Survival Flight Medical Helicopter Crashes in Ohio Forest! The Story of N191SF
A Survival Flight Bell 407 is flying across southern Ohio in the early hours of the morning. The crew are on their way to pick up a sick patient at a hospital when disaster strikes and the helicopter impacts the hilly terrain killing everyone on board.
This story will involve far more than the actual cause of the accident. The contributing factors are shocking and some people would say that they are simply unbelievable.
The full video investigation can be found here:
Now, it is important to remind everyone of the purposes of stories on The Doctor Medic- to learn. To discover the mistakes that others have made, and apply those lessons so that we don’t make the same mistakes moving forward. This isn’t just a story about a crash. Three people lost their lives in this accident. Three people who dedicated their lives to helping others, and doing so for chump change because this is the career that they love and because they wanted to have a positive impact on others. Many of these crashes are preventable which is why we really don't call them accidents, because accidents are not preventable, crashes are. And lastly, there are now almost 1,500 medical helicopters and airplanes in the U.S. alone. And every single pilot and every paramedic and every nurse and respiratory therapist and physician who flies on these aircraft are doing so because they care about other people. They deserve to have a clear understanding of how previous crashes may have occurred so that they, and their operators, can have the opportunity to learn from the past and be safer.
I never really knew much about Survival Flight before researching this incident.
They do have some bases here in my home state of Oklahoma and I do remember being in a State meeting about 6 years ago and someone introduced themselves as being from Survival Flight and they were just starting service in Oklahoma the next day. And then, 3 days later they had a crash in Lawton, OK.
Then, a few years later they put a beautiful Sikorsky S76 just down the street from my office and I thought that was great because giant twin engine medical helicopters are always cool and they even let Mrs. Doctor medic sit in it and take a picture.
The operator for this crash is actually called Viking Aviation and they have several different business ventures in the aviation world with one being their medical transport service called Survival Flight . Their venture actually began back in Arizona but then relocated to the midwest with their headquarters in Batesville, AR, and with rotorwing bases in Missouri, Arkansas, Illinois, Oklahoma, Ohio, and with recent expansions into the southeast in Alabama, Tennessee, Georgia, and Florida. Now, the accident helicopter was actually at 1 of 2 bases in Ohio but as of the time of this recording and according to Survival Flight ’s website, both bases in Ohio are no longer listed. Also, I reached out to Survival Flight on several occasions during my research for this story and never received any reply from them. They currently have about 20 bases and had 15 bases at the time of this crash
They had around 70 pilots at the time, with hundreds of flight nurses and flight paramedics. Their fleet was made up of 3 Bell 206 Long Rangers, 13 Bell 407s, a single Sikorsky S76, and a beautiful Pilatus PC12. Their flight operations control center is located in Batesville, AR and is a Part 135 requirement due to their fleet being larger than 10 aircraft. The operational control center, or OCS, or for the purpose of this story I'll just call them ‘dispatch’ - was usually staffed with a single dispatcher as well as an operational control manager, or OCM. This dispatcher exists to field the incoming flight requests from ground emergency medical services (EMS) crews and hospitals and then dispatch those requests to the appropriate bases while at the same time providing a level of oversight to the flight side of things by monitoring weather, tracking flights, and assisting pilots with anything they might need.
Survival Flight was not accredited by the Commission on Accreditation of Medical Transport Systems or CAMTS, and they still are not accredited today. The location of this crash occurred in a very heavily saturated market for EMS helicopters and Survival Flight had not really established themselves in this area yet.
The accident helicopter itself was a Bell 407 manufactured in 1996 with a single Rolls-Royce 250C47B turbine engine and a total of 1,179 hours on the airframe. Avionics were awesome and included a radar altimeter and a dual Garmin GTN650 system, a Garmin G500h and helicopter terrain awareness warning system, otherwise known as HTAWS. Also included were a Garmin GTS800 traffic collision avoidance system and a Garmin GTX 345R transponder. The helicopter did not have a cockpit voice recorder or a flight data recorder but it did contain an in-cabin audio recorder which will become very important later on in this story. It did not have an autopilot system and was not certified for instrument flight.
The pilot in this accident was named Jennifer and she was 34 years old and held a commercial pilot certificate with helicopter and instrument ratings as well as a private pilot certificate with ratings for airplane-single engine land and instrument airplane.
She was also a certified helicopter flight instructor and held a second class medical certificate with no limitations. She had been employed with Survival Flight for about 7 months at the time of the crash. At the time of her hire, she had a total of 1,855 flight hours with 589 hours in turbine and 1,125 in piston helicopters. She did not have any flight time in the Bell 407 when she was hired. And, she did not complete her proficiency and competency check in the Bell 407. Instead, it was done in a Bell 206L3, and then she was cleared to fly the Bell 407 while only having to complete ground training in differences. She did not complete ANY in-flight training in the Bell 407 which was the accident aircraft. For the 6 days before the accident, she had been working day shifts from 0700 to 1900 hrs. And on the day before the accident, she ended her shift around 1730. According to her fiancé, she spent the evening at home and had planned to arrive earlier than normal on the day of the accident to relieve the evening shift pilot since he arrived earlier than normal the night before to relieve her.
