Saturday, October 28, 2023


(This article originally appeared as a safety column submission in Vertical Valor/911. I reshare it here in the hope that it may offer some benefit to the HEMS industry. DCF)

image courtesy historyskills.com

I wish I could describe what real terror feels like. Words don't suffice. Either you have been there, or it's hyperbole.

Recently, my neighbor lost track of his 3-year-old. He ran through his house, gradually becoming frantic. No kid. He ran over to my house, opened the door and yelled: "is he here?"


We both went out front, and he yelled for his son at the top of his voice. The anguish and despair apparent in that call were very powerful. I witnessed full-blown terror in another human being. I have felt it in myself. 

My moments of terror took place in a Chinook in 1987. I was a young co-pilot, and my pilot-in-command and I had flown from Fort Bragg North Carolina to an airshow in Virginia. The hot humid summer day wore on, and clouds began to build. As we prepared to depart in the gathering dusk, he told me that we would return to base IFR.

Cool! Cloud time!

We planned and filed and got ourselves into the clouds headed home. Unfortunately, we didn't have airborne weather radar and data-linked radar didn’t exist. I learned about embedded thunderstorms that day. We were in a large, powerful aircraft - we weighed around 32,000 pounds against a max-gross weight of 50,000. We had lots of reserve power. We had heading-select and altitude-hold. We had each other. 

We got our butts handed to us. 

When you stumble into a worsening storm two things come to mind. How bad will this god-awful hammering get? And how strong is this helicopter?

Thank God Boeing builds a mighty strong machine.  I have never been so scared - before or since - as I was that evening. I was so scared I started giggling. And then I started flying away from the course line on the horizontal situation indicator (HSI). My brain quit. If we had been in a light helicopter, the kind we use for HEMS, I would be dead.

We turned off altitude hold and gave up on maintaining an altitude. We got slammed up, down, and sideways. 

The wind gusts put the blades out of phase and the helicopter shook mightily. The rain on the windshield and forward pylon made a roaring sound that mixed with the blood roaring in my head. It was all I could do to maintain aircraft control. My PIC started shaking his head, the expression on his face was one of pure dread.

You only have to learn that lesson once. Don't mess with a thunderstorm. When I remember that flight, it invokes imagery, "visually descriptive or figurative language..."  

Here's some imagery... Don't tickle the dragon!

I came into HEMS fresh from duty as a flight-lead in the 160th SOAR, with an attitude that was spring-loaded to the go-position. I was a real "can-do" guy. I used to run to the helicopter, and I went inadvertent-IMC twice in my first year of HEMS flying. I was going to get it done. I felt that being a can-do guy made me a better pilot than many of my peers. I was willing to do things that others weren't. There are still people like that in our industry today, and I fear for their safety - and the safety of the teams who climb in with them. 

In Ernest Gann’s aviation classic "Fate is the Hunter," he posits that fate pulls the strings of our destiny. I don't believe this premise; that it's all about luck, but I can tell you from experience that bad choices improve fate's aim. Back in the day, I made several really bad choices - so bad that more than once my fate did come down to dumb luck. Another pilot from that era with a similarly fatalistic bent said this: 

“Death is the handmaiden of the pilot. Sometimes it comes by accident, sometimes by an act of God.” 

I believe that most accidents aren’t. And I think it’s most-often us doing the bad-acting, not God.

Consider his case, a pilot with more than 9000 hours of experience. A pilot who was experienced with flying many different aircraft. "he was formerly an aeronautical research pilot with the National Advisory Committee for Aeronautics (NACA) High-Speed Flight Station at Edwards Air Force Base, California... On November 20, 1953, he became the first human to fly faster than twice the speed of sound in the Douglas D-558-II Skyrocket.  From 1955 to 1960, he was employed by North American Aviation as the chief engineering test pilot during the development and testing of the X-15 rocketplane." (NTSB report)

It's interesting that this pilot was involved in the beginnings of supersonic flight because such flights also invoked imagery in the minds of writers at the time.

"There was a demon that lived in the air. They said whoever challenged him would die. His controls would freeze up, his plane would buffet wildly, and he would disintegrate. The demon lived at Mach 1 on the meter, seven hundred and fifty miles an hour, where the air could no longer move out of the way. He lived behind a barrier through which they said no man would ever pass. They called it the sound barrier. (From the 1983 movie 'The Right Stuff.")

Well, as it turns out, there is no demon lurking behind the sound barrier. Indeed, there is no "barrier" at all. Just some aerodynamic phenomena that engineers and designers were able to overcome long ago. 

