight president and CEO Tom Allenstein outlined the events from Tuesday, Jan. 29.
At 6 a.m. on Jan. 29, MedFlight received a request to transport a patient from the Holzer-Meigs Emergency Room in Pomeroy, the statement reads. The assigned team’s pilot assessed weather conditions with a control center at Metro Aviation Inc., MedFlight’s aviation operator.
MedFlight operates numerous bases throughout Ohio, including one in Pomeroy located just less than one mile from the Holzer-Meigs ER. There are additional MedFlight bases located in Morgan, Ross and Scioto counties, which are each around 60-70 miles from Pomeroy.
The Medflight pilot “determined that weather conditions at the time of request were below our program’s weather minimums,” Allenstein stated. “Each helicopter ambulance service has their own protocols for making decisions about whether it is appropriate to fly under given conditions.”
Ultimately, MedFlight turned down the request.
The NTSB report states that HealthNet did not immediately decline the request, but told the emergency room technician that a weather test would be performed and a HealthNet representative would get back with an answer.
“The ERT said that after ending the call with HealthNet, she contacted Survival Flight (Viking Aviation). She had not received a response from HealthNet when the flight was accepted by Viking Aviation, but she later received a call from HealthNet refusing the flight due to weather,” the report stated.