Tuesday, April 25, 2017

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.

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

Wednesday, April 5, 2017

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...