Wednesday, December 31, 2014

Signs Of Icing - from the JH forum

Bigger, rounded items of the aircraft create a flow field that slows down the rate of ice accretion, compared to smaller, thinner items. 

So look for ice to begin accreting first on things like windshield wipers, OAT probes, and wire strike protection blades.

Those kinds of things on the aircraft are what you pick out to look at. 

You will see ice accreting on these sorts of shapes and projections first. 

You should be aware of likely icing conditions during preflight planning, so as to stay out of them.

But there is an old saying, "Ice is where you find it," it's hard to predict, many variables.

So no matter what the forecasts or rather lack of icing forecasts, I always tell people, when you punch into cloud, take a look right away at your OAT gauge and scan it regularly. 

If the temps are right in cloud for icing, basically +2C to -15C or thereabouts, take some action to get out of that environment. 

Know the temperatures aloft from preflight planning, climbing won't always get you into the colder air and descending won't always get you into the warmer.

On that note, a temperature inversion mixed with cloud is a likely recipe for freezing rain type conditions, DON'T GO THERE.

Air Ambulances Lack Oversight on Medical Care... The Bend Bulletin

Courtesy Marklan Hawryluk/The Bend Bulletin...

Want to know how we got to where we are in HEMS?

Click here for the full and informative story...

Tuesday, December 30, 2014

Rapid Growth in Air Ambulance Industry Raises Safety Concerns

Fueled by high reimbursement rates and scant regulation, the rapid growth of the helicopter EMS industry over the past 15 years has transformed what many consider a life-saving service into an industry fraught with safety concerns but little oversight.

Saturday, December 27, 2014

Feedback on Sleeping on Duty...from our friend Josh

Dan, i couldn't agree with this post more. I say this having worked in both arenas. 7 years in a busy level I trauma center ED and in the flight arena. And I can say this, working a long 3+ hour flight at night with a sick pt. is just as tiring as a 12 ED shift. However, there are a few things to consider when comparing the two. First, i 
think that the "powers that be" fail to recognize what i call "insensible flight stressors." These include low humidity, low O2 environment, high stress, high noise and relatively high pt. acuity. these things combined create an increased metabolic state in the flight crew. (pilot included). Stated plainly, we chew up all our natural glucose and we're damn tired with our bodies having been in overdrive to maintain homeostasis for the duration of the flight. Now, in the hospital, the effects of being tired can range from fairly simple, like walking into the wrong pt. room to moderately bad, such as a med error. In the flight arena, the consequences can be much more dire. Walking into a tail rotor, in my opinion is a FAR greater consequence. (i know we've all been habitualized to maintaining our situational awareness, but people still get punchy, or they're new, or they're just plain tired and not paying attention) The tired flight nurse/medic is also prone to making pt. care mistakes. Often the pt's we fly are of the higher acuity and thus, much more medically fragile. Medical mistakes in this pt. population have far greater consequences that giving 60 Keterolac IV instead of IM in the hospital. Furthermore, when and IF a pt. goes south in the hospital, multitudes of people rush in and the medical menagerie begins. In the aircraft, its just you and your equally tired partner. No help. No pulling over. No flying faster. Just you and your partner.
I guess what I'm saying is this; Nurses get tired on duty, but comparatively, flight nurses face greater fatigue factors than hospital based RN's. The consequences however are far greater for the flight team. Not only for the safety of the crew, but for the quality of care provided, the utilization of limited care providers and the reputation and quality of the flight program.
12 hr shift or 24 hr shift? it doesn't matter. I've also worked both types of schedules flying, and there is little difference given the topic of fatigue. (I much prefer 24 hr shifts however.)
Flight crews should be required to rest while on duty. Their duties, responsibilities and the sheer gravity of the job they volunteer for demands their full attention, not standardization of flight RN vs. Hospital RN rest requirements.

Tuesday, December 23, 2014

To Sleep on Duty, or Not to Sleep on Duty...That is the Question...

Flying at 3 am  is different than working in a hospital at 3 am.

Long ago, I showed up at a HEMS base in the early morning to teach an AMRM class. I went around back, found an open door, and walked in quietly finding on-duty clinicians napping in recliners. There were no beds for them at that base. It brought back memories of "the rule" for many hospital-based programs with clinicians working 12 hour shifts.

No Sleeping On Duty...

One can imagine how this rule got started. When helicopters were all hospital-based, the medical staff worked for the hospital, and were peers of the clinicians working in-house. As no ED, ICU or floor nurses are permitted to sleep on duty, why would a flight-crew be permitted to sleep? Even the appearance of being treated preferentially could cause problems for the flight program. If word got out that leadership was letting aircrew members sleep, other staff on night shift might demand the same treatment.

This is a case of safety taking a back-seat to politics, perceptions, and appearances. The nature of flight duty on night shift is completely different than that of working in-house. Sitting around and waiting is different than walking around and talking to people in a busy health-care environment.

Some leaders will read this and consider forcing flight crews to work in-house while not on a flight, but the truth is - that option degrades the quality of the program and the morale of the staff. Flight crew members are special; they volunteer for hazardous duty, they take on much more responsibility than a typical in-house clinician. They are expected to be "better." They should be treated that way or they will end up leaving.

When your experienced staff leaves, it costs money for training, orientation, and mistakes. How much better and simpler things will be if we look at every policy and rule from an operational standpoint - and remember that often, what's best for your staff is what's best for your company. You don't want just any clown taking care of sick people in your helicopter.

Morale and training costs are not the main reason that flight crews working a night shift should be permitted to take naps. The real reason is that you - Mr. or Ms. Manager - don't want to be the person explaining to the media why you are hosting a memorial service.

In 2009 I was the pilot of the last aircraft in this memorial-flight line-up. My second. We can go a day, We can go a month. Can we go a full year without a HEMS helicopter crash? It's not up to me... It's up to you!

The NTSB and the FAA have done research on aircrews and fatigue. So has Dr. Mark Rosekind, currently leading the NHTSA and an expert on fatigue. Fatigue is a hidden factor in many of our mishaps. Fatigue affects mood, performance and judgement.

