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Wednesday, November 1, 2017

Baby It's Cold Outside...

Crash review: two on the same day, two for the same reason...

Read. Do not repeat...

NTSB Identification: CEN13FA121
14 CFR Part 91: General Aviation
Accident occurred Wednesday, January 02, 2013 in Seminole, OK
Probable Cause Approval Date: 05/08/2014
Aircraft: EUROCOPTER EC130 B4, registration: N334AM
Injuries: 4 Serious.
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 pilot reported hearing a sound like something had struck the helicopter shortly after departure while about 1,600 to 1,700 feet mean sea level. The engine lost power, and the pilot performed an autorotation to a field. While maneuvering to land, he saw a barbed wire fence obstructing the intended landing area, so he maneuvered the helicopter to clear the fence. The helicopter subsequently cleared the fence and landed hard in a field.
Engine examination revealed that the four axial compressor blades exhibited significant deformation on the outboard tips of their leading edges in the direction opposite of normal rotation consistent with the ingestion of soft body foreign object debris, such as ice. A subsequent engine run did not detect any preimpact anomalies that would have precluded normal operation. For 3 days before the accident flight, the helicopter was parked outside without its engine cover installed and was exposed to light drizzle, rain, mist, and fog. The engine inlet cover was installed the day before the accident at an unknown time. The helicopter remained outside and exposed to freezing temperatures throughout the night until 2 hours before the flight. Although the helicopter was maintained in a ready status on the helipad and maintenance personnel performed daily preflight/airworthiness checks, the inlet to the first-stage of the axial compressor was not inspected to ensure that it was free of ice in accordance with the Aircraft Maintenance Manual. Based on the weather conditions that the helicopter was exposed to during the 3 days before the accident, it is likely that ice formed in the engine air inlet before the flight and that, when the pilot increased the engine power during takeoff, the accumulated ice separated from the inlet and was ingested by the engine and damaged the compressor blades.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of engine power due to ice ingestion. Contributing to the accident was maintenance personnel’s delayed decision to install the helicopter's engine inlet cover until after the engine had been exposed to moisture and freezing temperatures and their inadequate daily preflight/airworthiness checks, which did not detect the ice formation.

_________________________________________________________________________________

NTSB Identification: CEN13FA122
14 CFR Part 91: General Aviation
Accident occurred Wednesday, January 02, 2013 in Clear Lake, IA
Probable Cause Approval Date: 02/12/2015
Aircraft: BELL HELICOPTER 407, registration: N445MT
Injuries: 3 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.

GPS tracking data revealed that, after departure, the helicopter proceeded westbound about 600 ft above ground level (agl), following a roadway. About 6 minutes after liftoff, when the helicopter was about 3/4 mile south of the accident site, it turned right and became established on a northerly course. The helicopter subsequently turned left and appeared to be on a southerly heading at the final data point. Shortly before beginning the left turn, the helicopter entered a climb, reached an altitude of about 1,800 ft agl, and then entered a descent that continued until impact. Weather observations from the nearest Automated Surface Observing System, located about 7 miles east of the accident site, indicated that the ceilings and visibility appeared to be adequate for nighttime helicopter operations and did not detect any freezing precipitation. Although an airmen’s meteorological information advisory for icing conditions was current for the route of flight, and several pilot reports of icing conditions had been filed, none of the reports were in the immediate vicinity of the intended route of flight. Witnesses and first responders reported mist, drizzle, and icy road conditions at the time of the accident. It is likely that the pilot inadvertently encountered localized icing conditions, which resulted in his subsequent in-flight loss of helicopter control. A postaccident examination of the helicopter revealed no preimpact failures or malfunctions. The engine control unit recorded engine torque, engine overspeed, and rotor overspeed events; however, due to their timing and nature, the events were likely a result of damage that occurred during the impact sequence. Evidence also indicated that the cyclic centering, engine overspeed, and hydraulic system warning lights illuminated; it is also likely that their illumination was associated with the impact sequence. Further, the engine anti-ice status light was illuminated, which was consistent with the activation of the anti-ice system at some point during the accident flight.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s inadvertent encounter with localized icing conditions and his subsequent in-flight loss of helicopter control.

