Flashback Friday:Being in the Right Place, At the Right Time, With the Right People...

edited 2/13/15

I was laying in bed the other morning, thinking about speaking to an international audience who were going to be listening to me not because they had to but because they chose to;  a first-time event.  I teach subject matter that is required by CAMTS, and the Code of Federal Regulations:  the body that certifies air medical transport companies and the FAA.  Thus far the folks in my classes have been there because the boss said so. I was trying to sort out how to approach the problem of being meaningful, and how to relate to the audience. Sitting in front of me would be all sorts of people filling all sorts of roles in health-care, from senior leaders to the newest entry-level healthcare provider, from pilots to paramedics to professional safety managers.

Finally I decided to just talk to the people who work where the metal meets the mud; the flight crews. When I lecture - I am talking to them, because I want them to stay alive. Tragically, as I was thinking these thoughts three persons were losing their lives in a helicopter.

In our industry, safety folks are all about implementing "safety-management-systems." One organization after another touts the fact that they have "exited level one, or two, or three" and so on,  and to be sure I hope that eventually these things will help prevent accidents. But what about not dying right now? I attended a class in which a very smart, educated, and thoughtful pilot and safety executive put up slide after slide explaining that there really are lots of players in our game, and any one of multiple contributing factors can be why we crash aircraft and kill people. Good Stuff. How do I stay alive.

What about you, dear pilot, or nurse, or medic, or RT? What will you do to stay alive throughout your flying career? Do you have any personal strategies, or tricks, or philosophies on how to not get dead? If not, perhaps your should give this some thought. Because what we do is dangerous.

—According to the American Journal of Clinical Medicine (Winter 2009 issue) after assessing past statistics then projecting them forward, they predicted that if you fly in a HEMS helicopter and do that job for twenty years, you face a 40 percent chance of losing your life.

Before I started writing this, sitting in my sun-room on a Sunday morning, I was reading the weekend-edition of the Wall Street Journal. This is a great paper, with tons of information that is way over my head, and - my favorite part - book reviews and excerpts. One article covers Dr. Thomas Lee, a professor of medicine at Harvard, and his new book "Eugene Braunwald and the Rise of Modern Medicine." In this article there is a line about Dr. Braunwald; "over six decades, he (Braunwald) was repeatedly in the right place, at the right time, with the right people."

BAM. Put the paper down and go get the computer. Start writing. (If you are not yet a blogger, this is how it goes. You are doing something and all the sudden...)

This is my advice to you, dear HEMS person who climbs into an aircraft and takes to the sky. Seek always to put yourself in the right place at the right time with the right people. It's as simple as that. If you are not sure where the right place is, educate yourself. Your heart and your head will tell you about the people. The time is now.

In the right place... I now fly a single engine aircraft. I have dedicated myself over the last year to continuously evaluate if I am in a position to survive the loss of that one engine. When I take off, I fly as close as possible to the way the operators manual says I should, at max-continuous power, at best-climb speed, to an altitude allowing a safe landing should my engine fail. I deliberately fly as if the motor is going to quit, even though the odds are that my engine won't. If I am not in the right place, I try and get there as quickly as possible. My new flying style elicits comments from the back like, "wow, I never saw this view from such a high altitude," and "gee, things sure look different from way up here." This at two thousand feet above the ground! Why do we persist in flying so low?

(added 2/13/15: There is an increased industry/FAA interest in over water flight. If you fly a single engine helicopter over water without floats and vests, I recommend you fly at an altitude or on a path such that no person could ever misunderstand or question your ability to reach the nearest shore. Such a misunderstanding got an excellent pilot - who formerly flew the president of the United States - fired.)

By way of explanation...The odds of a sprag-clutch failing to engage on engine-start are probably a billion to one. That happened to me in a BK, and resulted in around a million dollars worth of damage to the aircraft I was in command of. I am not immune to bad fortune. If an engine is going to quit, I take it for granted that it's going to quit on me. I don't want to be in the wrong place when it happens.

With the right people... I heard a story not long ago about a crew heading out to do a PR flight. There was a seasoned pilot at the controls, and a seasoned crew in back. Sometime in flight, or perhaps after landing and on shutdown, the paramedic smelled fuel. He keyed up the mic and announced "I smell fuel." The pilot acknowledged the message and continued on with what he was doing. They shut down and got out, and the pilot wasn't taking any actions related to the fuel smell. The medic began to look into all the openings in the side cowls and observed fuel dripping from a filter assembly. He said, "hey, we have a fuel leak!" The pilot looked and said, "don't worry about it, it's just a drip, these things do that," and walked off to check out the PR.

Time passed and they prepared to leave. The medic asked the pilot again about the fuel leak, the pilot became irritated and told him to get in.

The medic sat still for the engine start and run-up, then announced, "Hey I forgot something, I have to get out for a second." The pilot went back to idle and the medic climbed back out and with his flashlight peered through the opening in the cowl. Jet fuel was spraying in a gusher from the filter assembly...

The flight team in question subsequently decided that this pilot wasn't "the right people," and they cut him loose. Pilots reading this are perhaps excoriating me right now, and to be sure any of the people involved with our work can have the "wrong stuff." Whatever - your job is to actively monitor who YOU are flying with and make sure they are right for you, and for your safety. And you friend have to be the right person too.

