More news about the Indiana PHI EMS Crash

[SASless]

http://www.theheraldbulletin.com/cnhi/heraldbulletin/homepage/local_story_033121720.html?keyword=leadpicturestory

Weather at approximately 0200 CST was supposed to be 400 overcast with 21/2 statute miles visibility. Aircraft was airborne for approximately 6 minutes before finally finding a place to alight. Pilot was quoted as telling the dispatcher...."We'll try it."

The article has a very interesting description of the final portion of the flight....it is a "must read" article.

Coming on the heels of the NTSB report on US EMS crashes.....this is not going to help matters any at all.

[SHortshaft]

‘400 overcast and 2.5 miles’ at night in a JetRanger…you are a braver man than me Gungha Din!

“We’ll try it”. On just such an occasion as this I like the phrase “If there is any doubt…there is no doubt”.

Let us not look too closely at the pilot’s actions here…the operator (PHI?) IMHO should be the one that is mauled first!

[BigMike]

You have to love old Ron, the guy next door. "heard a big boom" but dosn't go and have a look until the emergency services turn up. Then tells the reporters about "losing a good shade tree" oh dear...

The helicopter is a Longranger by the looks of it?

[Helipolarbear]

We were so lucky there were no power lines down. We are lucky we have a firefighter who’s a pilot. He knew exactly what to do. The engine was still running, the fuel pump was running. He was able to turn the power off quickly to ensure everyone’s safety. Fuel was leaking everywhere. There was no fire, but with the engine running, it could have ignited and caused major problems.”

Check the photo of the engine.......they must be very tough fuel lines...etc....:confused:

[SASless]

It is only a news report....thus some poetic license must be allowed. The observation about the engine is so telling. The photo of Rupert bending over and peering at what used to be a turbine engine....as compared to the written account does beg the imagination a bit.

As to the Shade tree....now that might have put a mechanic out of business you know?

A helicopter crashes into your neighbors house....and you don't go outside to see what the ruckus is about? Time to move neighborhoods I think.

[tottigol]

The departure airport (MAdison, Indiana) has an AWOS-3 and there's another one 18NM to the North.
WX was 400/2.5 at time of departure, sometime after 01:00 Local time.
Uncontrolled airport with a CTAF. The WX minimums for HEMS transport programs accredited in accordance to standards in the USA are 800/2 at night for local flying areas to be defined and published in the Operators specific Operations Specifications.
If that is the case, and in view of the latest amount of flack directed to Air Ambulance transports in the USA, this guy is about to have a very prolonged and unpleasant period in his life.
Hopefully this shall be the final straw that brings everyone else back to reality with what has really been going on regarding HEMS flying in the USA.
We got a live one this time and I wish him a speedy recovery, he'll likely need excellent legal advice in court as I expect his employer to dump him like the proverbial hot potato.

[SASless]

Friday, November 04 2005 @ 10:26 AM CST
Contributed by: Admin
Views: 335
On October the 19th, 2005 in the interest of developing an attitude of continuing cooperation between the FAA, the air medical helicopter pilots in the State of Indiana, the Indianapolis Air Traffic Control Center (ATC), the Indiana Department of Transportation Aeronautics Section (INDOT) and the Indiana Association of Air Medical Services (INAAMS) a meeting was held to discuss a variety of comprehensive yet common operational, safety and industry issues specifically directed to air medical operations.

This safety consortium was a direct result of a collaborative effort between the Indianapolis (IND) and South Bend (SBN) Flight Standards District Offices (FSDO) of the FAA's Great Lakes Region and INAAMS. Given the growth of the air medical industry in Indiana, from four helicopters six years ago to 16 helicopters today all parties involved were in unanimous agreement that this meeting was needed and was very timely in nature.

All Air Medical operators were well represented by their pilots at the meeting as was the FAA, DOT, ATC, and INAAMS. The key note speaker, Mike Atwood from Aviation Specialties Unlimited, Inc. presented an overview of Night Vision Goggle (NVG) equipment updates, installations and use in EMS mission applications. Items of discussion primarily focused on communications, airspace, hospital heliports, joint operations and safety issues that are indicative to the air medical industry of Indiana. The attendees of this consortium have agreed to meet as a whole at a minimum of once a year with the air medical pilots themselves meeting quarterly as a group.

