Chad Hammond, Jason Snipes, Stacey Cernadas and Zack Strickland (Photos source: Facebook) MONTGOMERY, AL (WSFA) -
Pilot error likely caused fatal medical helicopter crash
Friday, June 15 2018
By WSFA 12 News Staff
The National Transportation Safety Board, or NTSB, has released its final report on the 2016 south Alabama crash that killed four aboard a Haynes Ambulance medical helicopter.
Killed in the Haynes Ambulance medical helicopter crash on March 26, 2016, were pilot Chad Hammond, flight nurse Stacey Cernadas, flight medic Jason Snipes and patient Zach Strickland.
According to the official findings of the investigation, the pilot's actions were determined to be the probable cause of the crash with the report stating:
"The pilot's decision to perform visual flight rules flight into night instrument meteorological conditions, which resulted in loss of control due to spatial disorientation. Contributing to the accident was the pilot's self-induced pressure to complete the mission despite the weather conditions and the operator's inadequate oversight of the flight by its operational control center."
The NTSB report detailed the events of that night that led up to the fatal crash near Enterprise in Coffee County.
The flight crew of Life Flight 2 was dispatched from its base at Troy Regional Medical Center at 11:26 p.m. en route to the site of a car crash to pick up a patient for transport.
The helicopter landed at the scene at 11:53 p.m. The weather at the car crash scene included fog, mist, and light precipitation. A nearby weather station indicated there was a 300-foot ceiling and three miles of visibility.
At 12:16 a.m., once the patient was on board, the helicopter climbed from the crash scene, turned north, and climbed to an altitude of 1,100 feet. The chopper crashed to the ground about a half-mile away in a flight that lasted less than a minute.
When the pilot did not check in with the communications center as he was required to do, a search was started for the missing helicopter. The wreckage was found the next morning on County Road 615 near County Road 603 in the Goodman Community.
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National Transportation Safety Board
Aviation Accident Final Report
Location:
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Enterprise, AL
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Accident Number:
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ERA16FA140
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Date & Time:
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03/26/2016, 0018 CDT
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Registration:
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N911GF
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Aircraft:
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EUROCOPTER AS 350 B2
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Aircraft Damage:
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Substantial
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Defining Event:
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VFR encounter with IMC
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Injuries:
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4 Fatal
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Flight Conducted Under:
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Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Medical Emergency)
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Analysis
After
picking up a patient at a motor vehicle accident (MVA) site, the
airline transport pilot of the helicopter air ambulance flight, which
was operating under visual flight rules (VFR), departed in dark night
instrument meteorological conditions (IMC) to transport the patient to a
hospital; a flight nurse and paramedic were also on board. Witness
statements, video, and photographs indicated that reduced visibility in
fog and mist as well as very-light-to-light precipitation existed at the
MVA site, and the nearest weather station, 4 miles away, was reporting a
300-ft ceiling and 3 miles visibility. Radar data indicated that, after
takeoff, the helicopter entered a left turn and climbed to 1,000 ft
above mean sea level (msl). The rate of turn then began to increase,
and, after reaching a peak altitude of 1,100 ft msl, the helicopter
began a rapid descent that continued to ground impact. According to the
radar data, the flight lasted about 1 minute. A search was initiated
when the pilot did not check in with the communications center as
required, and the wreckage was located the next morning about 1/2 mile
from the departure location. Examination of the accident site and
wreckage revealed that the helicopter struck trees and terrain and was
highly fragmented. Examination of the wreckage did not reveal evidence
of any preimpact malfunctions or failures that would have precluded
normal operation of the helicopter.
Although
the helicopter was not certificated for flight in IMC, it had
sufficient instrumentation to operate in the event of an inadvertent
encounter with IMC and was equipped with a helicopter terrain avoidance
warning system, a night vision imaging system which included night
vision goggles (NVGs), and an autopilot. The pilot had about 265 hours
experience operating in IMC and had been trained in inadvertent IMC loss
of control recovery, but he was not instrument current. Further, he had
not been trained or qualified by the operator to fly in IMC. He was
likely using NVGs during the flight as one of the first responders who
helped load the patient into the helicopter saw the pilot wearing them.
