Baby It's Cold Outside...

Crash review: two on the same day, two for the same reason...

Read. Do not repeat...

NTSB Identification: CEN13FA121
14 CFR Part 91: General Aviation
Accident occurred Wednesday, January 02, 2013 in Seminole, OK
Probable Cause Approval Date: 05/08/2014
Aircraft: EUROCOPTER EC130 B4, registration: N334AM
Injuries: 4 Serious.
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 pilot reported hearing a sound like something had struck the helicopter shortly after departure while about 1,600 to 1,700 feet mean sea level. The engine lost power, and the pilot performed an autorotation to a field. While maneuvering to land, he saw a barbed wire fence obstructing the intended landing area, so he maneuvered the helicopter to clear the fence. The helicopter subsequently cleared the fence and landed hard in a field.
Engine examination revealed that the four axial compressor blades exhibited significant deformation on the outboard tips of their leading edges in the direction opposite of normal rotation consistent with the ingestion of soft body foreign object debris, such as ice. A subsequent engine run did not detect any preimpact anomalies that would have precluded normal operation. For 3 days before the accident flight, the helicopter was parked outside without its engine cover installed and was exposed to light drizzle, rain, mist, and fog. The engine inlet cover was installed the day before the accident at an unknown time. The helicopter remained outside and exposed to freezing temperatures throughout the night until 2 hours before the flight. Although the helicopter was maintained in a ready status on the helipad and maintenance personnel performed daily preflight/airworthiness checks, the inlet to the first-stage of the axial compressor was not inspected to ensure that it was free of ice in accordance with the Aircraft Maintenance Manual. Based on the weather conditions that the helicopter was exposed to during the 3 days before the accident, it is likely that ice formed in the engine air inlet before the flight and that, when the pilot increased the engine power during takeoff, the accumulated ice separated from the inlet and was ingested by the engine and damaged the compressor blades.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of engine power due to ice ingestion. Contributing to the accident was maintenance personnel’s delayed decision to install the helicopter's engine inlet cover until after the engine had been exposed to moisture and freezing temperatures and their inadequate daily preflight/airworthiness checks, which did not detect the ice formation.

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NTSB Identification: CEN13FA122
14 CFR Part 91: General Aviation
Accident occurred Wednesday, January 02, 2013 in Clear Lake, IA
Probable Cause Approval Date: 02/12/2015
Aircraft: BELL HELICOPTER 407, registration: N445MT
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.

GPS tracking data revealed that, after departure, the helicopter proceeded westbound about 600 ft above ground level (agl), following a roadway. About 6 minutes after liftoff, when the helicopter was about 3/4 mile south of the accident site, it turned right and became established on a northerly course. The helicopter subsequently turned left and appeared to be on a southerly heading at the final data point. Shortly before beginning the left turn, the helicopter entered a climb, reached an altitude of about 1,800 ft agl, and then entered a descent that continued until impact. Weather observations from the nearest Automated Surface Observing System, located about 7 miles east of the accident site, indicated that the ceilings and visibility appeared to be adequate for nighttime helicopter operations and did not detect any freezing precipitation. Although an airmen’s meteorological information advisory for icing conditions was current for the route of flight, and several pilot reports of icing conditions had been filed, none of the reports were in the immediate vicinity of the intended route of flight. Witnesses and first responders reported mist, drizzle, and icy road conditions at the time of the accident. It is likely that the pilot inadvertently encountered localized icing conditions, which resulted in his subsequent in-flight loss of helicopter control. A postaccident examination of the helicopter revealed no preimpact failures or malfunctions. The engine control unit recorded engine torque, engine overspeed, and rotor overspeed events; however, due to their timing and nature, the events were likely a result of damage that occurred during the impact sequence. Evidence also indicated that the cyclic centering, engine overspeed, and hydraulic system warning lights illuminated; it is also likely that their illumination was associated with the impact sequence. Further, the engine anti-ice status light was illuminated, which was consistent with the activation of the anti-ice system at some point during the accident flight.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s inadvertent encounter with localized icing conditions and his subsequent in-flight loss of helicopter control.

