Thursday, February 4, 2016

Guthrie One - 25 years later - A Situational Awareness Case Study. What would you do differently tonight?



Editors note: Please know that we don't intend to open old wounds or cause hurt by examining HEMS crashes. We want to derive something positive from tragedy;  if it's possible to do so. And that benefit? The knowledge to prevent another crash. If we don't learn from history we will be condemned to repeat it. For those for whom this pain is still fresh, you have our heartfelt sympathy. We are weary of loss - as you are...


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NTSB Identification: NYC91FA067
The docket is stored on NTSB microfiche number 43142.
Accident occurred Saturday, January 26, 1991 in SONESTOWN, PA
Probable Cause Approval Date: 04/30/1992
Aircraft: MBB BK 117 B-1, registration: N891GM
Injuries: 4 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

THE MEDIVAC HELICOPTER WAS RETURNING TO SAYRE AFTER TRANSPORTING A PATIENT TO DANVILLE. RECORDED RADAR DATA AND DATA OBTAINED FROM THE HELICOPTER'S LORAN-C MEMORY INDICATES THAT THE FLIGHT WAS FOLLOWING A DIRECT COURSE FROM THE GEISINGER MEDICAL CENTER AT DANVILLE TO THE ROBERT PACKER HOSPITAL AT SAYRE. THE ACFT'S HSI WAS SET TO DISPLAY LORAN COURSE INFORMATION. THE CLOSEST POINT OF THE COURSE TO THE CREST OF NORTH MOUNTAIN WAS APRX 3/4 MILE TO THE WEST. THE PILOT HAD ADVISED WILLIAMSPORT ATCT TRANSITTING THEIR CONTROL ZONE AT 2,500 FT. IMPACT OCCURRED AT 2,440 FT MSL. THE CREST OF THE RIDGE IS 2,520 FT MSL WITH 40-FT HIGH TREES. A WITNESS WHO LIVES IN A CABIN ON THE MOUNTAIN 200 YARDS FROM THE ACCIDENT SITE STATED THAT IT WAS SNOWING VERY HARD WHEN HE ARRIVED AT THE CABIN AROUND 1930.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
  • THE PILOT'S INADEQUATE PREFLIGHT PLANNING TO ASSURE THAT THE INTENDED COURSE AND ALTITUDE PROVIDED ADEQUATE TERRAIN CLEARANCE. CONTRIBUTING FACTOR(S) WAS: THE DARK NIGHT, SNOW AND MOUNTAINOUS TERRAIn
Guthie Air conducts a mock patient drill.
Jack...

Jack would tell us that this is life and life is worth living; live it to the fullest," said former Guthrie pilot, Stan Rose, in remembering his friend. "I still feel bad, but I want to thank you, Jack, for a great example of how to live a life.

Jack Goodwin was employed by Keystone Helicopter Services and had been with Guthrie One since the program began in 1989. A 10-year veteran of helicopter flying, Jack had been an EMS pilot since 1987. At the time of his death, he was a member of the Pennsylvania Air National Guard Unit in Phillipsburg, PA. He served in the U.S. Army Military Police at Fort Gordon, Georgia and also flew in Korea. He attended Penn State University and graduated from the U.S. Aviation Program at Fort Rucker, Alabama in 1981.

On a return flight from Robert Packer Hospital in Sayre, PA to Geisinger Medical Center, in Danville, PA, the helicopter Jack was flying crashed on North Mountain during a snow storm. All those aboard lost their lives including 35-year-old Jack Goodwin. The unfortunate accident happened on January 26, 1991.

A Kingston, PA native, Jack lived in Sayre with his wife, Louise, and two children, Mara and Colleen. Jack will be remembered for being an unbridled free spirit and for his thirst for life. (National EMS Memorial Service)



Deb...

"She always faced challenges and met them head on," said flight nurse, Jack Strollo of his colleague. "Deb was not afraid to die because she was not afraid to live. If everyone was a little bit less afraid to live, then the footprints that Deb has so deeply planted in our hearts will never fade away."

Deb Nole, 32, graduated from the Geisinger Medical Center School of Nursing and worked in the intensive care unit of Moses Taylor Hospital in Scranton before coming to Robert Packer Hospital. She began her career at Guthrie in 1986 as a nurse in the intensive care unit at Robert Packer Hospital. As soon as she heard of the plans for Guthrie One Helicopter and its flight program, she couldn't wait to climb on board.