The nature of flight operations at night are completely different than taking care of patients in a hospital setting. Especially the empty-leg back to base after dropping a patient at a distant facility - the leg in which bad things happen most often. Crews get "up" for the patient-care portion of the flight, then they struggle to stay alert on the way home. If this return trip occurs at the nightly physiologic low-point - typically between 2:00 am and 4:00 am - then your crew will be as sharp as a bowling ball.

Fatigued crews lose the mental-edge that prevents loose latches, cowl-strikes, tail-rotor strikes, open fuel-caps, objects dropped from aircraft in flight, still-connected cords and cables, and -  God-forbid - mid-air collisions. Surely you remember a time when you were wide awake at work, and almost fell asleep on the drive home. Well now imagine that it's your pilot falling asleep, and the crew is sleeping with him.

Flying at 3 am  is different than working in a hospital at 3 am.

As Dr. Mark noted in his research, when you are tired, "any sleep is better than no sleep." Maybe you don't want to provide beds in bedrooms, comfortable recliners in a quiet dark room will suffice...

In the interest of safety, it should be the policy of your flight program that crews are permitted to nap on night shift. Even crews working 12 hour shifts. They are probably doing it anyway, and forcing them to break a rule to do what comes so naturally creates cognitive dissonance and emotional discord.

safe flights...

Monday, December 22, 2014

Is Mechanism of Injury a Valid Reason to Fly a Patient?

“It’s sort of the perfect storm,” said Dr. Michael Abernethy, chief flight surgeon for University of Wisconsin Health’s Med Flight. “It’s great money, it’s unregulated and there’s really no utilization criteria.” (quoted in The Bulletin, Bend Oregon)

If your system does not support viewing this video clip, access it by clicking here...

When we fly a patient who walks out of the hospital hours after arrival, some question the appropriateness of the flight. Then again, there are injuries which cannot be detected in the field, which might prove serious or fatal after some time has elapsed.

In some cases, staff at receiving facilities give helicopter crews a hard time.  "Why did you fly this patient?" asks the overworked and fatigued resident. Few if any cases allow a crew to decide that a patient does not need to be flown after arriving on scene. If first responders call, the patient will fly...

What do you think? Do you have any stories about flights that ended up being appropriate after all?

Here is one anecdote...

Some years ago I flew a mechanism of injury patient who was alert, oriented, and telling us not to make such a fuss over her, she was "fine".

We were only minutes into the flight when she decompensated, she became unresponsive and her belly began to show evidence of internal bleeding.

We were on our way to the "closest trauma center" in Camden, NJ, and upon arrival were unable to land as the pad was occupied by the State Police helicopter, shut down and unmanned delivering a patient the facility.

My crew made the decision to "cross state lines" (if you operate in the Philly area, you will understand that statement) to take her to our trauma center in West Philly (all of a 2-3 minute furthther flight).

We landed at our facility before the helicopter at the original destination had cleared the pad, in fact as I recall, the patient was in the OR, exanguination protocols in effect, by the time the other pad was clear.

Moral of this true story, unless you have a CT scanner available in your A/C or ground unit, perhaps mechanism of injury is not such a bad thing.

For all the naysayers, if this one life was saved for certain by that criteria, how many others have been as well?

Thursday, December 18, 2014

What Will Cheap Oil Mean For Us In HEMS?

Image courtesy BBC News

The effects of America's flood of oil are rippling out across the world. OPEC decided to continue production at current levels, effectively assuring a collapse of prices. We probably won't again see oil selling for less than $12 a barrel - as it did in 1999 when my entire new-hire class of  Gulf of Mexico pilots got laid off from Air Logistics. But the drop in prices is going to be big.

Click here for a story about trouble in the oil and gas industry...

Every change to the status quo brings winners and losers - and fear of belonging to the latter group is why so many fear change.

So, should we in HEMS be afraid?

That depends on what you do here. If you are an operator, your fuel costs have gone down and are going to go down further. The airlines are in the news because they are enjoying reduced fuel costs, and "keeping the money." We are airlines too. HEMS stands to benefit from cheap oil. History however is full of unexpected adverse outcomes. Every silver lining has a cloud.

If you are a HEMS pilot, cheap oil - resulting in less offshore oil and gas production - will mean more competition for a finite number of  HEMS pilot seats. When the wells are idle, there is no need for a helicopter to move workers to and from platforms. Offshore pilots are going to be looking for work, and filling open HEMS positions at entry-level wages. This will decrease pressure on HEMS operators to raise pay, so we can expect stagnation in wage-growth in the immediate future.

Overtime - or "workover"  opportunities will diminish, and relief pilots (like me) will be less important  (oh well, it was fun while it lasted!) Companies will be in a position to pick and choose from the available-pilot pool, and experience-minimums will increase. On the downside, there will be more people with no HEMS experience making the same mistakes new HEMS pilots have always made, and we will suffer more crashes due to stupidity. On the plus side,  people with questionable histories will be passed over in favor of spotless candidates.

And yes, operators do compare notes about pilots...PRIA notwithstanding. There are few secrets in HEMS.

There will likewise be an increase in the size of the available mechanic pool, and the same downward pressure on wages. Companies might even be able to properly staff bases with two mechanics working week-on week-off which would improve the mechanic's lot in life. So - perhaps for you "wrenches," less pay and a better quality of life.

Cheap oil will mean more people traveling and crashing cars, More spendable cash will mean more risky behaviors - smoking, drinking, speeding, falling off golf carts and 4-wheelers. Flight volume should increase. This will keep more bases in operation, and should be good for clinicians who aren't facing a mass-reduction in other health-care production. When I started flying HEMS there were about 300 helicopters in HEMS service, now there are about 1500. So lots of nurses, medics, and RTs get to scratch the flying itch.

So, is cheap oil good or bad for HEMS?

I guess it depends on your position and perspective...

Tell us what YOU think...

safe flights.