________________________________________________________________________________

NTSB Identification: CEN13FA174
14 CFR Part 91: General Aviation
Accident occurred Friday, February 22, 2013 in Oklahoma City, OK
Probable Cause Approval Date: 01/14/2016
Aircraft: EUROCOPTER AS 350 B2, registration: N917EM
Injuries: 2 Fatal, 1 Serious.
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 services helicopter departed a hospital helipad in dark night visual flight rules conditions and proceeded on its mission. Satellite data showed that, after takeoff, the helicopter began a gradual climb toward its planned destination. The data stopped about 3 minutes and 30 seconds into the flight. No distress calls were heard from the pilot. Fixed video surveillance cameras located near the accident site showed the last few seconds of the helicopter descending toward the ground. The helicopter impacted a parking lot, and a postimpact fire occurred.
Examination of the wreckage revealed that three of the engine’s first-stage axial compressor blades exhibited deformation consistent with soft body foreign object damage. The remainder of the engine and airframe exhibited no evidence of malfunction that would have contributed to an in-flight loss of engine power.
The helicopter’s air intake design, which had been modified to accommodate a different engine than that originally supplied by the helicopter’s manufacturer, incorporated a blanking plate attached to the top side of the engine cowling that covered a portion of the air inlet screen. A gap in the area where the blanking plate and the screen overlapped made it possible, in certain meteorological conditions, for water or snow to pass through the screen, accumulate on the blanking plate, and freeze into ice. Ice accumulation in this area, if left undetected, could result in the ice detaching from the blanking plate and entering the engine during operation, causing soft body foreign object damage and a loss of engine power. Precipitation and outside temperatures ranging from 35 to 19 degrees F occurred during the 12-hour period preceding the accident. The combination of these meteorological conditions was conducive to the formation and accumulation of ice in the area between the air inlet screen and the blanking plate.
Although the helicopter’s flight manual supplement for cold weather operations recommended installation of an air inlet cover after the last flight of the day, during the day and night before the flight, the helicopter was parked outside on the helipad without an air inlet cover installed. According to the helicopter’s mechanic, he inspected the helicopter on the afternoon before the flight and noted that some snow had accumulated on it. It is likely that the lack of an engine air inlet cover allowed precipitation to accumulate in the vicinity of the engine air intake.
The helicopter’s flight manual cold weather operations supplement also contained instructions for the pilot to perform a visual and manual (tactile) inspection of the air intake duct up to the first-stage compressor for evidence of snow and ice. Furthermore, the manufacturer and the Federal Aviation Administration had previously released information notices regarding inflight loss of engine power due to snow or ice ingestion caused by inadequate inspection or removal of snow or ice from the engine air inlet. These notices recommended a thorough inspection in and around the engine inlet area in order to detect and remove any snow or ice accumulation before flight.
The initial on-scene examination found no remnants of ice or snow on these components because exposure to the postcrash fire would have melted such evidence. Surveillance video of the helipad showed that most of the helipad lights were off at the time of the pilot’s preflight inspection immediately before the flight, making it difficult for him to detect any ice or snow accumulation in the area of the engine air intake. Thus, the ice accumulation between the air inlet screen and the blanking plate remained undetected, and shortly after takeoff, the ice detached from the blanking plate, slid into the air inlet, and was subsequently ingested by the engine, resulting in an in-flight loss of engine power.
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The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of engine power due to engine ice ingestion during initial climb after takeoff in dark night light conditions. Contributing to the accident were the lack of an installed engine air inlet cover while the helicopter was parked outside, exposed to precipitation and freezing temperatures before the accident, and the pilot’s inadequate preflight inspection that failed to detect ice accumulation in the area of the air inlet.

AAMS 2017 Award Winners Announced...Jobs Well Done!

The Association of Air Medical Services has announced the winners of this year's community awards. While all the winners are undoubtedly deserving and have our congratulations - we know two of them. And we are excited for them and their achievements. And as for the award for an air medical mechanic? Well, it's just wonderful to see a mechanic being recognized. Perhaps it's time for an Air Medical Mechanics Association? Way to go friends! We are proud of you!












To see the other award winners, click here...

Duke Life Flight Memorial Service

Historic Perspective - The University of Iowa and AirCare

AirCare was the 11th EMS helicopter program in the country and has flown more than 30,000 patients over 3,000,000 miles. We are proud to be a part of the regional EMS system as we work very closely with area first responders, police, fire, and ambulance services to provide safe and rapid response to emergency situations.



It was no April Fool when AirCare had its first flight on April 1, 1979. Our first aircraft, the D model A-Star (the first A-Star to be utilized for air medical transport in the U.S.) had a transverse loading system (the second picture is of the loading system). No extra room for sure! The flight nurse sat forward going out to a scene and backwards when attending to the patient in a reversible seat. Of note, we flew with one flight nurse for the first seven years of the program. Flying alone with the pilot made for some very interesting flights and you haven't lived until you have done one-person CPR at 5,000 feet!




Our first A-Star left much to be desired. It was a cramped area with very little leg space for the patient, making it difficult at times to accommodate those Hare traction splints. We often used the MAST trousers as a pneumatic splint for lower extremity fractures, allowing for easier loading of the patient. It is hard to believe we made it through those early years.





What is that? It is an Allouette III helicopter which was used mostly for mountain flying as its powerful engine was capable of providing plenty of muscle in the thinner air of the mountains. We had the Allouette III helicopter for several months in the early 80s as a spare, while our primary A-Star was going through several modifications addressing the problem of limited patient space.

