NTSB rules in 2011 Mayo Clinic helicopter crash


Published: Tuesday, June 18, 2013 at 11:42 a.m.
Last Modified: Tuesday, June 18, 2013 at 7:18 p.m.

Financial pressures contributed to a helicopter pilot’s decision to continue flying through deteriorating weather before crashing in North Florida, killing a Mayo Clinic heart surgeon and technician on their way to retrieve a heart for transplant, according to the National Transportation Safety Board.

Neither the Bell 206 helicopter nor pilot E. Hoke Smith of SK Logistics in St. Augustine were experiencing any problems before the crash early in the morning on Dec. 26, 2011, according to the NTSB probable cause report, published late Monday.

However, the helicopter was not certified to handle the sporadically misty and overcast conditions between the Mayo Clinic in Jacksonville and UF Health Shands Hospital in Gainesville.

The crew was picking up a heart at Shands for transplant in a Mayo patient. Killed with Smith in the crash were cardiologist Dr. Luis Bonilla and organ procurement technician David Hines.

The board found that Smith’s decision to continue flying in the poor conditions resulted in the crash in a remote, wooded area in Clay County, killing all three men on board.

Smith did not make any backup plans for the organ transport. Other SK Logistic pilots told investigators that they would have made the same flight but would have arranged for ground transportation or a flight by a fixed-wing aircraft if they could not complete the mission as scheduled, according to the report.

“Contributing to the pilot’s improper decision was his self-induced pressure to complete the trip,” according to the report.

The helicopter had some equipment for navigation in bad weather, but it wasn’t certified to do so by the Federal Aviation Administration, said Bob Gretz, the senior NTSB investigator handling the crash.

“It was like pockets of good and bad weather all along the route,” Gretz said. “The board, they’re really not faulting him for initiating the flight. They’re faulting him for continuing in bad weather.”

Smith’s business had faltered in the recession, and the Mayo Clinic had begun looking at other companies to fly medical transport missions. The hospital’s preferred helicopter — the only one operated by SK Logistics that was certified to fly under instrument flight rules necessitated by the bad weather — had been grounded for four months while the company attempted to secure loans for engine maintenance, according to the NTSB report.

“Thus, the pilot would have been highly motivated to complete trips as requested so that he could demonstrate the reliability of his service,” the board said.

Derrick Smith, E. Hoke Smith’s son and the company’s vice president and general counsel, told The Sun at the time of the accident that the company has mechanics and maintenance staff who check the aircraft regularly.

The company has safety certification from several aviation organizations, he added.

“This type of helicopter is very common,” Smith said. “I don’t know of any issues that they have.”

Smith was a decorated veteran of combat missions in Vietnam and routinely flew medical transport flights for the company he founded in 1997, his son has said. In bankruptcy proceedings after the crash, SK Logistics listed $1.3 million in assets and more than $8.9 million in debt.

“Hoke continued to operate the company, however, and continued to put over $1 million of his own funds into the company because he had such a passion for flying and for his missions of delivering organs to patients. The accident was a real tragedy and the family was devastated,” said Nina LaFleur, the attorney who represented SK Logistics in the bankruptcy proceedings.

Dr. William Rupp, CEO of the Mayo Clinic of Florida, deferred questions on the report to the NTSB while praising Bonilla and Hines for their work.

“We will always remember the selfless and intense dedication they brought each day to making a difference in the lives of our patients,” Rupp said.

No flight plan was filed for the helicopter, and Smith’s last contact with the air traffic control tower at Jacksonville International Airport was routine, according to the report. There was no evidence in the wreckage of any in-flight fire or mechanical or structural malfunction before the crash, and Smith never made a distress call.

A former pilot for the company told investigators that the area where Smith crashed was susceptible to fog due to swampy terrain and turned into a “black hole” at altitudes of 200 to 400 feet, the board said.

Weather conditions in Jacksonville and Gainesville were safe, but Smith’s actions showed that conditions in between were variable, said Robert Spohrer, the attorney representing Hines’ family.

“He was flying at different altitudes and at different routes in an effort to stay legal or in visual meteorological conditions. We know from the circumstances of the crash that he couldn’t do that,” Spohrer said.

Staccie Allen, program director of ShandsCair, said it has no control over flights coming to the hospital other than requesting radio communications as the helicopter nears the landing pad to avoid conflict with other flights.

Allen said ShandsCair uses fixed-wing aircraft when teams travel to pick up organs, with an ambulance waiting at the airport for the final leg of the journey to the hospital.

Planes are more capable of flying around bad weather, Allen said, adding that all ShandsCair helicopters that respond to emergencies are certified to respond in bad weather.

“We have control of our own aircraft and we have lots and lots of safety rules and guidelines so that something like this would not happen in our program,” Allen said, adding that ShandsCair helicopters often turn around when they encounter bad weather.

“They are encouraged to do that. They should never risk safety to complete the mission,” she said. “In our program, it takes three to go and one to say ‘no.’ Anyone can ask the pilot to turn around.”

Staff writer Cindy Swirko and the Associated Press contributed to this report.

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