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Sunday, September 9, 2018

NTSB Final Report : North Memorial Air Care Crash



The pilot and two medical crewmembers were conducting a night instrument flight rules cross-country flight to pick up a patient. During the instrument approach to the destination airport, the weather conditions deteriorated. The pilot was using the helicopter's autopilot to fly the GPS approach to the airport, and the pilot and the medical crew reported normal helicopter operations. Upon reaching the GPS approach minimum descent altitude, the pilot was unable to see the airport and executed a go-around. The pilot reported that, after initiating the go-around, he attempted to counteract, with right cyclic input, an uncommanded sharp left 45° bank . Recorded flight data revealed that the helicopter climbed and made a progressive right bank that reached 50°. The helicopter descended as the right bank continued, and the airspeed increased until the helicopter impacted treetops. The helicopter then impacted terrain on it's right side and came to rest near a group of trees.

Postaccident examinations of the helicopter and flight control systems did not reveal any malfunctions or anomalies that would have precluded normal operation. The helicopter was equipped with a GPS roll steering modification that featured a switch that allowed the pilot to manually select the heading reference source. In case of a malfunction or an erroneous setting, the helicopter's automatic flight control system had at least two limiters in place to prevent excessive roll commands. Further testing revealed that the GPS roll steering modification could not compromise the flight director and autopilot functionalities to the point of upsetting the helicopter attitudes or moving beyond the systems limiters.

Recorded helicopter, engine, and flight track data were analyzed and used to conduct flight simulations. The simulations revealed that the helicopter was operated within the prescribed limits; no evidence of an uncommanded 45° left bank was found. The helicopter performed a constant right climbing turn with decreasing airspeed followed by a progressive right bank with the airspeed and descent rate increasing. In order to recover, the simulations required large collective inputs and a steep right bank; such maneuvers are difficult when performed in night conditions with no visual references, although less demanding in day conditions with clear visual references. The data are indicative of a descending accelerated spiral, likely precipitated by the pilot inputting excessive right cyclic control during the missed approach go-around maneuver, which resulted in a loss of control.



Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:


The pilot's excessive cyclic input during a missed approach maneuver in night instrument meteorological conditions, which resulted in a loss of control and spiraling descent into terrain.

Good Souls...

Sunday, June 17, 2018

...The Journey to High Reliability

While attending a recent Promedica Health Safety Conference to present a class on hazardous attitudes, I was able to take in a presentation by Dr. Katherine Kellogg (MedStar, Washington DC) on "High-Reliability Organizations."

Jonathan Godfrey, Randy Mains, and Dan Foulds
presenting AMRM topics and learning about
High-Reliability Organizations from
Dr. Katherine Kellogg, MD


At AMTC, I heard Dr. Ira Blumen state that, regarding risk to patients flown in EMS helicopters, "the real risk starts when they are unloaded from the helicopter and wheeled into the hospital." Hospitals have come under scrutiny for causing harm to patients, and some of them have looked for ways to stop doing this.



Many hospitals and health-care systems have made great strides in improving patient care and reducing incidents of harm by adopting the tenets of (Air) Crew Resource Management, and then developing them further. HRO research started with the Nuclear Navy, management of the power-grid (nuclear), and air traffic control. Instead of focusing on industries and companies that went wrong (Three Mile Island) three UCB researchers concentrated on complex industries that did things right - successfully!

This video is long, and you may not get through it all in one sitting, but I encourage you to get a cold drink, and a note-pad and capture the key ideas and techniques that Dr. Mark covers.

If we want to eliminate fatal crashes in HEMS, it's apparent that we are going to have to do something different. What we are doing now doesn't work. We kill patients and crews regularly.

When you think about fatal crashes in HEMS, the only acceptable number is ZERO.

PS. Feel free to share this with your company's C.E.O; because that's where your company's journey to High Reliability will have to start...

Tuesday, May 29, 2018

My Engine Just Quit! NOW WHAT? Pilot Professional Development Courtesy of the AOPA Air Safety Institute

British warbird pilot, Mark Levy, was part of a 21-airplane formation in the annual airshow at Duxford, England when the P-51 he was flying had a partial engine out. Levy recorded the entire event on a pair of point-of-view video cameras, and he shared the images, as well as his lessons learned, in a candid discussion with Richard McSpadden, Executive Director of the AOPA Air Safety Institute.

We recommend you gather a notepad and pen and catch the key words and phrases that Mark mentions as he discusses his mishap. This is an excellent foray into pilot-psychology, how emergencies affect our physiology, when to act instinctively and when to take a deep breath and think things through. Mark repeatedly mentions "startle effect" which is a hot topic with the FAA right now.

