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Aviation accident CEN19FA072

3 fatal · Bell 407 · 2019-01-29 · Zaleski, OH, USA

Event

NTSB number
CEN19FA072
Event ID
20190129X14921
Type
Accident
Date
2019-01-29
Location
Zaleski, OH, USA
Coordinates
39.323333, -82.309448

Injuries

Highest injury
FATL
Fatal
3
Serious
0
Minor
0
Uninjured
0
Total aboard
3

Aircraft

Make
Bell
Model
407
Registration
N191SF
FAR Part
135
Engines
1
Damage
DEST

Conditions

Light
NITE
Weather
Unk

Probable cause

The NTSB determines 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.

Source

Authoritative
NTSB CAROL
Machine
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