Tuesday, March 12, 2013

It Could Never Happen To Me... The Hazardous Attitude Known as "Invulnerability"

When I stand in front of a room full of Helicopter Emergency Medical Services (HEMS) professionals and conduct a class on Air Medical Resource Management, I don't read from a script. We attempt to cover the same points in each class; but the manner, words, and phrases often differ depending on the vibe. It's hard to illuminate a topic - often associated with "safety" - in a way that keeps these bright, busy, type-A individuals in the game. They expect value for their time. I often wonder if there is some way I can express a thought, or an emotion, that will keep these friendly faces alive. I have found that it helps to discuss something other than Helicopter EMS - for hazards abound in every aviation endeavor. One particular hazard worth mention is the attitude we call "invulnerability," the mindset that a fatal crash could never happen to me . So let me tell you about a young man I never met, although I wish I had. He was - by any measure - a great American, a great guy, and a fantastic aviator. He must have been a source of immeasurable pride and joy and sorrow to his mother and father.

I have spent so much time thinking about Lt. Commander Kevin Davis, and his last few moments alive, that I feel as if I know him, and I hope he doesn't mind me trying to derive some use, some benefit, from his tragic death. I watched him die, and it affected me.

Kevin Davis attended Embry Riddle Aeronautical University, earning a Bachelor of Science degree in Aeronautical Science with honors in 1996. We graduated from the same University in the same year. He completed primary flight training at NAS Corpus Christi, Texas, and transferred to NAS Meridian, Mississippi, for intermediate and advanced flight training. While there, he flew the T-2C Buckeye and TA-4J Skyhawk, and received his wings of gold in June 1999. I had just retired from the Army and begun flying EMS helicopters.  Kevin reported to Fighter Squadron 101 (VF-101) at NAS Oceana, Virginia, for training in the F-14 Tomcat and was the “Top Stick” in his class. I doubt that this was his first brush with being the best. His parents raised him right, and created the kind of young man that anyone would emulate, and admire. In December of 2004, Kevin graduated from the United States Navy Fighter Weapons School (TOPGUN) as an adversary pilot. Here again, he was standing out above the crowd, as the opposing-force pilots are  handpicked - the best - in order to adequately prepare students for combat. Kevin joined the Blue Angels in September 2005. His role at first was to be the voice of the Blues, and to fly members of the media and celebrity-guests in the interests of creating a positive image of  the United States Navy. Thanks to YouTube, we can join Kevin on the job. I want you to listen very carefully to Lt. Commander Davis as he subjects the aircraft to high-G maneuvers. A "G" is equivalent to one times the force of gravity. Fighter-jet aircraft can maneuver such that the force of gravity can be multiplied greatly. Listen to Kevin's voice and his breathing....you may hear him grunting in a turn. Also listen to his instructions to his passenger, Steve, a reporter for the Atlanta Journal Constitution.


Now, watch a famous person - a man who knows a thing or two about going fast - getting the ride of his life in a jet. During these maneuvers they will  exceed 7 Gs.


G forces are a large consideration during high speed maneuvers, because during positive G multiples, blood is pulled from the brain and begins to pool in the lower extremities. This leads to a gradual loss of ability, on all levels. Vision tunnels - as if one were looking down a progressively narrower tube with black around the edges. Pull hard enough and vision goes to a dot, then blackness followed by unconsciousness. The last thing to go, and the first thing to return, is awareness.  GLOC stands for G induced loss of consciousness. Gray-out refers to partial loss of ability to fly. Fighter pilots combat GLOC and gray-out with special leggings called G-Suits, which might be compared in function to MAST trousers. G-Suits are automatically inflated by aircraft systems during high G maneuvers and serve to prevent O2 rich blood from leaving the brain.

Blue Angel pilots don't wear G suits.

This because their demonstrations require them to fly within a foot or so of each other. Such precision flying requires very fine hand movements. To facilitate this, Blues run their seats forward, which raises their upper legs. They rest their forearms on their legs and make control inputs by moving their hands at the wrist. A G suit might inflate and cause an inadvertent control input with disastrous results. So Blues use other techniques. They do a lot of squats, and develop muscular torsos, and when flying hard they clench their leg muscles and grunt-breath. Grunting raises blood pressure and keeps blood in the brain. They do this without conscious thought, it's a secondary task.