The weather at the time of the accident was a bit unpredictable as it always is in the most rural part of the U.S. The farther you get away from heavily populated areas the less weather reporting stations there are and the less pilot reports, or PIREPS, exist as well. This all leads to much less information for any pilot wishing to file any form of visual flight rules (VFR) plan as they have to ensure that they are not putting themselves into a position where they might find themselves in inadvertent meteorological conditions. If you are unsure of the differences between VFR/IFR/VMC AND IMC then check out a few of my previous videos to get caught up.
The forecasts were showing marginal VFR conditions at the accident site with overcast cloud ceilings of 2,200 feet with a 30-60% chance of snow along with a winter weather advisory showing rapidly falling temperatures, flash freeze conditions, scattered snow showers, and up to an inch of snow accumulation possible. There were also several PIREPS of reported ice and snow in the area.
On January 29, 2019, an ER tech at Holzer-Meigs hospital in Pomeroy, Ohio, was told to set up a transfer for a patient from their hospital to Ohio Health Riverside Methodist in Columbus, OH. This ER tech then picks up the phone and calls their go-to flight service, MedFlight.
MedFlight takes just a few moments and then advises that they cannot take the flight due to weather. Later, this MedFlight pilot stated that he turned down the flight due to weather “Specifically icing probability at 1,000’ agl of greater than 75 percent. There were snow squalls present that would reduce visibility and/or ceilings to below minimums. In our area, these snow squalls don’t always show up on radar.”
She then calls their 2nd go-to helicopter, HealthNet. HealthNet says that they need to consult for a full weather check and they will let her know in just a few minutes. Prior to hearing back from HealthNet, she then picks up the phone and calls their newest helicopter partner, Survival Flight. The nursing manager for the ER later stated that they have been calling Survival Flight lately specifically because Survival Flight gave her a flyer that, amongst other items, states that they have different weather minimums than the competition and that if they cannot fly, call Survival Flight and they will try.
This flyer has certainly been the subject of much debate and was discovered by the National Transportation Safety Board (NTSB) during their investigation. It seemed very difficult to actually track down who created this flyer, who approved it, and what exactly it means.
Weather minimums are a big part of any Part 135 program and even more so when the program only flies VFR - meaning they can only fly when they can visually see out of the helicopter.
These minimums are usually split into a few categories and may be a bit different depending on if the flight is flown during the day or night, if the terrain is mountainous or not, and even if they are flying a local flight or what they call a cross-country flight which is not really across the country but really just means they are flying outside their coverage area.
So for instance, the Federal Aviation Administration (FAA) minimums for a medical helicopter, flying locally, during the day, in non-mountainous terrain would be 800 foot cloud ceilings with at least 2 miles of visibility. Now, the accreditor for medical helicopters in the U.S. is CAMTS, and contrary to popular belief, they do not have higher minimums than the FAA and they actually state helicopter EMS programs must meet the FAA minimums but they also may exceed the minimums if they should choose to do so, and they strongly encourage to exceed the minimums for any new pilots or pilots who are filling in at another base.
Most, if not all, CAMTS-accredited programs across the country have actually adopted stricter minimums just to add an extra layer of protection to that infamous Swiss-cheese model of safety. Now, with MedFlight, the hospital’s go-to service in this incident, they had adopted weather minimums of an absolute minimum of 1,000 feet ceilings and 3 miles visibility across the board no matter what.
So, who created this flyer? Flight Nurse Robin Piatt who was the clinical base lead at the other Ohio Survival Flight base said that she created it. Robin said she developed this flyer and then consulted with the clinical base lead of the accident base Amanda, who then sought and obtained approval from one of Survival Flight’s VPs, with final approval coming from the public relations (PR) and marketing manager, Rachael Millard, who is also the daughter of the primary owner of the company, Christopher Millard. However, during interviews, Rachel stated that the first time she had seen the flyer was on social media after the accident. Gary Mercer, who will we come to learn an awful lot about here shortly, was the Director of Operations for all of Survival Flight and is in charge of everything, including the aviation side of the business, had said during interviews that he had never seen or heard of this flyer and that the first time he was made aware of it was when NTSB investigators shared it with him.
Now, it is quite common for private EMS helicopters to spend a lot of time doing public relations events and marketing. They do this because in the U.S. with very few exceptions, helicopter EMS cannot be state-regulated and is really only regulated by the FAA, which is federal. This means that in most cases, there is no requirement as to which helicopter shows up to pick up patients. It really boils down to the relationships that local fire departments, local EMS agencies, law enforcement, and especially local hospitals, have with the local helicopter services. Many helicopter EMS, or HEMS, services do all that they can to get these people to call THEM for the flight. This is true for 911 calls and vehicle accidents and burns and hospital-to-hospital patient transfers. Usually, most of these HEMS companies sell themselves as the better choice based on things like having a premiere clinical team of highly qualified paramedics or nurses, maybe they have a bigger helicopter with more capabilities, maybe they can operate instrument flight rules (IFR) flights, maybe they carry blood, or maybe they just preach a high level of safety and professionalism.
This flyer sells none of those things. In fact, one could make the argument that it preaches the opposite. The most striking part of this flyer, is the fact that Survival Flight was advertising that, even though they did not have IFR-capable aircraft anywhere in Ohio, that they could somehow accept flights in lower minimums than the competition.