At the right time... Our business is one of extreme consequence. A failure or mistake by a surgeon might lead to the death of a patient. A failure by any of us might lead to the death of all of us. So there is no "right time" to do things right. We have to do the right thing every time. All the time. We might let things slip or cut a corner, and get away with it. That will lead us to slip more and more often and eventually we will get caught. Conversely we might let things slip once - and that will be the day... We just don't know - so our job has to be done deliberately, and thoughtfully, and cooperatively - right now

If you are going to fly for two decades, and you don't want to be one of the  forty-percent, make sure you keep yourself in the right place, at the right time, with the right people.

safe flights

Impressions from the Air Medical Transport Conference

We made it home safely from AMTC. This was my first time going in over a decade, and to be honest I only went because I wanted to be a presenter, and get some exposure for my business, AMRM Training Solutions. My first impression upon entering the exhibit hall was that it was smaller than I remember it from Orlando, but that may be due to the fact that the last "show" I went to was the Heli-Expo in Houston - and it is a monster. Still, there were plenty of exhibits to see, lots of vendors, and lots of shiny new helicopters to drool over. We even got to see the new split-personality helicopter that will soon be flying sick people in West Virginia and Ohio.

Yes, there are two paint schemes on one brand new Eurocopter EC-130, the newer, fatter, tour-friendly version of the Astar. You could probably walk around the patient in that cabin, but it still only has one motor and is restricted to visual-flight-rules ( no flying in the clouds). This machine is a cooperative risk/reward sharing venture between two organizations. It is more Aerospatiale (French)  than MBB (Messerschmitt-Bölkow-Blohm), with it's Starflex rotorhead (smoother in turbulence than the rigid system on the German machines) and it's Fenestron "Fan-in-Fin" shrouded tail-rotor. Pilots love it.

I saw Rick Hassman, an old friend and boss from my days with CareForce in Columbia SC,  Rick is now a VP with AvstarMedia, one of the two main computer-based-training suppliers we in HEMS use. He is a genuinely decent and honest man, and AvstarMedia was lucky to get him. It was nice to see him smiling and well. I think he is drinking from the fountain of youth.

We also stopped by the booth housing RSQ911 Solutions. A great lady and RN named Kelly Hawsey is involved with this organization, and it was nice to catch up with her and hear some history of the old, original "LifeReach" program that served Columbia, South Carolina so well for so many years. They were one of the first programs that had to deal with competition with another HEMS provider setting up shop "right-next-door," and they did it with grace and professionalism.

RSQ911 Solutions provides a customized customer satisfaction survey for air and ground ambulance providers to collect feedback on their crew interactions.  emsCharts has a collaborative partnership that connects our web-based patient data collection and incident reporting to RSQ911 Solutions' online survey tool. The streamlined functionality allows EMS agencies to easily connect a particular patient event to survey feedback from hospital personnel and other EMS on the scene, as well as feedback from patients and their families.

This was the year of the T-Shirt at AMTC. It seemed as if everyone except EMSFLIGHTCREW was giving them away. We have enough T-Shirts to star as Gunny Highway now - but no coozies. One savvy media company held a "put your shirt on now for a chance to win $500" event, and red shirts were everywhere. Nice work...

Golden Hour Data Systems sponsored a free beer-fest each night at a local disco-joint, and attendees took full advantage. Thank you! There were a whole bunch of blue ink-blots on the inside of right-wrists each morning, and some red eyes to go along with them. People got to let their hair down, let loose, and bond. I suspect the bonding was both vertical and horizontal - it's a conference after all.

I attended a class on high altitude EMS and rescue operations put on by a fellow who I totally misjudged on first impression. I sat down thinking he was a wacker from the sticks; I left his class thinking he was a Superman, Super-medic, and life-saving Angel for volunteering to spend two weeks on Denali at 14,000 feet living in a tent and taking care of sick people. That class was a high point of the conference.

Another high point was getting to hear General David Petraeus speak to the conference as Keynote Speaker. It was a little disappointing to find out, at literally the last second, that he wouldn't actually be "there" and instead would attend via video link. But, had he been on stage, I would have been looking at one of the two jumbo-screens anyway, so it worked fine. He spoke at length, and with humor and wisdom in equal parts. He could see us, and hear us, and took questions from the audience. I am glad the bullet that went through him during a training accident went through the "a"  in Petraeus vice the A in Army... What a coincidence that the surgeon who saved his life at Vanderbilt was named Frist and would go on to fame of his own.


                                                        "The business end of a Bell"

As I said, I went to promote my business, AMRM Training Solutions, thinking that being a speaker and letting people experience my product first hand would be better (and cheaper) than renting a booth and telling them how great it is. I got the idea to be a speaker from an email that was sent out early last year asking pilots to volunteer to speak at AMTC. I did and it was a great experience, with only one extremely sad and uncomfortable moment. During my presentation, I did a case study on a fatal accident, linking it to the hazardous attitude known as get-home-itis. When I finished a fellow walked up to me, thanked me, then asked if I knew that the same program had lost another aircraft and crew that morning. Lord have Mercy. I didn't know and regret terribly choosing that crash to study - unfortunately there are plenty.

 Even if you aren't interested in promoting a business, or speaking on a topic that interests you, I encourage you to attend the conference next year in Nashville if you work in HEMS.