The unique characteristic of the Allouette was the ability to shut down the spinning rotor blades and keep the engine running. It had a neutral. We used this capability at scenes ensuring a rapid departure, but one major drawback was that its top speed was 80 to 90 knots. It took forever to get anywhere!

After our A-Star came back from the shop, we investigated new and more efficient interior loading systems. In 1983, Omniflight Helicopters won the AirCare contract. Our vendor helped design our first fore-aft loading system, using the available space more efficiently, plus having complete access to the patient.

Omniflight Helicopters used Bell Long Rangers when the A-Star had prolonged hourly maintenance done.




For the first seven years of our program, AirCare averaged more than 900 flights per year, with many flights missed because we were already on another flight. In 1986, Rocky Mountain Helicopters won the contract and has been with us ever since (now operating as Air Methods).

In 1987, due to the ever increasing number of patient transports, AirCare trialed a second A-Star based at the University of Iowa Hospitals and Clinics.



After one year, the second A-Star was moved northward to Schoitz Hospital in Waterloo, Iowa (now based at Covenant Medical Center). AirCare II was put into service in 1988, which provided better response times for the Iowans in the northern tier of counties.

(As of this writing) AirCare consists of an EC-130 based at the University of Iowa Hospitals and Clinics and an A-Star based at Covenant Medical Center. (Added - the team now has three bases including a ground specialty team. HelicopterEMS.com)



This historical summary is a first-person narrative by Mike Dillard, RN, who was the longest serving member of AirCare. Mike joined the program in 1980 and retired after 30 years with over 3,100 patient transports.

Images and text courtesy of University of Iowa Hospitals and Clinics. For more info click here

Final Approach...

NTSB Identification: CEN16LA386
14 CFR Part 91: General Aviation
Accident occurred Thursday, September 29, 2016 in Lawton, OK
Aircraft: BELL 407, registration: N361SF
Injuries: 4 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 29, 2016, about 0600 central daylight time, a Bell 407 helicopter, N361SF, impacted terrain following a loss of control while attempting to land at the Comanche Country Memorial Hospital Heliport (18OK), Lawton, Oklahoma. The pilot and 3 crew members sustained minor injuries and the helicopter was substantially damaged. The helicopter was registered to and operated by Survival Flight Inc. under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed for the flight which operated on a company flight plan.

The pilot reported that he maneuvered the helicopter to align with the helipad. During the descending right turn to the helipad, the pilot input left cyclic and the helicopter was unresponsive. The pilot lost control of the helicopter and it landed hard then collided with a wall.

The helicopter was retained for further examination.

Position Paper : Incorporation of medical team members flying in single-pilot aircraft for challenge-and-response before-take-off confirmation checks.

Our objective is the safety and success of all HEMS/HAA flight operations. In addition to the tragedy for those involved in a mishap, the catastrophic loss of an aircraft or team significantly damages the reputation and standing of all programs engaged in HAA operations.

For this reason, we have agreed to join with other industry stakeholders and advocate for a best-practice concerning the incorporation of trained and briefed medical flight team members for confirmation checks immediately prior to lift off in an EMS helicopter.

At present most EMS helicopters in the US are flown by a single pilot. These pilots routinely start the engine(s) and prepare for takeoff using a cockpit “flow” or “wipeout,” that is to say they “DO” start their aircraft from memory, and one or more times during the preparations sequence they are responsible to pick up their checklist and, scanning it rapidly they “VERIFY” that all required steps have been completed.

This enables a much more rapid departure than would be possible were the pilot to proceed down the checklist line-by-line. While some programs do adhere to a line-by-line method of checklist accomplishment by a single pilot, having one person responsible for doing and verifying creates the opportunity for a "single point of failure" with tragic consequences. "The DV method has a higher inherent risk of an item on the checklist being missed." (Federal Aviation Administration - FAA)

In HAA operations, safety is paramount, but a timely departure is important too, and do-verify has worked well for the vast majority of HAA flights over the years. Having said that, there have been instances in which a pilot, for various reasons, fails to properly configure the aircraft for departure. In response to these events, some operators have added a “confirmation checklist” to be used immediately prior to liftoff. Typically included on this confirmation checklist would be items that, if overlooked, could cause the loss of the aircraft and/or the crew.

A customary method of posting the confirmation checklist is for it to be printed on a vinyl sticker which is then affixed to the instrument panel in plain view of the pilot. Unfortunately, the same human-factors which cause a pilot to overlook an item on the do-verify engine start and before take-off checklist procedures can cause a pilot to overlook the same items on the confirmation sticker.
Such errors of omission have resulted in damage or destruction of several aircraft, serious injury to crew members and pilots, and, in at least one incident, a fatality.