Sunday, December 14, 2014

The Details Matter...Even When We Are Tired

I had the pleasure of speaking with the Director of Flight Operation of a very large EMS helicopter company. We were discussing crashes. I mentioned that I had read a pilot's report to the NTSB stating that he had felt like his approach was fast and steep, as might occur if one was landing with the wind or "downwind" prior to initiating a go-around. As the pilot applied power to climb and accelerate, the aircraft began an uncommanded yaw that turned into several rotations in the yaw axis, loss of control, and a crash. People were killed.

The D.O. stated that this has happened more than once.  Pilot's preparing to land at 2:00 am don't perform as well as they might at 10:00 am, and this is made apparent by studying HEMS crashes and hospital security-camera feeds.

All pilots know that they should go through a deliberate set of steps prior to landing. A before-landing-check should be verbalized, a statement of the planned path in (and out) should be made with an announcement of any hazards observed. If you only have one motor, the forced landing location(s) should be announced so that you and all others on board know where you are going when the engine quits.

Sidebar: If your pilot has not announced a visible hazard, like a tower or wires or a vehicle - she might not see it. You must announce it.

And - very importantly - the pilot should announce his or her opinion of where the wind is coming from and how it might affect the helicopter. Often when we land there is no wind sock on scene. So we must determine the wind direction and velocity through other means. If I state where I think the wind is coming from, and you disagree, now is the time to speak up.

Unfortunately for us, when we are out in the wee hours, we don't perform as well as we do during the day when fresh and rested. It's a proven fact. Read the NTSB reports.  Our mood, performance, and judgement are degraded.

And that's why we tend to crash more in the middle of the night. When tired we just do the minimum to get by; to get the aircraft, crew and patient to the destination.

We can miss the details.

If we are landing, and you see smoke from a stack flowing in the
same direction we are flying, call a go-around. Landing downwind
leads to vortex-ring-state and loss of tail-rotor effectiveness

For this reason, at night is when established procedures, protocols, checklists and company best-practices must be adhered to. Like performing a high recon, like knowing where the wind is from, Like getting the aircraft slowed down per company policy. Like flying the correct angle.

Note that if I am falling short on any of these items, the only persons who can point this out to me are you two or three crew members flying with me. There is no second pilot to catch my mistake.This means you have to know how things are supposed to look and feel, and speak up if something is off. I am a damned good pilot. And I haven't crashed.


This makes me just like your pilot.

As a human being, I am subject to make a mistake, like a guy in Texas did. He initiated a go-around, aborting his approach because it didn't feel right. And it led to a crash.  In another event - on video - another guy did the same exact thing and got into the yawing spin. That helicopter went around about 45 times, yes forty-five times, before the pilot initiated a climb in desperation. He got some altitude , reduced power, and let the helicopter fall off to one side. The aircraft weather-vaned, stopped spinning, and he was able to fly out of it.

"Well pardon the crap in my pants..."

So, perhaps we should focus on getting it right the first time in - especially at night. Some aircraft are more susceptible to loss of tail-rotor effectiveness than others, but they are all subject to vortex-ring state, and hitting things. In any helicopter, a small decrease in rotor RPM - such as might occur during a massive power increase when aborting an approach and starting a climb - will equate to a much greater loss of tail-rotor/fan RPM and authority. In a BK the ratio is 8 to 1 TR to MR.  And when that tail rotor stops being effective we will push more pedal until it either is effective or it stalls.

Note: In the first event referred to here, the pilot reported that he did NOT apply FULL pedal against the yawing spin. We should be ready to apply full pedal to control the aircraft. This has never happened to me, but experts say full pedal will arrest the yawing motion. Both pilots reported that "the cyclic stopped working." This led the DO to surmise that the aircraft, when spinning rapidly - on the order of 360 degrees per second - can get out of sync/phase with cyclic inputs. If the nose is down, and the pilot inputs aft cyclic, the delay in cyclic effect means that the aircraft has spun to the point that the input is reversed. This is something to consider, and more reason to avoid letting the yaw get away from us. Apply full pedal against yaw as required...

Crews can assist with determining wind direction. Look fo flags in the wind, smoke from stacks, groundspeed versus airspeed comparisons, and wind correction headings inbound to the destination. All these serve to tell us the wind direction and speed. Wind can change near the ground, and we have to be ready for this, and ready to call a go-around.

Wednesday, December 10, 2014

Newest Cool Device : X-Stat Dressing (from the Trauma Professional's Blog)

You land at a scene for a shooting victim. You load him into your aircraft and a stream of blood sprays up and over the patient/pilot barrier and lands in a spotted pattern on the pilot's knee-board. He exclaims.

Gauze and pressure aren't stemming the flow, and you have a long flight back to a trauma center.

Perhaps this product would help...

We were pointed to this by Dr. McGonigal on his blog. Click here.

Read more at a PopSci article here...

Thursday, December 4, 2014

Some Thoughts for Today. What is The Role of Culture?

Air Medical Resource Management Operates at the Intersection of Psychology (what's going on between my ears) and Culture (what's going on in my organization) ... William T. Winn

By Dan Foulds

I am going through my AMRM presentation slides today, making some changes and preparing for classes next Monday and Tuesday. I decided this was worth sharing and hope you agree. If you have any thoughts let's hear 'em. And "war stories?" We love stories.

As a medical crewmember, communications specialist, mechanic, or member of hospital security, at times we hesitate to speak up, to ask a question. We don't want to appear dumb, we worry about appearing to lack trust. We worry about being perceived as a trouble-maker and perhaps losing our job.
As pilot, we may hesitate to speak up for fear of showing weakness.

This hesitation is especially prevalent in new crew-members. The nurse who died in a crash in Newberry SC was new. The nurse who died in Georgetown SC was new. 

You don't get to be new here. You must ask and learn NOW.

Ridicule, intimidation, and sarcasm have no business in this business. Culture begins with senior leadership and ends with you.

The National EMS Pilot's Association has prepared a great cultural health assessment tool, CHAMPS. It only costs $500 to find out what your cultural "pulse and pressure" are, and you can compare your organization to others ( no identifying information is shared). You can also compare one part of your program to another part. Visit NEMSPA to learn more.

Corporate Culture: A Case of Monkey See, Monkey Do?