I know a lot of HEMS pilots think AMTC is a waste of time; and primarily for clinicians. The fact is that it is our fault for not taking our place at the table. Only 17% of attendees this year were pilots, and if we won't represent ourselves who will - a non-pilot?. Anyone who has been around HEMS for awhile has something to offer, and would enjoy the experience. I watched a young communications-specialist who was as nervous as could be struggle through a class on communications. It was a good experience for him, and I learned something. I laughed out loud when Rex Alexander told me the story of the speaker he was coaching who decided at the last minute, after being "mic'ed up" for his class, that he had to use the toilet. He did so "hot mic," and returned to a room with the ice broken. Speakers receive a free night's lodging and a free registration to the show, so you get three days of edutainment for one hour of speaking. And you get to enjoy the sense of giving something back to your industry. If you don't like the way HEMS is now, here's your chance to change it.

On the last night of the show, we were having beers in the Hilton's beach side bar and grill. There are fire rings outside with seating.  I noticed a group of conference-folks laughing and having a good time, and thought to myself how that picture would nicely sum up the experience of attending a conference in Virginia Beach. I finally screwed up the courage to go out and introduce myself and ask for permission to take their picture. The ladies exclaimed, "Dan - we were in your class and it was the best class in the conference!" followed up with "yes, you can take our picture." So we laughed and I said, "don't look at me, just act like you are talking and having fun. (something I learned recently from Keith Colodny who owns Precision Aerial Filmworks and is a flight medic)

                                  This is what happens at AMTC after the days "work" is done...

I understand that if a business comes away from a conference with one or two new customers, things went well. I had a great meeting with a safety-manager from a flagship program in the northeast, and hope to spend time with them next spring. My old chief-pilot, Colin Henry, watched my presentation, and told me plainly the next morning that I will be speaking at MedFlight of Ohio next year.. So my trip was productive, and informative, and fun.

I hope to see you next year in Nashville and...

Safe Flights.

Shock and Disbelief....

We are at the Air Medical Transport Conference in Virginia Beach. Yesterday morning, right after our presentation, we were told about the crash of Hospital Wing's aircraft. We send our deepest condolences to the families of those killed, and to the entire flight team. These ladies spent their working lives taking care of others. We know God has wrapped these souls in his loving arms.

God Speed friends.

BASH, BAM, BOOM: The Bird Threat

NTSB Identification: ERA14CA009
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, October 20, 2013 in Madison, MS
Probable Cause Approval Date: 12/19/2013
Aircraft: EUROCOPTER AS 350 B2, registration: N911ES
Injuries: 3 Minor.

According to the pilot, he was climbing the helicopter through 1,300 feet when he felt an "explosion" in his face that knocked his visor up and affected both his visibility and crew communications. The pilot was eventually able to get his visor back down and land the helicopter, where it was discovered that both windshields were blown out, the center post and the cabin shell were damaged, the doors were blown open and on board medical equipment was missing. On the ground, a crew member stated that just before the event, he had seen a black bird fly toward the helicopter from above and left, but did not have enough time to call it out. Analysis of onboard residual bird feathers and a photograph of the suspect bird carcass indicated that it was a black vulture, which can weigh up to 4.8 pounds.

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

The helicopter's collision with a black vulture during a climb to cruise altitude.

BASH (Bird Aircraft Strike Hazard)  
BAM (Bird Avoidance Maneuver) 
BOOM (the sound of your windshield exploding in your face - keep your visor down when possible, and your guard up always.

Fly defensively!

During shift briefings, I like to question the crew members I will be flying with about proximate threats--what will kill us today? In a single-engine helicopter, engine failure comes up a lot. In fact, a bird strike is much more likely than an engine failure and can be more deadly.

Bird versus Blackhawk.

On January 4, 2009, a Sikorsky S-76 helicopter hit a Red-tailed Hawk in Louisiana. The hawk hit the helicopter just above the windscreen. The impact forced the activation of the engine fire suppression control handles, retarding the throttles and causing the engines to lose power. Eight of the nine persons on board died in the subsequent crash; the survivor, a passenger, was seriously injured  

Some aircraft have plastic windshields, some have glass. The picture above makes clear that even a glass windshield will give way for a big enough bird. 

"A 12-pound Canada goose struck by a 150-mph (aircraft) ... generates the kinetic energy of a 1,000-pound weight dropped from a height of 10 feet." 

(Bird Strike Committee, Boeing Aero Magazine online at http://www.boeing.com/commercial/aeromagazine/articles/2011_q3/4/

During my initial training with Air Methods, we were told about a pilot who took a bird through the windshield and then suffered a loss of power from both engines!  He pushed the collective down and entered autorotation. As he neared the ground, muscle memory and pattern recognition led him to sweep his hand overhead from back to front to verify that his throttles were all the way forward to the "flight" position, something he had done thousands of times as part of his before-landing checks. The bird had pushed them to the idle stop. He shoved them forward and regained power for a "normal" landing. That's a story I would rather hear than tell.

One of the hallmarks of safe flight operations is the identification of bad things that might happen, and the preparation for their eventual occurrence. We use drills, rehearsals, simulators, and table-talk to get ready for all sorts of unpleasant events, but how can we prepare for a bird coming in through the front window? Perhaps someone who has lived through it might be asked to speak at a safety meeting or group event or write his or her recollection of the event for dissemination.