Bold print my doing....

Anyone reckon "competition" might be a factor here?

Before we tar and feather this pilot....we should remember an accident derives from a chain of events....and not one simple action or decision. There's several people and organizations that need to stand up and discuss their role in this. Tott says it right...this crew is alive...and if they will follow the lead of the Lady in New Zealand...some very needed good might come of this event.

I hope the PHI, CAMTS, NEMSA, FAA, NTSB....to name a few are prepared to do so.

[Revolutionary]

Tottigol my geographically challenged friend, the aircraft took off from Anderson, IN, not Madison, IN.

Honestly I'm not picking on you. Just taking the opportunity to make a relevant contribution to the discussion;)

On a serious note, all three crew members are in serious but stable condition and all are expected to pull through.

[IHL]

I would have to agree with Shortshaft the Operator should be mauled first.

From whats posted here; one has to wonder at the "company culture" that would allow a pilot to "we'll try it" at night in a Jetranger with 400 & 2 1/2 .

400 and 2 1/2 is marginal VFR weather in the daytime.

[Decks]

I dsiagree to a extent. I would not lift off 400 and 2 1/2 in a Jetranger at night unless someone had a gun to my head. Come to think of it... one better be a competent experienced and current IFR pilot to be prepared to go to those mins SPIFR at night.
The fact that it's allowed is crazy, the fact that the pilot did it is crazy too.

[BigMike]

If you look at the photos of the engine you will see that it looks to be a C-30, check the exhaust, which means a Longranger. Hard to see how they thought it was still running after the crash...

[tottigol]

Rev, my friend and constant counselor. I apparently got those two locations mixed up, but Anderson (KAID) is equipped woth an AWOS-3 to the same extent as Madison, and frankly 400/2, or 2.5 would not even make me go to the aircraft to remove the rotor tiedowns.
Apparently several "community based" VFR only programs have a "consistency" problem when it comes to checking WX before departure.
I was wondering how mandating IFR certification and currency and removing Part 91 flying in EMS (except for training and maintenance check flights) would affect a certain mid west based company.
Another great step would be implementing a mandatory installation of automated WX reporting at any new "rural" HEMS base set up by one of these so called community based programs, unless another one existed within five miles.
But then, again how many of those would be able to survive economically?:E

The positive part about this whole disgrace, is that the crew is alive and hopefully they'll be able to come to a complete recovery.

[rotorspeed]

IHL

Why should the Operator be mauled first? Second, maybe, but is there not a chance the Operator did not know the pilot had launched in this weather? Ultimately it is surely the pilot's responsibility to know what weather is and make the decision as to whether it is right/he is happy to go. Admit not familiar with EMS ops but this does seem like a "blame the company first" attitude rather than the individual with the greatest obvious responsibility - the pilot. Companies are fundamentally only organisations made up of individuals with differing responsibilities.

[SASless]

Rotorspeed...

Take a wander thru FAR Part 135 and see how it deals with CP/DO responsibilities, flight dispatching, and flight following requirements.

The pilot is the final authority on the safe operation of the aircraft without a doubt. Management also carries the bucket when things go wrong....or should anyway.

"For evil to thrive, all it takes is for good men to do nothing."

[Two's in]

It's largely academic who gets "mauled" first. This will be no different from hundreds of other accidents. Sadly there is always the same chain of events which will include the company ethos, EMS Operational ethos, the crews' professionalism, operational pressures, wx, aircraft serviceability, etc, etc. Some of these score positively, some score negatively, clearly this outcome had an overall negative score. Sometimes pilots have no idea whether they avoided an incident by a whisker or a country mile, but getting all the factors you can personally control on the positive score sheet is always sound advice. That's why only a fool or a journalist will say they know what caused it while the wreckage is still smoking. It's because they confuse knowing what the outcome was (helo hit building - we can all see that) with knowing what truly caused it.

[SASless]

Here are METARs for KMIE (12nm NE of Anderson - [KAID]):

SPECI KMIE 020541Z (0041L) AUTO 32006KT 3SM BR OVC004 02/02 A2978 RMK AO2
METAR KMIE 020553Z (0053L) AUTO 31006KT 3SM BR OVC004 02/02 A2978 RMK AO2
METAR KMIE 020653Z (0153L) AUTO 28004KT 3SM BR OVC004 02/02 A2978 RMK AO2

There are no METARs archived for Anderson around the mishap time frame.