Written by Fred Nickols

Did you ever wonder how your company's culture – that set of beliefs, traditions, and behavioral norms that determines "the way things work around here" – came to be? Or why, when you try to change it, it seems so resistant? Well, here's a little story about a scientific experiment that shows how culture comes into being and why it is so resistant.

The experimenters began with a cage, a set of externally enforced boundaries. Inside the cage, they hung a banana on a string and placed a set of stairs under it. They then introduced five monkeys into the cage. Before long, one of the monkeys started to climb the stairs toward the banana. As soon as it touched the stairs the experimenters sprayed all the other monkeys with really cold water. When another monkey made an attempt to get the banana they again sprayed the other monkeys with cold water. After a while the monkeys prevented any of their group from going after the banana.

After the cultural prohibition against "going for the banana" had been established the experimenters put away the cold water. They took one of the original monkeys out of the cage and introduced a new one. Upon spotting the banana the new monkey went after it. To its surprise and dismay all of the other monkeys attacked it. After another attempt and attack the new monkey learned that if it tried to climb the stairs and get the banana it would be assaulted and so it stopped going after the banana. It had been acculturated, assimilated into the cage's "don't go for the banana" culture.

Next the experimenters removed another of the original five monkeys and replaced it with another new one. The second new monkey went to the stairs and predictably it was attacked. The first new monkey took part in this punishment with enthusiasm! Similarly a third original monkey was replaced with a new one, then a fourth, then the fifth.

Every time the newest monkey took to the stairs it was attacked by the other monkeys. Most of the monkeys that were beating it had no idea why they were not permitted to climb the stairs or why they were participating in the beating of the newest monkey. After all the original monkeys were replaced none of the remaining monkeys had ever been sprayed with cold water. Nevertheless, no monkey ever approached the stairs to try for the banana. Why not? Because as far as they knew: "That's the way it's always been done around here."

Tuesday, December 2, 2014

Is The Scene Safe?

The flight nurse looked out the back windows of the aircraft in disbelief. They had landed on a two lane road at an accident scene - in front of the aircraft a horrific car crash was being sorted out - behind them, the road was open. It was chaotic, and emergency vehicles were still inbound. As she glanced behind them, she observed a large vehicle bearing down on her. Too fast, too close. She yelled.

With feet to spare, the truck veered off the road and came to a stop beside the aircraft. The truck's driver had been unable to determine distance to the obstacle to his front - a running helicopter - because of the dozens of flashing lights and apparatus surrounding the scene. He was responding to a crash with his own lights and siren going, and had some adrenaline on board. It almost ended like this... ( the action starts about 1:45 in)

If the video is not supported on your device you can access it here.

The film above makes a good case for not having trucks driving next to a running helicopter on scene. If a picture is worth a thousand words, a film should be worth a few million (dollars - what that aircraft cost) How sad and ironic is it that you can survive for years operating "a collection of parts - flying in close formation - all supplied by the lowest bidder," and get whacked by a truck on the ground.

The hazards of  landing a helicopter at an accident scene are easily overlooked, especially after landing at a few hundred of them without incident. We take it for granted that everyone involved is trained, and knows what not to do - but every once in awhile this ends up not being the case.

I landed at a scene once in South Carolina. My crew asked me to stay running. As I watched them disappear into the back of the ambulance, the man they had designated as my "tail-rotor guard," wearing blue jeans with cigarette in hand, strolled up to my left front window and casually had a look at the cockpit. When asked to move away from the running helicopter, he stated that he knew what he needed to do.

Apparently not.

The situation is made more complex by the fact that we in HEMS depend on cordial relationships with first-responders for flight requests. If we don't get calls, we stop making house payments. We face competition in our service area, and we want them to call us, not the other program - so we walk a fine line between demanding a level of performance and accepting whatever-goes on scene. One thing you don't want to do is be the guy or gal who offends the volunteer-chief of the fire service setting up your scene; but you also don't want to kill a new probie - or have her kill you.

Clearly, the answer is communication and training. Someone from your flight program needs to visit every agency in your service area at least once a year to present a class on the good, bad, and ugly of scene operations. Someone needs to call and debrief each scene operation - what the military calls "after action review." If you are relegating this task to a business-development manager you are asking for trouble - they get paid to increase flight volume, not safety. Part of your training should be a review of actual accidents and incidents. There was a time when a director of operations I worked for didn't want us to speak about crashes with customers. As a person who has taught AMRM classes for several years and seen what works and what doesn't, there is nothing like a discussion of actual events - real people, real blood - to get someone's attention and buy-in for scene safety.

Click here for a story about the type of training that should be occurring everywhere.

Fly (and land) safely...


Tuesday, November 25, 2014


Since the installation of Appareo video and data recorders in EMS helicopters, there have been three separate incidents - two of them fatal helicopter crashes - in which a pilot continued flight into bad weather, became disoriented, and allowed the aircraft to enter unusual attitudes.

He then reached forward and caged the attitude indicator.


Let's consider what is happening  The pilot elects to fly under visual flight rules into reduced ceiling or visibility. He either thinks that he is up to the task of instrument flight, or he hopes that things won't get worse and will get better shortly. Things don't get better and the pilot loses ground reference entirely. He is in the goo and cannot tell which way is up or down by looking out the window

Although he may have some experience flying on instruments, he is not proficient; and he loses control of the aircraft, allowing it to get into an unusual attitude. This often occurs during a turn back to where things were better.

By now his vestibular and proprioceptive systems are lying to him, At some point he realizes he has gone too far, and fear kicks in. It's tragic that he wasn't more afraid sooner.

He looks at his attitude indicator, and doesn't believe it. It is tilted over on it's side, and pitched up or down, and it just can't be right. He doesn't "feel" like he is turning and diving.

So he takes his hand and re-cages the gauge. 

