Wyoming FACE 93WY007
Pilot Dies in Airplane Crash in Wyoming
A 33 year old male pilot died from injuries received when the air ambulance he was navigating crashed in a mountain range during a blizzard. The fixed-wing aircraft was approaching an airport in the central part of the state, some 8½ miles beyond the crash site, transporting an emergency heart patient to a hospital in that area. The craft was being followed by radar and had begun its approach to the east-west runway when it disappeared and was reported missing. A search was begun, and the wreckage was located more than 13 hours later. Four people were on board; a pilot, a patient, a paramedic and a flight nurse. None of the passengers survived the crash.
Search efforts were confounded by the disappearance of a second plane in the same storm. The second plane landed safely some 10 miles further from the airport due to engine trouble, and the survivors were found walking away from the disabled plane.
Employers may be able to minimize the potential for occurrence of this type of incident through the following precautions:
In the early morning hours of Tuesday, April 6, 1993, a pilot and 3 passengers were enroute from a hospital in the western part of the state to a more centralized hospital for the purpose of transferring an emergency heart patient to a hospital more able to provide adequate care. A paramedic and a flight nurse were aboard the aircraft to provide in-flight medical service to the patient.
The WY-FACE Program became aware of the incident through media coverage of the event. The WY-FACE Investigator travelled to the site and hand-delivered information requests to the coroner and the sheriff, and to ambulance officials. Additional interviews were held with the employer and NTSB personnel.
Several months after the incident occurred, requested reports had still not been received. The investigating law enforcement agency declined to release reports and neither the coroner's office nor NTSB had completed their reports. Therefore, much of the data available for analysis was from newspaper coverage of the incident.
A major winter storm hit on the day the incident occurred, with between 6" and a foot of snow involving law enforcement and emergency personnel in multiple cases including two downed aircraft during the early morning hours. In addition to cold and blowing snow conditions hampering efforts to locate the air ambulance that had gone down in a ridge of mountains approximately 8½ miles west of the airport, rescue efforts were complicated by the fact that the passengers of the second downed plane were walking to safety and carrying the emergency locator with them, making it even more difficult to determine where the second (and weaker) transmitter was located. After a full day of searching, the wreckage was found by helicopter over 13 hours after the incident, and not reached until snow cats could be driven to the crash site. During the search, heavy snow was falling and winds were blowing 20 to 30 mph, reducing visibility to about 200 yards. Around 70 rescue workers from three counties were involved in search and rescue efforts.
The seven-seat twin turbo-prop was being used as an air ambulance to transfer an elderly cardiac patient in critical condition from a smaller hospital to the destination hospital where more intensive care would be available. The craft was making its approach to the destination airport, and was overflying two ridges that lay within the approach. The plane came over the first ridge but crashed into the rocky face of the second ridge. All four of the plane's occupants apparently died instantly from the force of the crash. Debris indicated that the plane hit the ridge nose first and that the bodies were thrown back from the wreckage.
Investigations into fatal crashes of the same type of airplane in other incidents suggested that there was a concern about the hub and propeller assembly, and that the plane type is difficult to fly because of its high performance characteristics. While the wing location and roomy interior makes the craft highly accessible as an ambulance, it creates an instability that decreases air worthiness.
CAUSE OF DEATH
The Medical Examiner listed the cause of death as traumatic injuries, multiple, severe, extreme; with dismemberment and post-mortem burning.
This incident was preventable in that existing blizzard conditions in the area were not sufficient to have been the sole cause of the crash that occurred. The type of aircraft used in the air ambulance operation had been identified as having a poor safety record, and of being difficult to handle in emergency situations. The pilot had considerable experience in flying in the area where the crash occurred, but did not have extensive experience in the specific aircraft. Other pilots with experience in the subject aircraft consider its accessibility to ground ambulance transfer and interior convenience for in-flight medical care to be useful in air ambulance fights. However, they question the reliability of the vehicle in hazardous weather conditions because of its unique handling characteristics. Experienced pilots of that aircraft have recommended special flight training courses that include simulator training before using the specific craft in emergency situations.
Outside data indicates that 20% of the airplanes built of that specific vintage, have crashed, as compared to an average 10% rate for other popular small turboprop aircraft. Two earlier crashes in Wyoming had claimed seven lives in the fall of 1981, and a similar crash in another state less than two weeks after this incident took the life of the governor of a sister state. Nearly 700 mourners attended a memorial service for the workers who died in this air crash, to honor the workers who had devoted much of their lives to providing life-saving care for others.
FATAL ACCIDENT CIRCUMSTANCES AND EPIDEMIOLOGY (FACE) PROJECT
The National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), performs Fatal Accident Circumstances and Epidemiology (FACE) investigations when a participating state reports an occupational fatality and requests technical assistance. The goal of these evaluations is to prevent fatal work injuries in the future by studying the working environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact.
States participating in this study include: Kentucky, Maryland, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia.
NIOSH Funded/State-based FACE Projects providing surveillance and intervention capabilities to show a measurable reduction in workplace fatalities include: Alaska, California, Colorado, Georgia, Indiana, Iowa, Massachusetts, New Jersey, Minnesota, Missouri, Wisconsin and Wyoming.
Additional information regarding this report is available from:
Wyoming Occupational Fatality Analysis Program
522 Hathaway Building - 2300 Capitol Avenue
Cheyenne, WY 82002
Please use information listed on the Contact Sheet on the NIOSH FACE web site to contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.