Medical Helicopter Crash | Was the pilot properly trained? | The story of SkyLife 4
A SkyLife medical helicopter is transporting a patient and flying south through the San Joaquin Valley of central California when suddenly disaster strikes. While in the middle of a 180 degree turn the pilot somehow flies the helicopter straight into the ground. This helicopter was well-equipped, the pilot was super experienced, Skylife had an SMS and they were even CAMTS-accredited! So how could this have happened?
I want to take a moment here and quickly discuss the term ‘pilot error.’ Throughout aviation history, human error, or pilot error, can be attributed to the majority of all aviation accidents. So when the cause of an accident goes down as ‘pilot error’ many people simply misinterpret this to mean that somehow the pilot was not vigilant enough, or did not have the skills, or somehow lacked the overall conscientiousness to safely complete the flight. But, things aren't really that simple. When a pilot flies the aircraft straight into the ground, by all means, that error is on the pilot. But science and research has brought the industry a long way over the past 30-40 years and we now know that there are many other factors such as awkward ambiguities, task and stress overload, and organizational pressures, that can all play a role in leading even the most experienced pilots to make an error. When a pilot shuts down the wrong engine, it’s probably not because they are inexperienced or incompetent, when a pilot runs out of fuel it doesn't mean they didn't know how to read the fuel gauge, when a pilot flies the helicopter into super risky weather it doesn't always mean that the pilot was purposely taking a higher risk, more times than not, something else led to that mistake. So, in many cases, to simply say “this was 100% pilot error and nothing else” is simply to stick your head in the sand and ignore decades of research and science that proves otherwise. Do we have all the answers? No. But, the more we follow the research and evidence, the safer the industry becomes. With that being said, let’s dive into this story….
This story was requested by several viewers and takes place in the San Joaquin Valley in central California. The San Joaquin valley is one of the most productive agricultural regions in the entire world and sits between the Coastal Mountain range to the west and the Sierra Nevada mountain range to the east. The area is mostly flat farmland with hills forming along the edges of the mountain ranges.
This crash took place on December 10, 2015 and, at the time, the operator had quite a unique business structure. The parent company at the time was Rogers Helicopters based out of Fresno, CA. Rogers Helicopters was, and still is, the pure definition of a mom-and-pop style company with the founder starting the company back in 1962. For nearly 30 years, Rogers Helicopters focused completely on fire suppression work and also specialized in utility work such as with power lines and LIDAR systems up and down the western portion of the U.S. Due to Rogers' other work, their Part 133 operations, and federal contracts, they did already have a safety management system, or SMS, as part of the operations and applied that SMS to their Part 135 operations with their EMS division as well. In 1991, Rogers partnered with American Ambulance which is one of the largest EMS providers in the country. American Ambulance covers over 6,500 square miles, runs over 175,000 calls a year, and is the primary 911 provider for the central region of the San Joaquin Valley. Through this partnership, Rogers Helicopters would provide the pilots and mechanics and maintenance while American Ambulance would provide the medical crew, equipment, and medical oversight. Both companies shared in the cost of the helicopters. Rogers actually created a new entity called ROAM which was the general partnership between Rogers Helicopters and an offshoot of American Ambulance called American Airborne. This entity, ROAM, was doing business as SkyLife. Sound confusing? That’s because it is!!! So much so, that years later, during the lawsuit for this case, the CEO of American Ambulance actually admitted that he was unclear about the differences between American Ambulance and American Airborne. But, let’s come back to this later in the story. Basically, the pilots and mechanics are reporting to Rogers, and the medical crew are reporting to American Ambulance who also is doing the dispatching and flight following. Both companies shared equally in the profits. The company did have nearly 40 helicopters in its fleet with 3 of them in their EMS division. They had two Bell 407s and a single Bell 430 that was planned for heavy IFR usage in the future. SkyLife had two bases at the time with one base in Fresno and the other being in Visalia.