One of the greatest pilot-learning resources is "hangar flying" with other pilots, but a HEMS pilot has little opportunity to do this. This video is a great hangar-flying experience, and might just save your life someday. Kudos and thanks to AOPA and the Air Safety Institute...

Wednesday, May 9, 2018

Use of Automated Flight Control for the Single Pilot Helicopter Program - by John Bevilacqua - EC145 HAA Pilot and NEMSPA Board Member


Is your program flying  IFR, or is it VFR only? Single-pilot or dual-pilot? The advent of inexpensive and lightweight automation has enabled another concept, but the author doesn't think we realizing the full value of our investment

 SINGLE-PILOT/AUTOPILOT.


A prerequisite in the authorization of single-pilot programs to operate IFR, under actual IMC, is that the aircraft be equipped with a functioning Autopilot. During instrument flight, if the Autopilot is utilized, the pilot then becomes the “pilot monitoring” or PM, while the Pilot flying (PF), is actually the Autopilot!

The human pilot’s role is to correctly program the autopilot, monitor to make sure it is functioning correctly in its navigation and “coupling” functions, and be ready to take over if the Autopilot
malfunctions in a significant way. At a certain point of flight the pilot must take over, but for the majority, it is the autopilot that is in control of staying on course and on altitude.

There have been a chronic and disturbing number of HAA and other civil helicopter accidents which
could have most likely been prevented by smart use of the installed Autopilot equipment. An analysis of the probable causes of many of these accidents and close calls in the civil helicopter world show that the “mishap aircraft” were equipped with perfectly functioning and available Autopilots. (Referred subsequently in this article as APs). A simple push of two buttons, depending on the type of AP, could have stabilized the aircraft, established a safe climb and heading away from the hazards on the ground, and smoothly transitioned the flight to a safe cruise altitude and setup for an instrument approach (or flight to better weather and VFR recovery). BUT THE AUTOPILOT WAS NOT USED.
The aircraft was hand flown, unnecessarily and with adverse consequences. For various reasons due to aircraft certification, pilot training, and an aviation culture that emphasizes manual flying, the AP is not being utilized to the extent it should be.

The reason the AP modes are not being used when they should are numerous and varied, but can be
summarized by a lack of clear guidance on when and how to use an AP for pilots who are not IFR current or qualified, or ar in aircraft that are equipped with an AP, but for various regulatory reasons, are not
certified for IFR flight. There are also single pilot IFR programs in which both the pilot and aircraft are qualified and certified, but due to an “old-school” mindset, the AP is used only during actual IMC, and only sporadically during other phases of flight.

USE OF AP IN ROUTINE VFR FLIGHT AND DURING IN-FLIGHT EMERGENCIES

For routine VFR flight, the benefits of using the AP for many phases of flight are that it reduces pilot
workload, especially single pilot, and allows the pilot additional task management resources tomanage the overall flight. This includes scanning outside to enhance situational awareness regarding
weather, air traffic, birds or other hazards to flight. Ironically to some, the momentary ”heads down”
that might be necessary to engage the AP results in a much greater level of “heads up” for the rest of
the flight.

In the dynamic and changing flight environment in which helicopters operate, there are numerous
situations or hazards in which routine use of AP could be of immense benefit. A pilot incapacitation
event, especially with a lone pilot at the controls, could be fatal due to the subsequent loss of control.
Pilot incapacitation can result from a medical event, or from a bird or other object coming through the windscreen and striking the pilot. More recent flight hazards include laser strikes and an increase in the number of drones in the vicinity of helicopter operations. While strategies to mitigate these risks depend on the specific hazard, protective equipment, type of aircraft, and pilot training, one universal truth is that the AP is basically invulnerable to many of the human frailties that can take a pilot out of commission in his or her ability to operate the helicopter. It cannot be temporarily blinded, suffer from nausea, tunnel vision or vertigo, or panic when an extreme event occurs. Allowing the AP to operate the aircraft in routine flight, or activating it if possible ASAP after certain emergencies, could be just what is needed to stabilize the emergency situation and allow the pilot to recover or resume control with the assistance of the AP.

For flights in marginal VFR conditions, use of the Autopilot is even more important. Autopilots can help pilots fly safely when they lose visibility during inadvertent entry in instrument meteorological
conditions (IIMC) when their helicopter flies into clouds and/or fog. With the loss of visual flight
references, VFR pilots can lose an accurate sense of their location, altitude, and angle with respect to
the ground and horizon, thus they are flying “blind.”