________________________________________________________________________________

NTSB Identification: CEN13FA174
14 CFR Part 91: General Aviation
Accident occurred Friday, February 22, 2013 in Oklahoma City, OK
Probable Cause Approval Date: 01/14/2016
Aircraft: EUROCOPTER AS 350 B2, registration: N917EM
Injuries: 2 Fatal, 1 Serious.
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 emergency medical services helicopter departed a hospital helipad in dark night visual flight rules conditions and proceeded on its mission. Satellite data showed that, after takeoff, the helicopter began a gradual climb toward its planned destination. The data stopped about 3 minutes and 30 seconds into the flight. No distress calls were heard from the pilot. Fixed video surveillance cameras located near the accident site showed the last few seconds of the helicopter descending toward the ground. The helicopter impacted a parking lot, and a postimpact fire occurred.
Examination of the wreckage revealed that three of the engine’s first-stage axial compressor blades exhibited deformation consistent with soft body foreign object damage. The remainder of the engine and airframe exhibited no evidence of malfunction that would have contributed to an in-flight loss of engine power.
The helicopter’s air intake design, which had been modified to accommodate a different engine than that originally supplied by the helicopter’s manufacturer, incorporated a blanking plate attached to the top side of the engine cowling that covered a portion of the air inlet screen. A gap in the area where the blanking plate and the screen overlapped made it possible, in certain meteorological conditions, for water or snow to pass through the screen, accumulate on the blanking plate, and freeze into ice. Ice accumulation in this area, if left undetected, could result in the ice detaching from the blanking plate and entering the engine during operation, causing soft body foreign object damage and a loss of engine power. Precipitation and outside temperatures ranging from 35 to 19 degrees F occurred during the 12-hour period preceding the accident. The combination of these meteorological conditions was conducive to the formation and accumulation of ice in the area between the air inlet screen and the blanking plate.
Although the helicopter’s flight manual supplement for cold weather operations recommended installation of an air inlet cover after the last flight of the day, during the day and night before the flight, the helicopter was parked outside on the helipad without an air inlet cover installed. According to the helicopter’s mechanic, he inspected the helicopter on the afternoon before the flight and noted that some snow had accumulated on it. It is likely that the lack of an engine air inlet cover allowed precipitation to accumulate in the vicinity of the engine air intake.
The helicopter’s flight manual cold weather operations supplement also contained instructions for the pilot to perform a visual and manual (tactile) inspection of the air intake duct up to the first-stage compressor for evidence of snow and ice. Furthermore, the manufacturer and the Federal Aviation Administration had previously released information notices regarding inflight loss of engine power due to snow or ice ingestion caused by inadequate inspection or removal of snow or ice from the engine air inlet. These notices recommended a thorough inspection in and around the engine inlet area in order to detect and remove any snow or ice accumulation before flight.
The initial on-scene examination found no remnants of ice or snow on these components because exposure to the postcrash fire would have melted such evidence. Surveillance video of the helipad showed that most of the helipad lights were off at the time of the pilot’s preflight inspection immediately before the flight, making it difficult for him to detect any ice or snow accumulation in the area of the engine air intake. Thus, the ice accumulation between the air inlet screen and the blanking plate remained undetected, and shortly after takeoff, the ice detached from the blanking plate, slid into the air inlet, and was subsequently ingested by the engine, resulting in an in-flight loss of engine power.
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The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of engine power due to engine ice ingestion during initial climb after takeoff in dark night light conditions. Contributing to the accident were the lack of an installed engine air inlet cover while the helicopter was parked outside, exposed to precipitation and freezing temperatures before the accident, and the pilot’s inadequate preflight inspection that failed to detect ice accumulation in the area of the air inlet.

Tuesday, October 10, 2017

AAMS 2017 Award Winners Announced...Jobs Well Done!

