Accident Details
Probable Cause and Findings
The pilot’s decision to conduct a straight-in approach to the helipad, which resulted in the main rotor blade impacting a construction crane flag marker. Contributing to the accident was the erroneous information about the construction crane’s operation time and the pilot’s self-induced time pressure, which resulted from his awareness of the patient’s medical situation during the flight.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHTOn February 14, 2013, about 1221 eastern standard time, a Eurocopter MBB-BK-117 C-2, N481LF, operated by Geisinger Medical Center, doing business as Life Flight, was substantially damaged when the main rotor contacted a flag marker, mounted on a construction crane, during approach, at Geisinger Rooftop Heliport (79PN), Danville, Pennsylvania. The pilot, flight nurse, flight paramedic, and patient were uninjured. Visual meteorological conditions prevailed for the Title14 Code of Federal Regulations (CFR) Part 135 helicopter emergency medical services (HEMS) flight, which originated at Muncy Valley Hospital Heliport (7PS5), Muncy, Pennsylvania at 1210.
According to the pilot, they departed their base at Primrose Heliport (25PS), Minersville, Pennsylvania for 7PS5 to pick up a patient for an interfacility transfer. After arriving at 7PS5 at 1142, the patient was loaded and they departed for 79PN at 1212. The patient was "doing poorly" and there was some initial consideration as to whether the patient was alive and whether to fly him at all. After departure, the pilot climbed to 2000 feet above mean sea level (msl) and flew on an approximate 160 degree magnetic heading, direct to 79PN.
As the helicopter approached the mountains near Danville the pilot turned slightly right to pass through a gap in the ridgeline and continued to fly direct to the heliport. The pilot then radioed in that he was "3 minutes out." Around this time the medical team intubated the patient, and he was advised by the communications center that there were two people on the roof to assist him. He then observed two individuals on the rooftop landing pad, which "while not abnormal" was "not routine". He was "a bit concerned" as he wanted to make sure the personnel were clear of the helipad prior to him getting any closer.
The pilot recalled that he was somewhat more attuned to the patient's condition as the medical crew was working hard to keep the patient alive and were moving about the cabin unrestrained. He continued descending, and commenced his final approach to the rooftop helipad. About 100 yards from touchdown he noticed something "orange" out of the left window. At almost the same time the flight paramedic mentioned that he "saw something orange". The pilot then felt a "slight low frequency vibration". This vibration was also noticed by the flight nurse. About 6 seconds later, he landed on the landing pad, executed an emergency shutdown, and then cleared the crew to exit.
According to contractors who were operating a construction crane near the heliport, they were lowering a piece of equipment onto the roof of a building when one of them observed a helicopter approaching. Another one of the contractors then observed that "all of a sudden." He saw one of the blades of the helicopter hit the safety flag (flag marker) which was mounted on the top of the construction crane boom, and "pieces of wood and flag were flying all over the place." At this point, the contractors stopped all operations with the construction crane, to confirm that all of their personnel were uninjured, and to insure that the boom and cable did not receive any damage. PERSONNEL INFORMATIONAccording to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with ratings for rotorcraft-helicopter, commercial privileges for airplane single-engine land, airplane multiengine-land, and instrument airplane, and held type ratings for the SK-64 and SK-65. He also held a flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter. His most recent FAA first-class medical certificate was issued on September 11, 2012. He reported 3,035 hours of total flight experience, 12 of which was in the accident helicopter make and model. AIRCRAFT INFORMATIONThe accident aircraft was a twin-engine medium utility–transport helicopter of conventional construction, configured for emergency medical use. It utilized a four-bladed main rotor with a hingeless rotor system, fiber-reinforced plastic blades, and a semi-rigid, two bladed tail rotor. It was powered by two turboshaft engines each producing 708 shaft horsepower.
