Bell 407 accident near Zaleski, Ohio, January 29, 2019
On January 29, 2019 at about 11:50 am local time, a 1996 Bell 407 (helicopter), registered N191SF, was destroyed in an accident during enroute near Zaleski, Ohio. It was flown under charter and air-taxi rules (Part 135). 3 people were killed. The weather was conditions the NTSB did not record.
The NTSB's probable cause their words, unchanged
The NTSB determines that the probable cause of this accident was Survival Flight's inadequate management of safety, which normalized pilots' and operations control specialists' noncompliance with risk analysis procedures and resulted in the initiation of the flight without a comprehensive preflight weather evaluation, leading to the pilot's inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of the operator's risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- January 29, 2019 · about 11:50 am local time
- Place
- Zaleski, Ohio · map
- Type
- Accident
- Injuries
- 3 people were killed.
- Weather
- conditions the NTSB did not record
- Aircraft
- Bell 407 No Series, built 1996 · all 407s on the register
- Registration
- N191SF · no longer on the register · serial 53006
- Damage
- Destroyed
- Flight
- Flight · charter and air-taxi rules (Part 135)
The NTSB's narrative final · quoted from the NTSB record
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-20/01. On January 29, 2019, about 0650 eastern standard time, a single-engine, turbine-powered Bell 407 helicopter, N191SF, being operated as a helicopter air ambulance (HAA) flight, collided with forested terrain about 4 miles northeast of Zaleski, Ohio. The certificated commercial pilot, flight nurse, and flight paramedic died, and the helicopter was destroyed. The helicopter was registered to and operated by Viking Aviation, LLC, doing business as Survival Flight Inc., under Title 14 Code of Federal Regulations Part 135. Company flight-following procedures were in effect for the visual flight rules (VFR) flight, which departed Mount Carmel Hospital, Grove City, Ohio, about 0628 and was destined for Holzer Meigs Emergency Department, Pomeroy, Ohio, about 69 nautical miles southeast, to pick up a patient. Night visual meteorological conditions existed at the departure location, but available weather information indicated that snow showers and areas of instrument meteorological conditions (IMC) existed along the route of flight.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- VFR encounter with IMC during enroute
- Unknown or undetermined during enroute defining event
The NTSB's findings
- cause Personnel issues › Task performance › Planning/preparation › Weather planning › Pilot
- cause Organizational issues › Management › Culture › Safety › Operator
- cause Organizational issues › Management › Culture › Standard operating practices › Operator
- cause Organizational issues › Management › Policy/procedure › Adequacy of policy/proc › Operator
- factor Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation › FAA/Regulator
- factor Organizational issues › Support/oversight/monitoring › Enforcement › Operational procedures › FAA/Regulator
- factor Organizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program › Operator
- factor Organizational issues › Support/oversight/monitoring › Safety programs › Adherence to safety program › Operator
- cause Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Snow › Not specified
- cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude › Not attained/maintained
- cause Environmental issues › Physical environment › Terrain › (general) › Not specified
- Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima › Effect on operation
- Personnel issues › Task performance › Use of equip/info › Use of equip/system › Pilot
- Environmental issues › Operating environment › Meteorological services › (general) › Availability of related info
Pilot
- Certificate: flight instructor, commercial pilot
- Ratings: single-engine land; instructor: helicopter; instructor: instrument helicopter; instrument: airplane; instrument: helicopter; rotorcraft: helicopter
- Flight time: 1,855 hours in all; 83 in this make and model; 1,787 as pilot in command
- Last flight review: April 27, 2018
- Medical certificate: Class 2 (without waivers/limitations)
- Seat: rgt
- Injury: fatal
The aircraft
- Maximum gross weight: 5,501 lb
- Seats: 4
- Landing gear: fixed
- Engine: Rolls-Royc 250-C47B (turboshaft); 0 hours total
- Operator: Viking Aviation INC
The flight
- Departed from: Grove City OH at 11:28 am
- Destination: Pomeroy OH
Weather at the time
- Light: night
- Wind: from 280° at 7 knots
- Visibility: 10 statute miles
- Sky: overcast at 2,700 ft
- Temperature: 21°F (-6°C), dew point 14°F (-10°C)
- Altimeter: 29.92 inHg
- Observation at 11:55 am from KUNI, 7 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 3 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The NTSB has not released the docket for this case yet. The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), is usually released when the investigation is nearly complete, and the list here is refreshed when it appears. Check at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.