Several seconds later (at 2318:40), with the helicopter at high pitch and roll angles, the
pilot pulled a knob on the instrument panel to cage the attitude indicator (which sets it to display
a level flight attitude). Caging an attitude indicator is meant to be performed only when an
aircraft is in a level flight attitude, such as on the ground or in straight-and-level, unaccelerated
flight. As an experienced pilot and mechanic, he would have understood the conditions under
which the attitude indicator could be safely caged. Therefore, the NTSB concludes that the
pilot’s action to cage the attitude indicator outside those conditions under which it could be
safely caged indicates that he distrusted the information he was seeing. (Possible reasons for this
distrust are discussed in section 2.6.) By caging the attitude indicator while the helicopter was at
high pitch and roll angles, the pilot caused the instrument to provide erroneous attitude
indications that would be difficult to ignore in a high-stress situation

Click here for full report...

The attitude indicator, if caged while upside down, will indicate right side up. If you have just caged the attitude indicator in the picture above, with your aircraft upside down, it is still upside down!

God forbid, if you are a crew member and I have taken you into the clouds, and you see me reaching for that knob - tell me THAT WON'T WORK.

The attitude indicators on early aircraft failed often. The were considered a "secondary" instrument, less reliable than the altimeter, vertical speed indicator, heading indicator, and turn indicator. Pilots are required to demonstrate the ability to fly "partial panel" with a cover over the attitude indicator during instrument proficiency checks - but VFR EMS  helicopter pilots - even though an instrument "rating" is required, do not have to take an instrument check ride. We must only demonstrate the ability to recover from an unusual attitude and shoot a single approach.

This is not enough to prepare a visual pilot for instrument conditions.

(edit: 10/02/17 Here is an excerpt from an accident report involving a pilot, patient, and medical team that crashed after encountering fog at treetop level immediately after takeoff from an interstate highway accident scene.
"The pilot's...training records indicate that he completed initial new hire ground and flight
training between April 15 and April 20, 2003. During initial flight training, he received 6.6
hours of flight training in a Bell 407 of which 1.6 hours were at night and 0.2 hour was
simulated instrument flight. He completed recurrent training in a Bell 407 on August 28,
2003, receiving 1.3 hours of flight instruction of which 0.2 hour was simulated instrument
flight. He next completed recurrent training in a Bell 407 on April 19, 2004, receiving 1.2
hours flight instruction of which 0.3 hour was simulated instrument flight. On April 27, 2004,
he satisfactorily completed the required 12-month 14 CFR 135.293 competency check and the
14 CFR 135.299 line check in a Bell 407 lasting 0.9 hour."

This training experience is typical for a VFR HEMS pilot. This pilot had zero actual instrument time. He was not ready to fly in fog or cloud and his last decision before he killed himself and his crew was to attempt to get under it. As his record shows, the instrument training provided to a VFR HEMS pilot in a VFR helicopter is extremely limited.)

So we better stop or divert before we get there - in the clouds, or snow, or heavy rain,. Stop because we aren't prepared, we aren't proficient, we aren't ready.

And three of us have proved it by putting their hand on a knob.

This pilot made the mistake - and lived to tell the tale. Click here.

Disclosure: During my last check ride with my company, I was forced to demonstrate partial panel flying, with a cover over the AI. This is the first time in twenty five years or so that I had to do this. It is very good training and something we should all do regularly. You do not need an attitude indicator to fly on instruments. Practice, practice, practice.

VFR EMS pilots should be required to take an instrument proficiency check at least once a year. A real check ride, not one approach.

Crews - do not let your VFR  pilot take you into instrument conditions. Please. You can prevent a fatal crash. If you know of team members who are not as familiar with what is happening here - such as pediatric or neo-nate team members, or perfusionists - people who don't fly as often and don't hear about events like this,  please call them and discuss this. You may save their lives.

Speak up!

Monday, November 24, 2014

Quick and Dirty: Posterior Hip Dislocation

Here’s a quick 5 minute video full of tips on diagnosing and managing this injury. Click here to view video.

Material from Dr. McGonigal's "The Trauma Professional's Blog" posted with permission.

Action Team Trip...Dinner With Friends...

We just returned from Dallas after attending  the third set of "action team" (FAA term) meetings to advise a working group that will advise an aviation-rule-making committee on new rules for Helicopter Air Ambulance (FAA term) pilots training. Still with me? It is a real eye-opener getting to see how rules get made, and pretty cool being here for the National EMS Pilot's Association representing the guys and gals on the front line. And straight-up I have to say that there is a lot of good "face-time" with chiefs and directors of operations (and Terry Palmer who directs training for Metro and is an Omniflight graduate!) I volunteered for this duty and have given up about a week of my time, but it has been a learning experience. Pilots - I recommend you join NEMSPA, get involved, volunteer to take on a project, and have fun with it. To a man (and women) every person on this team is totally decent, respectful, and (I believe) appreciative that us pilots want to be better trained, more professional...
More safe.
Last night at dinner, Kevin (Bell instructor) and Dennis (Air Methods DO) got into a discussion about 206s and engine failures. Apparently in 80% of the engine failures in a 206, the engine would relight if given the chance. So a technique is - if the motor quits - to mash on the start button with the throttle WIDE OPEN. At 60 knots the airflow will prevent an overtemp - and honestly if there is an overtemp followed by a safe landing - who cares.
Dennis told us that - after losing a friend to an engine failure fighting fires, he would, when dropping water, just hold the start button on during his final run-in. This momentarily fails the generator (with a light) but ensures that if the engine would restart it does.
I think conversations like this (and there were lots more!) are a big reason pilot training should be in a group environment, with time to interact, socialize, tell stories, and...

Monday, November 17, 2014

CRM (AMRM) Fundamentals (posted on the JH original Forum)

Feel free to commit this to memory and also have it laminated for your wallet...

*Eight Multi-Crew Coordination Procedures Applicable to All Flight Operations*

1. If you do something, announce it

2. If you need/want something done, ask for it

3. When you hear a statement or question, acknowledge it

4. Announce changes to aircraft flight path, configuration, or condition

5. Question unannounced changes to the aircraft's flight path, configuration, or condition

6. If another crewmember does not perform as expected, prompt him

7. Listen to inputs and judge information, not the source

8. If you suspect a problem exists, talk about it and eliminate doubt

Picture credit: Brady Palmer
From a 'hooker...