The tenets of crew-resource-management dictate that we use “every resource available to us” for the safe, orderly, and expeditious accomplishment of our assigned flight tasks. A medical team member, while not “flight crew” per se, and while not regulated by the FAA (second crew member for NVG flight ops below 300 feet excepted) does, over time, become intimately familiar with flight operations. As well these medical team members have a vested interest in safety, as their lives are on the line right next to the pilot’s.

In many US flight programs, the decision has been made to have a medical team member act as an additional layer of safety by having that person read a before take-off checklist or confirmation checklist in the manner of “challenge and response,” This practice does not absolve the pilot of responsibility to ensure that all steps are accomplished. It simply incorporates a resource that is sitting there.

In FAA publication 8900-1 paragraph 3-3403, the FAA refers to this method as "Challenge-Do-Verify." We use the term challenge and response for clarity and brevity. A flight-team member refers to a list and issues a challenge. A second person - normally the pilot - verifies that the step is complete by looking and touching, then responds appropriately. Involving two people reduces the chance for a single point of failure.

"... (this) method keeps all ...involved 'in the loop'...and provides positive confirmation that the action was accomplished." (FAA)

At times the medical team is busy caring for a patient – but the request by the pilot for the “checklist please” is a clear alert that the aircraft is preparing to depart. This enhances everyone’s situational awareness, and in all but the most extreme patient-care situations (for example, CPR in progress), at least one team member can take the few seconds required for the challenges.

Examples of the items that might be included in a challenge and response confirmation checklist are: (these are only examples, your results might differ.)

Engine controls set to fly. (at least three twin-engine Agustas extensively damaged for one engine at ground idle during takeoff. At least three instances of a twin-engine Dauphin taking off with one engine at ground idle

Hydraulic switches set and checked. At least three Astars have been damaged or destroyed for hydraulic switch(es) set incorrectly. A news helicopter in the US was also destroyed for this error of omission and a person on the ground was killed.

Fuel transfer switches set “on.” At least two BK-117 aircraft have been extensively damaged due to the transfer switches set to “off.” One pilot was paralyzed. In Scotland, a police helicopter crashed through the roof of the Klutha Pub after supply tanks became empty with transfer pumps off, killing several persons on the ground in addition to the crew on board.

Internal and external light switches set, caution panel checked. In a BK-117, having the instrument light potentiometers/rheostats set to “on” during periods of daylight renders the caution segments and master caution lights too dim to see. This error of omission strikes in conjunction with the fuel transfer switches being left off. When the low fuel lights and master caution lights come on the pilot can’t see this during daylight conditions.

Drugs and mission equipment checked. This is an example of an optional item that may be included in a confirmation or BTO checklist. In more than one instance, an aircraft has departed without the required meds or equipment. This renders the aircraft and team not-mission-ready, and often requires a time-consuming delay, which is less than optimal for patient care. Obviously, the list of items on the confirmation checklist should be kept as short as possible. In this case, the medical team member calling out the challenge would either respond him or herself or would look to the second medical team member for a verbal response.

In summary…

With the clarity of hindsight, it is apparent that the vast majority of  HAA flight operations are conducted smoothly, safely, and to the benefit of the patients we fly. But our goal is ZERO aircraft destroyed and ZERO teams/pilots/patients injured or killed.


The cost of the recommendation we have laid out here is insignificant. The delay that this practice will entail - ten or twenty seconds - is insignificant. The significance of not losing lives to an error of omission cannot be overemphasized.

Please consider incorporating this recommendation as a “best practice” for HAA operations.

Thank you.

This practice has been endorsed by:

Dan Foulds, Owner - HelicopterEMS.com, Owner - AMRM Training Solutions, Emeritus board member -The National EMS Pilots Association. Retired EMS pilot. Retired Army Aviator. Contributor: Vertical 911

Miles Dunagan, Current president of the National EMS Pilots Association. Active EMS pilot.

Kurt Williams, Immediate past president of the National EMS Pilots Association. Former EMS pilot. Manager for a large HAA provider.

Rex Alexander, Past president of the National EMS Pilots Association. Former EMS Pilot. Former regional manager for Omnflight Helicopters. Industry expert.

Justin Laenen, Member, National EMS Pilots Association Board of Directors. Current EMS pilot.

Sam Matta, Co-founder of E.C.H.O. Active EMS flight nurse. Combat veteran.

Krista Haugen, Co-founder of the Survivor’s Network for Air Medical transport. Trained AMRM facilitator. Flight Nurse. Crash survivor - takeoff with one motor at ground idle.

Colin Henry. HEMS expert, safety consultant.  Former director of safety, Medflight of Ohio. Former chief pilot, Omniflight Helicopters. Colin writes, "On point! This is about Human Factors and not about good piloting skills."

Peter Carros. Retired military helicopter pilot. Former HEMS pilot. Safety Manager - Geisinger Life Flight, Danille PA.