Based on the weather conditions, the flight path of the helicopter, and
the lack of preimpact failures or anomalies, it is likely that the pilot
experienced spatial disorientation after entering IMC and subsequently
lost control of the helicopter.
To
accomplish operational control of its flights, the operator used an
operational control center (OCC) that was staffed 24 hours a day by
operational control coordinators. According to the operator, the pilot
had the final authority and responsibility for decisions relating to
safety of flight, and the operational control coordinators were
responsible for confirming whether a flight or series of flights could
be initiated, conducted, or terminated safely, in accordance with the
authorizations, limitations, and procedures in their operations manual,
and the applicable regulations. In the case of the accident flight, the
operator's required VFR weather minimums were a 1,000-ft ceiling with a
flight visibility of 3 miles.
The
operational control coordinators' role was accomplished by inputting
flight data into software programs that would perform automated database
queries for pilot currency and aircraft maintenance information and
would provide weather information based upon route of flight. Both OCC
personnel and pilots had the authority to terminate a flight at any time
if required conditions were not met. There were two personnel on duty
before and during the time of the accident at the operator's OCC, a
trainee operational control coordinator and a senior operational control
coordinator. About 1 hour before the helicopter accident, the OCC
received notification of the request for the helicopter to respond to
the MVA, and the coordinators used a software program called "OCC
Helper" to query weather information. Although the coordinates for the
location of the MVA provided to the OCC were correct, the format of the
coordinates was not the correct format for OCC Helper. Therefore, the
OCC Helper software only recognized the MVA site as being near the
helicopter's base, which was reporting visual meteorological conditions,
and did not show the IMC being reported at weather stations closer to
the MVA site. The trainee reported that latitude and longitude format
was a common problem with OCC Helper and, at times, required OCC
personnel to reformat the latitude and longitude coordinates to get the
coordinates to work in OCC Helper. On the night of the accident, the
incorrectly formatted latitude and longitude for the MVA site were not
corrected in OCC Helper until after the helicopter had departed its base
en route to the MVA site. Given the IMC weather conditions being
reported, which were below the required VFR weather minimums for the
flight, the OCC coordinators should have provided the pilot with
additional weather information after they had correctly input the
coordinates of the MVA site into the OCC Helper software; however, they
did not do so. The lack of monitoring of the flight by the OCC through
direct human interaction due to overreliance on mission support software
and other automated aids, and the incorrectly interpreted latitude and
longitude information by both the software and the operational control
coordinators resulted in a loss of operational control. Although the
software formatting issues were known, there was no standard operating
procedure to mitigate the problem.
The
pilot had access to internet-based weather information at the
helicopter's base, but it is unknown what weather information the pilot
reviewed before beginning the flight to the MVA. However, text messages
between the pilot and a friend and between the flight nurse on the
accident flight and the same friend indicated that the pilot was aware
of the possibility of encountering IMC before he departed the base for
the MVA site. Further, after landing at the MVA, the pilot would have
been aware that the weather conditions at the site were below the
company's VFR weather minimums. Given the weather conditions at the MVA
site, the pilot should have canceled the flight or, at a minimum,
contacted the OCC to obtain updated weather information and guidance.
However, the pilot's fixation on completing the mission probably
motivated him to depart on the accident flight in IMC, even though
significantly less risky alternatives existed, such as canceling the
flight and transporting the patient by ground ambulance.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The
pilot's decision to perform visual flight rules flight into night
instrument meteorological conditions, which resulted in loss of control
due to spatial disorientation. Contributing to the accident was the
pilot's self-induced pressure to complete the mission despite the
weather conditions and the operator's inadequate oversight of the flight
by its operational control center.