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Crash’s probable cause released

NTSB releases recommendations for air ambulance safety

Beginning Feb. 1, the Colorado Department of Public Health and Environment's Emergency Medical and Trauma Services Section will begin licensing air ambulance services that transport patients from or within the state.

The licensing requirements mark the end of a five-year process. The program is designed to improve safety, establish coordination between air ambulance operators and improve patient care in air medical transport.

"Colorado is one of the few geographical regions where terrain, weather and extreme sporting activities play a challenging role in air medical transport," said D. Randy Kuykendall, chief of the Emergency Medical and Trauma Services Section. "The licensing program has been established at a time when safety is a major concern for air ambulance services nationwide."

The new air ambulance rules and regulations can be viewed at http://www.coems.info. -- Pilot & Today staff

Icy conditions likely caused the Jan. 11, 2005, Yampa Valley Air Ambulance accident that claimed the lives of three crew members and seriously injured another, according to a report issued Thursday by the National Transportation Safety Board.

But pilot Tim Benway’s “inadequate planning” for the icy weather also played a role in the tragedy, the report states.

Benway and flight nurses Dave Linner and Jennifer Wells died in the crash near Rawlins, Wyo., and paramedic Tim Baldwin suffered serious injuries from which he continues to recover. The Steamboat Springs-based Yampa Valley Air Ambulance service was discontinued shortly after the crash, its second in two years.



On the night of the crash, the Yampa Valley Air Ambulance was en route to Rawlins to transport a patient from the Rawlins Municipal Airport to Casper, Wyo. But the flight never arrived, instead crashing about three miles northeast of the airport. Baldwin was rescued after a multiple-hour search for the plane’s wreckage.

According to the accident report, a weather briefing given to Benway shortly before takeoff indicated a band of light to moderate snow shower activity between Rock Springs, Wyo., and Rawlins.



The briefer also warned Benway about “mountain terrain obscuration, icing and turbulence,” according to the report.

“All of that fun stuff,” Benway responded.

The investigation determined that as much as 1 1/2 inches of ice covered the plane’s vertical stabilizer, wings, right propeller and right landing gear tire. The icing degraded the plane’s aerodynamic performance, resulting in a stall, the report states.

On Thursday, Baldwin and Mountain Flight Service co-owner Cindy Maddox emphasized there was no way for Benway to know what kind of weather he would encounter near Rawlins when the flight departed from Steamboat Springs Airport. The Yampa Valley Air Ambulance was operated by Mountain Flight Service.

“It wasn’t something that was known to us,” Baldwin said.

Although the crash investigation found insufficient evidence to indicate Mountain Flight Service pressured Benway into taking the flight, investigators did not rule out the possibility that Benway put pressure on himself to take the mission.

The Yampa Valley Air Ambulance accident was one of many EMS flight crashes that were the focus of an NTSB study that has resulted in calls for stricter requirements for all emergency medical services flights.

The NTSB adopted a special report Wednesday that, among other things, recommends that the Federal Aviation Administration require EMS flight operators to- develop and implement flight risk-evaluation programs, use forma-lized dispatch and flight-following pro-cedures and install terrain warning systems in all EMS flight aircraft.

The recommendations were the result of a study of 55 air ambulance accidents that occurred during a three-year period from January 2002 to January 2005.

“The very essence of the EMS mission is saving lives,” NTSB acting chairman Mark Rosenker said. “Operating an EMS flight in an unsafe environment just makes no sense.”

As part of its investigation, the NTSB examined the decision-making process of EMS flight operators when evaluating the potential risks of a flight. The NTSB found that none of the EMS flight operators involved in the highlighted accidents had an established aviation risk-evaluation program.

However, Maddox said her company had a similar but less formalized process in place to review mission risks.

“Our major feeling was that we had already complied with and were doing what they are recommending,” she said, adding that she fully supports formalization and adoption of a flight risk-evaluation pro-gram.

“I think it’s a great tool if the FAA can formalize it,” said Maddox, who attended the NTSB hearing in Washington, D.C., with her husband, Bob. “Everyone is interested in safety and improving operations.”

The NTSB also reported that many air ambulance operators don’t have a consistent and comprehensive flight dispatch procedure to help pilots determine the safety of a given flight.

Maddox said such a procedure could be difficult to put in place, particularly in regions such as the Rocky Mountains, where inconsistent radar and weather data make it difficult to accurately gauge up-to-the-minute weather conditions in remote areas.

Because the NTSB is an investigatory and advisory body, it remains unclear whether its recommendations will be adopted.

The FAA has 90 days to respond to the NTSB recommendations, said Laura Brown, an FAA spokeswoman.

“We haven’t ruled out making new rules or changing existing rules,” Brown said. “But rule-making is a lengthy process.”

Brown emphasized that the FAA already has been addressing EMS flight safety issues.

“We’ve been working on a lot of these issues since August 2004,” Brown said Thursday. “Some of the (NTSB’s) recommendations are things we’ve been working on.”


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