Several years back Dave Andrews, a HEMS pioneer, took a bird through the windshield of a BK-117 in South Carolina. This was before pilots flying EMS wore helmets, and the bird knocked off his headset before going back out through the greenhouse (the small overhead window that allows pilots to see where they are going during a turn). He couldn't communicate with the crew in the back just then, and it must have been quite an adventure for them; waiting to find out if they were going to crash. The wind and noise in the cockpit must be disorienting. Maintaining aircraft control and slowing down are probably hard with a pounding heart and a shaking hand. I have read of crews having trouble figuring out if the blood and loose parts in their faces belong to themselves or the bird.  

During the day, we can see a bird coming and make a gentle avoidance maneuver. Opinions vary on how to do that. For me, a climb usually works as most birds will tuck and dive when frightened. Some birds go into attack mode and turn into our path. Bird brains!

Striking a bird at night is a scary event for a pilot and crew. I was between Douglas Georgia and Doctor Still's burn hospital in Augusta one night at three thousand feet when we hit a big bird. The BOOM was so loud it brought the patient up out of sedation and so violent it knocked the gel-coat off the nose of our BK. Thank goodness it hit right on the knuckle of the nose. If it had hit a foot above, on the windshield, it would have been inside with us. I tasted copper in my mouth for several minutes.

After that, I began to leave the landing light on during night flights. Research on the effectiveness of this technique is mixed, but for me, it works. I haven't hit a bird since I began leaving a light on. I have always flown with my visor down since I began wearing a helmet for HEMS, but now I am flying at night with NVGs, and the only thing between my eyes and whatever comes through the windshield is a set of tubes.

Here's a bit about a more recent event. This pilot and crew were not as lucky as I and my crew were, on that flight from Douglas to Augusta.

"The helicopter was found on the bank of a reservoir on its right side on a heading about 205°... A post-impact fire consumed a majority of the fuselage... All main rotor blades remained attached to the main rotor hub. All blades were fractured in multiple locations; blade remnants and blade core pieces were found surrounding the accident site... Fragments of the pilot's night vision goggles were located in the area of the pilot controls. During the on-scene portion of the investigation, numerous geese, ducks, and cranes were observed in the reservoir and at another nearby reservoir.

Most bird strikes occur at low altitudes. Flying at or above 3000 feet AGL greatly reduces the risk of a bird strike. Birds congregate around bodies of water and trash dumps; these should be marked on hazard maps and route planning should account for these risks. 

During a discussion of bird strikes with HEMS-industry safety-expert  Rex Alexander, he mentioned that a company he was working with analyzed data from all their bird strikes. They found that one model of helicopter they were operating had significantly fewer strikes at night than others. They investigated what it might be about this particular model contributing to this statistic. 

The answer? Those machines all have white strobes. 

There is at least one vendor selling a pulsing white light as a form of bird strike protection. If you don't have one of these or white strobes, consider leaving a landing light on at night. If you aim it down at 30 to 45 degrees it doesn't totally wash out the image through your NVGs. This might save your life.

Even rocket ships hit birds.

It's All About the Pizza...

I almost had to buy pizza for my crew two nights ago. We were standing next to our aircraft around 10 PM on a cool still night, waiting for the wheels of health care to grind. As this was my crew's third patient flight for their 24-hour shift, and my first for a 12-hour night shift, our perspectives on going to work were different. I kept my mouth shut. As we waited, I glanced up at the top of my cabin and saw a push-latch sticking up, unfastened!

"Whoa! Crap! how did I do that?" I climbed up on the step and secured it. This kind of thing happens and it's worth talking about. A few years back an incorrectly fastened latch almost killed three people. I met one of them while teaching at their program.

The aircraft had not flown all day or been removed from it's hangar. During the day shift, maintenance called and asked the duty pilot to go out and check a measurement on the fuel control linkage. He did so, and reported closing the left side cowl upon completion. When the night shift arrived, the pilot completed his preflight inspection and later in the shift the crew was alerted for a flight. They opened the hangar door and pulled the aircraft outside. When the door button was pressed to close the door, nothing happened. 

Safety Briefing Topic: How does your team deal with a break in the normal sequence of events?

They talked about what to do, not wanting to pick up to a hover directly in front of an open hangar, as this would blow the place up. They decided to drag the aircraft off to the side of the ramp, away from the hangar and away from the lights. They put the tug away and all completed a walk around. 

The clock was ticking and they were taking too much time.

When the engines were started, a clinician in back alerted the pilot to "a clicking sound coming from over the pilot's head." The pilot asked her to step outside and check the aircraft on the right side for anything wrong.

She did, found nothing amiss, climbed back in and they departed to the small referring hospital. 

When they began a descending left turn for landing a loud BANG was heard and felt through the aircraft and then a severe shaking shuddering vibration made it difficult to fly or think. Fear impacts our ability to reason. The pilot had no idea what was wrong; only that something terrible had happened. He wasn't sure about his aircraft's condition or what to do. 

He didn't think that attempting an approach to a confined area was a good idea, worrying about losing his tail rotor or an engine. He pushed the mic button and proposed flying to an airport nearby for a run-on landing. 

The crew both emphatically requested landing immediately. As it turned out, that was the right choice. They suffered a cowl opening in flight.