Flights into IIMC are completely non-dramatic if the pilot understands the basics of the AP system and use, programs it properly, and get it activated as soon as possible after takeoff. Many recent HAA
accidents have been a result of pilots, usually on deck at a landing zone, taking off and encountering
unexpected low ceilings and then attempting to manually fly the aircraft in IMC. This is a recipe for
spatial disorientation and subsequent loss of control. For AP equipped aircraft, the formula for survival under similar circumstances is to have a plan in which the takeoff brief includes pre-selecting your altitude in the AP, and a heading which clears you of obstacles ASAP and is preferably into the wind. (This allows the pitot-static instruments to come up to speed expeditiously and allow instrument flight and AP use).

As soon as possible after the aircraft reaches Vmini, (minimum AP activation airspeed) activate the heading select and a vertical climb mode. Climb using max continuous power and accelerate to best climb airspeed. Your strategy will have the AP flying the aircraft, and if you experience spatial
disorientation it will be relatively benign because you are not flying the aircraft; the autopilot is.

Yes, you need to be vigilantly monitoring the AP’s performance, and ready to take over manually if necessary, but the primary focus is planning, programming, monitoring, and letting the automation complete the task of getting you up to a safe altitude and on a safe heading. Keep it on the AP for the rest of the flight as you tune radios, contact ATC, choose and program the approach to the most appropriate recovery airport.

Pilot Incapacitation

Medical events have the potential to incapacitate a pilot temporarily, at the very least. A medical
event due to a concussion or blinding because of an object striking the pilot. More recent flight hazards include laser strikes and an increase in the number of drones in the vicinity of helicopter operations. While strategies to mitigate these risks depend on the specific hazard, protective equipment, type of aircraft, and pilot training - one universal truth is that the AP is basically invulnerable to many of the human frailties that can take a pilot out of commission in
his or her ability to operate the helicopter. It cannot be temporarily blinded, will not suffer from nausea, tunnel vision or vertigo, or never panics when an extreme event occurs. Allowing the AP to operate the aircraft in routine flight, or activating it if possible ASAP after certain emergencies, could be just what is needed to stabilize the emergency situation and allow the pilot to recover or resume control with the assistance of the AP.

For AP equipped aircraft, the formula for survival under similar circumstances is to have a plan in which the takeoff brief includes pre-selecting your altitude in the AP, and a heading which clears you of obstacles ASAP, and is preferably into the wind. (This allows the pitot -static instruments to come up to speed expeditiously and allow instrument flight and AP use). As soon as possible after the aircraft reaches Vmini, (minimum AP activation airspeed) activate the heading select and a vertical climb mode.

Climb using max continuous power and accelerate to best climb airspeed. Your strategy will have the AP flying the aircraft, and if you experience spatial disorientation it will be relatively benign because you are not flying the aircraft, the AP is. You need to be vigilantly monitoring the AP’s performance, and ready to take over manually if necessary, but the primary focus is planning, programming, monitoring, and let the automation complete the task of getting you up to a safe altitude and on a safe heading. Keep it on the AP for the rest of the flight as you tune radios, contact ATC, choose and program and approach to the most appropriate recovery airport.

TRAINING FOR INCREASED ROUTINE USE OF THE AUTOPILOT

In the airline industry, there has been an increased emphasis on scenario-based training, also known asnLOFT (Line Oriented Flight Training). The philosophy of this training, which is usually flight simulator based, can be summarized below

(Source - ICAO Circular 217 AN/132 'Human Factors Digest No 2): “LOFT scenarios may be developed from many sources, but accident reports provide a realistic and appropriate starting point. A properly conducted LOFT program can provide great insight into the internal workings of an airline's operations and training program for the following reasons:

1. If similar mistakes seem to be recurring among pilots, it may indicate a potentially serious problem as a result of incorrect procedures, conflicting or incorrect manuals, or other operational aspects.
2. It may reveal areas in aircrew training programmes which are weak or which need emphasis.
3. It may reveal problems with instrument locations, the information being presented to pilots or other difficulties with the physical layout of a particular flight deck.
4. Air carriers can use it to test and verify flight deck operational procedures.

LOFT should not be used as a method of checking the performance of individuals. Instead, it is
a validation of training programs and operational procedures. An individual or crew needing
additional training after a LOFT session should be afforded that opportunity immediately with
no stigma or recrimination.”

With this training philosophy in mind, this is how HAA and other single pilot helicopter operators
industry could change normal training and checkrides with respect to AP use:

Flight Training plan – Inadvertent IMC . -Most Inadvertent IMC training is done on a checkride, at altitude, in cruise flight VFR. Focus the training scenario instead as a simulated inadvertent IMC at a low altitude while taking off from your home airport.

