Event Review - Case Study: Loss of Control Due to Retreating Blade Stall

Image courtesy Australian Transport Safety Board

About 10 years ago, I corresponded with my chief pilot at Omniflight Helicopters, Mr. Eric Pangburn, about the aircraft at my base "surging" nose-up in cruise flight. It was not a violent pitch up, rather it was a smooth and steady pitch up that was overcome with a reduction of collective and forward cyclic. It was disconcerting and I wanted to know why it was happening.

The phenomenon was also experienced by another pilot at my base, Mr. Tim Lilley. Our experiences were similar and in the same aircraft, N171MU a BK-117A4. These events were not "high and hot" but occurred near sea level and moderate temps.

Eric included his friend Shawn Coyle, a well-known helicopter expert, and writer, in our discussion, and Mr. Coyle added his thoughts - to wit that erosion of the leading edge of blades might reduce the margin to RBS. The answer: ease up and slow down.

A pilot-friend at another base, Mr. Mike Sharp (now deceased) had experienced an RBS loss of control event prior to our events. Mike was operating a BK-117A4 N117LS and in his case, he was high, it was hot, and the aircraft was heavy. He mentioned noticing that he was near the "haze line" in the atmosphere, with clear cooler air above the level of the haze and warmer "muggier" air below.  As he descended the aircraft snapped up violently - similar to the event described in the linked report from the Australian Transport Safety Board. First a pitch up to near vertical, then a flopping over to a dive straight down. The medical crew became weightless in flight and came out of their seats. (Mr. Don Lamb and Mrs. Robbin Perry)

I recommend you imagine yourselves in this crews seats as you read this report. Imagine the dismay they must have felt and consider their responses, determine if you would respond in the same way or would do something differently.  I also respectfully recommend that pilots avoid pitching over on the nose by way of accelerating in the dive. Since the recommended recovery for RBS is to lower the collective, lowering collective to descend should help prevent the occurrence. Mentally rehearse, prepare, and if possible prevent - this crew missed dying by a relatively small margin.

I have no data to back up the following assumption, but I imagine that a BK117, EC-135, or EC-145 might be similarly susceptible to this problem because of their rotor systems. If you have experience with RBS, please share what you have learned in a comment.

May you have safe flights and may you avoid a "soil-the-pants" situation.

Dan Foulds
HelicopterEMS.com

"Shortly after 1400 Central Daylight-saving Time, a ‘violent’, uncommanded nose-up pitching of the helicopter occurred. The pilot instinctively applied full forward cyclic control, but using both hands given the severity of the pitch-up, in an attempt to regain control but was unable to arrest the continuing nose-up pitch. At about 70° nose-up the helicopter rolled left through approximately 120° and commenced a steep descent. On seeing the ground through the windscreen, the pilot applied full rearward cyclic, which resulted in the helicopter pulling out of its now near vertical nose-down attitude and levelling off at about 1,000 ft (about 800 ft above ground level)."

Click here to access the Australian Transport Safety Board report.

Preliminary Report: Air Methods - Wisconsin - Crash Occurred April 2018. Final Report Pending. Flight Recording Device Onboard...

Image courtesy WSAW

Update...
Per the final report, it appears that the pilot fell asleep while flying. The aircraft rolled upside down and was unrecoverable....

Text courtesy NTSB...

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.

National Transportation Safety Board
Aviation Accident Preliminary Report
Location: Hazelhurst, WI Accident Number: CEN18FA149
Date & Time: 04/26/2018, 2250 CDT Registration: N127LN
Aircraft: EUROCOPTER AS 350 B2 Injuries: 3 Fatal

Flight Conducted Under: Part 91: General Aviation - Positioning

On April 26, 2018, about 2250 central daylight time, a Eurocopter AS 350 B2 helicopter,
N127LN, impacted trees and terrain during cruise flight near Hazelhurst, Wisconsin. The pilot
and two crewmembers were fatally injured. The helicopter was destroyed during the impact.

The helicopter was registered to and operated by Air Methods Corporation as a Title 14 Code of
Federal Regulations Part 91 repositioning flight. Night visual meteorological conditions were
reported in the area about the time of the accident, and the flight was operating on a company
visual flight rules flight plan. The flight originated from the Dane County Regional Airport-
Truax Field (MSN), near Madison, Wisconsin, about 2104 and was destined for the Howard
Young Medical Center Heliport (60WI), near Woodruff, Wisconsin.

Earlier in the day the emergency medical services (EMS) crew had transported a patient to the
Madison area. The purpose of this flight was to reposition the helicopter back to 60WI. The
helicopter was serviced with 80 gallons of fuel at MSN. According to initial information, the
pilot radioed that he departed from MSN. The helicopter did not arrive at its destination at its
estimated arrival time, and the operator started their search procedures for the helicopter. The
Air Force Rescue Coordination Center placed a call to the operator and advised that an
emergency locator transmitter signal associated with the helicopter was received by the center.

The center informed the operator of a latitude and longitude in which to look for the helicopter.
The helicopter was subsequently found near that location about 0215 on April 27, 2018.

The 34-year-old pilot held a Federal Aviation Administration (FAA) commercial pilot
certificate with rotorcraft-helicopter and instrument helicopter ratings. He also held a private
pilot certificate with an airplane single engine land rating. He held an FAA second class
medical certificate issued on May 31, 2017. On his last application for the medical certificate
the pilot reported having accumulated 3,200 hours of total flight time, with 100 hours logged
with the preceding six months. According to initial information from the operator, the pilot
received training on January 5 and 7, 2018 and satisfactorily passed a check ride.

N127LN was a 2006 model Eurocopter (Airbus) AS 350 B2, four-place, single-engine
helicopter, with serial number 4149. The helicopter was configured for EMS transport services.
It was powered by a Turbomeca Arriel 1D1 turboshaft engine, with serial number 19129. The
engine had a maximum takeoff power rating of 732 shaft horsepower and a continuous power

Page 2 of 4 CEN18FA149

rating of 625 horsepower. According to initial information, the helicopter was maintained
under a company aircraft inspection program and had undergone 100 and 600-hour
inspections on April 25, 2018, at an airframe total time of 5,152.8 hours. The helicopter was not
equipped with a vehicle engine multifunction display or a digital electronic control unit.
However, it was equipped with an enhanced ground proximity warning system (EGPWS).


