N207CFAgusta Spa A119 · 2000

On October 19, 2012, about 2215 mountain standard time, an Agusta A119 helicopter, N207CF, designated as CareFlight 14, sustained minor damage while standing under power, following a collision with a 26-foot box van truck about 17 nautical miles (nm) northwest of Dolan Springs, Arizona. The Emergency Medical Services (EMS) helicopter was registered to and operated by TriState CareFlight, of Bullhead City, Arizona. The pilot, flight nurse and paramedic on board the helicopter, as well as the 3 individuals in the moving vehicle were not injured. Visual meteorological conditions prevailed at the time of the collision. The flight, which was originating at the time of the incident, was being operated in accordance with 14 Code of Federal Regulations Part 91, and a company flight plan was active. The helicopter's planned destination was Kingman Airport (IGM), Kingman, Arizona.

The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) received statements from the 3 TriState CareFlight 14 EMS flight crewmembers, a formal report from the Arizona Department of Public Safety (AZDPS), which was inclusive of statements supplied by on-scene Department of Public Safety (DPS) officers, which was inclusive of the 3 TriState CareFlight 14 crewmember statements supplied to the NTSB IIC, a statement from a supervisory Captain assigned to the Lake Mohave Ranchos Fire Department (LMRFD), as well as statements from the 3 occupants of the vehicle that came into contact with the helicopter's main rotor blade tips. Representatives from the Federal Aviation Administration (FAA) did not respond to the site of the event.

TriState CareFlight 14 helicopter crewmember statements supplied to the NTSB IIC and AZDPS by TriState CareFlight:

Pilot-in-command (PIC)

The PIC reported that he was running the [helicopter's engine up] after being released from the accident scene, and at the time of the [engine] start the aircraft was on the shoulder of the [right] northbound lane facing south, which was consistent with the landing instructions and positions of multiple helicopters that had responded to the accident site. The PIC stated that upon reaching 100 percent engine power, he noticed that the DPS had allowed [vehicle] traffic to begin flowing in the far [left] lane of the northbound highway. The pilot further stated that he commented to the [para]medic, who was seated in the left front cockpit set next to the PIC, that he did not like the idea of the traffic in such proximity of the RUNNING helicopter, and about 5 to 10 seconds later, the helicopter was struck by a 26-foot box truck at the tip path plane [of the main rotor blades]. The PIC revealed that he immediately shut the engine down, examined the helicopter, and determined that there had been extensive damage to the blade tips of all 4 [main rotor] blades. The PIC added that while on the ground the flight crew's paramedic had requested that traffic not be allowed to continue until after their aircraft had departed. "The request was obviously ignored by the DPS Sergeant, and in my opinion, resulted in this mishap."

Flight nurse

The flight nurse reported that upon arriving at the accident site, the pilot landed on Highway 93 behind another helicopter. After exiting the helicopter, he and the crew's paramedic proceeded to the Incident Command Post, where they were informed by the Incident Commander (IC) that they were not needed and were released to return to their base at IGM. The flight nurse further reported that while returning to the helicopter, he and the paramedic notified the senior DPS officer on site that they intended to lift off immediately after the helicopter in front of them departed; the DPS officer said that he was going to open the road. The nurse stated that at this time the paramedic informed the officer that the helicopter's [main] rotor blades extended into the passing lane, and to not open the road until they had lifted off. After returning to the helicopter and in preparation for departure, the helicopter that was positioned in front of them lifted off. The nurse reported that while he was standing outside of the helicopter [to monitor the area], and as the pilot was starting the helicopter's engine, he observed a DPS vehicle drive past him with a line of cars and trucks following; he remained standing outside the helicopter to insure that the rear of the aircraft remained clear. The nurse stated that as the vehicles continued to proceed past the helicopter, he used his flashlight to direct traffic away from the helicopter's main rotor. When he was notified that they were ready to depart, the nurse entered the rear compartment of the helicopter and secured his safety restraints. As he was observing his area of responsibility for the lift off, which was the right side of the helicopter, he saw a lot of sparks and heard multiple loud bangs in succession, followed by the aircraft shaking violently. The crewmember stated that the pilot then yelled over the intercom, "What was that?" To which the crewmember responded, "A truck just hit the rotor blades." The pilot subsequently initiated an engine shutdown. The nurse's statement made no reference to any follow-up conversations with DPS personnel relative to the incident.