I would have been snuggled up to my pillow doing my very best to keep everyone else awake with weather numbers like that.

[rotorspeed]

SASless

I certainly would not have the time to even locate FAR Part 135, let alone take a wander through it.

But you said it: "The pilot is the final authority on the safe operation of the aircraft without a doubt".

It is reasonable for a company to expect its individual employees, pilots included, to take primary responsibility for the decisions they are supposed to, and do, make.

The commercial world is becoming increasingly burdened by a Health and Safety authority attitude that presumes the organisation is always automatically and primarily to blame rather individual employees, even when they have clearly acted outside policy and common sense. This is contributing to the development of an attitude of blaming others (ie the company) rather than ourselves when mistakes are made.

Running a successful business is hard enough - as the aviation world proves - without added unreasonable burden. You can bet the operator in this instance will incur a huge workload as a result of the accident, regardless of where the main responsibility is ultimately deemed to rest. And that is before the costs of aircraft and ground damage, reputation, loss of business etc are taken into account.

Agreed we do not know the full circumstances. Maybe the pilot was unreasonably pressured by ops to go. But then maybe he wasn't.

[Revolutionary]

Rotorspeed, you and others have suggested that pressure to fly from management may have been a factor. I don't know the pilot but I do know his boss, his bosses' boss, the base, the airport, the dispatchers, the aircraft and the company quite well. I don't know the circumstances of the accident either but in my own experience with this company I have never felt pressured to do anything. I have seen the occasional lowlevel manager take it upon himself to offer 'suggestions' or give 'advice' on what he would do, but it's very easy to just disregard their input and do what you think is safe instead. More often I've seen pilots put pressure upon themselves to fly, especially in the Gulf, in an effort to please a customer or get the job done.

[Hippolite]

PHI has tightened up on its dispatch weather minima in the last 2 or 3 years. The whole Company Operations Manual was re written and issued about 18 months ago with a whole section (almost another Manual) on EMS.

The re write took a year and the question of company versus legal disptach minima was debated long and hard. I do not believe, looking at the Metars, that the weather was anywhere near meeting company minima. The 02 02 temp and dewpoint and the time of night meant that nothing was going to change for the better for some considerable time.

PHI teaches and encourages a "crew" mentality for EMS operations and the whole crew is actively encouraged through dedicated CRM programs to become involved in the decision making process.

While management always has some responsibility, the decision and interpretation of the weather at the time has to be the responsibility of the crew, not just the pilot. In this case, it looks like managment could have had little influence on the outcome. First stop for the investigators should be the (alive fortunately) crew of this aircraft.

[SASless]

Hippo,

This is not a PHI problem, but rather an industry wide problem. Good folks are making decidedly bad decisions and unfortunately very few live to tell about it. Every pilot flying EMS has gone IIMC probably or encountered weather or climatic conditions they did not count on. Flight delays can catch you out and allow for weather to become a problem.

The NTSB recommended all sorts of equipment improvements that cost a lot of money. They are simple to acquire and install but expensive and add weight and cost.

The cheap part of the solution but the hardest one is to find a way to ensure good people make good decisions regarding flying or not. The flight not taken guarnatees there will be no accident. The trick is to take the right flights and not the ones that set you up for that accident.

If this was the first weather related accident in a while or an isolated indicident then this would not be such an issue. Unfortunately the EMS industry as a whole is doing a terrible job of assessing weather correctly and refusing to fly in hazardous weather.

I would suggest operators would be well put to conduct third party evaluation of their programs and seek to find methods that will provide the flexibility needed to operate but do so in a manner that effectively prevents bad judgement calls that are causing these accidents.

If a visit was conducted at any EMS base....where the pilots were immune from retribution....almost everyone would tell of feeling pressure to fly despite Management stating otherwise. In most cases, this perceived pressure is self inflicted but that does not free Management from responsibility in my book. The operator has a responsiblity to promote measures that combat that perception.