At 2255, the recorded weather at the Lakeland Airport/Noble F. Lee Memorial Field, near
Minocqua, Wisconsin, was: Wind calm; visibility 10 statute miles; sky condition clear;
temperature 0° C; dew point -1° C; altimeter 29.88 inches of mercury.
At 2253, the recorded weather at the Rhinelander-Oneida County Airport, near Rhinelander,
Wisconsin, was: Wind calm; visibility 10 statute miles; sky condition clear; temperature 2° C;
dew point 1° C; altimeter 29.87 inches of mercury.
At 2253, the recorded weather at the Eagle River Union Airport, near Eagle River, Wisconsin,
was: Wind calm; visibility 10 statute miles; sky condition clear; temperature 0° C; dew point 0°
C; altimeter 29.86 inches of mercury.
According to U.S. Naval Observatory Sun and Moon Data, the end of local civil twilight in the
Rhinelander, Wisconsin, area was 2031 and local moonset was at 0507 on April 27, 2018. The
observatory characterized the phase of the moon as "waxing gibbous with 88% of the Moon's
visible disk illuminated."


The helicopter was found in a wooded area about 178° and 8.4 nautical miles from 60WI. First
responders indicated that the sky was clear, the moon was visible, and there was a smell of fuel
at the time the helicopter was located. However, the wreckage did not exhibit any signs of fire.
A tree about 70 ft tall about 66° and 47 feet from the nose of the wreckage had branches broken
in its upper canopy. Trees in between this tree and the wreckage had their trunks and branches
broken and linearly separated. The path of the broken and separated trunks and branches
through the trees was steep. A ground impression about 11 ft by 9 ft and 2 ft deep was found in
front of the helicopter wreckage. The helicopter came to rest on its right side. The heading of
the wreckage from tail to nose was about 095°.

During the on-scene examination, the smell of
fuel was present at the site and in the ground below the helicopter. All major components of
the helicopter were located at the site. The cockpit and cabin area was destroyed. The fuselage
exhibited rearward crushing deformation. The tailboom was attached to the fuselage. The tail
rotor gear box and tail rotor blades remained on the tail. However, the vertical fin had partially
detached from the end of the tailboom. Both horizontal stabilizers were present on the tail. All
three rotor blades remained attached to the rotor hub, and the rotor hub was attached to the
transmission. The main rotor blades exhibited damage to include spar fractures and leadingedge
abrasions and depressions.

The main rotor hub rotated when the transmission's input drive shaft was rotated by hand. The fuel tank was fragmented. Yaw, pitch, lateral, and collective controls were traced from the cockpit to their respective servo actuators.

Engine controls were traced from the cockpit through their respective bellcranks to their engine
components. A magnetic plug in the hydraulic system had some particulate on its magnetic
end. The filter bypass button on the hydraulic control block was popped. The hydraulic pump
was turned by a drill and the pump exhibited a suction and pressure at the pump's inlet and
outlet. Disassembly of the hydraulic pump revealed scoring witness marks on the pump

Page 3 of 4 CEN18FA149

housing in its gear's plane of rotation and no debris or obstructions were observed within the
pump ports.
The engine was found on the ground and was separated from the fuselage. The engine's
compressor blades exhibited nick and gouge damage consistent with foreign object ingestion.
The power turbine blades exhibited silver colored deposits on them. The power turbine was
turned by hand and the drive train did not turn. Subsequent examination revealed that the
engine's Module 5 reduction gearbox had migrated out of its installed position, rearward, to the
extent its O-ring groove was visible. The Module 5 gearbox was removed for inspection of the
input pinion torque alignment marks. The marks were found to be misaligned approximately 2
millimeters in the tightening direction which is consistent with engine power being delivered to
the drive train during the main rotor blade impact sequence.

The Oneida County Coroner was asked to perform an autopsy on the pilot and to take
toxicological samples.


The helicopter was equipped with an Appareo Vision 1000 recorder unit, which records to both
a removable secure data (SD) card and internal memory. Both the unit and the SD card
sustained impact damage. The unit and its SD card were shipped to the National
Transportation Safety Board Recorder Laboratory to see if they contain data in reference to the
accident flight. (emphasis added)

A hydraulic fluid sample and a fuel sample were retained for testing.
Additionally, the hydraulic magnetic plug, the hydraulic pump, hydraulic filter, four actuators,
and the EGPWS were retained for further examination.
Aircraft and Owner/Operator Information
Aircraft Make: EUROCOPTER Registration: N127LN
Model/Series: AS 350 B2 NO SERIES Aircraft Category: Helicopter
Amateur Built: No
Operator: AIR METHODS CORP Operating Certificate(s)
Held:
On-demand Air Taxi (135)
Operator Does Business As: Operator Designator Code: QMLA
Page 4 of 4 CEN18FA149


Editor's note: These guys were just.like.us. What happened to them could happen to us. Let us never forget these good souls. Let us keep their families - who will suffer for this until the end of their days - in our hearts.  And let us resolve to learn from this tragedy in order to prevent something like this from happening again.

Otherwise?

It will.

It’s Time to Check the Checklist! By Josh Henke, Flight Nurse

Checklists and standardization have saved countless lives. But
"collective mindfulness" requires us to think beyond the list.

I think we can all agree that the checklist has revolutionized our industry both in commercial aviation, military aviation and HEMS. Gone are the days of going through checks thinking you put all the A tabs into the B slots and taking off by memory. And hopefully gone are the days of realizing at 500 feet of altittude that you forgot to put tab A123 into slot B 420 and returning rapidly to the earth.

Yes, checklists are good.

But they can also be bad.