Announce “inadvertent IMC” at about 100’ AGL. The drill should promote a before takeoff checklist which addresses the use of Autopilot modes and cockpit setup, the importance of an “airspeed over altitude” which gets you to Vmini quickly, and selecting the appropriate climb modes and power setting (for a two or three-axis autopilot).

Even if not set up and briefed for IFR flight, train how to quickly and efficiently identify and activate the right AP modes for the situation. Hand flying should be discouraged if the AP is available. For simulator training, the same applies. All takeoffs, even under simulated VMC, should be flown either with the AP engaged as soon as possible, or set up for immediate activation.

If the inadvertent IMC conditions are given at altitude while the pilot is flying manually, emphasize the need to activate the Autopilot. Hand-flying the aircraft under IMC, while single pilot, should be trained realistically, emphasizing that the pilot should not be conducting this type of flying
under real-world conditions and that the manually flying Single Pilot while IMC is an “emergency
procedure”. It is fine to practice in the simulator, but not in the aircraft unless there is another qualified Safety Pilot on board.

Unusual Attitude Recovery

Discuss the various visual illusions which can lead to spatial disorientation and the need for a good scan and transition to a pure instrument scan during night, IMC, marginal VFR and flat light conditions, and the need for an adequate visible horizon to continue a VMC flying

A common flight simulator and checkride item is “unusual attitude recovery” most often flown manually by manipulating the flight controls. For AP equipped aircraft the emphasis should shift to:

1. AVOIDANCE – Unusual Attitudes are usually a result of pilot distraction, poor instrument scan
technique, leading to severe, incapacitating spatial disorientation. The AP is not susceptible to these
illusions and incapacitation. ACTIVATE THE AP. Disciplined use of appropriate AP modes during
night, IMC, or low light/flat light conditions, will virtually eliminate the pilot’s disorienting analysis of the aircraft’s multi-dimensional flight attitude and subsequent attempt at manual recovery.

2. RECOVERY – If the preventative measure did not work, and an unusual attitude is noticed on the
pilot’s attitude gyro and other flight instruments, quick and simple activation of AP modes should be
considered as a primary method of recovery. In cruise flight, the current collective power should be
more than adequate to simply hit Altitude Hold and Heading Select. The aircraft will then level itself
and fly straight on the selected heading and any climb or descent should cease at the current
altitude. Once the aircraft is stabilized, check power setting and select an appropriate flight mode
for climbing if necessary, but STAY ON THE AP.

The “best practices” in this article are intentionally generic will need to be modified depending on individual aircraft and Autopilot types, company OPSPECS and types of operations. But the message is clear - if you are fortunate enough to have an Autopilot aboard your helicopter - use it!



Sunday, May 6, 2018

"We do these things, That Others May Live"

This is an excellent ADM training resource provided by Airbus. If you have never seen it, it's worth the time. If you have seen it, it's good to watch again with your flight team and discuss the events that occurred.

What strikes me is that the crew allowed the pilot to proceed so far into a bad situation without "stopping the train." I wonder how many funerals we could have avoided if a team member, typically a nurse or paramedic or RT, had said, "hey, this is a bad idea, we are going by ground" or "we aren't going." This flight team in this video was very very close to being dead. As Omniflight's director of operations said, "we dodged a bullet last night."

We can get so involved in a scenario that we accommodate to risk as a group. We can also fall prey to the social normalization of deviance. I have been in a risky situation myself - flying into a hospital sitting underneath a thunderstorm with a critical patient on board - and when I asked my crew what they wanted to do they said: "take the chance."

In retrospect, I was dumb for taking the chance and dumb for asking them to validate my bad decision. A pilot should let a team member make a more conservative decision, but a pilot should never let a team influence a more risky decision. If a pilot has to ask if something is dumb, it probably is and should be avoided...

You who crew are an integral part of the ADM (aeronautical decision making) process. You have a say in how high we fly and what we fly over, what turbulence level we should tolerate, how low our fuel state can be and most importantly - when we should STOP. If it appears that I the pilot am struggling to make things work, you can and should speak up about doing something different.

You are not a passenger. Don't act like one. Please. It's a better world with you in it.

Saturday, April 21, 2018

Snakes In The Grass

Contributing writer Josh Henke is an avid outdoorsman. He surfs and hikes the backcountry.  Josh is a former firefighter and serves as a flight nurse today. You can contact Josh at bosstyn@gmail.com



My friend Dave-bob is an avid hiker. Even in southern California, he finds time to hike nearly every day. Dave is old and tired and weathered, but he still hikes almost every day. We often give
him grief about his stick; low terrain, high terrain, it doesn't matter,  Dave-bob always has his
stick. After a few years of knowing Dave, I asked him about his stick and why he always carries it.