Paramedic

The paramedic reported that after landing, he and the flight nurse left the helicopter and proceeded to the command post, where they were told that they would not have a patient for transport, and that they were released to return to their base. The paramedic stated that on the way back to the helicopter he encountered a DPS sergeant, who informed him that he was about to open the highway. The paramedic reported that he told the DPS officer that their helicopter was still on the ground, to which the officer said they should have been on the berm and the lane should be opened. The paramedic to the officer, "We landed as far as we could, but our blades are extending over the center line." The paramedic added that at this point he returned to the helicopter, and waited about 5 minutes for the helicopter in front of them to depart. Subsequently, he stood outside of the left front door while the pilot started the engine, and then entered the cockpit and took his left front seat and secured his safety restraints. The paramedic revealed that as the pilot was starting the engine, he was looking at the gauges with the pilot as the engine went to 100 percent power. He then looked up from the gauges and observed some traffic approaching. Two or three vehicles passed safely, with the 4th vehicle being a Ryder truck, which subsequently came in contact with the helicopter's main rotor blades; the pilot immediately shut the engine down. The paramedic then exited the helicopter, checked for injuries, and reported to the command center. The paramedic's statement made no reference to any follow-up conversations with DPS personnel relative to the incident.

Arizona Department of Public Safety (AZDPS) Crash Reports of CareFlight 14 crewmembers:

Pilot of CareFlight 14

The pilot advised that he was running the helicopter up to depart an accident scent on US 93, when the aircraft was struck by an oncoming truck. The pilot was asked if there was traffic traveling past the helicopter prior to him starting the helicopter. The pilot said that approximately ten vehicles passed prior to him starting the helicopter.

Paramedic of CareFlight 14

The paramedic stated that he was seated in the left pilot seat looking for possible dangers. He said he spoke with DPS Officer #1 from the AZDPS prior to lift off and asked him not to open [the] highway until they departed. He stated that he noticed traffic during the run up to 100 percent power.

Flight Nurse of CareFlight 14

The crewmember said that his position is in the rear of the helicopter. He stated that prior to entering the helicopter for departure, he and his partner, the paramedic crewmember, notified a DPS sergeant that they would lift off after the helicopter that had a patient, and that their rotor blades were hanging into the passing lane. The flight nurse said that upon returning to the helicopter he stood outside the helicopter observing traffic while the pilot started the engine. After entering the helicopter and securing himself, and while observing the traffic from his seat, he heard multiple loud noises and the helicopter shuddered. He said the pilot immediately shut the engine down.

Arizona Department of Public Safety Traffic Accident Witness Statements provided by CareFlight 14 crewmembers:

Pilot of CareFlight 14

The pilot reported that he was running up the helicopter's engine prior to departing an accident scene on highway 93, with no patient, when the aircraft was struck by an oncoming truck. He stated that he was alerted to the accident (collision with the truck) by a loud thump and violent vibration, at which point he and the crew ascertained that they had been struck by a vehicle. The pilot stated that he then executed an emergency shutdown. The pilot added that prior to departing, an Arizona DPS officer was advised by the flight crew's medic to not open the highway until they had departed. He said that the advice was disregarded, and that the traffic flowed during the startup. He said that about the time they noticed the traffic was moving was when they were hit.