The helicopter in this accident is an amazing Bell 407 which was just 5 years old at the time, being built in 2000. It was powered by a 650 hp Rolls Royce turboshaft engine, passed its previous inspection just 6 months prior to this crash, and had a total of 9,017 hours on the airframe. This particular helicopter had a beautiful glass cockpit system consisting of a Garmin 500h with HTAWS, a Garmin GDU 620 primary flight display and multifunction display, and was outfitted for night vision goggle, or NVG use. This helicopter did also have an analog airspeed indicator and altimeter; however, no additional attitude reference instruments were installed. Why were these other items missing? Well, they are certainly not required but it is pretty common to have a backup attitude indicator AND this aircraft was not outfitted by Rogers helicopters as it came with the glass cockpit already installed when they purchased the helicopter from another operator. Now, remember that I said SkyLife had TWO bell 407s in their fleet? Well, the other 407 with tail number N101HF, did not have this glass cockpit setup and had a full analog instrument display setup. Keep that in the back of your mind for a moment…
The pilot in this accident was named Tom and he was a 49 year-old-male commercial pilot with rotorcraft helicopter and instrument ratings as well as a flight instructor certificate. Pilot Tom was hired with Rogers helicopters about 3 years prior to this accident in august of 2012 where he did tons of hours with ferry flights, utility, and LIDAR work and spent most of his time in a Bell 206 and two helicopters from McDonnell Douglas with the MD 500 and MD530. He had an absolute TON of experience with 11,415 hours. In June of 2015, pilot Tom was reassigned to the EMS division of Rogers helicopters where he would now be a brand new EMS pilot and now flying the bell 407 for the very first time. Now, remember that pilot tom had a total of 11,415 hours? Out of all those hours, he had only 159 hours at night. His previous work simply was not the type of stuff a helicopter pilot would be doing at night so this would make perfect sense. But, from the time he began at SkyLife in June until the accident in December, a span of just 6 months, Tom acquired just 15 hours of night time flights in the Bell 407. And on top of that, remember that SkyLife had two 407s with different instrument setups? Well, pilot Tom had just 18 minutes of solo night time flying the 407 with the glass cockpit. Why is this important? Because his records show that out of his previous 11,400 hours of flight time, pilot Tom had a total of ZERO hours in a helicopter equipped with a glass cockpit and advanced avionics. And finally, at the time of the accident, 6 months into his EMS career, pilot Tom had still not completed his NVG check ride and had to fly unaided at night.
Remember there were two bases with SkyLife, one in Visalia with a call sign of SkyLife 4 and one in Fresno with call sign SkyLife 1. The accident aircraft was SkyLife 4 and was flying out of the Visalia base that day and the crew received a request for a flight to transport a 40-year-old-female with symptoms from a non-hemorrhagic stroke. The patient was a substitute teacher working at an elementary school that day when she felt sick and complained of head, shoulder, and arm pain, and was transported by ground ambulance to Sierra View Medical Center in Porterville, CA. It appears that she was having an ischemic stroke and that the clot busting drug tPA was given to her in the emergency department. A stroke alert was called in the ED over 35 minutes before the helicopter arrived. Now I don't wanna go too far down this rabbit hole here but from the scarce information I could find it sounds like the patient’s symptoms had resolved by the time the helicopter arrived at the ED and that she only needed transport to another facility for further monitoring as her definitive treatment for her stroke, the tPA, had already been given and resolved her symptoms. Her family did file a wrongful death lawsuit alleging that the flight was unnecessary in the first place, but it appears that case was dismissed and probably settled out of court. Now, I don't have all the information on the patient but assuming that she was having an ischemic stroke and was then given tPA, and then her symptoms resolved, I see absolutely no reason why air transport would have been indicated in the first place. But like I said, I don't have all the patient info so I cannot be sure. If you’d like to see a video on the overuse of HEMS in the U.S. please leave a comment below and let me know a specific instance where the misuse of HEMS may have come into play.
