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Monday, August 18, 2014

"No One Rings A Bell" A story about crashing....

Edited 8/21, 11/08

The striking thing is how meticulous they are. The soldiers in their perfect dress-green uniforms are deliberate and precise as they fold the flag. They are not rushed, and seem unaffected by the quiet sobbing from the front row of mourners. I don't know how they do it - how they keep their composure in the face of so much grief and heart-break. They completed the task and handed a flag, folded into a perfect tight-fitting triangle, to the mother.

The widow was not there. Earlier, when the main entrance door of the chapel was pulled open for her, and she looked down the long carpeted aisle at the wooden box with her husband's body in it, she screamed, sobbed, and collapsed to the floor before anyone could catch her. She moaned "no no no" as she was lifted to her feet and carried outside. She couldn't do it. With a new child, and the prospect of living out her days without her soul-mate, she had hit her wall. The crowd outside, still waiting to get inside, parted like the sea and made a clear path for her to be helped to a limo. Just then, a formation of helicopters from several air ambulance companies flew across the parking lot at low level, and the church-bell began to ring.

Like the dozens of ambulances, fire-trucks, and law-enforcement vehicles, the helicopters with their crews were here to pay their respects. The thundering vibrations from their rotors went straight to the heart, and that was when the tears started. Tears that had never stopped.



It was such a tragedy. There were so many unanswered questions. "Why?" "How?" What happened?" It would only be later when we would ask "what can we do to make sure this never happens again?" Sadly, after crash upon crash, we cannot seem to come up with that answer and see the steps through.

Instead we bury friends. There is a tacit acceptance that some number of us will be killed each year.

Because the dead are usually strangers.

But not always.



This is what happened....

The call came in at 3:48 in the morning. The pilot rolled out of his bed. He had been watching a show about sharks on Discovery, and dozing off. He stepped over to his weather computer and looked at the ceiling and visibility at the reporting-stations surrounding his base. The numbers were all good, as was the forecast. He noted that the temperature and dew point were converging with each hourly report, but that happened regularly in his area. He accepted the flight and went to knock on the crew's doors.

When they took off, the ceiling was lower than he expected. On climb out, they passed through a thin layer of fog or low scud that reflected the white landing light back into the cabin and shut down their night-vision-goggles for an instant. After a few seconds of silence the medic asked, "should we call the com-center to abort?"  As the question was asked of no one in particular it was answered with more silence - then the pilot said, "ah...no I think we will be okay."

They got about a mile from their base and the medic looked out to the front. He knew that he would normally be able to see the flashing lights on the top of a nearby bridge from here, and he couldn't. This was different. "Hey, I can't see the bridge, what do you guys think?" The nurse was new - so much turnover lately - and she put her faith in the pilot. The pilot wasn't yet too worried. Sure the weather was worse than he had expected, but he only had to go 15 miles and then come back. He would be back in bed before things went to crap.

They flew on.

They left the built-up area of the city just as the ceiling was dropping.  It was still legal, but it was getting harder to see what lay in front of them. Out the windshield the forest was a green and black blanket through the goggles. It was hard to determine the visibility with so little to look at. The pilot began to descend and slow down without thinking about it - it was a natural reaction to the environment. He wasn't familiar with NEMSPA's enroute decision point, and didn't have a hard-and-fast abort-criteria. He hoped for the best; in 20 years of flying things had always worked out for him and he figured they would this time as well.

The medic was beginning to have a bad feeling in his stomach. He didn't want to sound afraid, or as if he didn't trust the pilot - and their base had only done 7 flights with the end of the month approaching. He put his finger on the talk-button on his com-cord, but did not press it...

The forest floor began to dissolve in the haze. The pilot slowed down some more and pushed the collective down to descend. The weather was now below minimums and he was making up his mind to turn around when the earth disappeared. He looked up under his goggles and couldn't see anything. He switched on his landing light and the brilliant reflection from thick cloud blinded him. "SHIT! Guys, we are in the clouds. I gotta do the procedure..."

He had already been halfway flying on his instruments, but he didn't have a full and deliberate scan going yet. He came inside with his eyeballs, pulled power and began to climb. He was already down to 70 knots, so he decided to leave his airspeed alone. He called off the IIMC steps from rote memory, with a slight quaver in his voice. He had screwed up, and was going to have to complete a report. This wasn't going to look good.

As they passed through a thousand feet off the ground, he made an attempt to call air traffic control on the radio. His call went out on the com-center frequency. They came back with, "sir check your radio - you are on flight-com." "Crap - wrong radio," he thought, and moved his hand to the selector. He put it on radio-one and made the call again. Approach answered, except it wasn't approach. It was the tower, now 10 miles to his rear. Tower responded and advised him to change to approach frequency.

"Holy crap" he thought. A sense of foreboding came over him. This was proving to be harder than he remembered. He had tons of cloud-flying experience - but none in a few years. He did one approach each year for his check-ride and that always went well, so he had considered himself ready. And he would be if things would work right. He said, "guys I am going to start a turn back." "Okay" came the response.