The Association of Air Medical Services has announced the winners of this year's community awards. While all the winners are undoubtedly deserving and have our congratulations - we know two of them. And we are excited for them and their achievements. And as for the award for an air medical mechanic? Well, it's just wonderful to see a mechanic being recognized. Perhaps it's time for an Air Medical Mechanics Association? Way to go friends! We are proud of you!












To see the other award winners, click here...

Monday, September 4, 2017

Historic Perspective - The University of Iowa and AirCare

AirCare was the 11th EMS helicopter program in the country and has flown more than 30,000 patients over 3,000,000 miles. We are proud to be a part of the regional EMS system as we work very closely with area first responders, police, fire, and ambulance services to provide safe and rapid response to emergency situations.

History 1

It was no April Fool when AirCare had its first flight on April 1, 1979. Our first aircraft, the D model A-Star (the first A-Star to be utilized for air medical transport in the U.S.) had a transverse loading system (the second picture is of the loading system). No extra room for sure! The flight nurse sat forward going out to a scene and backwards when attending to the patient in a reversible seat. Of note, we flew with one flight nurse for the first seven years of the program. Flying alone with the pilot made for some very interesting flights and you haven't lived until you have done one-person CPR at 5,000 feet!

History 2


Our first A-Star left much to be desired. It was a cramped area with very little leg space for the patient, making it difficult at times to accommodate those Hare traction splints. We often used the MAST trousers as a pneumatic splint for lower extremity fractures, allowing for easier loading of the patient. It is hard to believe we made it through those early years.


Helicopter


What is that? It is an Allouette III helicopter which was used mostly for mountain flying as its powerful engine was capable of providing plenty of muscle in the thinner air of the mountains. We had the Allouette III helicopter for several months in the early 80s as a spare, while our primary A-Star was going through several modifications addressing the problem of limited patient space.

The unique characteristic of the Allouette was the ability to shut down the spinning rotor blades and keep the engine running. It had a neutral. We used this capability at scenes ensuring a rapid departure, but one major drawback was that its top speed was 80 to 90 knots. It took forever to get anywhere!

After our A-Star came back from the shop, we investigated new and more efficient interior loading systems. In 1983, Omniflight Helicopters won the AirCare contract. Our vendor helped design our first fore-aft loading system, using the available space more efficiently, plus having complete access to the patient.

Omniflight Helicopters used Bell Long Rangers when the A-Star had prolonged hourly maintenance done.

History 4


For the first seven years of our program, AirCare averaged more than 900 flights per year, with many flights missed because we were already on another flight. In 1986, Rocky Mountain Helicopters won the contract and has been with us ever since (now operating as Air Methods).

In 1987, due to the ever increasing number of patient transports, AirCare trialed a second A-Star based at the University of Iowa Hospitals and Clinics.

History 5

After one year, the second A-Star was moved northward to Schoitz Hospital in Waterloo, Iowa (now based at Covenant Medical Center). AirCare II was put into service in 1988, which provided better response times for the Iowans in the northern tier of counties.

(As of this writing) AirCare consists of an EC-130 based at the University of Iowa Hospitals and Clinics and an A-Star based at Covenant Medical Center. (Added - the team now has three bases including a ground specialty team. HelicopterEMS.com)

History 6

This historical summary is a first-person narrative by Mike Dillard, RN, who was the longest serving member of AirCare. Mike joined the program in 1980 and retired after 30 years with over 3,100 patient transports.

Images and text courtesy of University of Iowa Hospitals and Clinics. For more info click here


Saturday, August 26, 2017

Final Approach...

NTSB Identification: CEN16LA386
14 CFR Part 91: General Aviation
Accident occurred Thursday, September 29, 2016 in Lawton, OK
Aircraft: BELL 407, registration: N361SF
Injuries: 4 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 29, 2016, about 0600 central daylight time, a Bell 407 helicopter, N361SF, impacted terrain following a loss of control while attempting to land at the Comanche Country Memorial Hospital Heliport (18OK), Lawton, Oklahoma. The pilot and 3 crew members sustained minor injuries and the helicopter was substantially damaged. The helicopter was registered to and operated by Survival Flight Inc. under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed for the flight which operated on a company flight plan.