So - the crew departs their base in Visalia at 1734 and arrives at Porterville municipal airport to meet a ground ambulance to pick up the patient and then transport her about 50 miles to the south to San Joaquin Community Hospital. SkyLife arrives at the Porterville airport about 1754. Just a few moments later pilot Tom receives a phone call from the pilot who is currently working at SkyLife 1 up in Fresno. The Fresno pilot himself had just received his own flight request to fly a neonate or NICU flight from Fresno also down to Bakersfield. But, the Fresno pilot was nearing his end of shift time and could not take the flight as he would have timed out by going over his duty time. So the Fresno pilot calls the oncoming pilot who is driving into Fresno from the south and can see some of the weather in his own car. When that pilot arrives at the base in Fresno he rechecked the weather conditions from Fresno to Bakersfield and turned down the flight. Just a moment or two later is when the Fresno pilots heard over their comms that the Visalia SkyLife 4 crew had just accepted a flight from Porterville to Bakersfield. This obviously concerned them since they just canceled their own flight due to weather forecasting in the exact same area. So, the Fresno pilot calls pilot tom after he lands in Porterville to consult with him over the phone about the weather. Pilot Tom had checked the weather in Bakersfield which was showing VMC and had 10 miles of visibility with 6,000 foot ceilings, a temperature of 14 deg C and a dew point of 11 deg C. They also had VMC in Porterville with 10 miles visibility and 3,300 foot ceilings with a temperature of 14 deg C and a dew point of 12 deg C. There was also some light to moderate rain but radar was showing this to be far off to the east or northwest of the area. There was an Airmen's Meteorological Information, or AIRMET, advisory for instrument conditions for the accident site at the accident time and a post-accident discussion with meteorologists at the NWS Weather Forecast Office indicated that the conditions about the time and near the location of the accident were conducive to fog.
The Fresno pilot voiced his concern that things were looking worse in Fresno than were being reported and he was concerned that the entire valley might have conditions that were worse than forecasted. The Fresno pilot then said that they “hung up with the understanding that it was a volatile weather picture but [pilot Tom] was taking that into consideration and would be checking it often.” It is important to note that while there are weather reporting stations in Porterville and Bakersfield, there are no reporting stations in between.
The crew is now loaded with the patient and ready to go and they depart Porterville at 1849 on their Part 135 flight and head almost due south following highway 65. They climb to about 1,500 feet and cruise at about 135 mph ground speed. 13 minutes later at 1903 and 8 seconds the helicopter descended pretty quickly and then leveled off. 20 seconds later at 1903 and 28 seconds the helicopter entered a left descending turn with ground speeds that initially increased and then decreased. According to the last 6 seconds of GPS data, the descent rate of the helicopter was about 2,210 ft per minute and they eventually impacted the ground in a descending left turn in an open, sparsely populated, unlit hilly terrain. Nearly 24 minutes goes by and then at 1927 the dispatcher calls them on the radio with no response. They check the Bakersfield airport and the San Joaquin Hospital who both advise that the helicopter has not arrived. An alert is put out at 2034 by the FAA that a helicopter is missing and the wreckage is finally found by air support from the Kern County Sheriff’s office helicopter. But, the Sheriff’s helicopter is unable to land as the pilot reports that the ground fog is so bad that he has to leave immediately. He then communicates the coordinates to ground EMS and fire units who finally make it to the wreckage at 2158 nearly 3 hours after SkyLife 4 impacted the ground.
There were no survivors. 49 year old Pilot Thomas Hampl, 42 year old flight nurse Marco Lopez, 37 year old flight paramedic Kyle Juarez, and, of course, the patient, 40 year old Kathryn Brown, all died in this accident.
So where did this flight go wrong? Well, there are several issues at play here. The first one is simply that the pilot most likely inadvertently entered instrument conditions. We cannot be certain though and while there were reports of fog in the area and the sheriff’s pilot also reported fog, we can only assume that pilot Tom encountered the same fog. But the policy at SkyLife was not to initiate a turn if a pilot encounters IIMC. The policy was to level off, maintain the heading, and only to turn if there were known obstacles. So, it is also possible that Tom was turning the aircraft only because he had changed his mind about pressing on and has now decided to simply abort the flight and turn around. Both cases are possible and I am not sure there is a way to tell for sure which one occurred.