Thursday, November 13, 2014

2009 Washington Post Special-Report on HEMS : In Five Years, Much Has Changed, Yet Much Remains the Same...

This report provides an interesting retrospective on our industry. Many of  the numbers have changed, and now most of us do fly with NVGs and radar altimeters. Yet many of the issues raised in this in-depth report continue to factor into our crash-rate today.

What began almost four decades ago as a way to save lives is now one of the most dangerous jobs in America -- deadlier than logging, mining or police work -- with 113 deaths for every 100,000 employees, The Post found. Only working on a fishing boat is riskier. 

October 2014 Crash, One of Three In Just Over a Year...

To Read This Multi-part Story Click Here...

Monday, November 10, 2014

Safety Through Helicopter Simulators...

The NTSB has prepared a video on the use of simulators to prevent crashes. I wish I was not as familiar with the crashes discussed, but this is a small industry and I know them all too well. Pay special attention to the point that our current auto-rotation training does not prepare us for a forced landing/engine failure sequence. Mental rehearsal and proper mindset are going to be key if our one motor quits.

To view this excellent video covering simulators and actual crashes click here...

NTSB: 'Inadequate safety management' contributed to fatal trooper helicopter crash

Photo Courtesy of Stephen Nowers

The deadly crash of Alaska State Trooper Helo 1 near Talkeetna in 2013 was tied to state Department of Public Safety policies that encouraged pilot Mel Nading to take dangerous risks, the National Transportation Safety Board has concluded.

Click here for full story..

Click here to link to crash sequence video...

Saturday, November 8, 2014

Unsung Heroes... Redux

With the advent of community-based operations, the aviation-services-vendors have become their own worst customers, demanding things that, in the past, would not have flown. And the mechanics have suffered.

Bobby Mordenti showed up at the hangar today, looking no worse for the wear. Amazing, considering what happened to him a few weeks ago. He was standing on a ladder, waxing the tail boom of  his aircraft, and fell. The ladder made a racket - thank-goodness - and the firefighter-medics here at the base went to see what was going on. One of them began treatment and the other came running inside to get more stuff and call for help. Bobby was out-cold on the concrete, with a plate-sized circle of blood coming from the split in his head.


Bobby has been a "wrench" for longer than some of his pilots have been alive. When speaking with him, a sense of camaraderie develops quickly. Hangar talking is good stuff - a pilot who asks questions and listens can learn something. Decades ago, Bobby sailed his boat to Charleston, South Carolina for a job as the mechanic for an EMS helicopter there; the Medical University of South Carolina's MeducareAir. When he was getting tied up at the dock, a kid working at the marina named Jess Perry helped him. They struck up a friendship, and Jess ended up going to Embry-Riddle and getting his Airframe and Powerplant certificate.

Jess was in Savannah maintaining a BK-117 when I showed up in 2000, after fleeing a Pennsylvania winter. We worked together four years. For years after I left, I would call and ask his advice about this or that happening with a helicopter, and he never complained or griped - he just kept giving up the gouge.  Jess spent twenty or so years himself as the LifeStar-Savannah mechanic, and did a wonderful job keeping a great ship in the air.

Jess now lives a "normal" life working for Gulfstream. I can't say that I blame him. A HEMS mechanic's life is grinding. They are on-call 24 hours a day, with perhaps one or two weekends off a month; by that I mean away from the base with the pager turned off. For the privilege of having a day off, they are usually responsible to cover another mechanic's base so that guy or gal can have a day off - it reminds me of the old HEMS pilot's "Chinese Vacation." If the helicopter gods are angry, and both ships break, there is hell to pay.

Image courtesy John Mulder, WARDOG

I don't know how they do it, these "knuckle-busting" trouble-shooting quiet-professionals. They have to get the aircraft exactly right every time or else, in the face of constant pressure for more in-service time. Now days scheduled-maintenance has to be performed during the hours when flight requests are least likely - this is when most humans are sleeping - and this mid-night labor often occurs out in the open on an exposed helipad; by flashlight. And guys still sign up to do it. When vendors had hospitals as customers, this wasn't how things were done. Maintenance was understood to be part of aviation, and it was done as required and when required - rarely in the middle of the night by a single mechanic out in the open. What kind of signal do we send to mechanics about their value to the organization when we treat them with so little regard? When we make a job so distasteful that the best and brightest, like Jess Perry, leave the workspace, what does that leave us with? How deep into the labor pool will we have to dip before we scrape the bottom?

With the advent of community-based operations, the aviation-services-vendors have become their own worst customers, demanding things that, in the past, would not have flown. And the mechanics have suffered.

I wonder why we don't make more of a fuss about the guys (and gals?) who keep our butts alive by providing us safe aircraft to fly. We have our professional organizations, and they recognize the Nurse or Medic or Pilot "of the year" but never have I seen a mechanic's face in a trade publication being honored for the huge part they play in a successful HEMS enterprise. Maybe it's time for AMMA. The Air Medical Mechanics Association... What the hell? All the other groups have their alphabet clubs.

They are like bass players or drummers in a rock-star band. We couldn't do this business without them, but they toil in the background, unseen, unheard, and largely unappreciated. They receive polite applause, because it's obligatory. But they are never recognized for being the absolute rock-solid foundation upon which safe aviation operations stand. When Omniflight Helicopter's owners decided to do away with their own ability to fix helicopters - it spelled the end of the company.

Times are changing.

There is a new breed of mechanic coming along now, and they are too smart and too cool to stay in the shadows. One is a young fellow named John Janiszewski. John decided to highlight the fact that "wrenches" are indeed "rock stars" and created a company selling Aircraft Mechanic Shirts (and other cool stuff).

                                         Photo from http://www.aircraftmechanicshirts.com/
                                         Property of John Janiszewski

He creates shirts and other items that make clear how much we need a good mechanic to fly sick people - indeed to fly at all. On top of this, John is a working HEMS mechanic, maintaining a helicopter on the line. When you go to Johns online "store" be sure and check out his blog post about using social media to enhance your business. I did, and it makes perfect sense. He is a real guy, with a bunch of real good products, and you can actually speak with him.