Yup, I said it. Blasphemy……

Yes, checklists can be bad.

We have likely seen it or been a part of it - I know I have. We all climb in the aircraft and run through the checklist and everything is the same as the day before.

“Chocks, covers, cords?

“Stowed”

“Engine mode switches?

“In flight”

“Caution and warning lights”

“All out”

“Doors and belts?

“Secure left, right, etc.”

We say the same things every flight. And we get into a routine. We all do it. You are not immune, I am not immune, Chuck Yeager is not immune.

Complacency is unavoidable. It is a problem that is NEVER solved, but constantly managed. The key to coping with complacency is learning how to have a functional relationship with it, knowing what it looks like and how to call it out on the carpet when it’s identified.

The checklist can be a great tool, but we need to check on it every now and then. It would be foolish to put a checklist in place, dust off our hands and say, “OK, the checklist is in place, now just follow it every time and we will be just fine.”

The checklist is a link to our survival and safety, but you can’t just put one in place and ignore it hoping that it is functioning appropriately. You need to monitor it. In short, just like everything else, you have got to check the oil and make sure it's functioning properly.

In the checklist above, can you see the problem?

Better yet, can you NOT see the problem?

In that checklist, we can lay eyes on every part of what we are covering just before lifting, except for the covers and chocks.

The point I’m trying to make is, just because you have a checklist doesn't mean that everything is OK. It needs to be evaluated and re-vamped from time to time. You need to seek out the faults in your checklist and bring them to light.

In our particular checklist, there is one item that we can’t visually inspect at the time the checklist is being performed. This leaves us prone to error. I have suggested a change of operation for my program to mitigate this.

I suggest that each of you take a look at your checklists and try to find a hole. Find something that isn’t quite right and fix it.

Go……go check the oil. Make sure everything is working the way it should be. Be a stickler about perfect function.

GO……..think outside of the box, look at things critically and make tomorrow just a little safer.

We save lives for a living. Let's save our own while we are at it.

NTSB Final Report : North Memorial Air Care Crash

The pilot and two medical crewmembers were conducting a night instrument flight rules cross-country flight to pick up a patient. During the instrument approach to the destination airport, the weather conditions deteriorated. The pilot was using the helicopter's autopilot to fly the GPS approach to the airport, and the pilot and the medical crew reported normal helicopter operations. Upon reaching the GPS approach minimum descent altitude, the pilot was unable to see the airport and executed a go-around. The pilot reported that, after initiating the go-around, he attempted to counteract, with right cyclic input, an uncommanded sharp left 45° bank . Recorded flight data revealed that the helicopter climbed and made a progressive right bank that reached 50°. The helicopter descended as the right bank continued, and the airspeed increased until the helicopter impacted treetops. The helicopter then impacted terrain on it's right side and came to rest near a group of trees.

Postaccident examinations of the helicopter and flight control systems did not reveal any malfunctions or anomalies that would have precluded normal operation. The helicopter was equipped with a GPS roll steering modification that featured a switch that allowed the pilot to manually select the heading reference source. In case of a malfunction or an erroneous setting, the helicopter's automatic flight control system had at least two limiters in place to prevent excessive roll commands. Further testing revealed that the GPS roll steering modification could not compromise the flight director and autopilot functionalities to the point of upsetting the helicopter attitudes or moving beyond the systems limiters.

Recorded helicopter, engine, and flight track data were analyzed and used to conduct flight simulations. The simulations revealed that the helicopter was operated within the prescribed limits; no evidence of an uncommanded 45° left bank was found. The helicopter performed a constant right climbing turn with decreasing airspeed followed by a progressive right bank with the airspeed and descent rate increasing. In order to recover, the simulations required large collective inputs and a steep right bank; such maneuvers are difficult when performed in night conditions with no visual references, although less demanding in day conditions with clear visual references. The data are indicative of a descending accelerated spiral, likely precipitated by the pilot inputting excessive right cyclic control during the missed approach go-around maneuver, which resulted in a loss of control.



Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:


The pilot's excessive cyclic input during a missed approach maneuver in night instrument meteorological conditions, which resulted in a loss of control and spiraling descent into terrain.

Good Souls...

...The Journey to High Reliability

While attending a recent Promedica Health Safety Conference to present a class on hazardous attitudes, I was able to take in a presentation by Dr. Kate Kellogg (MedStar, Washington DC) on "High-Reliability Organizations."

Jonathan Godfrey, Randy Mains, and Dan Foulds
presenting AMRM topics and learning about
High-Reliability Organizations from
Dr. Kate Kellogg, MD

At AMTC, I heard Dr. Ira Blumen state that, regarding risk to patients flown in EMS helicopters, "the real risk starts when they are unloaded from the helicopter and wheeled into the hospital." Hospitals have come under scrutiny for causing harm to patients, and some of them have looked for ways to stop doing this.



Many hospitals and health-care systems have made great strides in improving patient care and reducing incidents of harm by adopting the tenets of (Air) Crew Resource Management, and then developing them further. HRO research started with the Nuclear Navy, management of the power-grid (nuclear), and air traffic control. Instead of focusing on industries and companies that went wrong (Three Mile Island) three UCB researchers concentrated on complex industries that did things right - successfully!

This video is long, and you may not get through it all in one sitting, but I encourage you to get a cold drink, and a note-pad and capture the key ideas and techniques that Dr. Mark covers.

If we want to eliminate fatal crashes in HEMS, it's apparent that we are going to have to do something different. What we are doing now doesn't work. We kill patients and crews regularly.

When you think about fatal crashes in HEMS, the only acceptable number is ZERO.

PS. Feel free to share this with your company's C.E.O; because that's where your company's journey to High Reliability will have to start...

My Engine Just Quit! NOW WHAT? Pilot Professional Development Courtesy of the AOPA Air Safety Institute

British warbird pilot, Mark Levy, was part of a 21-airplane formation in the annual airshow at Duxford, England when the P-51 he was flying had a partial engine out. Levy recorded the entire event on a pair of point-of-view video cameras, and he shared the images, as well as his lessons learned, in a candid discussion with Richard McSpadden, Executive Director of the AOPA Air Safety Institute.