Side Bar: Primary versus Secondary Tasks

When pilots begin flight training, the most basic tasks -  like hovering, or making a normal approach to a landing - demand full concentration and effort. Ask a new student pilot a question while she is performing a maneuver,and she may be unable to answer. Manipulating flight controls to make an aircraft respond correctly takes a multitude of fine-motor skills, precision muscle movement, and constant correction and adjustment. In the beginning, it's hard.  As time passes and experience comes, tasks that were once difficult become progressively easier. Muscle memory and pattern recognition combine to permit pilots to relegate what were once primary tasks to secondary status. We can perform these secondary tasks without conscious thought. And this is a good thing - it allows us to do more than one thing at once, a vital skill for any pilot. We have to fly, think ahead, tune and talk on radios, and pay attention to what is going on around us - all at once. If we could not multi-task, we would need several crew members to do what one or two can do. Unfortunately, this ability to discriminate without awareness - what you are doing when you drive your car across town and realize after the fact that you remember nothing about the trip - can get us into trouble.

When we are distracted, or anxious, or under great stress, that task that we have relegated to secondary status may not be performed to standard. A helicopter pilot who is upset upon hearing that the fuel cap may not be on the aircraft - and may instead be laying on the parking apron at the airport just departed - may be so distracted during his approach to a large field for a check of the fuel tank - that he crashes the aircraft. This actually happened.

On the day that Kevin died, he was performing for the first time as a member of the demonstration team. His mom and dad were on hand. Under bright blue skies at Beaufort Marine Corps Air Station, Kevin and his team mates put on a dazzling performance of skill. Paramedic Les Langdale and I were there with the helicopter from Charleston. We had no nurse with us, and anticipated a pleasant day, friendly people, and good PR. As the show wound down, the signature "gotcha" flyby took place, in which the crowd's attention is drawn to one side of the airfield while a lone jet sneaks up from behind at almost supersonic speed and startles the novice Blues fan. These last minutes of flying left the aircraft spread around the horizon, and as an afterthought, they were joining up several miles away in order to return and land. Kevin was flying in the opposite direction to the other aircraft, and made a call to the team-leader, something like, "boss, I am out of position, I will be with you shortly." It was at this point that a minor oversight, a single lapse of attention, and the fact that Kevin could fly his jet without thinking about it, all combined to take his life. Kevin was "here" and wanted to be "there" and going in the opposite direction. So he moved the stick. And it would appear that he failed to "take a deep breath and clench those legs." A seven G maneuver, one that he could talk through with Dale Earnhardt Jr. on board, brought him down...


This occurred while Les and I were preparing to leave. I turned on the radio and asked the tower if they needed help. The tower advised us to proceed 300 degrees for three miles. A lone Blue orbited overhead. We flew over a small pond surrounded by people all pointing into the middle. I thought to myself, Good God, he's gone into the water. That was not the case. While some parts of the jet splashed down, other parts went smoking through roof peaks, lay here and there along a one lane road, and were embedded in a stand of pine trees. Les suggested we fly up his inbound path to search for a parachute, so we did, with no joy. Les said, "I think he rode it in so he wouldn't hit a house." The report says he had it nose-up, rolling wings level, in full after-burner, and may have been trying to save the jet. During the crash sequence, his seat ejected spontaneously and he was killed by the impact. He didn't kill anyone on the ground. A blessing.

CNN Reports:

The crash at 4:00 PM ET Saturday, during a precision-flying team demonstration, injured eight people on the ground and damaged eight structures. None of the injuries is life threatening. CNN is reporting that the jet clipped the top of a pine tree during a sharp turn at the end of the team's aerial exhibition. The crash sent a plume of smoke into the sky, which the five other jets in the formation then circled.

While I was in Concord NC recently, presenting this as a case study, I got to this point in the presentation and observed a young women in the back of the room with tears sliding down her cheek. It hit me. We should not take this  lightly. It was a tragedy and a huge loss for Kevin's family, our country, and all of us who fly.  Perhaps we can keep Kevin in mind as we go about our flying duties, and remember.

The next time you are feeling invincible, bullet-proof, and like God's gift to aviation, remember Kevin Davis. Remember that if the best of the best, a superbly skilled, highly trained, disciplined and dedicated aviation professional can have a momentary lapse and lose his life, well then, anyone can... Don't let this happen to you.

The full investigation report is here:


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