Flight nurse of CareFlight 14

The flight nurse stated that prior to departure, his partner, the paramedic, notified a DPS sergeant that they would lift off after the helicopter that had the patient departed, and that their main rotor blades were hanging into the passing lane. He said that as the pilot started the engine he stood outside of the helicopter observing traffic. He subsequently entered the helicopter, secured himself, and closed the door. As he was observing the traffic he heard multiple loud noises, and the helicopter shuddered. The pilot immediately shut the engine down.

Paramedic of CareFlight 14

The paramedic stated that he spoke to a DPS Sergeant prior to lift off, and that he asked him "not to open the highway till we lifted. Noticed traffic during run up to 100% power."

Arizona Department of Public Safety Crash Report

The AZDPS Crash Report revealed that the landing zone for the responding EMS helicopters was established on the emergency side of the right northbound lane, with all helicopters landing and coming to rest north of the tour bus accident. DPS personnel established permanent traffic control about 1/4 miles south of the accident site.

Crash Report statements

Driver of 26-foot box van truck

In a written statement supplied to AZDPS personnel, the driver of the 26-foot box van truck, which came into contact with the main rotor blade tips of CareFlight 14, reported that when DPS personnel released the traffic and shortly after entering a clear lane, he heard the side of the truck being struck. The driver further stated that in his opinion, no traffic should have been allowed to go with the helicopter running.

DPS Officer #1

A DPS sergeant reported that after the helicopter landed, and when the crew of CareFlight 14 came to the Command Post (CP), they confirmed that the helicopter was "off right". The CareFlight 14 paramedic was then informed that there were no patients for them, and that they were cleared to leave the accident scene. The DPS officer advised the paramedic that they would be opening the northbound traffic lane as soon as the second bus was loaded and under way. He said the paramedic then returned to the aircraft, with no further contact with him.

The DPS officer reported that the northbound traffic was released about 10 to 15 minutes after speaking with the paramedic, and that the traffic had been moving for about 10 to 15 minutes prior to the trucks impact with the helicopter. The officer also reported that neither he nor the CP ever received a request to stop traffic from any member of the CareFlight 14 flight crew, or anyone else. He also said that prior to the collision, he was aware of only two aircraft remaining on the ground – the DPS Jet Ranger and CareFlight 14.

With respect to the conversation the DPS officer had with the CareFlight 14 crewmember, the officer stated that he advised the crewmember that northbound traffic would be released soon, and confirmed with the crewmember that the helicopter was "off right". The officer further stated that the crewmember said they were "off right", but were "right there" (indicating close to the left lane). He said that the crewmember advised him that they did not have a patient and would be departing soon. The officer said he had no further conversation with the crewmembers of CareFlight 14, and did not see the helicopter depart. The officer reported that the Incident Captain (IC) from the Lake Mojave Ranchos Fire Department (LMRFD) assumed responsibility for the LZ, and that the Captain remained near the helicopter.

The DPS officer was asked about the IC's statement that the officer had refused to stop traffic, to which the officer replied that the Captain was most likely misinformed as to the original conversation regarding the officer's denial to stop traffic at the onset of the initial bus crash. The officer said that he believed the Captain had applied their initial conversation relative to stopping traffic to the entire length of time on both scenes.

DPS Officer #2

A second DPS officer reported that he directed the pilot of CareFlight 14 to position the helicopter further to the east on the emergency shoulder of the [northbound] right lane. The helicopter landed facing south, and the pilot remained with the aircraft. He said that the helicopter's main rotor blades were about 90 degrees to the aircraft, and that one of the 4 blades extended into the left, northbound lane. The officer stated that two people exited the helicopter and proceeded to the CP. He said that he thought they were both EMS personnel, and that he did not have a conversation with either individual. The officer said that he approached the pilot and requested that he rotate the main rotor blades so they were not extended into the [left] northbound traffic lane, which was about to be reopened. He said the pilot complied by manipulating the blades out of the left travel lane; at this time the helicopter was completely shut down.