Either way, Tom chose to initiate the turn. But, just as happened in many other cases, he slowly descended while turning and impacted the ground while still in the turn. So, we should be able to just say the pilot did not know what he was doing right and that this was simply “pilot error.” Well, like I said earlier, there is almost always something deeper that led to that pilot error in the first place. Remember, Tom had over 11,000 hours of flight time in a helicopter but less than 2% of that time was flown at night. Brian Guenthart was the assistant chief pilot and was asked about night training and seemed to imply that there are no specific requirements for training at night versus the day. And also remember that out of those 11,400 hours he had absolutely ZERO hours with a glass cockpit prior to getting into the accident helicopter and only 18 minutes flying a glass cockpit Bell 407 at night. To add to this, the layout of this glass cockpit did not have an analog attitude indicator which he would have been used to looking at for the last 11,000 hours and now he is looking at an attitude indicator that is built into his PFD. Investigators asked Brian “do you do any differences training, say between the two 407s?” Brian simply replied “we try to.”
And finally, as if all that lack of night time and glass cockpit experience wasn't enough, he was flying this flight UNAIDED, meaning withOUT the use of night vision goggles. How in the world could he have been flying without NVGs? Well, in order for the pilot to get checked off on NVGs they would actually have to do a nighttime checkride with a check airman. During post accident interviews, the executives of Rogers helicopters stated that they really only had one helicopter check airman and that he went out of currency which means he could no longer do any check rides for other SkyLife or Rogers pilots. In order to get Tom checked off on NVGs, Rogers and SkyLife had to actually go out of their region and try and get an FAA check airmen to do the checkride which they admitted they were having lots of issues with. According to SkyLife's SOP manual, pilots are required to undergo initial and recurrent qualification training to use NVGs. As part of initial training, 7 hours of ground training and 5 hours of flight training were required by Rogers. Tom had completed just 45 minutes of NVG training. During the interview it did not appear to me that NVGs were really a priority or a necessity by the management of SkyLife. Their chief pilot, Steve Wiedekamp, who was not a helicopter pilot, was asked about NVGs by investigators and he stated that ““Well, our philosophy, and we're open to others, but to us goggles are strictly a supplement” And then when pressed as to why Tom did not have his NVG checkride completed, Steve said “A lot of that, we have a little bit of trouble….helicopters in general and NVG in particular are fairly rare skills for check rides and to be authorized to give check rides. And so, a lot of times, we have difficulty having our check airman find somebody to do his check ride with the FAA.” The investigator noted that it had been 6 months and Tom still only had 45 minutes of 5 hours completed for NVG training and steve stated “He was caught…he was caught in the time…our NVG check airman, couldn't give check rides.” “And so, until we got [our check airmen] qualified, he was in limbo.”
In a post accident interview, Tom's wife recalled that she had numerous conversations with him about his concern for flying at night and not having NVGs and that he felt very ‘limited’ without them. The use of NVGs is not universal across HEMS in the U.S. but they are certainly a vital resource for safety with nighttime operations. Many HEMS operators would require the pilot as well as 1 or 2 of the medical crew, to wear NVGs during night time operations and many operators would never allow a pilot to be on shift at night and taking night flights without their NVG check ride and many would even take the base out of service if the pilot and crew did not have functioning NVGs. Pilots still certainly train to fly unaided without NVGs but to fly without them on purpose or because a pilot hasn't yet had their checkride seems downright unsafe to me.
And as with many crashes like this, we simply will never know whether or not one or both of the medical crew felt like speaking up and saying this wasn't a good flight to take but we obviously will never know. That being said, yes, I certainly know that medical crew are not considered to be a part of the flight crew as defined by the FAA, but they are certainly a part of the crew as a whole and as a philosophical approach to safety and crew resource management. During interviews, the director of operations for Rogers helicopters, William Poe, was asked who makes the determination of whether or not they accept the flight or not. Poe responded that “the crew does. The entire crew has part of the process, they decide if the flight can be done safely, they determine where they're going and how they're going to get there. We talk about -- we go through helicopter shopping, the importance of letting the crew know that somebody else has turned down the call and why they turned it down. And as much as I dislike CAMTS, that's a good thing out of them, because [that's what] they require.” Also, in SkyLife’s SOP they state “if medical personnel do not feel comfortable during any part of the flight it shall be canceled regardless of existing weather conditions." This certainly seems like the correct mindset and is in stark contrast to a previous episode I did where the owner, director of ops, and the chief pilot all said that the medical crew are not considered part of the crew.