We are killing people with an amazing regularity due to these kinds of accidents and there is lots of arm waving and yelling but no one is doing anything aggressive to change the environment we are working in.

Maybe they need to create a "Dispatch Office" much like the Part 121 operators do for overseeing flights. They all have computers....centralize the dispatch room to confirm weather decisions being made by pilots. Hire an experienced pilot, retired pilot and give them a remit to accept or decline takeoff decisions after the pilot and crew have reached a decision. That would be one last check on the guys before they go out the door.

[rotorspeed]

SASless

Why all the complication? Third party evaluations etc? You're adding cost to the industry again. Think individual responsibility.

The main thing that should happen is that pilots should keep to the rules. Simple. And cheap. The weather in this case was obviously well below minimums - either of policy or common sense.

Revolutionary; interested in your comments which don't surprise me. I still can understand pilots are sometimes pressured but they should be up to saying no. To be fired for saying no when weather was below minimums would deserve a big compensation claim and industry scandal. In this day and age I'm surprised if it is a big problem. And if it is, those operations should be reported. Is there not an anonymous risk-reporting system for EMS ops, whereby pilots can notify authorities of, for example, unreasonable pressure to fly?

[Hidden Agenda]

Rotorspeed,

What you say has been argued many times before…unfortunately your argument is on shaky ground…and consequently there continue to be failures of the ‘system’ and accidents as a result of those failures.

I would like to address some of your points:

1. Third party evaluations – the use of consultants does not need to add cost to the industry. It can, on many occasions, be cheaper than deploying a permanent staff member with the high cost of their overheads, salary, medical, leave and retirement benefits. Additionally, a consultant has no 'sacred cows' to defend, staff members will usual say enough to give the consultant the picture and management expects a harsh review, which is after all what they are paying for. Management doesn’t call for a third party evaluation to get a pat on the back, they do it to get an honest opinion on how they are doing…as well as to show others (shareholder, insurers, regulators and the like) that they are serious about catching problems before there are accidents.

2. Most pilots, by nature, will challenge the rules…the problem is convincing, or teaching, pilots which rules should not be challenged. When the HR department recruits pilots because they have a license, a pulse & they need little investment in training it is difficult to recruit pilots who can make appropriate decisions. A pilot that goes out when he shouldn’t will probably (eventually) have an accident and cost the company money…a pilot that doesn’t go out when he should will cost the company money by losing a revenue flight. Management oversight by closely monitoring each flight is one of the ways to try and get the balance right.

3. Never in a hundred years will you get a bunch of pilots to agree on when it is right to say 'no', especially when they are the only one on duty in the middle of the night and a call for ‘help’ comes in to the office. As someone on another thread rightly pointed out, 10 pilots = 12 opinions.

4. I would suggest that the helicopter industry is too small an environment for a truly anonymous risk-reporting system, let alone in just the EMS element. Employers will find out who reported it and the reporter (the “whistleblower”) will get screwed…maybe not immediately, but eventually…it is a given!

IMHO the issue is not helped by the national regulations in many countries that permit VFR operations at night. If it was clear-cut that all operations at night have to be operated IFR by appropriately rated crews in appropriately equipped aircraft it would be a giant leap in the right direction. Night = IFR is crystal clear; it is not open to interpretation.

I argued this point at an HAI Safety Committee Meeting during Heli-Expo several years ago and it was absolutely clear to me from the response that the industry in North America had no appetite for such an idea. The industry accident figures have not improved in the interim nor do I see any shift in the attitude of the operators.

I agree with the argument that if we continue to operate in the same way then it is the height of stupidity to expect a different outcome, and a reduced accident rate.

[SASless]

The main thing that should happen is that pilots should keep to the rules. Simple. And cheap. The weather in this case was obviously well below minimums - either of policy or common sense.


If this were an isolated occurrence, which it is not, I would agree with you.

The US EMS industry has a long list of these occurrences. I for one, cannot believe all of these people involved in similar crashes, were incompetent rebels or mindless crusaders who were hell bent upon saving lives at no consideration of their own. These are good dedicated caring folks in general who are out there doing a job who fully intend to go home to their family at the end of their shift.

Something is going on that lures them into the trap.

What is it?

Something is going on that allows them to make bad decisions on weather.