The officer stated that he met with the LMRFD IC, who requested that the northbound traffic remained stopped until the two remaining aircraft were loaded with patients and had departed. The officer reported he told the IC that the northbound traffic would be held to allow the forward helicopter to load their patient and take off. He said that once the forward helicopter departed, the single northbound lane would be reopened until CareFlight 14 was loaded and would be ready to depart. He said he told the IC that traffic would be stopped upon his request, to allow for the departure of the remaining helicopter, CareFlight 14. The officer added he was then advised that northbound traffic was allowed to proceed through the collision scene in the left northbound travel lane. Subsequently, when he was about 1.5 miles south of the accident site waking up motorists, he was informed that there had been a second collision, which involved a helicopter. He stated that the northbound traffic had been moving for about 10 minutes prior to receiving the report of the second collision, and estimated that CareFlight 14 had been on the ground in excess of 20 minutes before the collision occurred.

The officer reported that during the investigation, the pilot of CareFlight 14 stated that approximately 10 vehicles had driven past the helicopter prior to the pilot starting the engine and its blades beginning to rotate. He said the pilot had also stated that the flight medic told him that the first DPS officer, referred to as DPS Officer #1 in this report, had been advised to hold the vehicle traffic. The officer added that he did not speak with the flight medic relative to this information.

LMRFD Incident Captain (IC)

First DPS interview session with LMRFD Incident Captain (IC) – October 30, 2012

The LMRFD Incident Captain reported that when he arrived at the scene of the accident, he became aware that 8 helicopters were responding to the scene and needed a safe and well defined landing zone (LZ). He said he then requested the assistance of a DPS officer, identified as DPS Officer #1 in this report, who informed him that the road would not be shut down until the helicopters were prepared to land.

The IC stated that the helicopters were beginning to land "where they wanted," and that he subsequently directed the incoming aircraft where to land, which was on the northbound shoulder and right hand travel lane, north of the wrecked tour bus, [and facing south]. He said CareFlight 14 was positioned behind one other helicopter, Native Air, which was being loaded with the last patient.

The IC stated that he spoke with DPS Officer #2, and requested that the stopped traffic be held until the two remaining helicopters had departed the accident scene. He further stated that traffic was subsequently held until the Native Air helicopter had departed, at which time the traffic was allowed to move northbound after its departure.

The IC revealed that while he was walking away from the LZ for the CP, CareFlight 14 began to power up. He said he then approached DPS Officer #1 in the median along the southbound shoulder, and requested that traffic be stopped; no traffic was flowing at that time and he told the officer not to let traffic through. He added that not long after that, the helicopter was struck by the passing truck.

Follow-up interview session with LMRFD IC – December 17, 2012

The IC stated that there had been two DPS officers on scene at the time of his arrival, and that there had been a constant movement of helicopters in and out of the scene. He had been attempting to keep the road closed the entire time.

The IC revealed that DPS Officer #1 was constantly asking him when the road could be opened, and that there had been 3 additional traffic collisions due to the traffic backup; the IC said that he had not received any additional calls regarding secondary collisions. He added that DPS Officer #1 continued to reiterate to him, "I need the road open." He said he was cooperating with the officer by landing the helicopters in a manner, which could eventually allow for northbound traffic in the left northbound lane [to proceed].

The IC reported that prior to the collision there were 3 helicopters remaining on the highway; the DPS Jet Ranger, the Native Air helicopter, and CareFlight 14. He said he assisted in loading the Native Air helicopter with the last patient, then contacted CareFlight 14 and confirmed that they had no patient. He then went to the CP to confirm that CareFlight 14 was not getting a patient. After departing the CP, he met "face-to-face" with DPS Officer #1 and requested that the last two helicopters depart prior to opening the road. He said the officer did not seem to have a problem holding the traffic until the two remaining helicopters had departed. The IC stated that between the times he met with DPS Officer #1 and while walking back to the CP, the traffic was released. He further stated that while at the CP he "turned around" and CareFlight 14 had "spun up." He said he then heard the CareFlight 14 crew yelling, "We are going to make contact," which he said occurred 2 seconds prior to the collision.