We recommend you gather a notepad and pen and catch the key words and phrases that Mark mentions as he discusses his mishap. This is an excellent foray into pilot-psychology, how emergencies affect our physiology, when to act instinctively and when to take a deep breath and think things through. Mark repeatedly mentions "startle effect" which is a hot topic with the FAA right now.

One of the greatest pilot-learning resources is "hangar flying" with other pilots, but a HEMS pilot has little opportunity to do this. This video is a great hangar-flying experience, and might just save your life someday. Kudos and thanks to AOPA and the Air Safety Institute...

Use of Automated Flight Control for the Single Pilot Helicopter Program - by John Bevilacqua - EC145 HAA Pilot and NEMSPA Board Member

Is your program flying  IFR, or is it VFR only? Single-pilot or dual-pilot? The advent of inexpensive and lightweight automation has enabled another concept, but the author doesn't think we realizing the full value of our investment

 SINGLE-PILOT/AUTOPILOT.

A prerequisite in the authorization of single-pilot programs to operate IFR, under actual IMC, is that the aircraft be equipped with a functioning Autopilot. During instrument flight, if the Autopilot is utilized, the pilot then becomes the “pilot monitoring” or PM, while the Pilot flying (PF), is actually the Autopilot!

The human pilot’s role is to correctly program the autopilot, monitor to make sure it is functioning correctly in its navigation and “coupling” functions, and be ready to take over if the Autopilot
malfunctions in a significant way. At a certain point of flight the pilot must take over, but for the majority, it is the autopilot that is in control of staying on course and on altitude.

There have been a chronic and disturbing number of HAA and other civil helicopter accidents which
could have most likely been prevented by smart use of the installed Autopilot equipment. An analysis of the probable causes of many of these accidents and close calls in the civil helicopter world show that the “mishap aircraft” were equipped with perfectly functioning and available Autopilots. (Referred subsequently in this article as APs). A simple push of two buttons, depending on the type of AP, could have stabilized the aircraft, established a safe climb and heading away from the hazards on the ground, and smoothly transitioned the flight to a safe cruise altitude and setup for an instrument approach (or flight to better weather and VFR recovery). BUT THE AUTOPILOT WAS NOT USED.
The aircraft was hand flown, unnecessarily and with adverse consequences. For various reasons due to aircraft certification, pilot training, and an aviation culture that emphasizes manual flying, the AP is not being utilized to the extent it should be.

The reason the AP modes are not being used when they should are numerous and varied, but can be
summarized by a lack of clear guidance on when and how to use an AP for pilots who are not IFR current or qualified, or ar in aircraft that are equipped with an AP, but for various regulatory reasons, are not
certified for IFR flight. There are also single pilot IFR programs in which both the pilot and aircraft are qualified and certified, but due to an “old-school” mindset, the AP is used only during actual IMC, and only sporadically during other phases of flight.

USE OF AP IN ROUTINE VFR FLIGHT AND DURING IN-FLIGHT EMERGENCIES

For routine VFR flight, the benefits of using the AP for many phases of flight are that it reduces pilot
workload, especially single pilot, and allows the pilot additional task management resources tomanage the overall flight. This includes scanning outside to enhance situational awareness regarding
weather, air traffic, birds or other hazards to flight. Ironically to some, the momentary ”heads down”
that might be necessary to engage the AP results in a much greater level of “heads up” for the rest of
the flight.

In the dynamic and changing flight environment in which helicopters operate, there are numerous
situations or hazards in which routine use of AP could be of immense benefit. A pilot incapacitation
event, especially with a lone pilot at the controls, could be fatal due to the subsequent loss of control.
Pilot incapacitation can result from a medical event, or from a bird or other object coming through the windscreen and striking the pilot. More recent flight hazards include laser strikes and an increase in the number of drones in the vicinity of helicopter operations. While strategies to mitigate these risks depend on the specific hazard, protective equipment, type of aircraft, and pilot training, one universal truth is that the AP is basically invulnerable to many of the human frailties that can take a pilot out of commission in his or her ability to operate the helicopter. It cannot be temporarily blinded, suffer from nausea, tunnel vision or vertigo, or panic when an extreme event occurs. Allowing the AP to operate the aircraft in routine flight, or activating it if possible ASAP after certain emergencies, could be just what is needed to stabilize the emergency situation and allow the pilot to recover or resume control with the assistance of the AP.

For flights in marginal VFR conditions, use of the Autopilot is even more important. Autopilots can help pilots fly safely when they lose visibility during inadvertent entry in instrument meteorological
conditions (IIMC) when their helicopter flies into clouds and/or fog. With the loss of visual flight
references, VFR pilots can lose an accurate sense of their location, altitude, and angle with respect to
the ground and horizon, thus they are flying “blind.”

Flights into IIMC are completely non-dramatic if the pilot understands the basics of the AP system and use, programs it properly, and get it activated as soon as possible after takeoff. Many recent HAA
accidents have been a result of pilots, usually on deck at a landing zone, taking off and encountering
unexpected low ceilings and then attempting to manually fly the aircraft in IMC. This is a recipe for
spatial disorientation and subsequent loss of control. For AP equipped aircraft, the formula for survival under similar circumstances is to have a plan in which the takeoff brief includes pre-selecting your altitude in the AP, and a heading which clears you of obstacles ASAP and is preferably into the wind. (This allows the pitot-static instruments to come up to speed expeditiously and allow instrument flight and AP use).

As soon as possible after the aircraft reaches Vmini, (minimum AP activation airspeed) activate the heading select and a vertical climb mode. Climb using max continuous power and accelerate to best climb airspeed. Your strategy will have the AP flying the aircraft, and if you experience spatial
disorientation it will be relatively benign because you are not flying the aircraft; the autopilot is.

