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Air Pressure: Human Factors Are the Key to a Safer Flight Environment

On January 29 a cold snap reached Ohio. The high the day before in the Columbus suburb of Grove City was 43ºF. The day after it was 11ºF, the low below zero. 

The day dawned with snow, gusts over 20 mph, and a wind chill in the single digits. It was a difficult morning to fly. But a patient at Holzer Meigs Hospital in Pomeroy needed capabilities the hospital didn’t have, so its staff was seeking a flight north, to a larger facility in the capital area. 

Columbus’ MedFlight said no, citing conditions below its weather minimums. HealthNet Aeromedical Services in nearby West Virginia gave a similar response for similar reasons. Survival Flight said yes. The company operates in Ohio and several other states and advertises it will “fly anywhere in the United States where our services are needed.”1 

What happened next was tragedy: Survival Flight 14, a Bell 407, took off from Grove City and soon lost contact. Its badly fragmented wreckage was found in a remote part of Vinton County, along with the bodies of its crew: pilot Jennifer Topper, 34; flight nurse and firefighter-paramedic Bradley Haynes, 48; and flight nurse Rachel Cunningham, 33. 

No one’s officially cited weather as a factor in the crash. A preliminary NTSB report found the craft “collided with forested, rising terrain.”2 Flight data showed it made a pair of sharp turns before communication broke off. 

Helicopter Shopping

Helicopter shopping is the practice of sequentially calling multiple services until you find one that will take a flight the others declined. It has a bad rap, and cases like the above show why. “When one or two programs have already turned down a flight for weather and you just keep going down the list,” says Kevin Collopy, BA, FP-C, NRP, clinical outcomes manager for AirLink/VitaLink Critical Care Transport in North Carolina, “that puts people’s lives at risk.” 

That’s not a controversial view but probably  deserves some elaboration. Companies can have differences in pilot, aircraft, and technological capabilities and local weather conditions that may make it worthwhile to ask more than one possible flyer. A position paper from the Indiana Association of Air Medical Services, currently being revamped by the national Association of Air Medical Services (AAMS), notes “the calling of subsequent helicopters for air medical transport in and of itself is not a problem. The transporting of patients via helicopter takes place thousands of times…every day around the world safely and efficiently.”3

The problem occurs when callers don’t tell subsequent services 1) that previous companies have turned down the flight and 2) why. 

“A requester calling multiple programs is not inherently bad,” says AAMS President Rick Sherlock. “The problem is when that requester may leave out relevant information that other programs were called and not able to accept the request. That information should always be passed on. But companies may have different requirements based on what their equipment is, what their capabilities are, and where they are in location to the request being made.”

There are resources to share information about declined flights. Weather Turndown (, for instance, is a free site by which medical transport programs can share current information on requests they reject and why. It’s not known whether Survival Flight accessed that or other resources, and Sherlock emphasizes his comments are general and not specific to its case. The NTSB found conditions at Flight 14’s departure were suitable for visual flight, rather than instrument-guided, though the flight was initially accepted by the company’s night-shift pilot but, because of a shift change, actually undertaken by day-shift pilot Topper. 

More problematic, as a matter of perception, was a flyer Survival Flight had apparently circulated that read, Our weather minimums are different. If other companies turn down the flight for weather, call us.4 That was qualified by an If we can fly to you safely…, but the sentiment still looked pretty unflattering after a crash. 

A Safer Ride

Weather minimums and requirements for flying in bad weather were most recently addressed in a wide-ranging 2014 rule published by the FAA. The result of a series of crashes over the preceding years, the rule was billed by then-Transportation Secretary Anthony Foxx as “a landmark rule for helicopter safety.”5 It required helicopter air ambulances with medical personnel on board to operate under part 135 of the Federal Aviation Regulations, rather than the less-strict part 91, and set new weather minimums and visibility requirements for those operations. Air-medical companies and even individual pilots can observe minimums that are higher but not lower. 

The rule also required flight planning, preflight risk analyses, safety briefings for medical personnel, and the establishment of operation control centers to help with risk management and flight monitoring. Other provisions encouraged IFR (instrument flight rules) operations and mandated helicopter air ambulances be equipped with HTAWS (helicopter terrain awareness and warning systems), radio altimeters, emergency locators, and flight data monitoring systems. 