Cowlings have come open many times in HEMS, with varying degrees of damage done to aircraft. The BK-117 was notorious for this, and each time a cowl came open, another fastener was added. At last count there were seven latching or locking fasteners on a BK's side cowlings; only lacking being riveted shut to make them pilot proof. 

This aircraft was an EC-145 ( A BK-117C2 ) and as there wasn't much history with cowls coming open, they only had two latches. They look like this...

. 

That cowl may or may not be latched - you cannot tell by looking at the plastic cover. The actual "latching" metal buckle is underneath the cover. The cover will not hold the cowling shut by itself. 

As I am a human being, and subject to human factors; I ask my crew to help me ensure that, on OUR aircraft, the cowls are latched. To make sure they really look I took a technique from my friend Tim and like him, I have a standing offer to buy pizza for any crew member who finds a latch open on a helicopter that I am climbing into. It's a game with deadly serious consequences; I have bought once. 

The crew is actively trying to catch me. The problem with a cowl opening is that when they fly up they get in the way of the action above.

Because the blades are turning so quickly, they are all invariably damaged by anything getting in the way. 

In some cases the damage can destroy the structural integrity of one or more rotor blades and could result in loss of the aircraft and crew.

This almost happened to the crew in question, in fact the NTSB experts stated that had they attempted to continue flight to the nearby airport, at least one of the blades would have failed....

 Remember that rotor blades experience a tremendous amount of flexing in flight, and the engineers do not add in any structural extra stuff. It's not really a "chopper." If you want to make yourself ill, watch the mast-head video of a BK blade in flight. Watch this after you finish flying for one day...

Video of blade in flight

Over time, we tend to do our walk-around checks with the mental attitude that we are just confirming that all is well. This leads us to see what we want to see and miss what we should be looking for. 

We need to look as if something is amiss. Have a critical eye.

Mind you, it's also not enough to simply look UP at the aircraft - we have to look down too. At the the landing gear, the grounding cable, the belly...the fuel cap!

People still take off today with the fuel cap open. It can happen to you too. 

When there is something wrong with your aircraft, will you spot it?

Fly safely friends,

HelicopterEMS.com

(edited 9/6/16, clarity, brevity)

Making The Case For Tiered Reimbursement....

Recently, I spent two days in Concord North Carolina with team members from MedCenter Air. If you are not familiar with this flight program, take it from me - it's a squared-away organization. The hospital supports a first-class program, with great equipment, and highly qualified and continuously trained staff. The lead pilot formerly flew the President of the United States. When Clinicians leave MedCenter Air, it's to become PAs, CRNAs, NPs, or to run programs like Duke Lifeflight. The look and feel is one of excellence.

I had time to reflect on the fact that programs like; MedCenter Air, LifeLion and Geisinger LifeFlight in Pennsylvania, Mayo-One at "the Clinic", and the Order of the Sister's of Saint Francis Aviation program headquartered at the Peoria IL airport, which all spend huge sums of money to be the best in HEMS, get the exact same pay for flying patients as does someone transporting sick people in the cheapest, least capable aircraft available, with pilots and clinicians who barely meet the minimum requirements.

I have often wondered why the government, through the Centers for Medicare and Medicaid Services doesn't use a payment-differential scheme for Helicopter Emergency Medical Services (HEMS) for the public-good. They have done this for years with varying-payment-schemes to entice health-care providers and facilities to do their bidding,

A good discussion of CMS payments being used to influence what healthcare is available where is at...

http://cph.uiowa.edu/rupri/publications/finalreports/Medicare%20Physician%20Payment%20Policy%20and%20the%20Rural%20Perspective%20Final%20Report.pdf

For reasons both moral and ethical, society continues to move towards health-care provision that is more-safe, more capable, and more effective. This includes HEMS, which is a force-multiplier for the health-care industry, but which is provided at differing levels of capability while being marketed as uniformly wonderful.

To be sure, if we were to take away the 900-odd helicopters that are used on a daily basis to move patients from less capable rural health-care services to tertiary-care hospitals in major population centers,  the inadequacies of our national system would manifest themselves on a large scale. As it is, HEMS operates largely "under-the-radar," even in the face of NTSB reports that  highlight the fact that all HEMS companies are not equal. Most people simply don't understand the differences that mean some aircraft can only fly on nice clear days while others can fly through moderately adverse weather like rain showers and clouds. While some can transport two patients, others are restricted to one - and have to sacrifice fuel-range if that single patient is heavy. Some helicopters can transport patients supported by heavy, bulky equipment like an Intra-Aortic-Balloon-Pump, while others force crew members to literally squeeze in next to each other and make any real patient care in flight difficult if not impossible. Ironically, no matter how limited a programs capability, they all call themselves the same thing, a helicopter ambulance.

Under current reimbursement schemes, there is a moral hazard in that the financial incentive is for a helicopter ambulance company to operate the smallest, cheapest, least-capable equipment that will get a patient airborne, no matter what provisions for safety are left off. There are no single engine jets with the Delta logo on them, but single engine helicopters are the predominant choice - because turbines are both expensive and reliable.

But they do fail.

