Accident Review. What would you differently?

Lipperer, who grew up in the Jefferson area, became a pilot for UW Hospital and Clinics in 2000. He was employed by Air Methods, the company that leased the aircraft to the hospital. He was known for his flying skills, and colleagues felt safe getting into an aircraft with him, said Cisler, the hospital's director for emergency services.

"He was very thorough, very safety conscious, just smart at what he does," Cisler said.

Lipperer had worked for Air Methods since 1995 as both a mechanic and pilot, said Aaron Todd, the company's chief executive officer.

NTSB Identification: CHI08FA128
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 10, 2008 in La Crosse, WI
Probable Cause Approval Date: 09/02/2010
Aircraft: EUROCOPTER DEUTSCHLAND GMBH EC 135 T2+, registration: N135UW
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.

After transporting a patient to a local hospital and refueling at La Crosse Municipal Airport (LSE), the emergency medical services (EMS) helicopter departed LSE (elevation 656 feet mean sea level [msl]) about 2234 central daylight time (all times in this brief are central daylight time) on a return flight to its base heliport. Dark night visual meteorological conditions (VMC) prevailed at LSE. A ramp services employee at LSE who had observed the helicopter lift off and proceed east-southeast observed “moderate” rain and “fair” visibility at the time of takeoff. Witnesses located southeast of the airport reported hearing the helicopter in flight about the time of the accident, and one witness reported hearing a loud crashing sound. A search was initiated shortly after the crash but was hampered by the terrain and fog that had formed overnight. A search located the helicopter the following morning; the helicopter had impacted trees along a sparsely populated ridgeline about 5 miles southeast of LSE. The elevation of the ridgeline was approximately 1,164 feet msl, with 50- to 60-foot-tall trees in the area initially struck by the helicopter.

Distribution of the wreckage was consistent with the helicopter impacting the trees in a nearly level flight attitude under controlled flight. Examination of the helicopter’s engines revealed inlet debris, rotational scoring, and centrifugal turbine blade overload failures consistent with the engines being operated at a moderate to high power level (on both engines) at the time of impact. Nonvolatile memory downloaded from the digital engine control units (DECUs) indicated that both engines were in “flight mode” at the time of impact. Although the left engine main selector switch was observed in the “idle” position after the accident, the lack of anomalies related to the switch and the corresponding DECU in flight mode are consistent with the switch having been moved as a result of impact. No preimpact mechanical malfunctions of the helicopter were found.

The reported weather conditions at LSE about 2253 included VMC: calm winds, 8 miles visibility in light rain, few clouds at 1,400 feet above ground level (agl) [2,056 feet msl], overcast clouds at 5,000 feet agl (5,656 feet msl), temperature 10 degrees C, dew point 8 degrees C, and altimeter 29.70 inches of mercury. The preflight weather briefing obtained by the pilot about 1 hour before departure indicated VMC along the route of flight at the time of the briefing but forecasted deteriorating conditions later in the evening after about 2200, including possible instrument meteorological conditions (IMC). Search and rescue personnel reported fog and mist along the ridgeline overnight during the search operations. Additionally, an EMS pilot for another operator reported that when he departed LSE about 2 hours before the accident flight, fog was beginning to form on the west side of the Mississippi River and in the bluffs east of his flight route. He subsequently returned to LSE and declined at least one additional flight that evening due to deteriorating weather conditions. Because of the variability in weather conditions on the night of the accident, the investigation could not determine if the pilot encountered IMC at the time of the accident.

The pilot was transferred to the accident operator as a result of the accident operator’s acquisition of his previous employer about 3 months before the accident. The accident pilot was initially qualified as visual flight rules (VFR)-only. An instrument proficiency check was not completed in conjunction with initial training. As a result, the accident pilot was limited to VFR-only operations at the time of the accident. (The accident pilot was current for instrument flight rules [IFR] at his previous place of employment.) 

During preflight planning, the pilot should have identified any obstacles along the route of flight, including the tree-covered ridgeline. Company records indicated that the pilot had completed one prior flight to LSE within the previous 16-month period, which was about 2 months before the accident. To assist pilots, maximum elevation figures (MEF) are noted on sectional charts and are derived from such features as terrain, trees, and towers. An MEF is specified for each latitude/longitude quadrangle on the chart. Operation at or above the applicable MEF will ensure terrain and obstacle clearance. The MEF for the La Crosse area is 2,200 feet msl. In addition to the MEF, sectional charts depict terrain elevation and specific obstacle height information. If the accident pilot had observed the MEF of 2,200 feet msl, or the terrain elevation/obstacle height information, it would have provided clearance of the tree covered ridgeline. The elevation of the ridge in the vicinity of the tree strikes was approximately 1,164 feet msl. With the 50- to 60-foot-tall trees, the elevation of the treetops was about 1,224 feet msl, providing a margin of approximately 831 feet to the level of the reported “few clouds” and 4,431 feet to the overcast layer of clouds.