And if you think that this flyer is the problem, you’d be wrong. Because as you will see, this flyer is just a single visible example of a culture that would support such a flyer in the first place.
So, back to the ER tech! MedFlight has turned her down for weather and HealthNet is doing a weather check and while waiting for the weather check, the ER tech calls Survival Flight who immediately accepts the flight. A few moments later, HealthNet does call back and says they will refuse the flight due to weather.
So who accepted the flight? The accepting pilot’s name was Wally and he had been on shift since about 1730 or 1800 hrs the night before as he came in a bit early to cover for Jennifer, the accident pilot. Wally was slated to get off at 0700 the morning of January 19th but expected Jennifer to probably show up a bit earlier since he had shown up a bit earlier for her the night before. According to the reports, the medical crew (flight nurse and paramedic) at this base works 24 hours and do their shift change at 1000 which means they would have been sleeping when this call came in.
So, the call from their dispatch comes in at 0609 and Wally answers the phone. He checks the weather primarily using the HEMS tool, and finds that the flight pathway is showing marginal VFR with ceilings around 2,400 feet and about 7 miles visibility both which are well within the weather minimums to fly VFR. But, during interviews Wally didn't seem very confident in what the precipitation was showing along the same flight path stating “And then on the precip side I wasn't really -- I wasn't seeing anything.” Now, helicopters can certainly still fly in precipitation including rain and snow but only so long as they are not exceeding the limitations of the aircraft and, more importantly, that they can still meet the visibility requirements which in this case would need to be at least a few miles. But, even the chief pilot for Survival Flight, Jack Windes, acknowledged that there were reports of snow squalls in the area. Snow squalls are intense, and usually shortened periods of moderate to heavy snowfall, accompanied by strong, gusty surface winds and possibly lightning. They are certainly a hazard and not something that you would want to file a VFR flight plan through. The reports of snow squalls were documented through PIREPS but the accepting pilot mentioned that he did not check the PIREPS and wasn't aware of any snow forecast. And, ice, which is also a hazard for aircraft, was also forecast in the area from basically about 8,000 feet down to 2,000 feet. Wally also said that he did not recall seeing any advisories for ice even though they did exist and were available to him, and also available to the operational control specialist or dispatcher, who is supposed to assist the pilots with weather information. The dispatcher also stated that they primarily only rely on the HEMS tool. Even if Wally had seen the ice advisory, he said that at Survival Flight they just ignore those advisories and go and fly anyway stating “we still go and fly but you just -- in order to prevent icing, you have to stay out of visible moisture. You're not going to get iced up in clear air down at the surface where we fly. So it's not unusual for us to accept flights even though an AIRMET Zulu covers our area. We just stay out of visible moisture.'' Wally is saying that it is okay to just take off and see what happens and try and stay out of bad weather. Throughout the nearly 2,200 pages of documentation and interviews, it is very easy to see that this is a common theme across all of Survival Flight - where if they have questionable weather that they will just take off and try and get to the patient and if they run into some bad weather they will just turn around. Many pilots echoed that this was commonplace. There were many stories of pilots flying into IMC conditions and then having to declare an emergency and turn around. It all seemed quite, matter of fact and commonplace. In a VFR aircraft, without autopilot, with a medical crew and possibly a patient in the back, and with very little recurrent training on IIMC, this is an absolute recipe for disaster. It is very common for HEMS agencies that fly VFR-only to only accept a flight if the weather is obviously safe and clear and within minimums for ALL legs of the flight including getting to the patient, transporting the patient to the hospital, and then getting back to the base. At Survival Flight, it was documented that the philosophy was to “fly as close to the minimums as possible” and try and take every flight no matter what.
So, Wally accepts the flight. But, he was not told that another service, or two, had already turned down the flight for weather. But, I do not really think that would have mattered for several reasons. One, the flyer clearly states that Survival Flight’s philosophy was to take flights exactly like this because they can somehow accomplish these flights that other services cannot. And two, and far more upsetting to learn about, is the practice of REVERSE helicopter shopping.
We probably know what helicopter shopping is, right? If not, for a detailed explanation you can check out my video on the Regional One crash for a pretty in-depth chat about it. The ER tech in this story, unbeknownst to them, definitely was helicopter shopping. Helicopter shopping is where someone, which could be a dispatcher, a sending physician or nurse or ER tech or even a receptionist, or even a ground provider like ambulances and fire trucks, keep calling different helicopters to take their patient even though they keep refusing for weather. In all fairness, most of the time when this happens the caller is really unaware of how all of this works and all they care about is just getting someone to come get their patient. But, when the stakes are this high, I no longer believe that ignorance is a good excuse for this. All HEMS providers should be educating the people who request them to avoid the practice at all costs and to their credit some of them do but, in this case, Survival Flight clearly was telling their requestors the opposite. They have said to call them even if other services refuse - call them and they can make it work. That is helicopter shopping. If that wasn't bad enough, along comes reverse helicopter shopping. There is a wonderful resource that exists called weatherturndown.com This website was actually created by Airmed, which is an air ambulance service out of Alabama, in order to provide a resource to pilots and dispatchers who are doing weather checks to inform them of whether or not another service has already turned down a flight. This is an amazing resource and is 100% free and is used by hundreds of flight programs across the U.S. If a pilot gets a call request they can go to this website to see if another agency has turned it down already and more times than none, this will just be another level of confirmation that they should not accept the flight. But, that is not what Survival Flight was using it for. Survival Flight dispatchers would actually monitor this website, and when they would see a weather turndown, they would pick up the phone and call the actual requestor, usually a hospital, and ask if they ever got anyone to take the flight. If the hospital said they never found anyone, and the patient was still there, Survival Flight would attempt to find one of their helicopters to transport that patient even if that helicopter was extremely far away or had to fly really far around weather just to get to the patient. And, if they found a helicopter that could do the flight, the dispatcher would not inform their own pilot that they just reverse-helicopter-shopped this flight.