Additionally, some variation of this practice is already in effect at numerous flight programs across the United States.

disclaimer: This is not intended to suggest any action not in accordance with federal aviation regulations. Consult appropriate oversight personnel before implementing any change to flight procedures.

OMAHA — Three families will receive $18.4 million to settle their lawsuits over a 2002 medical helicopter crash in Norfolk that killed three people aboard.

We can learn from our history, or we can repeat it... Do you remember this crash?

Read the report and ask yourself, "what would I do differently if I had been in this pilot's seat?"

From the NTSB report...
"The helicopter impacted the terrain following a loss of control. Shortly after departing the hospital on a medivac flight, the pilot requested that company dispatch have the company mechanic meet him at a nearby airport because he was experiencing "binding in the right pedal."
An airport employee stated that just prior to the accident, she saw the helicopter hovering over the ramp and thought it was going to land.

Four other witnesses reported seeing the helicopter climbing and thought it was taking off. Witnesses also reported seeing the helicopter spinning (directions vary) prior to it descending to impact. One witness reported the nose of the helicopter was stationary on an east heading and the tail of the helicopter was swinging back and forth. He stated the helicopter then veered to the left and he lost sight of it when he traveled behind some buildings.
Another witness reported seeing the helicopter rocking nose to tail and going in a circle, but not spinning, prior to impact...

The guarded hydraulic cut-off switch was found in the off position.
Records show the pilot had approximately 2,500 hours of helicopter time with a total of 43.8 hours of flight time in this make and model of helicopter. Winds at the time of the accident were from 200 degrees at 16 knots, gusting to 21 knots.

The Federal Aviation Administration Rotorcraft Flying Handbook states that a loss of tail rotor effectiveness "may occur in all single-rotor helicopters at airspeeds less then 30 knots. It is the result of the tail rotor not proving adequate thrust to maintain directional control, and is usually caused be either certain wind azimuths (directions) while hovering, or by an insufficient tail rotor thrust for a given power setting at high altitudes."

(Editor's note, While the inclusion of this bit of information by the NTSB isn't technically erroneous, it indicates that they did not fully understand the causes of this crash, and simply listed things that may have been a factor. As it turns out, the tail-rotor on the Astar has tremendous authority, is on a long arm (the tail boom), and few pilots have ever mentioned LTE in the same sentence with the name Astar)

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A loss of tail rotor effectiveness and the pilot's failure to maintain control of the helicopter. Factors associated with the accident were the binding of the tail rotor pitch changed rod, the gusty wind conditions, and the pilot’s lack of total experience in this make and model of helicopter.

We humbly suggest that the problem was not a lack of technical proficiency. The problem seems to have been the choices this pilot made. The problem was judgment or the lack of it.
Because there was no voice-recorder on board, we don't know when the pilot first became aware of a flight control problem. Was it as he came up to a hover off the pad? Was it on climb out? Was it in cruise flight?

One thing we do know however, is that at the first sign of problems with a flight control system, we should land - either as soon as possible or as soon as practicable, depending on the problem. Don't try and diagnose a flight control problem while flying. Land.

This pilot apparently was thinking about other things besides landing right now. It appears he was attempting to be a "team player" by requesting a technician to meet him at the airport. But what if he could have simply performed a precautionary landing at the first sign of trouble? When faced with a problem in flight, we will be better served by landing and sorting things out on the ground.
To include "how will maintenance find us?" Years after this event a pilot flew an Astar for 15 or 20 minutes with the red oil pressure light on. And then crashed.

When something is wrong - LAND. Better to over-react than under-react.
Maybe this pilot was worried about hovering with limited ability to control the tail rotor. And maybe that is why he headed to an airport. But if that was the case, shouldn't he have performed a run-on landing? Or a slow shallow approach? Or an autorotation? To the runway? Isn't that what we do when we lose tail rotor control? (depending on problem and rotorcraft EP...)
Maybe he didn't think his problem was a big deal. But then it was. It is unlikely that he took off with the hydraulic cutoff switch off, more likely that he was attempting to sort out a problem while flying. Instead of landing...

If you encounter a situation like this while flying; as soon as you get the aircraft to a state where you can control it, stop making changes to aircraft configuration and land. And if you have to run it on, do it. Don't hesitate to ask for help and execute the the most conservative response.
(while complying with the rotorcraft flight manual emergency procedure and company guidance...)

Disclaimer - This post is not intended to open old wounds or cause pain or discomfort to the families of those involved. The sole reason for these discussions is to learn, so that no one repeats this tragedy. If there is any good to come from a crash, it is that we learn how never to do that again. We also know that luck plays a part in any crew's life, and that on any given day it may be our turn to measure up - or not.

You can read more about this crash by clicking here.

Trust - But Verify!