LAKE CITY, AR  – The Air-Evac rescue team in Lake City walked away unharmed after a hard landing late Wednesday night.
According to Air-Evac, the rescue helicopter was on final approach to their base when they suffered an engine malfunction. 
The pilot was able to set the helicopter down close to the heli-pad in what they called a hard landing. 
No one was injured in the landing, but the helicopter did receive minor damage.
The crew does have a spare helicopter on scene, so no services will be disrupted.
Air-Evac says the incident is being looked into, and the damaged helicopter will be sent off for repairs.

Note: Details of this event are unconfirmed. Hard landing is an aviation euphemism for, "we crashed, tore up the aircraft, and don't want to make a big deal about it, or have YOU make a big deal about it."  When the skids are spread apart and the tail boom is broken off,  it's a crash. The aircraft will be covered with tarps, loaded onto a flatbed and whisked into a hangar. 

Last year, two different helicopter companies had single engine helicopters crash on the same day after suffering loss of power from their one available engine. Because turbines DO fail, airliners have at least two engines available for safety and redundancy. We take it for granted that multiple engines are part of the picture on a big jet, but not on a helicopter, because many people don't understand how helicopters work, or what their limitations are.

Another reason that "anything goes" in the HEMS world is that the passengers, who are also patients, are usually not in a condition to ask questions about the crews or aircraft they are being shoved into. While some county EMS directors are aware of the differences between companies and the aircraft and crews they bring to the scenes, and are selective on whom they will call, the vast majority of times the call is for a "helicopter," and the nearest one gets the call.

To move HEMS towards more safe and capable operations the time has come  for tiered-reimbursements, starting with CMS. It is common knowledge that as goes Medicare, so goes private insurance.  Of course we have to get from where we are now to where we should be without decreasing the capabilities and resources that exist today. It is also not fair to ignore the fact that putting any helicopter into HEMS represents a huge investment and risk-undertaking. Some people operate a Bell 206L3, parked next to a single wide trailer in the middle of a corn field, because that is all they and their service-area can afford, and it's better to have something than nothing that flies.

Conversely, "OSF Aviation is located in an aeromedical operations facility, opened in Summer 2007. This structure allowed OSF HealthCare to base the life-saving services of all three entities under one roof.

The $2.6 million facility includes 12,000 square feet of hangar space and over 7,000 square feet of office space. It can hold either six twin-blade helicopters, four multi-blade helicopters, or four twin-blade helicopters and one fixed wing aircraft.The four American Eurocopter EC 145 helicopters housed within the facility were a much needed upgrade in the summer of 2012. OSF Aviation also has its own Part 135 Certificate from the FAA. (OSF website)

Changing the rules should not create a glut of single-engine helicopters. Change must allow the extant investment to pay off, and must be reasonable and thought out (as I have alluded to in a prior blog-post)

There are two mechanisms for doing this, grandfathering or sun-setting.

Grandfathering would mean that anyone operating an aircraft as of a certain "start-date" would be exempt from any changes to reimbursement (think decrements or deductions) that might be effective after that date, for as long as that aircraft is operated in HEMS by that company. While this might reduce the resale value of a helicopter, it would allow the operator to continue under the current paradigm until the cost of putting the aircraft into service has been recouped. This might mean that change would come more slowly to the HEMS industry than is desired.

Sun-setting (as the FAA did with airline regulations decades ago) would leave things as they are initially, then gradually incentivize moving to more capable, safe, and sophisticated aircraft, and could include other factors such as medical staff who meet certain criteria. One measurement of program capability and sophistication might be "CAMTS" certification. Reimbursement should favor more capable aircraft, pilots, and crews, able to offer more service in a more safe manner to the American public.

One possible sunset scheme would be to leave things as they are for three years. Then separate transports into three tiers, tier one or "A," two or "B," and three or "C." This differentiation would apply to individual transports as with  basic-life-support and advance-life-support ground-ambulance trips, based upon equipment and/or staff. A tier one trip would include a twin-engine instrument-flight-capable aircraft with full autopilot, night vision goggles, a specially trained and highly experienced pilot and medical crew, with the highest levels of available certification such as ATP for the pilot, CFRN or CFP for the medical staff, and CAMTS for the program . If all these conditions were met for a trip, tier-one reimbursement could be claimed.

Tier-three would equate to the least capable aircraft, typically with one engine, limited to flying in visual-flight conditions (fair weather), perhaps even restricted to daylight conditions (I think the FAA will soon require NVGs for night VFR HEMS flights). The pilots would have to have whatever experience the FAA, the operator, and the operator's insurance company requires and nothing more. The medical crew might be new-graduates or might have only a year or so of practical experience.

Tier-two would fall somewhere in the middle, with criteria to be hashed out by the FAA, CMS, CAMTS, and perhaps the professional organizations devoted to HEMS such as NEMSPA, ASTNA, AMPA, AAMS, and the IAFCP.

After the sunset period, reimbursements would be paid in full for tier one, with a percentage reduction for tiers two and three, phasing over successive years to reflect the gross disparity in costs associated with the different types of  HEMS programs available today. The end goal is to have ALL services eventually work towards the tier-one level of service, because that will be where the money is.

And that is what our patients deserve.

Out of Sight But Never Out of Mind - Tail-Rotor Tales

I have to admit, Colin tried to warn me.