He put  the aircraft into a standard-rate turn to the right, still climbing, and as things settled down he leaned over to change the frequency on the radio. This required him to put his head down for a few seconds. It took him two tries to roll in the frequency - why was everything so hard to do? He pressed the flip-button to move the frequency into the active-field and looked up to the instruments.

"HOLY SHI...!" As his head came up in the turn, he accelerated the fluid in the three semi-circular canals in his inner ear in different directions. He had an overpowering sense that the aircraft was rolling, pitching, and yawing - all at once. He tried to look at his instruments but his eyeballs were jerking laterally in his head. He had a sudden urge to throw up....

It would not last long.

The radar track that the NTSB put together showed that during the last few seconds of this crews life, the aircraft went through wild gyrations in altitude, heading, and airspeed. As high as 4000 feet, as slow as 40 knots, as fast as 140 knots and as low as the surface. There was no voice recorder on board, so no one knew for sure what the crew experienced, or thought, or said near the end. But it must have been a terrible last few breaths.

The addition of Appareo devices tells the real story. 


When the aircraft fell out of the bottom of the clouds, the medic was confused. The picture was upside down and tilted crazily. He was trying to make sense of this, and the fact that what was up was rushing at him so fast. It looked like they were climbing - but that was the forest above them.  He never put it together. The pilot did at the last second, but it was too late to do anything about it.



Editors note:  I don't know about you, but I hate stories like this. They are told repeatedly; each year we agonize over this type of event. We could reduce, or even eliminate our accident rate by spending more time and money on the three "Ts," training, technology and temperament.  At least we might have a crash-free year. But we don't spend the time, we don't spend the money, and we continue to destroy aircraft and kill people.

We do have one inexpensive relief-mechanism though. It involves studying ourselves, how we work together, how we communicate, how we can help each other. It also involves three key concepts....Inquiry, Advocacy, and Assertion. We call this education AMRM or air medical resource management training.

And now we will change our story a bit.

The nurse was new. She wanted to let go of her concern, relax and trust the pilot. But her recent AMRM training was still fresh in her mind. The instructor had hammered home certain points during the 4 hours, and he had looked at her so often - the new girl - she had almost thought he was picking on her.

He was. Every time he taught a new nurse, he thought about the new nurse who died in a helicopter in Newberry, South Carolina on one of her first flights. And another one in Georgetown, and dozens more. The instructor drove the fact that she might be the last line of defense into her head. And as she heard the medic say, "Hey, I can't see the bridge, what do you guys think?" she remembered how the instructor had made her sit through a scenario - not exactly like this one, but not too different.

"Okay" she said. Is it normal to see the bridge from here?"  "Dan, is it?" (inquiry)

"Well yeah, I guess so, but it's not too bad out here." he replied.

"Okay, I know I am new - so I am going to lean toward being conservative. Please bear with me." (advocacy)

Dan thought to himself, "crap, the woman is brand new and already being a pain. I can see how this is going to work out." He said, "I think we are good. I would like to continue for a bit."

The nurse remembered this from class as well - time to be assertive. She said, "Dan! (step one - say the person's name), "I am really uncomfortable with this. It's my first flight at night and already we are doing something different" (step two - state the owned emotion)." "It sounds like the weather is worse than normal" (step three, state the problem) I think we should turn around and go back. Maybe the weather will improve in a bit and we can try again." (step four - offer a solution ).

"I know I am new, but is that okay with you Dan?" (step five - you are a team - look for agreement or buy-in)

The pilot thought about it for a second. "Okay, screw it, let's go back."

He would looking at sharks again in just a few minutes...



Nobody rings a bell when you don't crash...


If you are a HEMS pilot, and don't agree with the flight crew questioning your decisions, well, I get it. Sometimes I don't like it either.  I would respectfully ask you to put yourself in their seats however. You may be absolutely convinced of your ability to deal with any situation. But often enough HEMS pilots fall short - and like it or not you are a member of that group and viewed as such.

The best way to understand what your crews go through would be for you to climb in-back some night in marginal weather with another pilot flying, with no access to controls, and no control of what is happening. It can be disconcerting. I know that some crews make trouble, I have been run off from a job by a nurse who was a trouble-maker. We however have to try and keep to the high road. It's not always easy, but it's something we can do with humility and perseverance.

I salute you and hope you enjoy safe flights...

16 comments:

  1. What a terrific thought. I am glad that you have shared an empathetic view from the medical crew perspective. It could be a helpless position to be in if I did not have a good relationship with every pilot that I fly with.

    I do however sympathise with the pilot perspective of being the "target" of some unreasonable medical crew member. Culture drives an awful lot of that and some bases are more toxic than others.