Soviet–American relations. Suzanne Massie, a writer in Russia, met with President Ronald Reagan many times between 1984 and 1987. She taught him the Russian proverb, "Доверяй, но проверяй" {Doveryai, no proveryai} (trust, but verify) advising him that "The Russians like to talk in proverbs.
Wikipedia

Image courtesy Belfast Telegraph

Pilot Dara Fitzpatrick and her crew were lost as a result of a crash. There are lessons for all of us in this event. And if you do some soul-searching, you will realize that what happened to them could also happen to us. Take care. May God bless their souls and comfort their families.

"Ireland's Air Accident Investigation Unit (AAIU) released its preliminary report on the crash which stated that the helicopter's Honeywell Enhanced Ground Proximity Warning System (EGPWS), which alerts pilots to imminent danger from terrain and obstacles, does not include either the terrain of Blackrock island or the lighthouse on the island."

That single statement points towards a human-factors accident. A human failure to act that resulted in needless deaths.

We can never rely completely on a sole-source of information as to our position, safe-altitude, or hazards ahead. In the interest of true situational-awareness we must continually verify one source of information with another. Heading, altitude, destination, route to be flown... As well we must never put our complete faith in an onboard system. These systems are "aids," but the human at the pilot's station is the final defense should a system fail to operate as intended. If ANY system suddenly begins to malfunction - for instance if an autopilot suddenly commands an unexpected hard turn at the end of a coupled-approach - the pilot must be ready for this. He or she must be instantly ready to override the system and take manual control.

We cannot get so focused on the task, the mission, or outside distractions that we place responsibility for our safety on technology. The U.S. Federal Aviation Administration has warned that we are "addicted" to technology. The worry is that our basic airmanship skills have degraded, that we are becoming "direct-to-and-go pilots."

Tomorrow, 4.26.17 marks 13 months without a fatal HEMS crash in America.

We can never let our guard down.

Image courtesy Belfast Telegraph.

Click here to read full story from the Belfast Telegraph

Flights On The Bubble

Update: Since I first wrote this, the NTSB has released their findings on one of the events discussed here. Not everyone agrees with the NTSB's conclusions - that is a common occurrence in events like this. I now believe it is an over-simplification and unproductive to find "pilot error" as the main source of a crash - in all but the most egregious and willful incidents of wrong-doing.

Did the pilot err? Maybe. But what role did the other parties play? What role did the culture of the organization play? What subtle pressures were being exerted - or not exerted - and how did that contribute to the pilot's error.

If we were to reexamine these crashes in the light of high-reliability-theory and system analysis and design, the causes would be revealed as more complex and nuanced. Repeatedly blaming the pilot doesn't change anything. If we don't change our way of thinking - these types of events will continue.

Whatever mistakes were or were not made - the victims paid the greatest price. As the companies and the lawyers and the insurance companies swerve, lunge and parry, let's remember this. In a fatal crash, no one wins. (Except maybe the legal teams.)

The crashes discussed here caused a tremendous amount of pain and suffering for the families and friends of these victims. Their lives are forever altered. Their suffering will not end and the sad memories will not ever be completely gone. Please keep these souls in your heart and your thoughts.

Please know that the purpose of writing this is not to cause fresh pain or re-open a wound. I write this in the hope that we can prevent a repeat occurrence. We have broken enough hearts and scarred enough souls.

Since family members contact me personally, I want them - and you - to know that I and others like me - Jonathan Godfrey, Krista Haugen, Randy Mains, Miles Dunagan, et al - are doing everything we can to make sure that no one else has to endure what these families must. We know that we can never push change on this industry, but together we might just give it a nudge.

Sadly, there have been more HEMS deaths since I wrote this. I wish it were not so. (dcf)

From before...

I have been thinking about Chad Hammond the last few days, Chad was a well-liked and well-respected helicopter air ambulance pilot who, along with his crew and patient, were the last souls to be killed in a HEMS/HAA crash, as of this writing. The anniversary of their deaths was March 26th. As that date drew near, I wondered if we - collectively - could go a full year without killing anyone. And I hoped. I have come to know Chad's widow Natalin over the year since his death, and pondered his loss, and hers, at length. The NTSB report on this crash is not yet complete, so any discussion of cause is pure speculation. But I see similarities in this event and others, and I think it's worth a discussion between you and your HEMS team mates. It may well turn out that all assumptions about what happened to Chad and his team and patient are wrong. About the other events, there is no question.

As an Air Medical Resource Management instructor, I look for patterns and attempt to point these out when I find them - so that you might recognize a pattern as well. So that you might realize an accident chain is being welded together. So that you will not be the subject of a story like this.

And this morning I thought about HEMS flights on the bubble.

Are you familiar with this phrase, "on the bubble?" It normally refers to a team or team member who is right on the edge of not making the cut. It is often used in the context of a sport.  But it has another meaning. According to the Urban Dictionary "on the bubble" can be defined as...

At risk. In peril. Most often used to describe someone or something that may be cut from scope or removed from the group.