The FAA estimated the cost of the new rule at $224 million, though many operators were already taking some of the steps.

“It was a fairly comprehensive rule,” says Collopy. “It could have gone further. It probably fell short in some areas due to concerns about the costs for operators. For example, it required crash-resistant fuel systems for all new helicopters but didn’t mandate an immediate swap-out for existing helicopters. That’s something many operators were doing anyway, but it could have taken a stronger stance in an earlier timeline.” 

If you have the money to spend, the latest safety equipment can indeed help make your air environment safer. STAR Flight, which is funded by Texas’ Travis County and serves that and 19 surrounding counties, is about to field three new AW169 helicopters from the Leonardo Company with an array of defenses that make them the safest birds in the sky. To name a few:

  • A four-axis digital autopilot that adds a collective axis to the existing pitch, roll, and yaw; this automatically levels the craft if control starts to waver. 
  • Synthetic vision technology: “You can basically fly the aircraft into clouds,” says STAR Flight Safety Officer Joe Lebrecque, “and the synthetic vision will tell you what’s on the ground. It’ll show you where airports are, buildings, lakes—the pilot sees all that in front of them.” 
  • HTAWS and a traffic collision avoidance system (TCAS) with audible and visual warnings
  • Weather radar
  • A health and usage monitoring system (HUMS) to identify fatiguing parts before failure
  • ADS-B Out technology that uses satellite signals rather than ground radar and navigational aids to guide flights
  • Two-pilot and one-engine-inoperative flying capabilities
  • Redundant systems for critical functions such as engine, hydraulics, and autopilot 
  • Auxiliary power mode that keeps the engine running without the rotors, allowing electronics and heat/AC to stay on
  • Full night-vision goggle capability (with a service upgrade to white phosphorus NVGs)
  • A crash-resistant air frame, fuel system, and seats.

The company is also converting to full IFR operations for further safety and ability to operate in marginal conditions. 

With a broad mission profile that includes EMS and critical-care transports, land and water rescues, and firefighting and law enforcement components, STAR Flight places a special emphasis on safety. Beyond its state-of-the-air craft, the service trains more than most and embraces practices like crew resource management (CRM) with unusual vigor. It’s a place where safety culture is more than a trendy phrase. 

“We’re about to have the most state-of-the-art aircraft available out there, but that’s not really what ultimately keeps us safe,” says Ashley Voss-Liebig, RN, BSN, a flight nurse and rescue specialist and STAR Flight’s division chief for clinical performance and education. “The human factors are what give you the safety—the culture and environment people work in and the decisions they make every day. How you make decisions, cognitive offloading, task saturation, those sort of things play a huge part. When you look at the investigations of many of these crashes, they don’t come down to the aircraft as much the human factors involved.” 

Human Factors

It’s well recognized that human factors play an enormous role in aviation safety; that’s where concepts like CRM and “three to go, one to say no” come from. The latter describes an approach where the approval of the entire crew is required to accept a flight, but even one member who feels uncomfortable can veto it. It’s used by STAR Flight and broadly in helicopter EMS. 

“If a nurse is ready to go out on a hoist rescue and gets that spidey-sense that it doesn’t feel or look right, they can say ‘Nope, I’m not comfortable’ and abort that mission immediately,” says Voss-Liebig. “They don’t get questioned, second-guessed, or razzed; we just respect each other’s ability to know when something doesn’t feel good.”

“The industry has taken great strides to make sure the decision to accept a flight request is based completely on aviation safety considerations,” says Sherlock. “Crews typically operate on a ‘three to go, one to say no’ kind of system, and we’ve implemented safety management and just culture-type systems throughout the industry where if someone doesn’t feel comfortable with the circumstances surrounding a request, they are free to speak up and turn it down. We also have operational control centers for programs with 10 or more aircraft that can assist the pilot’s decision-making and identify risks they see.”

AAMS tracks the number of air-medical services in the U.S. through its ADAMS (Atlas and Database of Air Medical Services) resource. As of September 2018 it tallied 300 services fielding a combined 1,461 rotor- and fixed-wing aircraft. (The ADAMS map shows just how many options were available for that patient in southern Ohio.6) A 2017 report from Grand View Research projects the market to keep growing over the next half-decade.7 That potentially means more services vying for those patients who need flown, and potentially more patients who need flown due to things like ongoing hospital closures. 

