Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Rapid City, South Dakota 57703
Monday, June 15, 2009 16:52 MDT
NTSB Narrative Summary Released at Completion of Accident
The air-ambulance flight encountered clear-air turbulence during cruise descent. During the turbulence encounter, the patient’s unrestrained upper-torso fell off the aircraft mounted stretcher assembly. After the turbulence had subsided, the patient’s unrestrained head, neck, and upper-torso were laying off the stretcher in the center aisle. His restrained lower body remained attached to the stretcher which was elevated off the cabin floor. The cabin flight crewmembers stabilized the patient’s neck before repositioning him back onto the stretcher. The airplane then made an uneventful landing at its intended destination. The patient suffered a fracture of the C3 cervical vertebra during the turbulence encounter. The stretcher’s available over-the-shoulder restraints were not used because of an interference caused by a flexible lift system that was used to transfer the patient from the ambulance gurney to the aircraft’s stretcher. After the accident the aeromedical transport company discontinued the use of the flexible patient lift system model used during the accident flight and required flight crewmembers to only use lift systems that allowed the use of the aircraft stretcher’s available over-the-shoulder restraints.
NTSB Probable Cause Narrative
The flight crewmembers’ failure to secure the patient using the available over-the-shoulder restraints and the encounter with clear-air turbulence during cruise descent.
Event Information
| Type of Event | Accident |
| Event Date | 6/15/2009 |
| Event Day of the Week | Monday |
| Time of Event | 1652 |
| Event Time Zone | Mountain Daylight Time |
| Event City | Rapid City |
| Event State | SOUTH DAKOTA |
| Event Country | -- |
| Zipcode of the event site | 57703 |
| Event Date Year | 2009 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 440243N |
| Event Location Longitude | 1030327W |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | -- |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1652 Mountain Daylight Time |
| Direction of event from weather observation facility (degrees) | 145 |
| Weather Observation Facility ID | KRAP |
| Elevation of weather observation facility | 3204 |
| Distance of event from weather observation facility (units?) | 10 |
| Time Zone of the weather observation | MDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 19 |
| Dew Point at event time (in degress fahrenheit) | 10 |
| Wind Direction (degrees magnetic) | 360 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 10 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.74 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Serious |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | 4 |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 5 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 27309 |
| NTSB Notification Source | Air Methods - Dennis McCall |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Aug 18 2010 9:44AM |
| User who most recently changed record | bowl |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N4490M |
| NTSB Number | CEN09LA388 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 135: Air Taxi & Commuter |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | None |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Beech |
| Aircraft Model | B100 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | BE-64 |
| Certified Max Gross Weight | 11600 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 6 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | May 12 2009 12:00AM |
| Airframe hours since last inspection | -- |
| Airframe Hours | 9898 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | C91 |
| Aircraft Owner Name | Vesey Air, LLC. |
| Aircraft Owner Street Address | C/O General Electric Capital Corporation |
| Aircraft Owner City | Danbury |
| Aircraft Owner State | CT |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 06810-5107 |
| Operator is an individual? | No |
| Operator Name | Air Methods Corporation |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 7301 South Peoria Street |
| Operator City | Englewood |
| Operator State | CO |
| Operator Country | USA |
| Operator Zip code | 80112-4133 |
| Operator Code | -- |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Non-scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | KGRN |
| Departure City | Gordon |
| Departure State | NE |
| Departure Country | USA |
| Departure Time | 1619 |
| Departure Time Zone | MDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | KRAP |
| Destination City | Rapid City |
| Destination State | SD |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Aug 16 2010 5:57PM |
| User who most recently changed record | foxt |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | Yes |
| Medical Flight | Medical Emergency |