So, would it have mattered if wally knew that the other services had turned the flight down? Based on the history of Survival Flight - probably not. In fact, it may have been more of a factor to actually take the flight. Wally was even quoted as saying that he doesn't pay much attention to other companies turning down flights and that he believes these other companies are actually out of service and just say they’re available so they can purposely turn down flights and boost their numbers.
Now, remember, it is 0609 and Wally is expecting Jennifer, the day pilot, to come in a bit early for him since he came in early the night before. So, he picks up the phone and calls Jennifer on her cell phone, while she is driving. This was an interesting point in one of the interviews as the pilot is admitting to the NTSB that he called Jennifer on her cell phone knowing that she was driving. The NTSB even went out of their way to point out in their report that they highly advise against such practices. He briefs her on the flight in general and seems to tell her that she should take the flight. He did NOT brief her on the weather at all. He asks her if she wants the night vision goggles, and she says no. Now, the helipad at this base is not right out in front of the living quarters and the pilot and med crew typically need to jump in a vehicle and drive maybe a half mile or so to get to the actual aircraft. Wally wakes up the med crew and the 3 of them drive down to the aircraft and get ready for the flight.
Jennifer shows up a few minutes later and grabs her gear and helmet and goes straight to the pilot’s seat where Wally has already started the helicopter which is sitting there waiting for her. Jennifer immediately jumps up in the seat and gets ready to go. Apparently, they call this ‘hot seating.’ I had never heard this term but that’s what they call it. So — She does not check weather and she does not preflight the aircraft and she does not complete their risk assessment (RA) form. Jennifer and Wally do not say much to each other and Wally clocks out and heads home to go to sleep. Jennifer takes off with the medical crew and starts to head towards Holzer-Meigs hospital to pick up their patient.
Just after takeoff, the Survival Flight dispatcher calls Jennifer on the helicopter radio and asks for a flight release. The flight release is that RA form I told you about. This RA form is usually done at the beginning of each shift and is a safety check to highlight risks to better inform the pilot and dispatch of their overall risk for that day.
Many services do an RA for each flight but Survival Flight only did one for each shift. This worksheet has nearly 40 lines on it and each asks a question that needs to be answered. There are 4 sections to Survival Flight’s RA form - weather, aircraft status, personnel and human factors, and what kind of flight they will be doing. It takes a few minutes to get through this sheet and cannot be completed in just a few seconds. Weather has to be checked. Preflight has to be completed. Discussion with the rest of the crew, including the medical crew, needs to take place to verify overall sleep, exhaustion, and stress levels. Once the form is completed, there are 4 levels of risk that can be documented. Green - which means they will take all flight requests without question, amber - which means they probably need to check weather, amber critical - which means there could be some form of delay, and red, which means they will not take any flight requests at all and won't even be dispatched.
But Jennifer did not have time to get any of that information because she jumped right in the helicopter and took off. Even though she did not preflight the aircraft, did not check weather, and did not have any time to chat with her crew, just moments after taking off she tells dispatch that they are all green and have taken the flight. The accident site was showing MVFR with around 3 miles of visibility and light snow. These are right on the limits of the minimums and, don't forget, Jennifer said she did not want the NVGs even though it was still completely dark out. Jennifer actually could have checked weather in the aircraft.
Post-flight analysis shows that they traveled southeast for about 22 minutes at about 3,000 feet mean sea level (MSL) at about 120-140 knots. Over the next 10 minutes the aircraft descended down 1,000 feet and then climbed again all the way to 2,600 feet and it was at this time that the aircraft encountered the first of 2 snow bands. A few minutes later at 0647, they encounter the second snow band and they now descend another 500 feet and pull up for a bit and then descend again another 900 feet as the aircraft is flying through the second snow band.
Just after this encounter with the second snow band, Jennifer turns the aircraft consistent with a 180-degree descending left hand turn, possibly indicating that she had encountered inadvertent IMC (IIMC) conditions, or just that she was aborting the flight and heading home. During the entire turn, the aircraft continued to slowly descend. Towards the end of this 180-degree turn, while still descending, the aircraft impacted a tree-covered hill.
There were no survivors, the pilot Jennifer, the flight nurse, Rachel Cunningham, and flight paramedic Bradley Haynes were all killed.
Examination of the accident site revealed that the helicopter initially collided with a tree at a height about 30 ft. above the ground on a heading of about 345°.