The NTSB did a thorough investigation which took nearly 3 and a half years, and found that there was absolutely nothing wrong with the helicopter. Why it took so long I have no idea, The engine had no issues. The ECU showed no faults or problems up until the impact. All of the avionics were working as they should. All of the controls, servos, and drivetrain moved freely and showed no issues whatsoever. The toxicology report completed by the FAA's Bioaeronautical Sciences Research Laboratory here in Oklahoma City, Oklahoma, performed toxicological tests on specimens recovered from the pilot, which were negative for drugs, ethanol, and carbon monoxide.
So why did this super experienced pilot, in this super badass helicopter, with all of the advanced avionics at his disposal fly this helicopter into the ground? Most likely, he did so because he encountered either poor weather or full blown IMC, and then decided to turn around. But, he was not comfortable with flying at night, he was not experienced with the advanced avionics, and he did not have NVGs on, and during his 180 degree turn, he simply lost reference with both the ground and his instruments and probably never saw the ground until just before impact.
Upon completion of the investigation the NTSB’s probable cause was “The pilot's loss of control and collision with terrain while attempting a course reversal after inadvertently entering an area of reduced visibility weather conditions. Contributing to the accident was the pilot's lack of recent experience with night time operations.”
SkyLife had been in business for nearly 25 years at this point and had never had a fatal accident in over 22,000 patient transports. Within a year of this accident, American Ambulance and Rogers Helicopters parted ways with American Ambulance then partnering up with Airmethods, one of the largest air ambulance providers in the world, to provide the aviation and maintenance aspect of their operations. American Ambulance still provides the medical crew, medical oversight, and dispatching as of today.
Just days after the crash there was also an email sent to the NTSB by Seth Velho, another pilot at the SkyLife 4 base who claimed that he was scheduled to work at SkyLife 4 the night of the crash and that there is a lack of training at Rogers and SkyLife and that, even though management isn't calling and yelling at them all the time, there is a pressure to take flights. I also interviewed several former employees including medical crew and pilots of SkyLife, and while they did not sound as upset as Seth did, they did agree that there was an overall lack of training at SkyLife under Rogers helicopters and that they, too, felt a sort of passive pressure to take flights in questionable weather.
Several years after this crash, the wife of Kyle Juarez filed a wrongful death lawsuit claiming negligence on the part of Rogers helicopters. This case normally would not have been able to be brought at all due to this being a workers compensation situation but due to the complex business structure, the lawsuit was able to move forward for a bit but in the end, the Judge released quite an in-depth opinion regarding “special employers” and ultimately decided that while Kyle was paid by American Ambulance and a medical crew member, that Rogers Helicopters and ROAM were also still considered his employers and therefore the same situation exists where workers compensation applies and the lawsuit was subsequently dismissed. The worker’s compensation situation with medical crew members is certainly a topic for a future episode.
This was a sad story and it always makes it even worse when you feel like it was preventable. By all accounts, pilot Tom seemed like he was an absolute student of the profession. One pilot even said “Tom was a very thoughtful, safe pilot who was not a risk taker at all and I knew he would make the correct decision.” “He was comfortable in the aircraft and had extremely sound judgment. This accident comes as a complete shock to me considering Tom's careful nature and excellent planning.” His colleagues said he was always studying and always trying to learn and was just an impeccable human being. I am confident that the same could be said for Marco, Kyle, and Kathryn. It is also worth noting that both Marco the nurse and Kyle the paramedic were not even scheduled to work that night but they had both switched shifts with two other crew members.
Was it pilot error? Sure was. But that error could have been mitigated by better training and ensuring that the pilot had passed all of his check rides prior to letting him fly at night on his own, unaided, and in an aircraft that he was not really familiar with.