Yes, you need to be vigilantly monitoring the AP’s performance, and ready to take over manually if necessary, but the primary focus is planning, programming, monitoring, and letting the automation complete the task of getting you up to a safe altitude and on a safe heading. Keep it on the AP for the rest of the flight as you tune radios, contact ATC, choose and program the approach to the most appropriate recovery airport.

Pilot Incapacitation

Medical events have the potential to incapacitate a pilot temporarily, at the very least. A medical
event due to a concussion or blinding because of an object striking the pilot. More recent flight hazards include laser strikes and an increase in the number of drones in the vicinity of helicopter operations. While strategies to mitigate these risks depend on the specific hazard, protective equipment, type of aircraft, and pilot training - one universal truth is that the AP is basically invulnerable to many of the human frailties that can take a pilot out of commission in
his or her ability to operate the helicopter. It cannot be temporarily blinded, will not suffer from nausea, tunnel vision or vertigo, or never panics when an extreme event occurs. Allowing the AP to operate the aircraft in routine flight, or activating it if possible ASAP after certain emergencies, could be just what is needed to stabilize the emergency situation and allow the pilot to recover or resume control with the assistance of the AP.

For AP equipped aircraft, the formula for survival under similar circumstances is to have a plan in which the takeoff brief includes pre-selecting your altitude in the AP, and a heading which clears you of obstacles ASAP, and is preferably into the wind. (This allows the pitot -static instruments to come up to speed expeditiously and allow instrument flight and AP use). As soon as possible after the aircraft reaches Vmini, (minimum AP activation airspeed) activate the heading select and a vertical climb mode.

Climb using max continuous power and accelerate to best climb airspeed. Your strategy will have the AP flying the aircraft, and if you experience spatial disorientation it will be relatively benign because you are not flying the aircraft, the AP is. You need to be vigilantly monitoring the AP’s performance, and ready to take over manually if necessary, but the primary focus is planning, programming, monitoring, and let the automation complete the task of getting you up to a safe altitude and on a safe heading. Keep it on the AP for the rest of the flight as you tune radios, contact ATC, choose and program and approach to the most appropriate recovery airport.

TRAINING FOR INCREASED ROUTINE USE OF THE AUTOPILOT

In the airline industry, there has been an increased emphasis on scenario-based training, also known asnLOFT (Line Oriented Flight Training). The philosophy of this training, which is usually flight simulator based, can be summarized below

(Source - ICAO Circular 217 AN/132 'Human Factors Digest No 2): “LOFT scenarios may be developed from many sources, but accident reports provide a realistic and appropriate starting point. A properly conducted LOFT program can provide great insight into the internal workings of an airline's operations and training program for the following reasons:

1. If similar mistakes seem to be recurring among pilots, it may indicate a potentially serious problem as a result of incorrect procedures, conflicting or incorrect manuals, or other operational aspects.
2. It may reveal areas in aircrew training programmes which are weak or which need emphasis.
3. It may reveal problems with instrument locations, the information being presented to pilots or other difficulties with the physical layout of a particular flight deck.
4. Air carriers can use it to test and verify flight deck operational procedures.

LOFT should not be used as a method of checking the performance of individuals. Instead, it is
a validation of training programs and operational procedures. An individual or crew needing
additional training after a LOFT session should be afforded that opportunity immediately with
no stigma or recrimination.”

With this training philosophy in mind, this is how HAA and other single pilot helicopter operators
industry could change normal training and checkrides with respect to AP use:

Flight Training plan – Inadvertent IMC . -Most Inadvertent IMC training is done on a checkride, at altitude, in cruise flight VFR. Focus the training scenario instead as a simulated inadvertent IMC at a low altitude while taking off from your home airport.

Announce “inadvertent IMC” at about 100’ AGL. The drill should promote a before takeoff checklist which addresses the use of Autopilot modes and cockpit setup, the importance of an “airspeed over altitude” which gets you to Vmini quickly, and selecting the appropriate climb modes and power setting (for a two or three-axis autopilot).

Even if not set up and briefed for IFR flight, train how to quickly and efficiently identify and activate the right AP modes for the situation. Hand flying should be discouraged if the AP is available. For simulator training, the same applies. All takeoffs, even under simulated VMC, should be flown either with the AP engaged as soon as possible, or set up for immediate activation.

If the inadvertent IMC conditions are given at altitude while the pilot is flying manually, emphasize the need to activate the Autopilot. Hand-flying the aircraft under IMC, while single pilot, should be trained realistically, emphasizing that the pilot should not be conducting this type of flying
under real-world conditions and that the manually flying Single Pilot while IMC is an “emergency
procedure”. It is fine to practice in the simulator, but not in the aircraft unless there is another qualified Safety Pilot on board.

Unusual Attitude Recovery

Discuss the various visual illusions which can lead to spatial disorientation and the need for a good scan and transition to a pure instrument scan during night, IMC, marginal VFR and flat light conditions, and the need for an adequate visible horizon to continue a VMC flying

A common flight simulator and checkride item is “unusual attitude recovery” most often flown manually by manipulating the flight controls. For AP equipped aircraft the emphasis should shift to:

1. AVOIDANCE – Unusual Attitudes are usually a result of pilot distraction, poor instrument scan
technique, leading to severe, incapacitating spatial disorientation. The AP is not susceptible to these
illusions and incapacitation. ACTIVATE THE AP. Disciplined use of appropriate AP modes during
night, IMC, or low light/flat light conditions, will virtually eliminate the pilot’s disorienting analysis of the aircraft’s multi-dimensional flight attitude and subsequent attempt at manual recovery.

2. RECOVERY – If the preventative measure did not work, and an unusual attitude is noticed on the
pilot’s attitude gyro and other flight instruments, quick and simple activation of AP modes should be
considered as a primary method of recovery. In cruise flight, the current collective power should be
more than adequate to simply hit Altitude Hold and Heading Select. The aircraft will then level itself
and fly straight on the selected heading and any climb or descent should cease at the current
altitude. Once the aircraft is stabilized, check power setting and select an appropriate flight mode
for climbing if necessary, but STAY ON THE AP.

