Tuesday, September 25, 2018

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?


“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.

Sunday, September 9, 2018

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...