The pilot reported that he maneuvered the helicopter to align with the helipad. During the descending right turn to the helipad, the pilot input left cyclic and the helicopter was unresponsive. The pilot lost control of the helicopter and it landed hard then collided with a wall.

The helicopter was retained for further examination.

Wednesday, August 23, 2017

Position Paper : Incorporation of medical team members flying in single-pilot aircraft for challenge-and-response before-take-off confirmation checks.



Our objective is the safety and success of all HEMS/HAA flight operations. In addition to the tragedy for those involved in a mishap, the catastrophic loss of an aircraft or team significantly damages the reputation and standing of all programs engaged in HAA operations.

For this reason, we have agreed to join with other industry stakeholders and advocate for a best-practice concerning the incorporation of trained and briefed medical flight team members for confirmation checks immediately prior to lift off in an EMS helicopter.

At present most EMS helicopters in the US are flown by a single pilot. These pilots routinely start the engine(s) and prepare for takeoff using a cockpit “flow” or “wipeout,” that is to say they “DO” start their aircraft from memory, and one or more times during the preparations sequence they are responsible to pick up their checklist and, scanning it rapidly they “VERIFY” that all required steps have been completed.

This enables a much more rapid departure than would be possible were the pilot to proceed down the checklist line-by-line. While some programs do adhere to a line-by-line method of checklist accomplishment by a single pilot, having one person responsible for doing and verifying creates the opportunity for a "single point of failure" with tragic consequences. "The DV method has a higher inherent risk of an item on the checklist being missed." (Federal Aviation Administration - FAA)

In HAA operations, safety is paramount, but a timely departure is important too, and do-verify has worked well for the vast majority of HAA flights over the years. Having said that, there have been instances in which a pilot, for various reasons, fails to properly configure the aircraft for departure. In response to these events, some operators have added a “confirmation checklist” to be used immediately prior to liftoff. Typically included on this confirmation checklist would be items that, if overlooked, could cause the loss of the aircraft and/or the crew.

A customary method of posting the confirmation checklist is for it to be printed on a vinyl sticker which is then affixed to the instrument panel in plain view of the pilot. Unfortunately, the same human-factors which cause a pilot to overlook an item on the do-verify engine start and before take-off checklist procedures can cause a pilot to overlook the same items on the confirmation sticker.
Such errors of omission have resulted in damage or destruction of several aircraft, serious injury to crew members and pilots, and, in at least one incident, a fatality.

The tenets of crew-resource-management dictate that we use “every resource available to us” for the safe, orderly, and expeditious accomplishment of our assigned flight tasks. A medical team member, while not “flight crew” per se, and while not regulated by the FAA (second crew member for NVG flight ops below 300 feet excepted) does, over time, become intimately familiar with flight operations. As well these medical team members have a vested interest in safety, as their lives are on the line right next to the pilot’s.

In many US flight programs, the decision has been made to have a medical team member act as an additional layer of safety by having that person read a before take-off checklist or confirmation checklist in the manner of “challenge and response,” This practice does not absolve the pilot of responsibility to ensure that all steps are accomplished. It simply incorporates a resource that is sitting there.

In FAA publication 8900-1 paragraph 3-3403, the FAA refers to this method as "Challenge-Do-Verify." We use the term challenge and response for clarity and brevity. A flight-team member refers to a list and issues a challenge. A second person - normally the pilot - verifies that the step is complete by looking and touching, then responds appropriately. Involving two people reduces the chance for a single point of failure.

"... (this) method keeps all ...involved 'in the loop'...and provides positive confirmation that the action was accomplished." (FAA)

At times the medical team is busy caring for a patient – but the request by the pilot for the “checklist please” is a clear alert that the aircraft is preparing to depart. This enhances everyone’s situational awareness, and in all but the most extreme patient-care situations (for example, CPR in progress), at least one team member can take the few seconds required for the challenges.

Examples of the items that might be included in a challenge and response confirmation checklist are: (these are only examples, your results might differ.)