It was early 2004, and I was undergoing Bell 222 aircraft-transition and single-pilot instrument-flight-rules (SPIFR) training with Omniflight's chief pilot near Dallas, Texas. We were shooting approaches and mixing that with some traffic-pattern work and emergency-procedures training. While taking a break from the training, Colin had me get out and walk clear of the aircraft, then head backwards until I was abeam the tail rotor. The point he wanted to make was that the tail on a 222 is much longer and lower than the tail on the BK-117 that I was familiar with. Perhaps because I was tired, and concentrating on all the mistakes I was making during training, I didn't get his message - but he tried.

A few weeks later, shortly after dark, I was flying the Deuce into Richland Hospital's helipad for our contract-opening meet-and-greet. I had two or three other pilots on board, and there was a crowd of hospital-folks on hand; up against the building.  I completed my high recon, and set up for a landing to the west on the patient drop-off pad nearest the hospital, as another aircraft occupied the primary pad.

I was very conscious of being watched as I made my approach, and tried to be as smooth and deliberate as possible in an aircraft that was still  new to me. 

Without even thinking about why, I concentrated on landing dead-center on the helipad, with my aircraft right on top of the "H."  I was completing the shutdown checks, and told the other guys they were clear to exit the aircraft. I sat there filling in the blanks on my forms when my door opened and one of the other pilots told me, "your tail is really close to a fence behind you, you need to shut it down!"  I said, "hold on, I am almost done." He said, "no Dan, it's really close!"

After shutting down, I got out and walked back to the rear of my aircraft, and my knees almost buckled. My stinger, the metal rod sticking out below the tail fin to protect the tail-rotor from a ground strike, was about 4 inches from a 3 foot high chain-link fence. I don't remember seeing the fence on the way in, and if I had drifted backwards on landing...

Mike Eastlee, a pilot working with the customer, played it off by saying, "it's no big deal, he landed on the H." But it was a big deal. I almost damaged an aircraft, and and could have hurt some people; and I was actually trying to be careful. 

So, what happened?

Well, as it turns out, what almost happened to me, has  happened to other HEMS crews,  

For example;

On July 2, 2009, about 2100 eastern daylight time, a Eurocopter AS 350 B2 helicopter, N53963, operated by Omniflight Helicopters Inc., was substantially damaged while landing at Loris Community Hospital Heliport (5SC5), Loris, South Carolina. The certificated commercial pilot and two clinicians were not injured. Night visual meteorological conditions prevailed and a company flight plan was filed for the medical positioning flight conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from Conway-Horry County Airport (HYW), Conway, South Carolina, at 2040.

According to the pilot, the purpose of the flight was to pick up a patient at 5SC5 for transport. The pilot initiated an approach to 5SC5, to the west, into the wind. As the helicopter approached the helipad, the clinicians were "call(ing)" clear of obstructions, such as trees and light poles. About 5 feet above the helipad, the helicopter shuttered and vibrated. The pilot continued the landing and performed an emergency engine shutdown.

A Federal Aviation Administration (FAA) inspector subsequently interviewed the pilot and clinicians. The FAA inspector stated that although all three persons had been to the heliport before, they simply forgot about several steel poles aligned adjacent to the helipad. Just prior to landing, the tailrotor struck one of the steel poles, and the helicopter came to rest on the helipad.

Two of the four steel poles were about 2 feet high and 4 inches in diameter, and the other two were about 3 feet high and 6 inches in diameter. The poles were placed along one side of the helipad along the perimeter line that separated the helipad from a road.

According to the operator's Vice President of Clinical Services, all clinicians are trained with the pilots in Air Medical Resource Management (AMRM). Through that training, the clinicians are taught to point out obstacles and hazards to flight.

Examination of the helicopter by the FAA inspector revealed damage to the tailboom, tailrotor, tailrotor gearbox, tailrotor drive shaft, main rotor, and horizontal stabilizer.

The recorded weather at an airport approximately 15 miles northeast of the accident site, at 2058, included calm wind, clear skies, and visibility 10 miles.

The pilot had accumulated 2,587 total flight hours in rotorcraft, including 501 hours as pilot-in-command in the Eurocopter AS 350 B2 helicopters. The pilot logged 46, 19, and 2 flight hours in the previous 90, 30, and 1 days respectively.

Subsequent to the accident, the hospital removed the short steel poles adjacent to the helipad.

“The conclusion of the Pilot involved and the Company Chief Pilot was that the incident could have been averted if the landing to the landing zone had been made further into the landing zone (added: nose into a corner) as to prevent the tail rotor from impacting any obstruction in the vicinity of the edge of the landing zone. Initial and immediate action has been to indoctrinate all pilots flying into medium to small sized landing zones / heliports to position aircraft in such a manner to ensure that all components of the aircraft are clear of all hazards on the periphery and or confines/boundaries of marked landing zones/heliports rather than attempting to place the center of the aircraft at the center of the landing zone / heliport. Corporate wide reassessment of hazards at landing zones/heliports within each regions normal operating area is underway and will be added/updated as needed and posted as part of normal preflight briefings / risk assessments.”

I think the two main factors are a pilot's innate desire to be "squared away," (a human factor) and land perfectly on-center on a helipad, coupled with the fact that helicopter landing areas, or "helipads" come in so many shapes and sizes. 

Here's another example... "He maneuvered the helicopter to center it over the pad..."