According to Air Methods Corporation, the accident pilot performed a formal flight risk assessment before the flight. Further, the flight was being tracked by a company flight-following program and received flight dispatch services before the start of the flight. According to the Air Methods General Operating Manual, the pilot’s risk assessment was to be recorded in the pilot’s daily flight log. However, the pilot’s daily flight log was destroyed during the crash. The pilot entered a risk assessment of “A” (normal operations) into the flight dispatch computer system before the flight. While the weather in the LSE area was marginal at the time of the accident, it was above the minimums required by Federal Aviation Administration (FAA) regulations and the operator’s procedures. There were no identified weather risks that would have warranted classifying the flight in the risk assessment category “B” (caution).

"Discretion Is The Better Part Of Valor..."

     "Caution is preferable to rash bravery." Falstaff in King Henry the Fourth, 

by William Shakespeare

The pilot's decision to land during unfavorable wind conditions, which resulted in a loss of control due to settling with power. Contributing to the accident were the lack of an adequate approach path due to numerous obstructions and the lack of available guidance regarding the helicopter's performance capabilities in the right quartering tailwind condition.

NTSB: HISTORY OF FLIGHT (edited for brevity and clarity)

On March 6, 2015, at 2310 central standard time, an Airbus Helicopters (Eurocopter) EC-130-B4, N356AM, ... struck the edge of a hospital building and impacted its parking lot during a visual approach to the St Louis University Hospital elevated rooftop helipad (MO55), St Louis, Missouri. During the approach, the helicopter experienced a loss of directional control and entered an uncontrolled descent. The helicopter was destroyed by impact forces and a post-crash fire. The commercial pilot, who was the sole occupant, sustained fatal injuries.

The helicopter was operated under Title 14 Code of Federal Regulations Part 91 as an air medical positioning flight that was operating on a company flight plan. Night visual meteorological conditions prevailed at the time of the accident. The flight was returning to MO55 after it had been refueled at the operator's base located at Arch Heliport (MU05), St. Louis, Missouri.

The flight's first approach and landing at MO55 was to drop off a medic, nurse, and a patient, who was not in critical condition. The flight release for the flight and the accident flight had a green weather status, whose criteria is solely based upon ceilings and visibility. The risk assessment, which was completed for the flight and not for the accident flight, was assessed as low. The medic said that he had been employed as a medic for about a year and flew on previous flights that landed at MO55 "couple of times" and had flown with other (company) pilots. The nurse stated that she began employment at (the company) in January 2015 and she had two years of experience with another aviation company.

The medic stated that during the first approach for landing to MO55 with the pilot, the pilot said that there was a 25-knot wind, but the medic did not know the source of the pilot's wind information. The medic said that the windsock on the helipad was illuminated and pointing "straight out" towards the elevator shaft, located toward the northeast next to the helipad. During the approach, the helicopter tail was "sideways a little bit." The pilot said it was going to be "a little rough" and that "it was a little windy."

The medic said that the approach was "straight-in," and he felt a "little drop" when they came in. The helicopter did not slow down during the approach. The approach felt lower than usual and about 10-20 feet lower than that used by other pilots he had flown with and seemed closer to the elevator than the middle of the helipad while the helicopter was about a "football field" or "half of a football field" away from the helipad. The nose of the helicopter was directed away from elevator and the pilot would "straighten out" the helicopter when it was closer in.

The nurse said that there was "a lot of rolling" and "a lot of yawing" during the approach. Over the helipad, the pilot was having a "hard time" and "a couple of more seconds" she would have told him to abort the landing and to do another "recon."

The medic said that after landing, the pilot needed to shut down the helicopter at MO55 to remove a helicopter seat. After the helicopter shut down, the pilot said that he wanted to stay on the helipad, but the medic told the pilot that the helicopter could not remain on the helipad because there were other helicopters coming in. The nurse stated that it was not a "typical thing to do" to have the helicopter remain on the helipad because of other helicopter arrivals.

