One of our objectives 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 not only of the program involved but indeed in all programs engaged in HEMS/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 HEMS/HAA ships in the US are flown by a single pilot. These pilots routinely start 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.
In HEMS, safety is paramount, but a timely departure is important too, and do-verify has worked well in the vast majority of HEMS 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 crew 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 serve 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 his or her responsibility to ensure that all steps are accomplished. It simply incorporates a resource that is sitting there. 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 two Agustas extensively damaged for one engine at ground idle during takeoff. At least three instances of a Dauphin taking off with one engine at ground idle)
Hydraulic switches set and checked. (at least two Astars have been damaged or destroyed for hydraulic switch(es) set incorrectly. A news copter 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 number of items on the confirmation checklist should be kept as short as possible. In this case, the medical crew member calling out the challenge would either respond him or herself or would look to the second medical crew member for a verbal response.
Over the years, and with the experience and visual clarity of hindsight, it is apparent that the vast majority of HEMS/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 crew/pilots/patients injured or killed.
The recommendation we have laid out here will not cost any extra money, other than the cost of stickers with checklist items printed on them. The practice of having a team member challenge a pilot will not significantly delay patient care – at most a 10 or 20 second delay may be encountered. But if one life is saved, we think it’s worth it. Please consider incorporating this recommendation as a “best practice” for HEMS/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.
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.
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.