The wreckage path was 600 feet and there was no evidence of a post-crash fire, and a strong smell of fuel was noted.
The final satellite and ECU data show that, as the helicopter descended, two over-torque events occurred about 8 and 3 seconds, respectively, before the end of recorded data. The over-torque events correlated with increases in the collective position, which could be consistent with the pilot responding to either an HTAWS alert or perceived imminent ground contact, or both, by attempting to climb.
This scenario, on its surface, unfortunately, does not seem that strange. You have a medical helicopter, that probably encountered IIMC, and then, due to a lack of regular recurrent training flies the aircraft straight into the ground. It has happened dozens of times in the past, with the NTSB usually concluding as much. But in this case, there is far more to this story and there is far more to the cause.
By all accounts, every single mention and interview regarding Jennifer shows that not only was she a wonderful human being but she was one of the more safety-oriented pilots with Survival Flight and was certainly no pushover. But, if this is the case, then why would she take this flight? And not do a preflight? And not check the weather? And rattle off an RA release without actually doing it? And then subsequently fly the aircraft into the ground? Well, as always, there's a story to be told…
As with most organizations, a culture of safety and reporting and learning all come from the top. With Survival Flight, Christopher Millard is the primary owner and it was commonplace for Christopher to see and hear all flight requests for Survival Flight all across the country. Some Survival pilots stated that they always felt like they were walking on eggshells when it came to flight requests and they never felt comfortable leaning towards safety when it came to documenting their RA status or turning down flights for weather. Early on, if and when they tried to put the aircraft out of service for a safety issue or turn down flights for weather, several of them reported that Chris would immediately call them at the base and yell at them for not taking the flight or demanding that the aircraft be listed as green or amber even though it was out of service. It didn't take long though for Christopher Millard, the owner, to then turn over most operational control of the company over to the director of operations, Gary Mercer. Let’s come back to Gary later though.
In a true just culture that embraces safety and reporting, pilots and med crew are all involved in flight decisions and, if and when, a decision is made to turn down a flight or put an aircraft out of service, there are absolutely no questions asked. This is done so that everyone involved has a sense of safety that they can safely speak up without the fear of retaliation and report literally anything that they feel is unsafe or even if they are just unsure of something.
And when dealing with an actual flight, all of the crew members have an equal say as to whether or not they turn down the flight or abort. If a nurse is on her 4th flight of the day, even though the weather is great and everyone else is ready to go, if she feels her fatigue and exhaustion are a safety issue, then she can turn down the flight, or abort a flight already in progress, with no questions asked. If a paramedic is in the air and he sees clouds that he does not like or gets an uneasy feeling about the weather, he can say abort the flight and the pilot will say “no problem” and they will abort the flight no questions asked. If a pilot feels that an aircraft is too close to a maintenance interval to take another flight, they can call their mechanic, get the maintenance started, and take the aircraft out of service, with no questions asked.
This is all a part of the common saying you’ve heard of ‘3-to-go-and-1-to-stay.’ In order for this philosophy to safely take place they must utilize crew resource management and they must be able to exist in a just culture where they feel there is no fear of relation.
Crew resource management is now required on all major airlines and is also required of all EMS helicopters in the U.S. who are CAMTS-accredited.
I have to point out that I have never seen an investigation that goes this deep into the culture of a helicopter EMS agency. The NTSB interviewed 23 personnel including pilots, mechanics, dispatchers, nurses, paramedics, executives, FAA personnel, hospital personnel, and it is important to note that they interviewed both former AND current Survival Flight employees.
So, did the pilots at Survival Flight feel like they worked in a just culture of safety and reporting?
The actual director of safety and training said the safety culture at Survival Flight was “pretty good” however, he also knew pilots were not comfortable reporting safety issues to management. Another pilot stated that there was a bad vibe at the accident base. Another former pilot stated that it would be “difficult to report to management that management is unsafe...I feel that’s a wall that, you know, would be difficult to punch through.” And a current pilot reported, “I like my job. I like the people I work with. But you get the sense that you’re going to be blackballed, you know, if you go against them.” Another pilot who was a former Marine pilot who flew for Survival Flight out of Lawton, Oklahoma stated medical crew from other bases brought safety concerns to him about other pilots. He basically takes the stance that since the paramedic and nurse are not pilots that he really cannot take their concerns any further and that he cannot really help them. When talking about them not being pilots, he stated that “I mean they are not -- they are by no means meteorologists and they are not pilots but they are not dumb individuals.” He seemed frustrated when the medical crew complained that the dispatch manager forced their aircraft to remain amber even though it was out of service and with the mechanic. When asked what his biggest issue was with Survival Flight, he stated that it was their competition, MedFlight. He felt that MedFlight was going out of their way to make things difficult especially when MedFlight apparently complained about Survival Flight flying under lower minimums. This pilot’s response “I’ve been doing this for 5 years and felt I could speak for myself that flying to lower minimums didn’t equate to less safety.'' The same pilot, when asked about anonymous reporting in safety culture, said that he supports the reporting but also feels people abuse the reporting under the guise of safety.