Engine controls set to fly. (at least three twin-engine Agustas extensively damaged for one engine at ground idle during takeoff. At least three instances of a twin-engine Dauphin taking off with one engine at ground idle)

Hydraulic switches set and checked. (At least three Astars have been damaged or destroyed for hydraulic switch(es) set incorrectly. A news helicopter in the US was also destroyed for this error of omission and a person on the ground was killed.)

Fuel transfer switches set “on” (At least two BK-117 aircraft have been extensively damaged due to the transfer switches set to “off.” One pilot was paralyzed. In Scotland, a police helicopter crashed through the roof of the Klutha Pub after supply tanks became empty with transfer pumps off, killing several persons on the ground in addition to the crew on board.)

Internal and external light switches set, caution panel checked. (In a BK-117, having the instrument light potentiometers/rheostats set to “on” during periods of daylight renders the caution segments and master caution lights too dim to see. This error of omission strikes in conjunction with the fuel transfer switches being left off. When the low fuel lights and master caution lights come on the pilot can’t see this during daylight conditions.

Drugs and mission equipment checked. (This is an example of an optional item that may be included in a confirmation or BTO checklist. In more than one instance, an aircraft has departed without the required meds or equipment. This renders the aircraft and team not-mission-ready, and often requires a time-consuming delay, which is less than optimal for patient care. Obviously, the list of items on the confirmation checklist should be kept as short as possible. In this case, the medical team member calling out the challenge would either respond him or herself or would look to the second medical team member for a verbal response.
In summary…

With the visual clarity of hindsight, it is apparent that the vast majority of  HAA flight operations are conducted smoothly, safely, and to the benefit of the patients we fly. But our goal is ZERO aircraft destroyed and ZERO teams/pilots/patients injured or killed.


The cost of the recommendation we have laid out here is insignificant. The delay that this practice will entail - ten or twenty seconds - is insignificant. The significance of not losing lives to an error of ommission cannot be overemphasized.

Please consider incorporating this recommendation as a “best practice” for HAA operations.

Thank you.

This practice has been endorsed by:

Dan Foulds, Owner - HelicopterEMS.com, Owner - AMRM Training Solutions, Emeritus board member -The National EMS Pilots Association. Retired EMS pilot. Retired Army Aviator.

Miles Dunagan, Current president of the National EMS Pilots Association. Active EMS pilot.

Kurt Williams, Immediate past president of the National EMS Pilots Association. Former EMS pilot. Manager for a large HAA provider.

Rex Alexander, Past president of the National EMS Pilots Association. Former EMS Pilot. Former regional manager for Omnflight Helicopters. Industry expert.

Justin Laenen, Member, National EMS Pilots Association Board of Directors. Current EMS pilot.

Sam Matta, Co-founder of E.C.H.O. Active EMS flight nurse. Combat veteran.

Krista Haugen, Co-founder of the Survivor’s Network for Air Medical transport. Trained AMRM facilitator. Flight Nurse. Crash survivor - takeoff with one motor at ground idle.

Colin Henry. HEMS expert, safety consultant.  Former director of safety, Medflight of Ohio. Former chief pilot, Omniflight Helicopters. Colin writes, "On point! This is about Human Factors and not about good piloting skills."

Peter Carros. Retired military helicopter pilot. Former HEMS pilot. Safety Manager - Geisinger Life Flight, Danille PA.

Additionally, some variation of this practice is already in effect at numerous flight programs across the United States.

disclaimer: This is not intended to suggest any action not in accordance with federal aviation regulations. Consult appropriate oversight personnel before implementing any change to flight procedures.

Wednesday, May 24, 2017

OMAHA — Three families will receive $18.4 million to settle their lawsuits over a 2002 medical helicopter crash in Norfolk that killed three people aboard.






We can learn from our history, or we can repeat it... Do you remember this crash?

Read the report and ask yourself, "what would I do differently if I had been in this pilot's seat?"