The nurse stated that the pilot did not tell her why he wanted to remain on the helipad, but her "gut reaction was that it was a hard landing and he did not want to do that again." She said it was "difficult" to get the helicopter skids onto the helipad. The flight then departed to obtain fuel at MU05 (located about 1.3 nautical miles from MO55).

Upon refueling, the flight returned to MO55, to pick up the medic and nurse. Neither the medic nor the nurse saw the helicopter takeoff from MO55 for the flight to refuel at MU05. The nurse stated that at 2258 she sent a text message to the pilot stating that they were ready to be picked up from MO55, and he responded in text that he was on his way. She said that at 2309, she looked at the time and thought it was "taking a while for his return."

The accident occurred during the flight's return, during the approach for landing. A witness stated that he was sitting in his truck parked across from the St Louis University Hospital emergency room when he saw a light shine on his truck, "the light was coming closer and closer." After a while the light turned around and disappeared "quick." The light shined for about two minutes. His truck was facing west because it was parked on Vista, which is a one way street.The light turned sideways, and it was a clear white light. The other lights he saw on the back of the helicopter "looked like red and green" from the tail. He said he could not hear the helicopter. The helicopter was "coming forward" and it took a "little tailspin" before it went out of sight. The helicopter went north and "went down." He saw the helicopter "side" and "back" and then it went down. He did not see any fire from the helicopter before the accident. He did not hear any noise after it went out of sight.

He said the helicopter was pointing "straight down as it turned left." He said it was not "quite straight down" and the light was shining on the ground as it was going down on an angle. He said that he did not see the helicopter "wobble." He said a security guard came out and walked down Thistle. The witness said he got out of his truck, and the wind was "going pretty hard" going north. He said that helicopter was about 15 feet above the overhead tunnel between the hospital and hospital garage. He did not see the bottom of the helicopter because of the light. He said the wind was not shaking his truck when he was sitting inside of it.

 The medic said if there is a lot of wind, it is "always weird" coming in for approach to land at MO55. The nurse said that her knowing the area and the St Louis University Hospital helipad (MO55), she knew that it was going to be a "hard landing" on a good day." A pilot that was not employed by (the company) stated that he had flown in a Eurocopter "a handful of times. He said that flying into MO55 "is not the hardest pad but it's a difficult pad especially when the winds are at different angles and you have a lot of mechanical turbulence." The winds come around the building and can create a tailwind. Obstructions to the pad are the elevator shaft and buildings surround the pad. He takes new hire helicopter pilots and shows them the mechanical turbulence associated during flight training. He said that if "don't get set up at the right altitude and closure rate" for at MO55, you can "find yourself in a bad situation."

AIRCRAFT 1 FINAL REPORT


The emergency medical service (EMS) helicopter was landing on a privately owned elevated heliport to pick up two medical crewmembers. The medical crewmembers had been dropped off with a patient on a preceding flight. During the preceding flight, the nurse thought about telling the pilot to abort the landing on the heliport because there was a lot of rolling and yawing, and he was having a hard time landing the helicopter. After the landing, the nurse and another medical crewmember stated that the pilot did not want to depart the heliport, but the medical crewmembers told the pilot that there may be potential arrivals of other EMS helicopters. The pilot chose to depart the heliport and obtained fuel at the operator's base of operations. For the return flight to pick up the two medical crewmembers, the wind had increased, and the helicopter approached the heliport in high-wind conditions and with a right, quartering tailwind. Also, the wind along with the surrounding buildings likely created a turbulent airflow/windshear environment in which the helicopter was operating as it approached for landing. The helicopter's operation in a high-power, low-airspeed condition in high-wind conditions, including a right quartering tailwind, likely resulted in a loss of control due to settling with power. A security video showed the helicopter on a northerly flightpath descending at about a 45-degree angle before impacting the ground and coming to rest on an approximate northerly heading. The pilot sustained fatal injuries due to the subsequent fuel tank fire/explosion, which otherwise would have been a survivable accident. Postaccident safety evaluation of the heliport showed that the final approach and takeoff area/safety area were obstructed by permanent and semi-permanent objects that pose a serious hazard to helicopter operations. These obstructions limited the available approach paths to the heliport, which precludes, at times, approaches and landings with a headwind. The helipad is privately owned; therefore, it is not subject to Federal Aviation Administration (FAA) certification or regulation. A review of the helicopter's flight manual revealed that there were no wind speed/azimuth limitations or suggested information available to pilots to base the performance capabilities of the make and model helicopter in their flight planning/decision-making process. Examination of the helicopter revealed no anomalies that would have precluded normal operation and showed engine power at the time of impact.