Another pilot mentioned that things were good when he started at Survival Flight but then when he moved to Ohio there was a huge push to get numbers and was even told that their flight volume “was going to me 150 flights a month.” I can tell you now that 30-45 flights is a massive amount of flights and 150, anywhere in the world, is just simply astronomical and unrealistic, especially in a heavily competitive area like Ohio. He said that Survival Flight management told him that they should have a lift time of just 5 minutes and that he was constantly challenged when turning down flights for safety or weather. He even stated that one time the helicopter got stuck at a hangar during weather and they were IFR and the owner’s daughter, Rachel Millard, called him and demanded that he get the helicopter back to the base simply for the visual effect of having the helicopter sitting on the pad.
There was a common theme among many of the interviews regarding a major safety issue with a pilot named Kevin Johnson, or KJ, who was Jennifer’s direct supervisor. There was a situation where one pilot tried to report KJ’s unsafe flying and that the chief pilot for SF called him up and yelled at him and told him that you “never ever tell on another pilot here.”
It was reported by at least one pilot and two medical crew members that KJ got so mad during a flight where a nurse expressed a safety concern because they had flown into IIMC, and when they got back to the base, KJ told the crew that he would wait for a clear day and then fly them up into a cloud to make them feel better. The med crew, not knowing this was wrong and against the law, agreed, and it wasn't until Jennifer caught wind of this that a stop was put to it. There were some pilots who flat out said that they disregard whatever the med crew are saying about flying into weather.
Another former Survival Flight pilot described an example in which a helicopter experienced a hot-start that required an engine inspection. Management refused to allow the inspection and, as a result, the mechanic threatened to quit. When management agreed to the inspection to keep the mechanic on staff, the engine was found to be damaged.
But then you talk to pilots at other bases such as down at Lawton, Oklahoma and they state that they embrace 3 to go and 1 to stay and embrace CRM.
There seemed to be two groups of pilots in these interviews, those that embrace CRM and expressed lots of concerns about management pressuring them into taking flights, pressuring them into changing their RA number, and complaining about management ignoring the med crew and their opinions.
With the other group sounding like a bunch of cowboys who are bragging about pushing the limits of weather, regularly flying to IIMC, and taking the mindset that they will simply accept every flight, and then attempt the flight, and then simply turn around if things got bad. There were many reports there were from all crewmembers about aborting flights right when they got into bad weather or IIMC and even at least one instance of IIMC occurring and then not even reporting it.
On the medical side, the interviews make it sound like the nurses and paramedics, especially in Ohio, were literally walking around nervous all day that someone was going to pressure them into taking flights that they did not want to take or yelling at them or demeaning them or even sexually harassing them. One flight nurse tells a story about expressing concerns about the weather during flight and the pilot just ignored her and pressed on. She even complained to her supervisor and was ignored. She also confirmed that the medical crew is not involved in any weather discussions. She even mentioned that the pilot KJ would get emotional during flight debriefs and would yell and cuss at the medical crew for making mistakes. Another very experienced paramedic stated how nervous she was all the time and that the last time she complained about a pilot’s dangerous actions she was actually written up and placed on an improvement plan.
Another nurse tells the story of a pilot who turned down a flight for weather. Gary Mercer, the director of operations, immediately calls the base to tell the pilot to take the flight. The nurse refuses due to weather and Gary Mercer gets on the phone with her and yells at her so badly that she starts crying.
Many of the medical crew members at Survival Flight, especially in Ohio, simply felt unsafe, and then when they complained they felt like no one listened and sometimes, even worse, they would be the ones to get into trouble.
In fact, Rachel Cunningham, the flight nurse who was killed in this accident, actually sent an official email to her base supervisor, Amanda, complaining about KJ and other pilots.
She complained about derogatory comments made towards the female flight nurses and their outfits, getting yelled at for expressing concern about turning down flights for bad weather, witnessing a pilot bragging during a PR event with local FD that he could land the helicopter on 40x40 (when the norm is 100x100), two separate events where pilots would perform extreme maneuvers in the aircraft while pretending to avoid a bird, for the sole purpose of scaring the medical crew, and another pilot taking off on purpose even though the paramedic said his seatbelt wasn’t on yet.
Out of the 23 current and former employees that were interviewed by the NTSB, 11 reported that pilots were pressured to take flights.
So how could this be happening? In this day and age, with all of the technology that we have and all of the science and all of the data?? We know that a safety culture and CRM saves lives so how could this be taking place and on such a large scale?
Well, I said I would come back to Gary Mercer, director of operations and now here we are.
It is absolutely poor practice to incentivize flight crews to take flights. You cannot pay them bonuses or stipends or reward them for having more flights each month as this will obviously place them in a position to accept flights when they would otherwise turn them down. Survival Flight had a program where any base that reached 30 flights would get a top-of-the-line massage chair for their base.
It was documented that several bases even had a countdown chart to 30. During interviews, Gary Mercer stated that Survival Flight never incentivizes their employees. The accident base was at 26 for the month.