So the context I am considering is a flight that a HEMS pilot and crew are considering that is "just good enough to go"  The weather minimums that we VFR HEMS pilots use are pretty loose. Here they are.



So you can see that if we have night vision imaging systems or an approved helicopter terrain avoidance and warning system, our route is non-mountainous, and our destination is within our "local flying area," (as much as fifty nautical miles away from the base) the weather can be as low as 3 statute miles of visibility and 800 feet of clearance between earth and clouds for a night flight. Now, most flight teams understand that those numbers aren't used to start a flight, they are used to terminate one, but invariably some volume-conscious manager will push, or an over-zealous flight team will blast off hoping for the best.  Perhaps the pilot is seeing a trend of improvement and assumes the trend will continue. Never mind the fact that when we consider weather categorically, 800 and 3 is considered IFR, or instrument flight rules weather.

IFR = 500-1000′ and/or 1-3 miles

I imagine helicopter operators pushed for such low numbers and were given them by the regulators because some of the things we can do with a helicopter involve flights very close to the takeoff point, or flights at a very low speed, such as hovering over a grove of fruit trees to keep them from freezing on a cold winter's night, moving timber down a hill to a river, or hovering along next to a high tension power line. And of course, a helicopter can stop just about anywhere, even though many of us pilots have died because of a shocking reluctance to use this capability.

So let's consider the pilot who checks the weather, and finds it "legal" and convinces the crew that all is well. As they proceed to the patient pickup point, things aren't great, but they are good enough to get by.

We are now flying "on the bubble."

We land on a scene or at a hospital pad, and the waiting game starts. Here is where we can get ourselves into trouble. We arrive on the bubble and while we wait it pops.

JALAPA -- Three times before dawn Tuesday, calls went out to emergency medical helicopters: A woman with a broken leg needed help along I-26 in Newberry County. 

Air rescue units from two Columbia hospitals and another in Greenville said it was too foggy to fly.

(added: One helicopter, "CareForce" from Richland Hospital in Columbia, launched and then aborted for weather.) 

A fourth call went to Spartanburg, where Regional One pilot Bob Giard checked the radar, decided the weather looked clear and took off with two crew members. 

The crew never reported problems with the weather en route to the site. But minutes after picking up the patient, their helicopter crashed in woods near the Palmetto Trail, about 1,000 yards from an I-26 rest area, authorities said. 

Giard, 41, flight paramedic David Bacon, 31, nurse Glenda Frazier Tessnear, 42, and an unidentified female patient died.  (text courtesy Associated Press)

Here is a bit from the NTSB on this crash.

"A single-engine emergency medical services (EMS) helicopter was destroyed after impacting trees in a national forest about 0532 eastern daylight time. Night visual meteorological conditions with mist and light fog prevailed in the area of the accident site. The flight crew was contacted about 0452 to determine if they could accept the mission. The pilot performed a weather check and accepted the mission about 0455. He departed about 0502. The helicopter arrived at the accident scene and landed on the interstate highway near a rest stop about 0523. The helicopter departed the scene about 10 minutes later, flying toward the national forest located north of the interstate. A witness reported that the helicopter made no abrupt maneuvers and that the engine "didn't sound like it was missing, sputtering, or any other kind of power loss." He reported that the helicopter was straight and level then it "pitched forward to go forward." He reported the helicopter was "flying level" as it descended into the trees. He reported that the helicopter's searchlight was on and that fog and mist were visible at treetop level. Postaccident inspection of the helicopter revealed no preexisting anomalies that could be associated with a pre-impact condition. Download of the engine's electronic control unit nonvolatile memory indicated that the engine was operating at 98 percent Ng when it impacted the trees. Three other EMS helicopter operators had turned down the mission, including one who had attempted it but had to return because of fog conditions. However, the accident pilot was not informed that other pilots had declined the mission because of fog."

Now maybe you are thinking that "about 10 minutes" isn't long enough for the weather to go from just above minimums to well below them, but I assure you, saturated air can go from muggy to foggy very quickly. Giving this crew the benefit of the doubt, and assuming they weren't breaking the law on the way to the patient, one must surmise that conditions deteriorated while they sat on the ground at the scene. And sadly, they decided they had to go anyway.

When I was doing AMRM for Omniflight, I was privy to event reports in which pilots described adverse flight scenarios they had lived through. I used these redacted reports for classroom discussions so that we might learn from someone else's "thrilling" moments. In one such event report, a pilot recounted a night flight to a patient in which he noticed the weather deteriorating and decided to abort and return to base. The requestor, a ground-based ambulance crew, asked if the aircraft and crew might stop somewhere mid-trip for a linkup and patient transfer. So after doing a 180, this pilot landed and waited for the ambulance to show up. And as he and his crew waited they observed the weather getting worse and worse. Finally, he had had enough and he set about departing for his base. But just as they came up to a high hover, the ambulance pulled into the parking lot!