Now let's talk about thunderstorms. Tangle with a thunderstorm and your aircraft may indeed buffet wildly and disintegrate. The Airman's Information Manual covers the topic in detail, but it's hard to get the full effect of what they are saying when you are reading the text safe and warm in an easy chair. They write, "avoid by at least 20 miles any thunderstorm identified as severe or giving an intense radar echo. This is especially true under the anvil of a large cumulonimbus." and also "above all, remember this: never regard any thunderstorm 'lightly' even when radar observers report the echoes are of light intensity. Avoiding thunderstorms is the best policy." 

I cannot over-emphasize the importance of taking this to heart, but not everyone does.

A HEMS pilot decided that he was going to get home after dropping a patient at a distant hospital. A peer warned him about storms approaching the destination, and the victim ignored the warning. He almost only killed himself, but as he was preparing to depart, the crew popped out of a door and waved to come aboard.

"Although the pilot encountered an area of deteriorating weather, this did not have to occur as the pilot could have chosen to stay at the hospital helipad. The pilot, however, decided to enter the area of weather, despite the availability of a safer option. Based on the pilot’s statement to the oncoming pilot about the need to “beat the storm” and his intention to leave the flight nurses behind and bring the helicopter back... he was aware of the storm and still chose to fly into it. The pilot made a risky decision to attempt to outrun the storm in night conditions, which would enable him to return the helicopter to its home base and end his shift there, rather than choosing a safer alternative of parking the helicopter in a secure area and exploring alternate transportation arrangements or waiting for the storm to pass and returning to base after sunrise when conditions improved. This decision-making error played an important causal role in this accident." (NTSB)

The initial mistake was in leaving the distant hospital. He had been offered a van ride and turned the offer down. As he proceeded he was probably evaluating conditions - thinking he could stop if it got too bad.  As he crept closer and closer to the dragon, he might have been thinking, "well, we made it this far and now we are almost there." He could have decided to land anywhere along the way, but as he was in for a penny, he was in for a pound. "The helicopter crashed in an open wheat field about 2.5 miles east of the home base." 

Any pilot should study decision-making in naturalistic environments. The real world isn't rational, neat, or orderly, and HEMS puts us in high-consequence, time-critical situations. There isn't enough time to think things through, and the penalty for choosing wrong means someone suffers or dies. 

One of the key points in the study of naturalistic decision-making is that experience doesn’t always equal good judgment. Very experienced people - even pilots with 9000 hours - make bad choices; partly because they recognize situations as similar to past experiences and use heuristics. Rather than making the best choice, they pick a choice that works, a choice that "satisfices." Too often, the results don't suffice or satisfy.

An experienced person is also liable to think "Well, I did this before and got away with it." Such an attitude might manifest like this, "The pilot also discussed the weather with an acquaintance, mentioning that he might need to work his way around some weather." The urge to keep pressing on and the lack of concern about being in the vicinity of convective weather prompted a tragic choice. "The airplane entered the severe convective weather; the pilot then requested and received clearance from the air traffic controller to initiate a turn to escape the weather. The airplane was lost from radar about 30 seconds after the pilot initiated the turn."

A toxic soup of hazardous attitudes combined to kill this good man - an aviation hero and icon. It wasn't a demon that did him in, it was a thunderstorm - a dragon! 

You can read more about this event here.

The last of these events I will dredge up involves an almost identical scenario. From reading the text, I imagine that it's the same NTSB investigator in two of these investigations. I bet after picking through rubble and body parts and then having to write about it, he feels sick about these outcomes and wishes us pilots would behave differently.

In this case, the pilot was a friend of mine. After he was hired, I briefed him on being a base manager, helped him start his base, and witnessed him making bad choices. I guess in the end I wasn't a very good friend because if I had been, I would have talked to him before the fact instead of talking about him after. The problem is, when you raise your voice before a crash, people think you are crazy or bad for business. There isn't much pleasure in saying "I told you so."

"Although the pilot encountered an area of deteriorating weather and IMC, this did not have to occur as the pilot did not have to enter the weather and could have returned to (a safe) airport or landed at an alternate location. The pilot, however, chose to enter the area of weather, despite the availability of safer options.” (NTSB)

Now here's the crazy part of this event. This pilot knew the weather was bad in the area. He had just flown through it. Indeed he warned another pilot not to go there...

"...the pilot of the accident helicopter contacted (another pilot) by radio and advised him to double check the weather before returning to (the area) The accident pilot stated that “bad thunderstorms” were in the area and that he did not know if he would be able to return to his base that night."(NTSB)

None of the people I am discussing here were bad. None of them were dumb. These were good, smart souls who fell prey to a bad choice. If you fly, you owe it to yourself to try and understand what it was that led to these choices. You should understand that these folks were just like us. And if they could make a bad choice, so might we. After all, the last thing we want is for the NTSB to write our epitaph,

"Based on the pilot’s statement ... regarding bad thunderstorms in the area, he was aware of the weather and still chose to fly into it." 

These pilots tickled the dragon and it ate them. 

Don't tickle the dragon.

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