When asked about taking flights in bad weather? He seemed to imply that there is always a way to accept flights if you just get smart and learn to take the right route. He also seems to think that so long as the weather is reported as 1,000 foot ceilings and 3 miles visibility that IIMC could never happen. He stated “It is impossible to go inadvertent IMC if the weather's 1,000 and 3. It can't happen.'' When asked about the weather minimums that Survival Flight has he said that Survival Flight doesn't have any weather minimums and that they fly the FAA minimums and seemed to insinuate that they would even fly in lower minimums than the current FAA standards if they were allowed to. When pressed by NTSB investigators about possibly raising their standards to meet CAMTS standards he stated “the problem with CAMTS, in my view, besides it being an Air Methods run program, in my view -- only my view, it's their program; it's tied to them. We are a little different from them. And again -- well, never mind. It's a tender subject.”
But here is one of the big kickers - when asked if the paramedic and nurse are a part of the crew Gary stated “Oh, you don't want to go down that road. The problem is we can't call them crew. The crew -- people in the back -- because it's really hard not to call them that, because it's a partnership. No one wants – everyone wants to succeed. And so the people in the back, anytime they can help, by all means help is taken.” But then Gary was pressed by another investigator about CAMTS standards and the medical crew and said “It's a CAMTS thing. It's their attempt to make…[to] create an environment by which everyone felt more equal in the decision-making process. And the thing that I -- the problem I have with CAMTS as far as how they come at it is they're asking people without the skill set to make decisions that they really don't understand, aviation decisions…. So then what? …I want to have the pilot go and give them advice on how to intubate a patient.”
Well, I agree that pilots should not tell nurses or paramedics how to intubate. The fallacy here though is that if the paramedic screws up the intubation, the aircraft doesn’t crash and kill everyone on board.
He continues on:
“What I am saying is that people spend some fair amount of time and effort to become a meteorologist, to become a pilot, to become whatever. And someone walks in without any of those skill sets and now they have an equal place at the table to make those decisions. I struggle with that…. I don't want a pilot doing an intubation, not trained to. I don't want a nurse making a weather decision because she's not trained to.” Remember, this is the Director of Operations and is in control of all day-to-day operations of Survival Flight.
Maybe that is just one person’s opinions. But what about the chief pilot for all of Survival Flight. His name is Jack Windes and was asked the same question about the paramedic and nurse being a part of the crew.
His answer? “They're not, they're not part of the crew; they're medical personnel. Yeah. They're not flight crew.” Every pilot at Survival Flight reported to Jack, and his stance is clear that the paramedic and nurse are not a part of the crew.
As you can see, Survival Flight, at least at the time of this accident, was in absolute disarray in terms of safety and reporting. Some of their pilots were unsafe and regularly pushed the weather limits. Other pilots were quite safe and cautious but were scorned and admonished for doing so. Even though Survival Flight said that they encouraged 3-to-go-and-1-to-stay, medical crew were not considered part of the crew and their opinions meant absolutely nothing, and even if and when they did report something, it fell on deaf ears or came back to them in a retaliatory fashion. All of this is happening while the dispatchers are reverse helicopter shopping, the PR folks are dropping off flyers and stating they can fly when others cannot, and the company is incentivizing bases to complete as many flights as possible by luring them with a massage chair.
The NTSB obviously quickly discovers all of this and releases a Chairman’s Factual Report hinting at this while also noting that the pilot obviously must have encountered inadvertent instrument conditions leading her to make her 180-degree turn to the left. The snow squalls were in post-accident analysis, two other services had turned it down, and PIREPS were reporting snow.
But this factual report did not sit well with Survival Flight. When doing an investigation after one of these accidents, the NTSB usually completes some form of joint investigation with representatives from the NTSB, FAA, the operator, in this case Survival Flight, the manufacturer, in this case Bell, and a host of others. When doing so, all parties typically sign some form of non-disclosure or agreement that says that they will not comment publicly until the investigation is over. This is why you always hear things like “we cannot comment on an ongoing investigation.”
Even more, during a federal investigation, 49CFR831.13 actually prohibits any unauthorized personnel “from providing opinions or analysis of the accident outside of the participants in the investigation” Survival Flight did sign this agreement on January 31, 2019. Yet, Survival Flight went on to publicly state that all of the interviews were simply a bunch of disgruntled employees, that the weather was great, and that something must have hit the aircraft causing it to crash.
Remember, this crash happened in January of 2019. The final report did not come out until May of 2020. The following claims were made by Survival Flight after the factual report was published in September of 2019:
Survival Flight claimed that they were left out of the investigation even though it is documented that Survival Flight personnel were present during interviews and other sessions. They claim that the interviews were not fair because they are all just disgruntled former employees. They claimed that even though they admit to reverse helicopter shopping, that this practice was irrelevant since they did not reverse helicopter shop on the actual accident flight. They claimed that a bird must have hit the aircraft even though there is no evidence to support it. They claim that the NTSB report has caused them to lose business in Ohio and Oklahoma City and that hospitals and customers are reaching out to Survival Flight to complain about the culture and the report. They complain that they can no longer find employees who are willing to work for them. They claim that pressuring pilots to take flights is irrelevant in this case because, in this case, no one actually called and pressured the pilot to take the flight. Survival Flight says that there is no evidence that weather had any causal impact on the accident, even though there is a plethora of evidence to show that while visibility and ceilings were showing within limits, that there were documented reports of icing and snow squalls in the area. Survival Flight claims that the NTSB should not even bring up the fact that Jennifer was only trained in a Bell 206 and not a Bell 407 because deep down in the paperwork, and even though it was a bad idea, it was technically allowed. Survival Flight addresses the controversial flyer and defends its use because the other accredited programs actually do have higher minimums so therefore there was nothing wrong with what Survival Flight did. Survival Flight claims that because Jennifer was an amazing and qualified pilot and that because the aircraft had such great technology in the cockpit, that it is inconceivable that she could not have performed an exit from a IIMC with ease. Really? Then why has it happened so many times in the past? What about the Regional One crash? What about Kobe Bryant's crash? What about dozens of others? All the technology in the world cannot counteract a retaliatory culture and a poor training environment.
