First, MedFlight said no. A patient needed to be transported from a hospital in a small village on the Ohio River to a better-equipped emergency room, but the helicopter pilot didn’t feel the craft could make it to both locations safely.

Health-Net Areo-Medical Services said “no” next, for pretty much the same reason. Snow showers were falling along the route Tuesday morning, with 21 mph wind gusts. Wind chills were in the single digits.

But another company, Survival Flight, said yes. And the company’s Bell 407 helicopter took off from Mount Carmel Grove City hospital en route to the smaller facility’s emergency room, with the pilot and two nurses aboard.

They never made it.

Minutes after the helicopter took off, officials with Survival Flight notified the Ohio Highway Patrol that they had lost contact with one of their helicopters. Investigators pinged the cellphone of one of the people aboard and found the wreckage of Survival Flight 14 in a mountainous area of southeastern Ohio that could only be reached via logging trails. Scarred trees and scattered debris with red and black paint marked the crash site.

Authorities identified the dead as pilot Jennifer L. Topper, 34, of Sunbury, Ohio, and flight nurses Bradley J. Haynes, 48, of London, Ohio, and Rachel L. Cunningham, 33, of Galloway, Ohio.

The Highway Patrol is investigating the crash, and so is the National Transportation Safety Board, although full results could take months. The Highway Patrol told the Columbus Dispatch that it was too soon to know whether the weather factored into the crash.

But after two companies announced that they had deemed the flight too risky an undertaking, one question has ricocheted around southeastern Ohio’s first-responder community:

Why did one air ambulance take off after two others refused to?

Transferring patients between facilities is a relatively routine aspect of 21st century medical care. In mountainous parts of southeastern Ohio and West Virginia, ground travel can be slowed by bad weather and winding roads. Properly equipped and staffed helicopters can make the hops between hospitals in much shorter times, according to the National Institutes of Health, vastly improving the care of people suffering from severe trauma, heart attacks or strokes.

That care does not come cheap, and can easily climb into the tens of thousands of dollars, according to the Associated Press, sparking a fiercely competitive industry in mountainous or remote regions of the country. Some have called on their legislators to help corral costs, especially because people who suddenly face some medical emergency typically have few options.

Survival Flight has bases in Ohio and four other states “but will fly anywhere in the United States where our services are needed,” according to its website. It operates a fleet of Bell and Sikorsky helicopters and a Pilatus PC-12 airplane.

It is unclear what factors went into the final decision to take off. MedFlight’s news release said its Ohio pilot worked with an aviation director in determining how safe the conditions were, according to Columbus NBC affiliate WCMH. But none of the companies that received calls publicized their criteria.

“The Survival Flight family is heartbroken this morning as we process and mourn the loss of three of our family members yesterday morning,” the company posted on its Facebook page. “We are devastated as are the families and our crews.”

The loss was particularly heartbreaking, Ohio State Highway Patrol Lt. Robert Sellers told the Columbus Dispatch, because the people on the helicopter were “first responders flying in adverse conditions to help somebody else.”

Haynes, for example, was a paramedic and firefighter who worked three full-time first-responder jobs — at the Jefferson Township Fire Department, with the medical flight unit, and at Hamilton Township Fire Department in Franklin County, according to the Dispatch.

“The guys that were on duty here, we just looked at each other over and over like, ‘Is this real?’” Paul “Buck” Van Horn, chief of the 45-member Jefferson Township Fire Department, told the Dispatch on Tuesday night. He worked with Haynes, but knew all three of the people who died in the crash.

"It’s been a tough, tough day,” he said.

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