There are published guidelines for how to construct a helipad, and you have to look no further than the advisory circular at...

  http://www.faa.gov/documentLibrary/media/Advisory_Circular/150_5390_2c.pdf

to learn all about what a helipad could look like, but in typical FAA fashion they have confused helicopter flight operations with commercial jet travel, and the airports they use and created a document and a set of standards that are, to put it tactfully, unwieldy. 

The last time I checked, the only time the advisory circular must be complied with is when a helipad is completed using federal funds. Otherwise, anything goes.

Now when a helipad is obviously an afterthought, it's much like landing at an accident scene, or "off-airport" in FAA-speak. I think these are actually less dangerous than those landing pads that have the look of legitimacy, and are almost correct. When landing on a road, one's senses are on high-alert, and trouble is expected. A hospital pad might be approached with a more relaxed attitude, or even complacency, because it's designed for the use of helicopters, right? 

That was the case with Richland's. It looked legit, but the fence was so close to the pad that unless one landed a 222 diagonally, with the nose tucked well into a corner it was possible to make contact between helicopter and obstruction. That lesson was not lost on me...

Part of work, or work of art. An FEC heliports design. 

As I was briefing this topic this morning, my nurse, an experienced fellow new to us from New York, commented that he would have never thought that landing to the H would present a problem. Okay, he's not a pilot, but a pilot might think the same way, 

A while back some fellow quoted a line from an interesting bit of conventional wisdom, and because of my near-miss with my tail rotor it resonated with me.  The source was posted today on JustHelicopters.com. It is line number 2, for good reason. After rotor RPM, nothing is so important as a working tail rotor for continued success. I will leave the rest for your enjoyment...

So having addressed the fact that people who have no idea about helipad design do so, and understanding that we should approach all hospital helipads as if the designer was trying to kill us; we might also say that in the case of an enclosed, or encumbered rectangle, we should land diagonally to provide the most room, nose-to-tail. That's not a hard fast rule, but it's something to consider...

During my time teaching Air Medical Resource Management for Omniflight, we had more than one tail rotor strike on or near the ground at an accident scene. And of course we tried to figure out how to stop suffering events like this; 

The pilot said that upon landing at the scene he kept the helicopter operating with him at the controls, while the medical crew attended to the patient. After loading the patient into the helicopter, the paramedic did a walk around inspection, entered the helicopter, and called out the before-takeoff-checklist, while voicing an alert to the pilot concerning overhanging trees on the port side of the helicopter. 

The pilot acknowledged, and told the crew that he intended to pick the helicopter up into a hover, slide to the right, and then perform a left pedal turn to exit the scene to the west. The pilot said that while performing a left pedal turn at a hover, a vibration occurred throughout the airframe, and he immediately set the helicopter back on the ground, facing west. 

An EMS technician on the ground who had been observing the helicopter, stated that after the patient had been loaded into the helicopter, the helicopter was lifted into about a 3-foot hover, and then began to rotate and face into the direction of the light wind, coming from the west. After the helicopter completed the rotation into the wind, the EMS technician stated that it then began to increase altitude, and as the altitude increased the tail rotor struck a small pine tree limb that stuck out about 1 to 2 feet into, and over the westbound traffic lane closest to the median. 

He said he heard the change in pitch to the sound of the helicopter's engine, and also saw the tail rotor begin a slight "wobbling." At this point the EMS technician said the helicopter was about 6 to 8 feet off the ground, and he believes that the pilot sensed that something was wrong with the helicopter, and set the helicopter down firmly on the curbside lane, facing west. An examination reveal no evidence of a preaccident mechanical failure or malfunction to the helicopter or any of its systems.

The simplest fix seemed to be asking pilots and crews to minimize manouvering while near the ground, ie. if you fly in and land safely, why not consider staying put, and when you leave, climb vertically until clear of obstacles. Every situation is different of course, but in any case moving around close to the ground is dangerous, and should be thoroughly briefed and understood by all involved - before moving... In the case above, it appears that the crew member attempted to advise the pilot of a nearby hazard, and the pilot acknowledged the advice - and then commenced to hit it. I am familiar with the event in question, and can tell you that they only had to slightly touch a small branch to remove a fist-sized chunk of the skin and core of one of  the tail rotor blades. This put the system out of balance, and the "wobbling" assembly was in the process of ripping itself off the tail fin as you might rip a beer can in half after drinking a few. 

What are we to do? Like the man said, guard your tail rotor... It's back there out of sight, but it can never be out of mind. 

All close-ground movements must be considered hazardous, and should be briefed in detail first. 

A positive "three-way" communication between pilot and observer might go something like, "guys, I need to bring my nose right and my tail left. Can you clear my tail left?"  

The response might be, "Yes sir, I can see to the left rear and your tail is clear" at which point the pilot would say, "nose right - tail left," and do it.

Conversely, we might hear,"No Dan, I cannot see to your left rear, or "you are not clear" and then we won't do that move. 

When landing, and there is any question about the size and security of the area, stopping the aircraft at a safe hover altitude, and the pilot announcing, "I want to land here, does this look okay? Can you clear my sides and rear?" will help prevent striking an obstacle. 

This may require clinicians to let the patient go for a few seconds, when one is on board, but in the scheme of things I think it's a fair trade-off...This is simple crew-coordination, and it's how we stay alive.

Safe flights...