So, Survival Flight is unhappy with the federal investigation. So what do they do? They do their own investigation.
Survival Flight does not contest that this was a controlled flight into terrain. But they add that this controlled flight into terrain was the result of the pilot being incapacitated in some manner due to a noise they heard on the audio recording. Remember I told you that while there is not a cockpit voice recorder but that there was a cockpit audio recorder. About 6 seconds before the final impact there was a unique noise that was heard and then continued through the entire 6 seconds until the aircraft crashed. The NTSB did detailed forensic analyses of this sound and concluded that while they cannot confirm what the sound is, that the sound was described as “A whining sound, potentially aerodynamic in nature.” Something like air running across the top of a bottle, or one of the crewmembers opening a window. This was a Bell 407 and it certainly seems plausible that if they encountered IIMC that the pilot or one of the CREW slid open a window which is quite common on this aircraft. But, I cannot be sure, and neither can the NTSB. But, somehow Survival Flight says that they are sure that not only is this sound not a window sliding open, that it must have been associated with the pilot being incapacitated. They go on to say that it could have been a bird strike. Or, it could have been a drone. A drone - in the rural Ohio hills miles from nowhere - 6 in the morning - in the snowy and icy weather. Survival Flight posits that there was lots of criminal activity in the area. The criminal activity? Timber thieves.
And that the local landowners may have been protecting their property by flying these drones to spy on the timber thieves. Or, it could have been a criminal who shot the helicopter down. The criminals may have shot the helicopter because they thought the helicopter was law enforcement. This is all documented, in Survival Flight’s report.
Sure, it could be all of these things. But there is no evidence to support this. Survival Flight’s only reasoning for even bringing up the criminal activity is because the park ranger who walked them down to the accident site made a side comment about criminal activity in the area and people stealing trees. That’s it. No other evidence. Yet Survival Flight thinks that timber thieves shot down this aircraft, even though there is no evidence to support it.
And finally, Survival Flight again says that because Jennifer was super qualified and the aircraft had all the technology, especially the HTAWS with color changing maps, that it would be impossible for her to fly the aircraft into the ground and that she must have been incapacitated. What about the female pilot from the Lee County crash down in Florida? Her HTAWS was alarming and changing color and she still flew it right into the Gulf of Mexico. What about Kobe Bryant's pilot? That dude had 5 times the experience as Jennifer and he was flying a Sikorsky S76 with an autopilot and he still flew that thing right into the ground after entering IIMC.
And either way, I find it hard to believe she was incapacitated because the data shows that she pulled massive collective pitch 8 and 3 seconds before the impact happened which was documented in the ECU data as over torque events.
Well, what did the NTSB conclude?
They determined “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.”
I am sure it has happened before but this is the first time I have seen a helicopter ems crash with a probable cause of “the crash happened because the culture here is unsafe.”
Around the world, and especially in the United States, becoming a flight paramedic is one of the peaks of the profession. Same thing for flight nurses. These medical crew constantly find themselves in situations where their patients are in critical condition and the nurse or paramedic has to think critically and make like saving decisions. And they have to do it many times in the back of a tiny aircraft, with a jet engine above their ear, and oftentimes with night vision goggles on. Many of them perform this job for little to no extra pay over what a paramedic or nurse might make working on an ambulance or in the hospital. For nurses, it is oftentimes a lot LESS than they would make in the hospital. But they do it because they love it. But they need to be in a safe environment to do so. It is not right that their lives could be jeopardized because some boss is pushing everyone for more flights, or because a pilot is disregarding their opinions, or because they are being sexually harassed and are afraid to speak up. These paramedics and nurses, just like the pilots, are professionals at what they do. And they are 100% crewmembers.
So, then, why did Jennifer take that flight? Because Survival Flight thought it was okay for pilots to hot seat and just jump in a running aircraft and take off. Because Survival Flight was okay, and encouraged, their RAs to be pencil-whipped and just made up. Because they relied too heavily upon the HEMS tool and did not routinely also look at METARs AIRMETS and PIREPS. Because even if the paramedic and nurse were nervous when taking this flight, they were probably even more nervous about speaking up and catching retaliation after the fact. Because Survival Flight did not consider the paramedic and the nurse crewmembers. Because Survival Flight did not properly train their pilots in the aircraft that they would be flying in.
But most importantly, Jennifer took that flight due to poor leadership at the very top of Survival Flight. The culture told her that it might be easier to take this flight without checking weather, than it would have been to catch the wrath on the backside should she have turned it down. And that, is tragic…..and is not her fault.
Please stay safe. Follow the science….and take care of each other.