Deborah J. Nole, a critical care flight nurse, lost her life when the helicopter she was riding crashed on return from transporting a patient from Robert Packer Hospital to Geisinger Medical Center in Pennsylvania. Deb was one of three crew members who lost their life aboard Flight #609. An estimated crowd of 2,000 filled the sanctuary for the memorial service for the crew. EMS personnel arrived in emergency vehicles from many of the areas the helicopter had visited during its first year and a half. Tributes were sent from as far away as California.


Deb Nole is survived by her father, Alexander Nole, and her fiance, Kevin Tomasello. (National EMS Memorial Service)



Mark...

"What I admired most was the way Mark dedicated his life to helping people and the professional way in which he did it. I'll miss his guidance and his assistance," said a co-worker, Tom Brandt, a flight nurse, of how Mr. Haussler influenced his career. When Mr. Brandt entered the flight service he said he had a "very clinical approach" to the work. His association with Mr. Haussler helped him to develop a "new pattern in emergency medical nursing," he said.

Mark Haussler, 26, was a Guthrie One flight paramedic. He joined the Guthrie family in 1987 as an EMS training coordinator. Mark graduated from Davenport College Center for the Study of Emergency Medical Services in Michigan with a degree in paramedic/EMS management. Long committed to EMS, Mark's career included serving as a volunteer firefighter with Athens Borough. He also served as regional training coordinator for the Bradford/Susquehanna Emergency Health Service Region and was a staff paramedic and supervisor with Bay State Ambulance Service of New England.


On a return flight from Robert Packer Hospital in Sayre, PA to Geisinger Medical Center, in Danville, PA, the helicopter crashed on North Mountain during a snow storm. All those aboard lost their lives including Mark Haussler. The unfortunate accident happened on January 26, 1991. Mark is survived by his wife, Kim. (National EMS Memorial Service)


Ed...

"He was a kind and gentle man and a super uncle," said nephew Walt Rogers as he remembered Ed Soper. "From the first time he saw Guthrie One, Ed had a dream to fly with the flight team. Other than his family, his life revolved around being good enough to get aboard that bird."

A dedicated EMS volunteer, Mr. Soper was a member of the H.O.P.S. Ambulance Service, served 10 years with the LeRaysville Fire Department and was an emergency communications dispatcher for Bradford and Sullivan counties. He lived on and operated a dairy farm in LeRaysville at the time of his death.

Mr. Soper was a flight observer aboard Guthrie One helicopter #609, on a patient transport from Robert Packer Hospital to Geisinger Medical Center, in Pennsylvania when it crashed, ending the lives of all aboard. An estimated crowd of 2,000 filled the sanctuary as family, colleagues and friends remembered the crew. Tributes and memorial donations were sent from other flight teams throughout the northeast, and as far away as California.


Mr. Soper is survived by his wife, Linda, and three children, Candace Lynn, Jeremy, and Adam Edward. (National EMS Memorial Service)


4 comments:

  1. The current Guthrie helicopter is not hospital owned like Guthrie One was. It is an Air Methods program and the name it carries is Guthrie Air, not Guthrie One. It was a very sad time to live through, but they live on forever in those who knew them and worked with them.

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  2. Thank you for this information Deb - and for being their witness. We didn't know these souls, but they were obviously loved and respected.

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  3. From the NTSB's very limited narrative, this sounds more like a case of continuing VFR flight into IMC and type I spatial disorientation. Yeah, the NTSB concluded that inadequate preflight altitude planning was the culprit but the bigger question is why were they flying in that weather in the first place? It would be interesting to know if the radar tapes showed unusual airwork deviations prior to impact or if there were witness marks on the flight controls to indicate whether the pilot was flying straight and level, attempting to maneuver clear of the terrain, or was trying to recover the aircraft from an unusual attitude. I guess the NTSB is right, if you're going to go IIMC you should probably climb to clear the surrounding terrain but perhaps the more important takeaway is not to go IIMC in the first place. As a helicopter pilot in PA I would love to know more about this accident because it is part of the local history that I should learn from. Sadly, the NTSB doesn't have the full accident report posted online.

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    1. Thanks for commenting Joe. You might get in touch with Stan Rose who is quoted in the post. Stan now works with HAI and could offer some more insights perhaps. I flew EMS in PA and the weather there is quite unpredictable - and changes quickly. Perhaps the thing to keep in mind is that we never have to get anywhere. We can stop. Good luck to you and safe flights.

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