National Transportation Safety Board (NTSB) Report on Med Flight Released
MADISON - The National Transportation Safety Board (NTSB) report on the probable cause of the May 2008 crash of Med Flight has been released.
While the report provides some answers about the tragic accident, many important questions remain unanswered and may never be answered. It identifies several contributing factors to the cause of the accident. One member of the NTSB disagreed with the analysis and in an unusual move, filed a dissenting statement.
Significantly, the report reiterates that winds were calm and visibility was eight miles in light rain around the time of the accident. The investigation could not determine if the pilot encountered instrument flight conditions during the flight; visual conditions prevailed at the time of liftoff. The report also noted that pilot Steve Lipperer was current for instrument flight rules at CJ Systems, his previous employer, which was acquired by Air Methods in the summer of 2007.
It also notes that there were no identified weather risks that would have warranted classifying the flight in a higher-risk category than normal operations and that there were no pre-impact mechanical malfunctions of the helicopter found.
The report says the helicopter's radar altimeter would have visually alerted the pilot that his terrain clearance dropped below 500 feet. The NTSB could not determine why the pilot did not take corrective action in response to these alerts or, if he did, why that action was not effective. The path the aircraft may have taken may not have triggered an alarm until the last seconds.
The report also says a helicopter-TAWS (Terrain Awareness and Warning system) could have alerted the pilot audibly, giving the opportunity to avoid the terrain. At the time of the crash, the only TAWS available was designed for fixed-wing aircraft, not helicopters. Med Flight had a helicopter TAWS installed in the fall of 2008. Night Vision Goggles (NVGs) were acquired in February, 2009 and have been in use regularly since. The technology was not readily available because most of the units went to the U.S. Military operations in the Middle East, limiting supply for civilian use.
We are grateful for the thorough investigation and thoughtful decision-making by the NTSB. The final report noted variable weather conditions and other factors that prevent a firm conclusion. The report also indicates that we will never know what happened in the final seconds of the flight. There is no definitive conclusion about whether or not there were contributing mechanical issues with the aircraft.
One of the unanswered questions is whether the pilot would have received visual warning cues from the aircraft's radar altimeter. The radar altimeter measures the distance between the belly of the aircraft and the terrain immediately below, and is set at night to visually alarm when the terrain is at or less than 500 feet. Again, the path the aircraft took may not have triggered an alarm until the last seconds, if at all.
The pilot, Steve Lipperer, was very skilled and experienced in helicopter emergency medical service (HEMS) flying. Lipperer's judgment and flying skills were never in doubt to those who flew with him on hundreds of flights, and thousands of hours of flight time (in often challenging circumstances unique to HEMS flying).
Med Flight safety efforts since the accident have gone beyond equipment and pilot training. Each of its 1,300 flights per year is followed by a safety debriefing by all participants. Crew members reach out to family members of patients to assure them and let them know when their loved ones have arrived safely at the hospital and they remind family members to keep themselves safe. The program has developed comprehensive training for all staff, and implemented a series of 10 "ride-alongs" to help new residents transition to aviation medicine.
Additionally, the program is very conservative in making decisions about weather and staff confirms there is never any pressure to fly. In fact, a multidisciplinary briefing is held after each flight to review the flight and any issues that may (or may not) have arisen.
The loss of the pilot Steve Lipperer, flight physician Dr. Darren Bean and nurse Mark Coyne was a tragedy for UW Hospital and Clinics as well as the community they served. The skills and dedication they offered live on in the Med Flight crews today.
Date Published: 09/03/2010