AIRCRAFT 1 CAUSE REPORT


The pilot's decision to land during unfavorable wind conditions, which resulted in a loss of control due to settling with power. Contributing to the accident were the lack of an adequate approach path due to numerous obstructions and the lack of available guidance regarding the helicopter's performance capabilities in the right quartering tailwind condition.

Remember Rebecca - Remember That It Is Okay To Say Stop...

"Weather overlays with the GPS track indicated that the helicopter made the 360° turn about the same time that an outflow boundary wave, which could have increased the potential for windshear and strong updrafts and downdrafts and reduced ceilings and visibility. Following the 360° turn, the helicopter proceeded toward the destination. About 14 minutes later, the helicopter turned right and began flying toward a major highway. It is likely that, due to the reduced visibility in the area, the pilot was flying toward the highway to follow the lights toward the city. The helicopter then turned further right and began to climb. As the helicopter entered another outflow boundary wave, it turned left. The left turn tightened, and the helicopter began to rapidly descend into terrain. The helicopter impacted a mesa in a near-level attitude."

Excerpt from NTSB report for the crash that killed Rebecca Serkey and her team. Click here for complete synopsis

First You Dream...

Recently we got into a philosophical discussion about what a rational mission-based HEMS structure would look like: as opposed to today's structure, which is partly market-based and partly based on struggles for market dominance.

"Who pays and does it cost the same for each airframe or is it funded differently?  Then the next question is about fees; or should it be a tax supported system.  I will say that a tax-supported system is something that I distrust. It would eventually look like the VA running our medevac community which would be more flawed than what we have now."

Jonathan Godfrey, Flight Nurse, Industry Expert, Co-Founder Survivor's Network for the Air Medical Community

I envision IFR twins at the metro hospitals, VFR or limited-IFR singles distributed evenly across the area, and at least one tilt-rotor per larger state, based near the geographic center, ready to respond to pad or runway, and able to leap vast distances with a single fuel load. As much as I favor free markets and respect the benefits of competition, I feel that naked ambition, greed, and fear-driven marketing strategies lead to waste and inefficiency.

 "I believe that it is one of the Scandinavian countries that has provider bid on contracts for areas of operation. This seems like a pretty sound plan to me. I agree with Jonathan we do not want US HEMS to become the "VA" however If we set up a system where companies have to bid on contracts it enables some quality control and sensible deployment of resources. Unlike today where it is a free for all." Sam Matta, Flight Nurse, Combat Veteran, Co-Founder East Coast Helicopter Organization (ECHO).

The IFR twins, with their larger cabins, are better suited to transporting pediatric and neo-nate teams from the hospital to the kids, and then everyone back to definitive care.

"Couldn't it work like other public service utilities? Or like the public/private partnerships the fire service employs in many locations? It seems that the pure open market we have now creates a competitive situation that is also bad for safety."  Dr. Cathy Jaynes, Former director of research at The Center For Medical Transport Research. Former College Campus Chair at the University of Phoenix, Former Assistant Professor at The University of Colorado - Denver, Former Chief Flight Nurse at SkyMed.

The IFR twins can move adults when the weather grounds the singles out in the countryside. The singles can move patients in good weather, and are less costly to operate.

When Rocky Mountain Helicopters began to lose lucrative hospital contracts, they came up with the idea of the "Community Based" EMS helicopter, in which all staff work for the aviation provider. Thus was born LifeNet. This step got the helicopters away from the hospital, and put them out in the country where the patients are. Air Evac Lifeteam developed this model further, and experienced explosive growth. AEL provides rapid access to definitive care for millions of Americans. AEL looks for support from the communities they serve, and originated the idea of selling subscriptions. These subscriptions shield those transported from rapidly rising bills, now estimated to be in the range of $50,000 per flight. A subscriber is not liable for any costs beyond what his or her insurance company pays.

HEMS is, today, largely a fair-weather resource. In the advent of low ceilings and visibility, the vast majority of EMS helicopters are grounded. This is a tremendous weakness in the HEMS system, and the technology exists to overcome it. Today.

Tiered reimbursement, in which government payments would be adjusted to account for the costs of providing the transport, would help drive the industry towards - if not all-weather, at least adverse-weather capability. Instrument-flight-capable twin engine helicopters are much more expensive to operate, but beyond the increased safety and chance to capture more flight opportunities, there is no financial incentive to operate these more expensive machines. The ultimate capability to transport the ill and injured could be realized by use of a tilt-rotor. The tilt-rotor can operate around or above weather that will ground all the pure-helos. And it can best move patients interstate.