From the NTSB report...
"The helicopter impacted the terrain following a loss of control. Shortly after departing the hospital on a medivac flight, the pilot requested that company dispatch have the company mechanic meet him at a nearby airport because he was experiencing "binding in the right pedal."
An airport employee stated that just prior to the accident, she saw the helicopter hovering over the ramp and thought it was going to land.

Four other witnesses reported seeing the helicopter climbing and thought it was taking off. Witnesses also reported seeing the helicopter spinning (directions vary) prior to it descending to impact. One witness reported the nose of the helicopter was stationary on an east heading and the tail of the helicopter was swinging back and forth. He stated the helicopter then veered to the left and he lost sight of it when he traveled behind some buildings.
Another witness reported seeing the helicopter rocking nose to tail and going in a circle, but not spinning, prior to impact...

The guarded hydraulic cut-off switch was found in the off position.
Records show the pilot had approximately 2,500 hours of helicopter time with a total of 43.8 hours of flight time in this make and model of helicopter. Winds at the time of the accident were from 200 degrees at 16 knots, gusting to 21 knots.

The Federal Aviation Administration Rotorcraft Flying Handbook states that a loss of tail rotor effectiveness "may occur in all single-rotor helicopters at airspeeds less then 30 knots. It is the result of the tail rotor not proving adequate thrust to maintain directional control, and is usually caused be either certain wind azimuths (directions) while hovering, or by an insufficient tail rotor thrust for a given power setting at high altitudes."

(Editor's note, While the inclusion of this bit of information by the NTSB isn't technically erroneous, it indicates that they did not fully understand the causes of this crash, and simply listed things that may have been a factor. As it turns out, the tail-rotor on the Astar has tremendous authority, is on a long arm (the tail boom), and few pilots have ever mentioned LTE in the same sentence with the name Astar)

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A loss of tail rotor effectiveness and the pilot's failure to maintain control of the helicopter. Factors associated with the accident were the binding of the tail rotor pitch changed rod, the gusty wind conditions, and the pilot’s lack of total experience in this make and model of helicopter.

We humbly suggest that the problem was not a lack of technical proficiency. The problem seems to have been the choices this pilot made. The problem was judgment or the lack of it.
Because there was no voice-recorder on board, we don't know when the pilot first became aware of a flight control problem. Was it as he came up to a hover off the pad? Was it on climb out? Was it in cruise flight?

One thing we do know however, is that at the first sign of problems with a flight control system, we should land - either as soon as possible or as soon as practicable, depending on the problem. Don't try and diagnose a flight control problem while flying. Land.

This pilot apparently was thinking about other things besides landing right now. It appears he was attempting to be a "team player" by requesting a technician to meet him at the airport. But what if he could have simply performed a precautionary landing at the first sign of trouble? When faced with a problem in flight, we will be better served by landing and sorting things out on the ground.
To include "how will maintenance find us?" Years after this event a pilot flew an Astar for 15 or 20 minutes with the red oil pressure light on. And then crashed.

When something is wrong - LAND. Better to over-react than under-react.
Maybe this pilot was worried about hovering with limited ability to control the tail rotor. And maybe that is why he headed to an airport. But if that was the case, shouldn't he have performed a run-on landing? Or a slow shallow approach? Or an autorotation? To the runway? Isn't that what we do when we lose tail rotor control? (depending on problem and rotorcraft EP...)
Maybe he didn't think his problem was a big deal. But then it was. It is unlikely that he took off with the hydraulic cutoff switch off, more likely that he was attempting to sort out a problem while flying. Instead of landing...

If you encounter a situation like this while flying; as soon as you get the aircraft to a state where you can control it, stop making changes to aircraft configuration and land. And if you have to run it on, do it. Don't hesitate to ask for help and execute the the most conservative response.
(while complying with the rotorcraft flight manual emergency procedure and company guidance...)

Disclaimer - This post is not intended to open old wounds or cause pain or discomfort to the families of those involved. The sole reason for these discussions is to learn, so that no one repeats this tragedy. If there is any good to come from a crash, it is that we learn how never to do that again. We also know that luck plays a part in any crew's life, and that on any given day it may be our turn to measure up - or not.

You can read more about this crash by clicking here.