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Report: Pilot Error Blamed For Wisconsin Crash

MADISON, Wis. - Pilot error and the lack of proper warning equipment were blamed Friday by the National Transportation Safety Board for the 2008 crash of a University of Wisconsin Med Flight helicopter that killed three people.

NTSB Report ID: CHI08FA128

The UW Med Flight helicopter crashed into a hilly, wooded area about 4 miles from the La Crosse airport on May 10, 2008. The crash killed pilot Steve Lipperer, nurse Mark Coyne and doctor Darren Bean. The 86-year-old patient who was transported died hours later.

The NTSB report blames the crash on the pilot's failure to maintain clearance from trees along the top of a ridgeline due to inadequate preflight planning. It also said the helicopter wasn't high enough and there wasn't an onboard warning system that would alert the pilot of the approaching trees.

The NTSB in 2006 recommended that helicopters have that equipment as well as night vision goggles to prevent accidents.

Many important questions about the accident remain unanswered, such as whether the pilot would have had visual warning cues from the aircraft's radar before the crash, said Ronald Sliwinski, chief operating officer of the UW Hospital and Clinics, in a prepared statement.

Sliwinski defended Lipperer, the pilot, saying he was very skilled and experienced. Lipperer had more than 4,000 hours of flight time, according to the NTSB report.

"Lipperer's judgment and flying skills were never in doubt to those who flew with him on hundreds of flights, and thousands of hours of flight time in often challenging circumstances," Sliwinski said.

The helicopter, operated by Denver-based Air Methods, was leased to the UW Hospital for its Med Flight program. Air Methods vice president Mike Allen defended Lipperer's decision to fly, saying Friday he didn't believe the pilot did anything wrong. Allen said the report didn't properly vet all the issues related to the flight, including some evidence that there may have been a mechanical failure.

"We don't know precisely what the cause of the accident was," Allen said.

He said Air Methods was retrofitting its roughly 300 helicopters with both pieces of safety equipment recommended by the NTSB and expected to finish the work by 2011. The warning equipment was installed on both of UW's Med Flight helicopters in the fall of 2008 and night vision goggles have been used regularly since February 2009, Sliwinski said.

One of the NTSB's five members, Robert Sumwalt, dissented from the findings released Friday, saying more blame should have been placed on a lack of training Lipperer received from Air Methods.

Sumwalt said the report should have detailed the fact that Air Methods did not recertify Lipperer to ensure he was current with training on "instrument flight rules" that could have helped him navigate through the bad weather.

The pilot was flying visually, not using instruments, when the helicopter crashed. Sumwalt said that could explain why he was flying too low.

Air Methods' Allen said the dissent was speculative and it was irresponsible to suggest that the accident might have been avoided if Lipperer been recertified.

The helicopter left the University of Wisconsin Hospital in Madison the night of the accident to drop off a patient at a hospital in La Crosse. It crashed shortly after leaving the La Crosse airport at about 10:30 p.m.


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