"Once you fly on a tiltrotor you realize that it cannot be compared to any helicopter. Its a turboprop that hovers while the helicopter is a helicopter with its limitations. God bless the tiltrotor. ....it has its place in EMS" Skip Robinson, Helicopter Industry Observer, Photographer, Author. 

Dr. Ira Blumen with the UCAN  Dauphin. Dr. Blumen led the

"Opportunities for Safety Improvement in Helicopter EMS" project.

Thanks to the knowledge and hard work of

people like Dr. Blumen, we have hope for a bright future for HEMS.

As Congress, the General Accounting Office, and the states come to grips with the issues facing HEMS and the health-care system; an understanding of where we are, how we got here, and where we might go in the future of HEMS will be key to sound decisions.

"(All this) sounds better than the race to the bottom we are in now but me thinks you're a dreamer." Tim Lilley, Pilot, 10 year HEMS veteran, MSM. 

 "Dreaming is critical! 😉"
Dr. Cathy Jaynes

Accident Review... Knowing when to say "enough."

14 CFR Part 91: General Aviation
Accident occurred Friday, March 06, 2015 in St Louis, MO
Probable Cause Approval Date: 06/22/2016
Aircraft: Airbus Helicopters (Eurocopte EC-130-B4, registration: N356AM
Injuries: 1 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.

The emergency medical service (EMS) helicopter was landing on a privately owned elevated heliport to pick up two medical crewmembers. The medical crewmembers had been dropped off with a patient on a preceding flight. During the preceding flight, the nurse thought about telling the pilot to abort the landing on the heliport because there was a lot of rolling and yawing, and he was having a hard time landing the helicopter. After the landing, the nurse and another medical crewmember stated that the pilot did not want to depart the heliport, but the medical crewmembers told the pilot that there may be potential arrivals of other EMS helicopters. The pilot chose to depart the heliport and obtained fuel at the operator's base of operations. For the return flight to pick up the two medical crewmembers, the wind had increased, and the helicopter approached the heliport in high-wind conditions and with a right, quartering tailwind. Also, the wind along with the surrounding buildings likely created a turbulent airflow/windshear environment in which the helicopter was operating as it approached for landing. The helicopter's operation in a high-power, low-airspeed condition in high-wind conditions, including a right quartering tailwind, likely resulted in a loss of control due to settling with power.

A security video showed the helicopter on a northerly flightpath descending at about a 45-degree angle before impacting the ground and coming to rest on an approximate northerly heading. The pilot sustained fatal injuries due to the subsequent fuel tank fire/explosion, which otherwise would have been a survivable accident.

A postaccident safety evaluation of the heliport showed that the final approach and takeoff area/safety area were obstructed by permanent and semi-permanent objects that pose a serious hazard to helicopter operations. These obstructions limited the available approach paths to the heliport, which precludes, at times, approaches and landings with a headwind. The helipad is privately owned; therefore, it is not subject to Federal Aviation Administration (FAA) certification or regulation.

A review of the helicopter's flight manual revealed that there were no wind speed/azimuth limitations or suggested information available to pilots to base the performance capabilities of the make and model helicopter in their flight planning/decision-making process. Examination of the helicopter revealed no anomalies that would have precluded normal operation and showed engine power at the time of impact.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's decision to land during unfavorable wind conditions, which resulted in a loss of control due to settling with power. Contributing to the accident were the lack of an adequate approach path due to numerous obstructions and the lack of available guidance regarding the helicopter's performance capabilities in the right quartering tailwind condition.

Born in Flight...

Flashback Friday: ICE ICE Baby!

In some parts of the country, it's almost that time of year for ice on and in the aircraft. a couple of years ago, we in HEMS crashed a machine due to liquid water (rain) getting into the skyward facing engine air inlet - which was covered by a particulate (dirt) barrier.
As temps dropped throughout the night, the liquid turned to ice. The crew launched on a flight, and the ice underneath the filter broke loose and got sucked into the turbine a short time after takeoff. The ice destroyed the engine and the aircraft did not autorotate successfully. 

A warm hangar would have helped...

A special notice about this is here...

While installing inlet covers is a pain, if a hangar is not available, and it is going to rain on your aircraft as the temperatures drop, it may be something to consider. We at this base are going to have to go out and run the aircraft each cold morning to defrost the blades, or suffer a delay upon activation for a ground run and visual check of the rotor blades. If there is frost on the cars in the parking lot, there is frost on the blades...

safe flights...