The “best practices” in this article are intentionally generic will need to be modified depending on individual aircraft and Autopilot types, company OPSPECS and types of operations. But the message is clear - if you are fortunate enough to have an Autopilot aboard your helicopter - use it!

"We do these things, That Others May Live"

This is an excellent ADM training resource provided by Airbus. If you have never seen it, it's worth the time. If you have seen it, it's good to watch again with your flight team and discuss the events that occurred.

What strikes me is that the crew allowed the pilot to proceed so far into a bad situation without "stopping the train." I wonder how many funerals we could have avoided if a team member, typically a nurse or paramedic or RT, had said, "hey, this is a bad idea, we are going by ground" or "we aren't going." This flight team in this video was very very close to being dead. As Omniflight's director of operations said, "we dodged a bullet last night."

We can get so involved in a scenario that we accommodate to risk as a group. We can also fall prey to the social normalization of deviance. I have been in a risky situation myself - flying into a hospital sitting underneath a thunderstorm with a critical patient on board - and when I asked my crew what they wanted to do they said: "take the chance."

In retrospect, I was dumb for taking the chance and dumb for asking them to validate my bad decision. A pilot should let a team member make a more conservative decision, but a pilot should never let a team influence a more risky decision. If a pilot has to ask if something is dumb, it probably is and should be avoided...

You who crew are an integral part of the ADM (aeronautical decision making) process. You have a say in how high we fly and what we fly over, what turbulence level we should tolerate, how low our fuel state can be and most importantly - when we should STOP. If it appears that I the pilot am struggling to make things work, you can and should speak up about doing something different.

You are not a passenger. Don't act like one. Please. It's a better world with you in it.

Snakes In The Grass

Contributing writer Josh Henke is an avid outdoorsman. He surfs and hikes the backcountry.  Josh is a former firefighter and serves as a flight nurse today. You can contact Josh at bosstyn@gmail.com

My friend Dave-bob is an avid hiker. Even in southern California, he finds time to hike nearly every day. Dave is old and tired and weathered, but he still hikes almost every day. We often give
him grief about his stick; low terrain, high terrain, it doesn't matter,  Dave-bob always has his
stick. After a few years of knowing Dave, I asked him about his stick and why he always carries it.

"Snakes."

“Yes, of course,” I thought. That seems plainly obvious now that he says it. Southern California
is known for its rattlesnakes. Big black things that hide in the brush. They are a terrifying thing
when you see one.

I then asked him, “why such a big stick then”. His stick is damn near a Gandolf-sized staff.
His thoughtful reply was this; “small sticks are good for small snakes, but not big ones. A big
stick is good for small snakes as well as big ones. I use this stick to roust snakes up along the
trail before they have a chance to strike”

I thought about this in an oft way for weeks as a continued on with life. A few weeks after that
conversation, I saw Dave and he told me a story about hiking. (he loves to tell hiking stories)
Dave told me about how he went hiking at a place called four bush; which actually only has
three bushes, but never mind.

He was driving up to the trailhead listening to a deeply riveting Paul Harvey episode when he
parked. As many of us do with Paul Harvey, he sat and listened for a while longer. One of those
driveway moments….
He told me how he began his hike and realized he forgot his stick about 3 miles into the trip.
“I figured oh well,” he said and continued on. At mile four he saw a “really interesting bird. Kind
of a grasshopper/bird/old cat kinda thing”. (Dave loves to describe things he sees, however,
he’s not very good at describing more than making up combinations of animals to describe
other animals)
“when I go to the top I stopped and turned around to head back down, and sure as hell, there
was a big black rattlesnake sitting in the path about 5 yards in front of me. He wasn't moving,
just laying in the sun”.

We both took a silent second to think about that snake, A big slate colored rattlesnake is no
joke, and 6 miles into a hike; a bite from a snake like that is often a death sentence. (or a
helicopter ride at least)
“I sat there and looked at that snake and all I could think about was my damn stick. He looked
at me and I looked at him, and as we both sat there, he began to move. Not fast; he moved in
a very slow, purposeful way directly towards me. As I back up he stopped. When I stopped, he
began moving again. Not in a “hunter” way, but in a “you’re damn lucky Dave” kinda way; as if
he was telling me “I’m not going to bite you, but this is your only warning.”

I commiserated with him over the snake knowing that you can't just step over it, and
often times on these trails, you are surrounded by grass. The only option for Dave was to leave
the trail and clear around the snake through the grass. The hard part is, there's often snakes in the
grass, and with no stick, it's a big gamble.

Dave did leave the trail, walking through the grass. He was more than a little worried about it, I could
hear it in his voice as he related his “trail of fears."
The story made me think about sticks and snakes. It also made me think about complacency
and the dangers we face, how the snakes are always in the grass and about how having a
good stick is often salvation.

I recalled when I was a new flight nurse. Most times when we got a call we would pile into the
aircraft, even before the pilot. We would buckle in even before the pilot had turned up. Once
we got comms, we would ask where we were going and he would point and say something like
“that way about 19 miles”

We didn’t check the weather with him. We didn’t scout the LZ prior to leaving. Hell, we didn’t even
ask him where we were going. We just hopped up, strapped in and blasted off. We weren't crew, we were pax.

I'm not afraid to admit it, we had very small sticks.
They did not provide us with a good defense against the snakes in the grass.
Sure, if the helicopter was leaking oil or started smoking on startup, we could see that and cancel the
flight, but our small stick was no good at picking out the less obvious snakes such as weather in
a small valley, knowledge of a known tight LZ, etc.

Over time I found that my stick got bigger.
And the bigger my stick got, the better prepared I was to meet a snake on the trail or go
wandering off through the grass unplanned.
I grew my stick by asking questions of my pilots. I questioned things that looked wrong. I took a deeply vested interest in my safety by speaking up and looking for “snakes” in our day to day operations.