According to FAA and maintenance records, the helicopter was manufactured in 2010. The helicopter's most recent continuous airworthiness inspection was completed on January 10, 2013. At the time of the inspection, the helicopter had accrued 635.6 total hours of operation. METEOROLOGICAL INFORMATIONThe reported weather at Penn Valley Airport (SEG), Selinsgrove, Pennsylvania, located 15 nautical miles southwest of the accident site, at 1253, included: calm winds, 10 miles visibility, clear, temperature 04 degrees C, dew point -03 degrees C, and an altimeter setting of 29.96 inches of mercury. AIRPORT INFORMATIONThe accident aircraft was a twin-engine medium utility–transport helicopter of conventional construction, configured for emergency medical use. It utilized a four-bladed main rotor with a hingeless rotor system, fiber-reinforced plastic blades, and a semi-rigid, two bladed tail rotor. It was powered by two turboshaft engines each producing 708 shaft horsepower.
According to FAA and maintenance records, the helicopter was manufactured in 2010. The helicopter's most recent continuous airworthiness inspection was completed on January 10, 2013. At the time of the inspection, the helicopter had accrued 635.6 total hours of operation. WRECKAGE AND IMPACT INFORMATIONExamination of Construction Crane
Examination of the construction crane revealed that the metal pole that held the flag marker was damaged and the wooden pole that the flag marker was attached to was missing.
Examination of Helicopter
Examination of the helicopter confirmed that the main rotor had come into contact with the flag marker.
Two blades; the Green Blade, and the Blue Blade of the four-bladed main rotor were damaged. The Green Blade incurred minor tip damage. The Blue Blade was substantially damaged and required replacement.
According to the pilot neither he, the flight nurse, nor the flight paramedic, had seen the construction crane prior to coming into contact with it while approaching the landing pad. ADDITIONAL INFORMATIONIn order to improve safety, Geisinger Medical Center took the following actions:
1. In the event there is a crane in the vicinity of the hospital they would acquire multiple images of the crane from different angles to confirm location, angle, and exact height.
2. If a crane was placed in the direct path of flight to the rooftop helipad, the helipad would be temporarily closed. All incoming flights would land at the secondary helipad and patients would be transported to the Emergency Room via ground transportation.
3. To be sure the flight crews were aware of changes or notices, they will require an email confirmation that the flight crew has received the notice and that they have read and understood it.
4. Shift change and briefing reports will have stronger emphasis placed on discussing every detail with the oncoming crew during shift changes.
5. They will ensure that the communications center is fully staffed and that no Communications Technician is on the roof top helipad off-loading patients.
6. Communications Technicians will announce advisory hazards not only for takeoffs but during approaches as well, and the announcements will be made over one program-wide frequency, rather than a separate frequency for a particular helipad.
7. Required all pilots, flight paramedics, nurses and physicians, communication technicians, maintenance technicians, managers and support staff to participate in Air Medical Resource Management (AMRM) training to enhance the safety culture by promoting group cohesiveness and adaptation during change.
8. Created a Safety Manager position to develop and organize programs that support operational excellence, prevent accidents and incidents, and manage risk. TESTS AND RESEARCHConstruction Crane Information
Review of photographs taken after the accident revealed that the helicopter's final approach passed over the location of the construction crane which was positioned next to a building known as the "Annex" where it was being used to remove condensers from the roof.
Interviews with the crane operator revealed that at time of the accident, the construction crane's boom had been inclined upward on a 66 degree angle and extended out 133 feet, and was aligned with the helicopter's flight path along its final approach.
Flight crews had been notified of the construction crane's position on February 12, 2013. Prior to their departure from 25PS, the pilot believed that he had briefed his crew about the presence of the construction crane at the medical center.
According to the notification, the crane was to be in position about 0700 to approximately 1000 and was going to have a beacon on top, because of the proximity of the helipad. However, no beacon was installed; the crane was in use, and still in position, 2 hours and 21 minutes after the notification advised that contractors removing the condensers from the roof were supposed to have completed their work.
Communications Information
According to the Geisinger Medical Center General Operations Manual (GOM), Maximum use of radio facilities would be made on all departures and arrivals.
During the investigation it was determined however, that one of the people observed by the pilot on the rooftop helipad when the helicopter was inbound was the Communications Technician that would normally man the radio in what was known as the "Glass House" next to the helipad on the roof of the hospital.
Helicopter Approach and Restrictions to Visibility
According to the pilot, he approached the heliport from the north which was not the way they would usually come in to the helipad. They usually would approach from the south.
Review of witness statements revealed that despite the prevailing visibility of...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA13LA134