Most will value safety. But in a landscape that competitive, it can get gray around the edges. No one wants to be reckless, but for-profit models have to survive. They may make different calculations—shaped less by bad faith than simple circumstances—about things like aircraft and mission risk. 

“I see people taking helicopters that were made for daytime VFR flights and turning them into EMS helicopters that fly at night in marginal VFR,” says Lebrecque. “We just spent $13 million a helicopter so we could fly IFR, because we know what we do is risky. You can go buy a $2 million, $3 million helicopter and make it an EMS helicopter, and it’ll get the job done. Day VFR flying in that type of helicopter is safe all day long. But when you start throwing darkness and low weather in there, it gets a lot more dangerous.” 

“Our funding eliminates any pressure to fly or need to go out and count customers,” adds Voss-Liebig. “I think from an industry perspective, we’d all like to say there’s no pressure to fly, but if someone has a flight volume count hanging on the board by the door—if you know your base staying open is contingent on the number of flights you get every month—then there is pressure to fly. We’re fortunate we don’t have that concern. You could walk into STAR Flight right now and ask anyone how many flights we did last month, and not a single crew member would be able to tell you.”

Brave Enough to Say No

What else, then, short of replicating Travis County’s government-funded model, should we be doing to keep improving air-medical safety? 

“Where I think we have to continue to focus is just constant vigilance,” says Sherlock. “I think as an industry, our operators have all committed to safety and now spent a cumulative $500–$700 million in improvements—HTAWS, flight data monitoring systems, night vision goggles, a variety of things voluntarily and in conjunction with the FAA. Going forward I don’t think there’s a silver bullet, just a constant focusing of our maintenance people on what they’re doing, of our training people on what they’re doing, of our aviation crew members and medical team members, not just on patient care but the safety of the operation.” 

Collopy’s ideas are more specific: Make night-vision goggles mandatory for all night operations; look to dual-engine helicopters and having dual pilots; provide more aviation training centers and education on the nonclinical side of helicopter EMS; and maybe even designate emergency landing zones along interstates and major highways. 

“Most interstates have spaces along the sides or in the middle where there’s just ditches and grass,” he says. “It wouldn’t take much to have a 100-by-100 pad poured between or alongside them every 20 or 30 miles.”

Lebrecque mentions better training for unexpected instrument conditions and marginal weather in general. “Most pilots I talk to, the only time they get inadvertent IMC training is during their annual check ride,” he says. “A valuable, well-thought-out IFR training program is key.”

Those would help. But the biggest difference we can make is probably less technological than it is related to those human factors. 

“Folks just have to be brave enough to say no,” says Voss-Liebig. “It takes bravery to say no and for their colleagues to respect that. Even junior at STAR Flight, I never would have been afraid to say, ‘No, I don’t want to go on this water rescue,’ because I know my colleagues would have supported that. 

“When it becomes attached to your sense of pride or your sense of livelihood, that’s when it becomes dangerous. So I feel like not having that constant need to seek flight volume is the direction we need to go. But how we get there is going to be a challenge.” 


1. Wootson CR Jr. Two air ambulances turned down a flight because of the weather. A third agreed, then crashed. Washington Post, 2019 Feb 1.

2. National Transportation Safety Board. NTSB Identification: CEN 19FA072,

3. Alexander RJ. “Helicopter Shopping” What hospital & first responders need to know. Indiana Assoc. of Air Medical Services,

4. Londberg M. Weather grounded med helicopters, but ‘higher risk-taker’ accepted fatal flight in Ohio. Cincinnati Enquirer, 2019 Feb 15.

5. Federal Aviation Administration. Press Release—FAA Issues Final Rule to Improve Helicopter Safety. 2014 Feb 20.

6. Association of Air Medical Services. Atlas & Database of Air Medical Services (ADAMS),

7. ABNewswire. Air Ambulance Services Market Is Anticipated to Grow Switftly Due to Increasing Awareness About Air Medical Transport Services Till 2025: Grand View Research Inc., 2017 Jul 3.

John Erich is the senior editor for EMS World. Reach him at 

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