For a neat little video about John and his company, click here!

That young man's going places. His ad is on this blog because I believe in him, his work, and his message.

Maybe - thanks to people like John - and his products - we can bring  bring  mechanics out of the background - to the front of the stage. Like the rock stars they are!

                               Photo courtesy of Mike Harrington. Flight Engineer, Crew Chief,
                               Helicopter Mechanic!

safe flights...

Sunday, November 2, 2014

Ever Wonder Where The Golden Hour Came From?

The BTLS course attributes the term to R Adams Cowley from the ShockTrauma Center in Baltimore. Unfortunately, no references are given. A biography of Cowley entitled Shock-Trauma names him the author of the term, basing it on dog research.

To read more from Dr. McGonigal's great trauma blog, click here.

Avoiding a Mid-Air with "Rough Air"

While riding in one of Delta's cramped cabins last week on the way to Denver, I listened as a flight attendant announced that we should wear our seat belts when seated in case we encounter...

"rough air."

I like this euphemism for turbulence. It sooths. Rough air isn't something to be overly concerned about. Turbulence is.

As we cruised along, with my shoulder, arm,  and leg in constant contact with a stranger sitting next to me on what Delta calls a seat, I looked out the window and thought to myself, "at least it's a beautiful day with a smooth ride."

Without warning the aircraft dropped with a violent motion. If I hadn't been strapped in, I would have come unseated. Nervous laughter filled the cabin, then a quiet waiting for the other shoe to drop.

A few minutes later, a pilot made a PA and explained that we had encountered the wake turbulence of an aircraft 8 miles ahead. Wow - 8 miles and it rocked our world - in a fully loaded passenger jet.

Imagine hitting that wake in your little helicopter.

I did that once myself. I was departing from the now-closed Caraway hospital in Birmingham, Alabama, which sits close to the airport and near the final approach course to one of the runways. I took off headed away from the airport and turned back toward the University of Alabama Hospital at Birmingham, which lies across that same final approach course. A jet had just landed at the airport, but as I hadn't seen him on his final I didn't give it much thought. He was down and no factor.

His wake was still there though, invisible, in front of me; in my mighty Bell 206 L-4. Under a cloudless blue sky in calm winds we flew right into an invisible hammer that slammed us. It was an Oh-crap! moment. And a lesson.

Pilots of all aircraft should visualize the location of the vortex trail behind larger aircraft and use proper vortex avoidance procedures to achieve safe operation.

Crew members can assist with situational awareness, by staying aware of other aircraft in the vicinity and visualizing a wake streaming along behind and perhaps below these aircraft. Ask questions about where that wake might be now, and where it might be going. In a busy moment, while talking to ATC and listening to an LZ briefing, and getting ready to land near an airport, a pilot might not be aware of a pending wake turbulence encounter. You can help with this. It's no different than looking for wires and towers.

Except you might be able to see them. You have to anticipate "rough air."

Too learn more about wake turbulence, click here...

Safe Flights...

Image courtesy AirLiners.net

Friday, October 31, 2014

A Powerful Message From Randy Mains...


After returning to my hotel room from the second round of meetings with the HAA action team in Denver yesterday, my phone rang - it was a number I didn't recognize.

"Hello this is Dan..."

"Hi Dan, this is Randy Mains, did I get you at a bad time?"

I had the time and we talked for an hour, sharing experiences, AMRM teaching ideas, and things we have seen in the classroom that didn't fit - like a student fixated on a smartphone while we are doing everything within the limits of heart and soul to keep them alive.

I have known about Randy for years, as he writes in several magazines, has published books, and has presented several times at the Air Medical Transport Conference. When NEMSPA president Kurt Williams and I met him this year in Nashville - it made the trip! Randy is absolutely committed to ending the loss of EMS helicopters and crews.

As am I.

It was an honor to speak with him again, and hear about his trip to produce a "Digital Safety Story." This is a great project and these stories impart wisdom. We can learn from someone else's pain and suffering - instead of our own.

Check out Randy's digital safety story here by clicking here.

Wednesday, October 29, 2014

Acting NTSB chief says automation affects professionalism...

Click here to read full story pointed out to us at nemspa.org

"How do we design this whole human-machine system to work better so we don’t lose the professionalism in the humans who are doing this?”

Tuesday, October 28, 2014

Lesson Learned

Blogger is not the place to post an album of pictures. Facebook works better for that. The NBAA pics are at helicopterems.com on facebook. Hope to see you there...tell us what you think.

Saturday, October 25, 2014

ATC Audio From Mid-Air Collision.

One of the hazardous attitudes we face is "invulnerability," or "it could never happen to me.

It could.

Watch out!

Click here for audio...warning...discretion advised.

Saturday, October 18, 2014

Lawsuit Filed in Fixed Wing Air Ambulance Mis-Fueling Crash

According to a report released by the National Transportation Safety Board last month, the twin-engine aircraft was refueled with 40 gallons of jet fuel instead of aviation gasoline before it took off from the Las Cruces airport on Aug. 27.

Read full story by clicking here...

Wednesday, October 15, 2014

Throw-Back-Thursday... The Smartest Person in the Helicopter...

The guy or gal flying the aircraft you are riding in may not have the best handle on what is going on with the aircraft, the environment, and the situation at any instant.

Don't believe me? Start reading  N. T. S. B. reports.

How could this be?

As we contemplate crashes, mishaps, and injuries, it is easy to fall into armchair mode and smugly ask ourselves "how the heck did they do that?" Monday-morning quarter-backing ignores the fact that the people who participated in the adverse event were in the arena.

As safety-expert, AMRM wizard, and former EMS pilot William Winn pointed out in his work on AMRM and situational awareness; we who fly operate in a naturalistic environment. So, what does that mean, "naturalistic environment?"

It means that flying an aircraft into uncertain weather at 2:00 AM with unlit towers in our path, birds everywhere, a patient whose condition is deteriorating, a headwind that wasn't forecast, and a fuel gauge racing to empty is much different than sitting on one's sun-porch and pontificating.