    Watch a video and let me know what you would do as a medical crew member:
    https://www.youtube.com/watch?v=TqzDlk0amxQ

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  2. I've never flown EMS, just combat/mil time. I've got two distinct memories of days when I made a poor choice. It's tough sometimes overcoming that false feeling that you're "quitting". It doesn't help when someone's life could be on the line by adding self-induced pressures. The worse part when not managed properly, is not promoting a voice from the rest of the crew - or worse off, ignoring their input.

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    1. Thank you for reading and commenting... and thanks very much for your service to our country...

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  3. Excellent piece. An issue I have experienced is that we are like family and it is very painful at times to speak up. Speaking up has to happen and personal feelings need to be put aside. I suspect what makes HEMS such a great job is also our weakness. We are a tight group and speaking up can wreak havoc among the group dynamics. It shouldn't, and big picture; it is certainly better to feel uncomfortable than to feel nothing ever again. Be safe out there.

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    1. That is a wonderful comment. Than you.

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  4. What a great story for discussing the challenging situations we face. Next Safety Story workshop is November 4-6 in Denver. We need 5 more storytellers. Cost is $250 plus airfare to Denver. We have scholarships if that doesn't fit your budget. Thanks to MedEvac Foundation Int'l for funding. If you have a story about "what safet looks like" - and we all do - send me an email to register. Drcathyj@gmail.com

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    1. Thanks for all you do Dr. Jaynes. We share "Turn Around" with every class.

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  5. Dan that was an excellent and very well written piece detailing a story with a powerful message, one I hope air crews and more importantly upper and middle management can relate to. AMRM truly is our last line of defense where the final links in a building error chain can be broken by those at the 'sharp end' who strap themselves in a helicopter every day. AMRM training is the foremost effective weapon against poor decision making and human error. In commercial aviation going back to 1940 when records began to be kept, human error is noted as a factor in 80% of all aircraft accidents. In HEMS that percentage is frighteningly higher. According to Dr. Ira Blumen’s Opportunities for Safe Improvement (OSI) study, human error is sited in approximately 94% of HEMS accidents Take a moment to think about that crazy statistic for a moment. Ninety-four percent! What it means is we do have the power to produce a safe outcome of every flight if every team member from the top CEO, medical director, communications specialist, medical crew, pilot, mechanic aircraft refueler, et. al, anyone who can impact the safety of the flight practices the elements of CRM and AMRM. Everyone needs to understand the power CRM has to prevent accidents especially when we don't receive a lot of support from the FAA, NTSB or even those organizations within the HEMS community who still buy into the fallacy that sitting in front of a computer answering questions once a year will change behavior. The airlines and military aviation learned 35-years ago here and abroad that for adults to change their behavior they have to attend CRM training 'guided' by a trained facilitator and not just a 'tick in the box' computer program that satisfies the letter of the law but not the spirit of the law. I would ask every HEMS team member in America at this moment to ask themselves "Does our flight program have a 'tick the box' mentality or is my program serious about really changing behavior by presenting CRM and AMRM by a trained facilitator?" Facilitation brings out an individual's fears, beliefs, personal experiences, insights and potential answers to solving an unacceptable but totally 'fixable' accident rate statistic. Until there is full commitment for real change in our industry from all concerned, especially upper and middle-management and the organizations that support us we will continue to see scenarios occurring like this. Randy Mains CRMI, author of 'Air Medical Resource Management—A Potential Life Saver' in the current edition of the Air Medical Physician Association textbook, Principles and Direction of Air Medical Transport.

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  6. The recreation of the flight data recorded video referenced in the post of the AS 350. Where can I find the video can't seem to find it... Would like to show it during a monthly meeting at the base so that all may learn.

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  7. Aaron, search "That others may live AND Airbus" on youtube.
    Dan

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  8. Well written Dan. Thanks for your work on these issues my friend.

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  9. CRM is great, but the industry is broken, seriously broken. The real solution is two professional pilots up front and no medical involvement. HEMs is run by finance companies and private equity firms, it needs to be run by aviation experts.

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  10. This sent chills through me. My son Chad Hammond was a Haynes Life Flight Pilot who crashed with his crew in Enterprise AL March 26th, 2016. No one knows what happened and won't until NTSB report comes out. Every day it eats away at me what my son was thinking in his last moments. I have a million and fifty two questions with no one to give me answers. My baby boy was just 29 years old with his whole life ahead of him.

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    1. As a parent and grand parent, I want you to know how terribly sad I am at the loss of your son. I work on behalf of all EMS pilots as a member of NEMSPA, our mission is to prevent events like this and we failed. We failed him and we failed you. I am so sorry, and I and the others will keeo trying. Several of the pilots that Chad worked with have winessed for him, and he was a good man, a good dad, a good husband - and I bet a good son. May God ease your pain.

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  11. This sent chills through me. My son Chad Hammond was a Haynes Life Flight Pilot who crashed with his crew in Enterprise AL March 26th, 2016. No one knows what happened and won't until NTSB report comes out. Every day it eats away at me what my son was thinking in his last moments. I have a million and fifty two questions with no one to give me answers. My baby boy was just 29 years old with his whole life ahead of him.

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