I read the archives and thoughtfully explored how a crew got themselves into a situation and
how I could avoid such mistakes in the future.
I wrote about ideas and thoughts I had on safety and how to make others think about safety
All of these things, both big and small, helped me grow my stick to a point where I felt I could
go hiking safely and face down the dangers in the grass, no matter how big.
We as flight crews need big sticks. Complacency is a snake in the grass and small sticks just
won't do. As Dave mentioned, “small sticks only work for small snakes, but a big stick works for
all snakes.”
As we hit the “trail” day in and day out, think about the snakes in the grass you may encounter.
Don’t get distracted before you begin your hike through HEMS. Take the time to remember your stick, because if you forget it, that snake may bite you.

If you have a HEMS related story to tell - something that might help another crew - drop us a line.

The Airlines are Hiring Helicopter Pilots!

Is it time for a change of pace? There are programs sponsored by the airlines in which a commercial helicopter pilot can receive transition training and land an airline job. It's happening all over HEMS, right now!

We tend to favor competitive environments, you either get better or you get lost. The developing competition for a relatively scarce resource - a commercial pilot - has been brought on by the conditions created by aviation employers. When Sully said (the airlines) should respect the profession, no one listened. "The life" of an airline pilot - especially one flying for a regional carrier - became less and less desirable. This was all made starkly apparent during the investigation into the Colgan Air crash near Buffalo New York. Low wages and crash-pad life drove prospective candidates, especially rotor-pilots coming out of the military, into off-shore or HEMS jobs.

Perhaps the airline industry has passed the nadir; perhaps becoming an airline pilot will once again be a good-paying, respectable employment option. .As the airlines cherry-pick the best rotor-pilots - many of whom have and will continue to come from the ranks of HEMS - a predictable set of events will occur.

First, companies will try and force overtime on current pilots. Lean is cheap, and there are more vacancies in HEMS than ever before. Eventually, there will be too many holes to fill. As well, HEMS companies will look to hire the very young and the very old. They will dip deeper and deeper into the labor pool.

We can imagine a conversation like this between two new-hire HEMS pilots.

"Hey, young fellow! When I started flying, you were in diapers."

"Oh yeah, Gramps? Well, when I finish flying, it'll be you in the diapers. As a matter of fact, you look pretty 'dependable' today!"

Barring restraint, and with bases out of service, some companies will hire pilots previously let go; pilots who are too new to get any other job or who have hit the 65 year age limit for part 121 flying. Companies will also seek to lower the hiring-requirements for HEMS pilot. If the rules get in the way of making money, the first thing you do is change the rules.

We expect that these developments will show up in the accident and error rate, and they will result in clinicians departing HEMS after becoming dismayed at the lack of proficiency of the persons flying. (At least those clinicians who know what a lack of proficiency looks like.) Flying a single-pilot VFR helicopter to an accident scene at 3am is different than flying an airliner as a member of a flight crew. It's not necessarily harder, but it is different. It requires an entirely different set of interpersonal and aviation skills.

The transitioning rotor pilot will serve in the airlines as a co-pilot until his or her performance has been verified. A retiring airline pilot entering HEMS will be given 8 to 10 hours and a check ride before being cast loose upon the skies. And the med crews. When we flew BKs, A new pilot coud gain initial operating experience with a training captain. Not so in most singles.

At some point, insurance rates and astronomical lawsuits will drive the fix most strenuously avoided by the HEMS industry.

Wages will increase to the level of the economic value the pilot brings to the endeavor.

After all, the airlines are hiring.

What is Your Tolerance for Turbulence?

Image courtesy Teddy Fujimoto and AZCentral.com

The question of the day...

What is Your Tolerance for Turbulence?

Is it a light tossing? Significant slams? Occasional loss of control? Are you more concerned with turbulence at altitude or near the surface? How much wind will you tolerate near mountainous terrain or large buildings?

Let's consider an event from 2002...

"The medevac helicopter lifted off the hospital's rooftop helipad at night. The pilot made a right pedal turn to the northwest, facing a building that extended above the height of the helipad by approximately 10-feet. The paramedic said that when the helicopter was about 20-feet above the helipad, and while he was programming the GPS receiver, a "sudden gust" of wind push the helicopter from directly behind. He was not alerted to anything unusual until he looked up and noticed the helicopter's close proximity to a 16-floor brick building, located at the northern corner of the heliport, which extended above the height of the helipad by 4 floors. The paramedic yelled, "building, building, building!" to alert the pilot. The pilot then made a rapid right cyclic input to avoid hitting the building, but the helicopter struck the building and fell about 13 floors to ground level. The paramedic did not see or hear any warning lights, horns or unusual noises, and was not aware of any mechanical problems with the helicopter. A police officer who flew two missions in the local area prior to the accident said the wind speed at 500 feet agl was at least 25 knots and gusting from the south/southwest. He stood on the primary helipad after the accident and said mechanical turbulence from the building was evident. An FAA inspector who also stood on the rooftop helipad after the accident said the wind gusts were about 20-30 knots from the southwest and they swirled around the heliport. Review of the helicopter flight manual revealed, "Directional controllability during take-off and landing is assured for flight condition with crosswind components up to 17 [knots]." (added - do you know the conditions under which that number was derived?)




Here's another bit from a later event,

On March 6, 2015, at 2310 central standard time, an Airbus Helicopters (Eurocopter) EC-130-B4 ... 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 CFR 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 in St. Louis, Missouri.

The flight’s first approach and landing at MO55 was to drop off a medic, nurse, and a patient. During the approach, the pilot reported to the flight nurse and medic that winds were gusting to 25 knots. The flight nurse stated that helicopter was yawing quite a bit and there was a noticeable roll side to side during landing. The helicopter landed without incident during the first approach and landing. The flight then departed to obtain fuel at the operator’s base and then departed to return to MO55, to pick up the medic and flight nurse.The accident occurred during the return’s approach for landing at MO55.

Does your General Operations Manual provide your pilots clear and unambiguous
guidance to be followed upon encountering turbulence? Tactics, Techniques, and Procedures?
If not, what are you waiting for?