"Snakes."

“Yes, of course,” I thought. That seems plainly obvious now that he says it. Southern California
is known for its rattlesnakes. Big black things that hide in the brush. They are a terrifying thing
when you see one.

I then asked him, “why such a big stick then”. His stick is damn near a Gandolf-sized staff.
His thoughtful reply was this; “small sticks are good for small snakes, but not big ones. A big
stick is good for small snakes as well as big ones. I use this stick to roust snakes up along the
trail before they have a chance to strike”

I thought about this in an oft way for weeks as a continued on with life. A few weeks after that
conversation, I saw Dave and he told me a story about hiking. (he loves to tell hiking stories)
Dave told me about how he went hiking at a place called four bush; which actually only has
three bushes, but never mind.

He was driving up to the trailhead listening to a deeply riveting Paul Harvey episode when he
parked. As many of us do with Paul Harvey, he sat and listened for a while longer. One of those
driveway moments….
He told me how he began his hike and realized he forgot his stick about 3 miles into the trip.
“I figured oh well,” he said and continued on. At mile four he saw a “really interesting bird. Kind
of a grasshopper/bird/old cat kinda thing”. (Dave loves to describe things he sees, however,
he’s not very good at describing more than making up combinations of animals to describe
other animals)
“when I go to the top I stopped and turned around to head back down, and sure as hell, there
was a big black rattlesnake sitting in the path about 5 yards in front of me. He wasn't moving,
just laying in the sun”.

We both took a silent second to think about that snake, A big slate colored rattlesnake is no
joke, and 6 miles into a hike; a bite from a snake like that is often a death sentence. (or a
helicopter ride at least)
“I sat there and looked at that snake and all I could think about was my damn stick. He looked
at me and I looked at him, and as we both sat there, he began to move. Not fast; he moved in
a very slow, purposeful way directly towards me. As I back up he stopped. When I stopped, he
began moving again. Not in a “hunter” way, but in a “you’re damn lucky Dave” kinda way; as if
he was telling me “I’m not going to bite you, but this is your only warning.”

I commiserated with him over the snake knowing that you can't just step over it, and
often times on these trails, you are surrounded by grass. The only option for Dave was to leave
the trail and clear around the snake through the grass. The hard part is, there's often snakes in the
grass, and with no stick, it's a big gamble.

Dave did leave the trail, walking through the grass. He was more than a little worried about it, I could
hear it in his voice as he related his “trail of fears."
The story made me think about sticks and snakes. It also made me think about complacency
and the dangers we face, how the snakes are always in the grass and about how having a
good stick is often salvation.

I recalled when I was a new flight nurse. Most times when we got a call we would pile into the
aircraft, even before the pilot. We would buckle in even before the pilot had turned up. Once
we got comms, we would ask where we were going and he would point and say something like
“that way about 19 miles”

We didn’t check the weather with him. We didn’t scout the LZ prior to leaving. Hell, we didn’t even
ask him where we were going. We just hopped up, strapped in and blasted off. We weren't crew, we were pax.

I'm not afraid to admit it, we had very small sticks.
They did not provide us with a good defense against the snakes in the grass.
Sure, if the helicopter was leaking oil or started smoking on startup, we could see that and cancel the
flight, but our small stick was no good at picking out the less obvious snakes such as weather in
a small valley, knowledge of a known tight LZ, etc.

Over time I found that my stick got bigger.
And the bigger my stick got, the better prepared I was to meet a snake on the trail or go
wandering off through the grass unplanned.
I grew my stick by asking questions of my pilots. I questioned things that looked wrong. I took a deeply vested interest in my safety by speaking up and looking for “snakes” in our day to day operations.

I read the archives and thoughtfully explored how a crew got themselves into a situation and
how I could avoid such mistakes in the future.
I wrote about ideas and thoughts I had on safety and how to make others think about safety
All of these things, both big and small, helped me grow my stick to a point where I felt I could
go hiking safely and face down the dangers in the grass, no matter how big.
We as flight crews need big sticks. Complacency is a snake in the grass and small sticks just
won't do. As Dave mentioned, “small sticks only work for small snakes, but a big stick works for
all snakes.”
As we hit the “trail” day in and day out, think about the snakes in the grass you may encounter.
Don’t get distracted before you begin your hike through HEMS. Take the time to remember your stick, because if you forget it, that snake may bite you.



If you have a HEMS related story to tell - something that might help another crew - drop us a line.