This is a very uncomfortable position to be in as a pilot. I have been there and done it wrong. I didn't want to disappoint the "customers," (the ambulance crew) and I didn't want to leave the patient in the lurch.

So as this pilot and his crew see the bus pull up, somebody decides to land and load in a hurry and hope for the best. The next few minutes were undoubtedly an experience that none of them will ever forget. The text in the event report went something like, "I took off and got into the clouds and could no longer see the ground. I lost control. The aircraft spun to the left and spun to the right, then I got on the instruments and regained control. I flew on to the receiving hospital." In actuality, there was a little bit more to it. I presented this case study at this pilot's base, not knowing who he was or where he worked, and after the class, he confessed to me that it had been him. I now have the utmost admiration for this man's courage and candor, because he rightly assumed that his experience might be repeated. So he volunteered to tell his story in a video sponsored by Airbus Helicopters.

You can watch this video, titled "That Others May Live" here.  It is chock full of lessons, and it has undoubtedly saved some lives.






So now let's consider the most recent fatal crash. Here is a bit from the initial NTSB report,

"On March 26, 2016 about 0018 central daylight time, a Eurocopter AS 350 B2, N911GF, impacted trees and terrain near Enterprise, Alabama. The airline transport pilot, flight nurse, flight paramedic, and patient being transported, were fatally injured. The helicopter, registered to Haynes Life Flight LLC. and operated by Metro Aviation Inc. was substantially damaged. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 135, as a helicopter emergency medical services flight. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on a company visual flight rules (VFR) flight plan. The flight departed from a farm field near Goodman, Alabama about 0017, destined for Baptist Medical Center Heliport (AL11), Montgomery, Alabama.

According to the Coffee County Sherriff's Office, on March 25, 2016 at approximately 2309, a 911 called was received when a witness observed a motor vehicle accident on County Road 606 near Goodman, Alabama. Sheriff's deputies were dispatched along with Enterprise Rescue Squad. Deputies also contacted Haynes Life Flight dispatch, when it was discovered that the vehicle was overturned and that an unconscious victim was inside.

According to communications records, the call from the deputies was received by Haynes Life Flight Dispatch at 23:19:10. The pilot of "Life Flight 2," which was based at the Troy Regional Medical Center, Troy Alabama was notified at 23:20:38. The helicopter departed Troy at 23:26:57 and arrived at the landing zone (LZ) in a farm field adjacent to County Road 606 at 23:53:15.

According to witnesses, after touchdown, the pilot remained in the helicopter with the engine running. The flight paramedic and flight nurse exited the helicopter and entered the Enterprise Rescue Squad ambulance to help prepare the patient for transport. Once the patient was ready for transport, the flight nurse and flight paramedic along with several other emergency responders rolled the gurney approximately 70 yards through a grassy area to the helicopter and loaded the patient on-board. Once the patient had been loaded, the flight nurse and flight paramedic boarded, and at 00:16:45 the helicopter lifted off and turned north towards AL11.

Fog, mist, and reduced visibility existed at the LZ at the time of the helicopter's arrival. Witnesses also observed that these same conditions were still present when the helicopter lifted off approximately 23 minutes later. The helicopter climbed vertically into cloud layer that was approximately 150 feet above ground level and disappeared when it turned left in a northbound direction toward AL11. Review of the recorded weather at Enterprise Municipal Airport (EDN), Enterprise, Alabama, located 4 nautical miles east of the accident site, at 0015, included winds from 120 degrees at 4 knots, 3 statute miles visibility in drizzle, overcast clouds at 3oo feet, temperature 17 degrees C, dew point 17 degrees C, and an altimeter setting of 29.97 inches of mercury."

So, do you see a pattern? We get to the patient, and the weather gets worse, and for whatever reason, we give it a shot. None of these pilots were bad people. They weren't dumb. They were respected and liked and loved. And they certainly didn't walk out to their aircraft thinking "tonight's the night." And yet they all took off into weather that contributed to their deaths.

 (added - bystanders observed low cloud and fog at the scene. If you are a clinician at a scene walking back to your VFR helicopter with your patient, look up! If you see clouds or fog at or near treetop level - or the rain is so thick you can't see anything - don't fly!)

No matter your role on board, be aware of the weather where you are. And be aware of how a pilot's mind works. He or she wants to get the job done. We want to help the patient and avoid disappointing anyone. But in our efforts to do this, in some cases, we cause disappointment beyond belief. YOU may be the person who says, "hey friend, while we have been here things have gotten worse. So I am making the call. We are going by ground." (If your program permits that option, if not maybe you should not go at all.)

Flights on the bubble put us at risk, in peril. I don't want you to be cut from the scope of our business, or removed from the group.



Safe Flights friends...

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