And here is yet another comment in the media regarding a crash for which the investigation is ongoing.

"More than 20 first responders had to hike to the downed helicopter from an area only accessible with certain vehicles. Emergency crews then had to wait for strong winds to quiet before they could lift passengers out of the canyon."
In this event, a bystander reported gusts to 50 miles per hour on the upper rim of the canyon.

Here is a bit of text from "Skybrary" on turbulence.

"Air moving over or around high ground may create turbulence in the lee of the terrain feature. This may produce violent and, for smaller aircraft, potentially uncontrollable effects resulting in pitch and/or roll to extreme positions"

Of course, we don't ever want to fly our helicopters into "uncontrollable" conditions. Do we? The question is; how close to uncontrollable should we get? The answer is not in the rotorcraft flight manual. The manufacturer wants to sell you an aircraft, not talk you out of it. The answer is also most-likely not coming from your company. They leave a decision like this up to you the pilot - and to a lesser extent the medical team. "Tribal knowledge" has been offered as guidance. Or perhaps we should ask ourselves "what would the other guys do?"

Here's the problem with that idea... What if the other guys are out flying because we are? What if we are all waiting for the first crew to say "stop!"

I humbly offer a bit of advice. If at any time you feel that turbulence is putting you at risk for loss of control and unplanned contact with an obstacle,...

Knock it off!

"The pilot reported that he performed his approach into the wind. On short final he could feel periodic gusts of wind. The pilot executed the standard approach to the helipad and the helicopter encountered another gust that picked the helicopter's nose up as it was moving over the pad. He maneuvered the helicopter to center it over the pad when he heard a sound like "metal on metal as if the tail rotor had hit something a couple times." The pilot felt no initial feedback in the controls, he felt the helicopter yaw to the left, and the helicopter continued to yaw to the left with his full application of right pedal. He lowered the collective and rolled off the throttle to enter a hovering autorotation and attempted to land it as level as possible. The helicopter landed hard. The operator reported substantial ground damage occurred to the tail rotor gearbox and tail rotor blades and a review of images revealed damage to the tail boom. A nearby fence and light were reported to be damaged. The operator's accident report indicated that there were no mechanical malfunctions with the helicopter.

Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's failure to maintain clearance from the ground obstacle during the landing with gusting winds present."

Are you performing operations near an obstructed confined area or a perilous pinnacle? Are you getting your butt handed to you?

Go to a big flat airport with few obstacles and greater chances for stable flowing winds. That's where manufacturers test for controllability. Give yourself the same benefits that the test pilots get.

Thank you for stopping by...

Each of us has an obligation to pass on what we have learned, as others
passed knowledge and experience on to us.

Greetings friends and Happy New Year!

In the spirit of new beginnings, I am henceforth going to focus on writing for Vertical 911 with the help of my friend and editor Elan Head.  The frequency of posts here will likely decrease since getting paid for writing is more fun. I never received a penny for any of this, yet it has been the most rewarding experience imaginable. I recommend blogging to anyone - and anyone has stories to tell. And it's free! On occasion, I spoke truth to power - and that was refreshing. I have had strangers walk up to me at conferences, look me in the eye, and thank me for this blog.

Free and Priceless!

I want to thank each of you who have stopped by to visit HelicopterEMS.com, and especially those of you who took the time to comment - and in some cases - to contribute to the blog.  When I began this project it was a natural progression from visiting Lyn Burks' bulletin board at "JustHelicopters.com"  and discussing helicopter topics there. I was an active HEMS pilot, had time on my hands, and things to say. Blogger offered a platform for that discussion. I remember exclaiming to my flight-nurse wife Jeanne that two hundred people had visited the blog! That number now approaches a quarter of a million. It has been a ton of fun!

I hope that you who have visited, and you who visit anew have or will derive some enjoyment from the thoughts of a common helicopter pilot. When I started, Air Methods was a middling-sized outfit, Omniflight was in ascension, OCC's were a new development, and crashes were all too common. Somewhere along the way, I began to think that maybe one person with a keyboard could affect the number of fatal crashes we experience in HEMS.

Crazy right?

HEMS doesn't pay much, but there is a great view from the office. At Beaufort Memorial
with the Green Machine - she's been there and done that and got a new tail.I was
thinking of her when I wrote "Out of Sight but Never Out of Mind-Tail Rotor Tales"

On the last USHST conference call, a speaker talked about the personal side of safety education and outreach. What I took away from his comments is that we have to make an emotional connection - as well as a cognitive one - with the people who climb in helicopters and decide how to operate them. I think that is the key, and rather than differentiating the people who have crashed and killed themselves and others, I think it's best to relate to them as personally as possible: To understand their humanity, their strengths and weaknesses, and what might have led them to disaster. Once we relate to crash victims, to "see their side of the story," then perhaps we are in a better position to understand when we might be on the path to a fatal-end ourselves. Rather than beating people over the head with a litany of criticisms and mandates, we should "nudge" flight teams in the right direction; toward safety and success and long life.

Life is Good, right?

From my time spent on this blog I got to be involved with NEMSPA. I got to meet Josh Henke and Krista Haugen and Jonathan Godfrey, and Kurt and Miles and Bill. And maybe I got to meet you. I  got to present at several AMTCs, and perhaps I was able to make HEMS just a little bit better.

My most fervent desire was for us to experience a complete year without anyone being killed. And we - make that YOU - did it. And we could do it again if we set our minds to the task.
I certainly hope so - because there isn't anyone on earth I admire more than a HEMS flight-team. We are blessed to have people who walk out to a helicopter at 3am and launch into a night sky to help others. We should do everything possible to ensure their success.

I wish you every success and hope you will check out my columns in Vertical 911. If there is something you want to talk about or want me to write about, let me or Elan know. She is my editor and counselor and coach. Meeting her made this all better.

Best wishes for 2018 and beyond

Dan

In "Ejection Decision" I wrote about a flight with Jill and Don. That's Don
on the right. Fast with a tube and fun to fly with...