The IC said that the only other problem with the control of the LZ was from the DPS [Jet] Ranger crew, which was providing instructions to other responding helicopters that was contradictory to his.

LMRFD EMS Chief

The LMRFD EMS Chief was interviewed as part of the DPS investigation. The EMS Chief reported that he was on scene at the CP when CareFlight 14 landed, and that upon meeting the crewmembers, he informed them that there were no patients, and immediately released them from the scene. He further stated that he believed that they were going to depart immediately, and that he received no requests for traffic control assistance from either crewmember. He also reported that a LMRFD Incident Captain was in charge of the established LZ, and had been directing aircraft landings and departures.

River Medical Ambulance Service employee

A River Medical Ambulance Service employee was interviewed as part of the DPS investigation. The employee stated that he had been present at the CP when the 2 crewmembers of CareFlight 14 approached the CP. He said the crewmembers were immediately advised that there were no critical patients who required aircraft removal, and that they were immediately advised that they could depart the accident site. He estimated the helicopter was on the ground for about 15 to 20 minutes prior to its attempted departure.

(Refer to the Arizona Department of Public Safety Arizona Crash Report, #2012-044543, dated December 26, 2012, which is appended to this report.)

The airframe of the helicopter was not damaged during the incident. However, all 4 main rotor blade tips were damaged. A subsequent inspection of the helicopter's main rotor blade structures revealed that each had not sustained damage during the event. According to the TriState CareFlight's Director of Maintenance (DOM), and as the event was not classified as a "sudden stoppage" of the aircraft's drive train, the helicopter's drive train was not subject to a postincident inspection. The DOM reported that the helicopter's main rotor blades were replaced, and that the aircraft was returned to service.

Guidance for Emergency Medical Service (EMS) Operations

Aeronautical Information Manual (AIM)

According to the Aeronautical Information Manual (AIM), 10-2-4, Emergency Medical Service (EMS) Multiple Helicopter Operations, EMS helicopter operators often overlap other EMS operator areas. Standardized procedures can enhance the safety of operating multiple helicopters to landing zones (LZs) and to hospital heliports. Communication is the key to successful operations and in maintaining organization between helicopters, ground units and communication centers. EMS helicopter operators which operate in the same areas should establish joint operating procedures and provide them to related agencies.

Traffic Incident Management (TIM)

TIM consists of a planned and coordinated multi-disciplinary process to detect, respond to, and clear traffic incidents so that traffic flow may be restored as safely and quickly as possible. Effective TIM reduces the duration and impacts of traffic incidents and improves the safety of motorists, crash victims and emergency responders.

According to the United States Department of Transportation Federal Highway Administration, Office of Transportation Operations 2010 Traffic Incident Management Handbook Update, FHWA-HOP-10-013, 3.2.2, Incident Command System/Unified Command states, "How responders execute their respective roles and responsibilities at the incident scene is a major factor that contributes to the successful, safe, and quick clearance of the scene. As defined in the National Incident Management System (NIMS), the Incident Command System (ICS) provides a framework for responding to all emergencies, and must be used and understood by all parties at the scene of an emergency.

The ICS is a well-established, standardized on-scene process for managing incident response activities. The ICS was developed in the 1970s to manage rapidly moving wildfires where response activities were adversely impacted by:

• Too many individuals reporting to one response commander.

• Lack of interoperable communications and lack of reliable information.

• Different organizational structures between emergency response agencies.

• Lack of structure for coordinating response activities and lack of authority over response activities.

• Lack of a common terminology between agencies.

• Differing and/or unclear incident response objectives.

ICS is used as the key strategic incident command structure. The rationale is that ICS provides a flexible, yet standardized approach for incident command, and that ICS defines the operating characteristics, interactive management components, and structure of incident management and emergency response organizations engaged throughout the life cycle of an incident.