Here is a note on a famous "naturalistic environment."

On January 22nd 1991, during the Gulf War, an eight-man S.A.S. (Special Air Service - Britain's version of -  and the precursor of -  our Delta Force) team known as Bravo-Two-Zero were sent on a mission behind enemy lines. Their mission was to remain concealed near the main supply route in Western Iraq for 14 days. During this time they would be expected to sever Iraqi fibre-optic cables, and report on the movement of scud missile launchers. However, due to source limitations, they were given suboptimal equipment. They also received vague intelligence reports. This was apparent when they arrived at their drop off point to find it only about 200 meters from an Iraqi anti-aircraft stronghold. This had not been reported by Intelligence. Because this information was crucial to the success of the mission, the group attempted to contact their base via radio and inform them of the new situation. It was at this time that they realised that they had no contact with base. It was later discovered they had been given the wrong radio frequencies. The group then made the decision to sit out until a liaison arrived in 24 hours. Unfortunately, that was too long a wait. They were spotted by an Iraqi goat herder, and from then a malady of errors began its course. The team were separated. They were confronted with intermittent enemy contact, and were completely unsupported by the larger organisation. Over the next three days, three of the eight died, and four were captured. Only one man made his way back across the Syrian border. This planning error resulted in one of the most costly patrols in SAS history. 
(David, 1997) 

This event was described in a riveting book and movie, and points out how the best-laid plans can go to hell in a handbasket.

This happens to us too, in our helicopters, as we fly sick people from one place to another...

If you want to become more informed about how naturalistic environments affect decision-making, click here (paper by Dr. Taryn Elliot)

In a nutshell, what we have to do at 2:00 AM (or at anytime we are flying) is react to ever-changing conditions by an ongoing process of situation-assessment, pattern-recognition, situational-awareness, and decision-making. Each choice we make affects our future, and typically leads to other choices having to be made, to react to future changes in our situation. All this occurs in a rapidly-changing dynamic environment with various stressors - like fatigue, distractions, and a lack of resources like time.

 The pilot said he performed a "high recon" of ...the... helipad and called out his intentions to land. He performed the pre-landing checklists, and started the approach to the helipad from the northwest at an altitude of 700 feet above ground level (agl). Both of the hospital's lighted windsocks were "limp" but were positioned so they were pointing toward the northwest. The pilot, who had landed at this helipad on numerous occasions, said the approach was normal until he got closer to the helipad. He said he felt fast "about 12-15 knots" and a "little high," so he decided to abort the approach. At this point, with about ¼ to ½ -inch of left anti-torque pedal applied, he added power, "tipped the nose over to get airspeed," and "pulled collective." The pilot said that as soon as he brought the collective up, the helicopter entered a rapid right turn. He described the turn as "violent" and that it was the fastest he had ever "spun" in a helicopter. The pilot told the crew to hold on and that he was "going to try and fly out of it." The pilot said he tried hard to get control of the helicopter by applying cyclic and initially "some" left anti-torque pedal "but nothing happened." The pilot said he added more, but not full left anti-torque pedal as the helicopter continued to spin and he was still unable to regain control. He also said the engine had plenty of power and was operating fine. The pilot recalled the helicopter spinning at least five times before impacting the ground. The pilot said the helicopter landed inverted and quickly filled up with smoke. He unbuckled his seatbelt assembly, took off his helmet, punched out the windshield and exited the burning helicopter.

On it's surface, this event started with a decision to abort the approach because it didn't feel right. Although the official cause has not been determined, one possible scenario is a downwind approach, followed by vortices from the main rotor disk interfering with the tail rotor and creating loss of tail rotor effectiveness. The downwind landing would have felt wrong because the speed across the ground would have been faster than normal, and faster than the speed through the air. Being pushed forward by a tail wind would steepen the approach angle and make one feel a "little high" on approach.

At night, it is hard to determine wind direction in flight. And easy to get it wrong.

"It would be expected that the more experience a person had, the more successful they would be at decision-making. However this has been found to be incorrect. It seems that decision error can be attributed to any of: individual, organisational, or social factors." (Dr. Elliot)

It's no wonder that things go wrong. Indeed, it's a wonder that things don't go wrong more often. The standard operating model in HEMS is a single-pilot, single-engine aircraft with modest capabilities, and "crew-members" who are not really recognized as such by the FAA or - frequently - the pilots flying the aircraft. Vernacular statements like, "self-loading baggage," "climb-in, strap-in, and shut-up," and "you take care of the sick people and I will fly the aircraft," reveal the state of things in our industry.

And this contributes to fatal crashes.

Although we don't usually don't have a copilot in our helicopters, we do have at least two smart people on board who can be developed into resources able to help us make choices that don't kill us.

We can discuss what we think is going on, with our medical crew, and ask them what they think. We can also ask them to point out things, like flags blowing in the wind, smoke coming from smoke stacks, or wind effects on bodies of water. As an instrument pilot, I used to brief crews on approaches, and if I said, "now what was that decision altitude again?" they would announce it.

In short, I treat my crew like pilots in training, and explain as much and as often as possible.  They begin to think like pilots. I haven't crashed yet.

Sometimes a layman comes up with the answer that saves the day. We can't shut anyone out, or alienate anyone to the point that they sit back and shut up and watch us make a mistake. Although my medical crew members are - perhaps - busy taking care of a patient, they are certainly NOT mired down with flying the aircraft. They may see something I don't, or become aware of something I am not, like a new ticking sound or a new vibration, or a new smell...

Note to crew: It's very hard to only crash a part of a helicopter. Never give up on the situation, even if your pilot doesn't play well with others.

I sat in the jump-seat of a C-5 Galaxy once, on a flight from Japan to Korea. As we got ready to take-off, the PIC stopped the aircraft (all 380,000 pounds of it), turned around, and stated to the entire body present, "okay, so what we are going to do is..." After describing his understanding of the future, he made sure that's what we all had in mind too - even me, an army warrant officer helicopter pilot. He wanted to develop a "shared-mental-model," and offer a chance for anyone to detect a plot-flaw.