Geisenger Rooftop Heliport Airport
Aircraft Accident/Incident Report

Danville, Pennsylvania 17821
Thursday, February 14, 2013 12:21 EST

NTSB Narrative Summary Released at Completion of Accident

The pilot reported that, as the helicopter approached mountainous terrain near the hospital during a helicopter emergency medical services (HEMS) flight, he turned the helicopter slightly right to pass through a gap in the ridgeline and then continued to fly directly to the heliport. The pilot then radioed that he was “3 minutes out.” About this time, the medical crew intubated the patient, and the communications center advised the pilot that two people were on the roof to assist him. He then observed two individuals on the rooftop helipad, which, “while not abnormal,” was “not routine.” He was “a bit concerned” because he wanted to make sure the personnel were clear of the helipad before landing. The pilot recalled that he was somewhat more attuned to the patient’s condition because the medical crew was working hard to keep the patient alive and was moving around the cabin unrestrained. He continued descending the helicopter on a straight-in approach and began the final approach to the rooftop helipad. About 100 yards from touchdown, he noticed something “orange” out of the left window. At almost the same time, the flight paramedic mentioned that he also “saw something orange.” The pilot then felt a “slight low frequency vibration,” which was also noticed by the flight nurse. About 6 seconds later, he landed the helicopter on the helipad, executed an emergency shutdown, and then cleared the crew to exit. A contractor who was operating a construction crane near the heliport reported that he was lowering a piece of equipment onto the roof of a building when he observed a helicopter approaching. Another contractor then observed one of the helicopter’s blades contact the flag marker, which was mounted on the top of the construction crane boom, and “pieces of wood and flag…flying all over the place.” Examination of the helicopter confirmed that the main rotor had contacted the flag marker and that one of its blades was substantially damaged. According to the pilot, neither he, the flight nurse, nor the flight paramedic had seen the construction crane before the helicopter contacted it while approaching the helipad. Review of photographs taken after the accident revealed that the pilot’s straight-in approach to the rooftop helipad passed over the location of the construction crane, which was positioned next to a nearby building. Flight crews had been notified of the construction crane’s position 2 days before the accident, and the pilot believed that he had briefed the crew about the presence of the construction crane at the medical center. According to the notification, the crane was to be in position between about 0700 to 1000 local time and was going to have a beacon on top because of the proximity of the helipad. However, no beacon was installed, and the crane was still in use and in position 2 hours 21 minutes after the notification advised that the work was supposed to be completed. No evidence was found indicating that the continued operation of the construction crane nor its presence was transmitted to the flight crewmembers when the flight was approaching the hospital. The investigation revealed that the communications technician was on the rooftop helipad at the time of the accident, not at her duty station manning the radio. The investigation also revealed that another helipad, which was located at ground level and was not near the construction crane, was available at the time of the accident and could have been used for the landing. If the pilot had been provided with correct information about the construction crane’s operation time and its presence or if he had used the available ground-level helipad, he would have been more likely to have avoided the crane. However, if the pilot had followed the guidance in the company’s general operations manual, which required that a high-orbiting reconnaissance be completed before beginning the approach and that all published helicopter procedures for the heliport and helipad be observed (which in the case of the rooftop helipad designated a left traffic pattern), the accident could have been prevented. Instead, the pilot flew a straight-in approach, which placed the helicopter’s flightpath near the construction crane, restricted his ability to see due to sun glare, and placed the helicopter in a position that obstructed his view of the construction crane, which would have been behind the instrument panel as the helicopter approached the rooftop helipad. The National Transportation Safety Board has previously cited time pressure as a risk factor in HEMS flights. Due to the patient’s critical condition, the pilot likely felt a sense of urgency to land, which influenced his decision to fly a straight-in approach to the rooftop helipad rather than to conduct a high-orbiting reconnaissance before initiating the approach. Although attempts are generally made to isolate HEMS pilots from the patient’s condition while making go/no-go decisions, once onboard, it is difficult for pilots to be unaware of serious medical conditions that may be time critical, which leads to self-induced time pressures.

NTSB Probable Cause Narrative

The pilot’s decision to conduct a straight-in approach to the helipad, which resulted in the main rotor blade impacting a construction crane flag marker. Contributing to the accident was the erroneous information about the construction crane’s operation time and the pilot’s self-induced time pressure, which resulted from his awareness of the patient’s medical situation during the flight.

Event Information

Type of Event Accident
Event Date 2/14/2013
Event Day of the Week Thursday
Time of Event 1221
Event Time Zone Eastern Standard Time
Event City Danville
Event State PENNSYLVANIA
Event Country --
Zipcode of the event site 17821
Event Date Year 2013
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 405804N
Event Location Longitude 0763620W
Event Location Airport Geisenger Rooftop Heliport
Event Location Nearest Airport ID 79PN
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 0
Degrees magnetic from airport --
Airport Elevation 674
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1153 Eastern Standard Time
Direction of event from weather observation facility (degrees) 225
Weather Observation Facility ID SEG
Elevation of weather observation facility 464
Distance of event from weather observation facility (units?) 15
Time Zone of the weather observation EST
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) 2
Dew Point at event time (in degress fahrenheit) -4
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator Calm
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.98
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 4
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 33288
NTSB Notification Source FAA Eastern ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Oct 16 2014 1:49PM
User who most recently changed record kenj
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N481LF
NTSB Number ERA13LA134
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name EUROCOPTER DEUTSCHLAND GMBH
Aircraft Model MBB-BK 117 C-2
Aircraft Series Identifier --
Aircraft Serial Number 9392
Certified Max Gross Weight 7900
Aircraft Category Helicopter
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 5
Number of Engines 2
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Jan 10 2013 12:00AM
Airframe hours since last inspection --
Airframe Hours 636
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name Geisinger Medical Center
Aircraft Owner Street Address 100 N. Academy Ave.
Aircraft Owner City Danville
Aircraft Owner State PA
Aircraft Owner Country USA
Aircraft Owner Zipcode 17822-9800
Operator is an individual? No
Operator Name Geisinger Medical Center
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 100 N. Academy Ave.
Operator City Danville
Operator State PA
Operator Country USA
Operator Zip code 17822-9800
Operator Code 3GMA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number 3GMA077N
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 No
Departure Point Same as Event No
Departure Airport Code 7PS5
Departure City Muncy
Departure State PA
Departure Country USA
Departure Time 1210
Departure Time Zone EST
Destination Same as Local Flt crash at destination city
Destination Airport Code 79PN
Destination City Danville
Destination State PA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Oct 16 2014 1:50PM
User who most recently changed record kenj
Since inspection or accident Last Inspection
Event Location Runway Number and Location H2
Runway Length 60
Runway Width 50
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Medical Emergency