What is it?

Is there a pattern to their behaviour that could be spotted ahead of time?

Is it a particular crew mix that sets this up?

Is CRM breaking down and crew members are reluctant to say something when it happens?

Have they experienced similar instances in the past but got away with it?

Has an operator ever fired anyone for going IIMC? Has an operator ever fired someone for taking off in below minimum weather?

Has an operator ever rebuked a pilot for refusing to fly a flight as a result of a weather call?

What is going on Rotorspeed? Why do good people make such bad decisions? Why do good people keep dying as a result of such bad decisions?

The important question I see...exactly where and when was the bad decision made? Did the FAA, Hospital, and Management make the "real" decision and the actual decisions being made by the pilot and crews are flawed because of the policies that put them at risk no matter what they do at the time of dispatch?

An independent study of this, one that involves EMS crews (particularly pilots), in an anonymous manner will go a long ways towards resolving that issue.

There are long standing operations that have had no accidents. I wonder what they do right.....some of the others are doing wrong. The EMS operation located a mile from where I sit has had two fatal crashes. One with a VFR only single pilot BK and one with a two pilot IFR 412. Thus, VFR or IFR, single pilot or two pilot, does not magically cure the problem. They both happened in the mountains in daylight and bad weather...thus not even at night.

[Hippolite]

SAS

I wan't trying to imply that this wasn't an industry wide problem, actually I was defending PHI against previous posts of "maul the operator", a sentiment in this case with which I disagree for various reasons.

In this case, the operator has many procedures and limitations designed to stop this sort of thing happening....that is an undeniable fact. If the pilot decides to go against the company's limits and in questionable weather as in this case, the operator cannot be blamed.

EMS pilots must think of themselves as pilots and not ambulance drivers, paramedics or heroes. They are pilots of aircraft....sometimes that means you just have to stay on the ground.

HH

[SASless]

I agree the best Safety plan can be compromised by the actions of a single individual. I also accept that most EMS operators, including PHI, have good plans and procedures on the books.

Without pointing fingers at any specific EMS operator...I also suggest that unless the operator has an effective oversight of those very plans and procedures to confirm conformance and detect any variation with the view towards ensuring constant compliance...at that point they become part of the problem.

As an industry, with the demonstrated track record that exists, it is plain as the nose on our faces.....that has not been done across the board. Granted, that is a broad brushed statement that is unfair to those few operators or operations that do good work and exercise excellent safety practices, but as an industry evaluation, I think you have to agree with my position.

Lets use the recent New Orleans disaster for an example. A review of the New Orleans Emergency Management Program as posted on the official City of New Orleans web site, clearly shows the plan was unworkable and made assumptions that just were not going to happen. Actual events confirmed the plan even as written was not followed. We see the results of that failure on the nightly news.

That is my point....Safety programs are only as good as the committment to use them. If the safety climate of the operator gives lip service to the policy and procedures, the plan is dead on arrival, just like so many EMS crews.

Has any EMS operator taken a 24 hour Safety Stand Down after a fatal accident? One operator had two fatal crashes in one week....did they take any drastic measures to reassess what they were doing? If they did....lets hear about it?

When I say "maul" the operator....what I mean is ensure the root causes for the accident are examined and not merely the poor slob who makes a bad decision and is usually not around to defend himself. Probably the worse situation is to be that poor "hurt" slob who has to rebuild his life physically and emotionally while being lunch for the lawyers and folks trying to shift all the blame his way in the hopes of escaping any harm themselves.

It is always easy to blame the crew....and ignore the role other factors and people played. We should learn from every accident or incident and use them to prevent similar occurences whenever possible. I suggest the EMS industry does a poor job of that.

[rotorspeed]

Hidden Agenda

On your points:

1. Third party evaluations - of course using consultants is going to cost the industry money! You not going to get the service for free are you?

2. "Most pilots, by nature, will challenge the rules" Exactly! That is a major problem. If the night ops limits are 800ft and a pilot launches with 400ft, clearly what is required is a change of pilot attitude to respect the rules. He must know them, surely? Not exactly ambiguous in this example is it? How much nannying does one need as a pilot to understand that?

3. "10 pilots - 12 opinions". The margin over which disagreement should exist between pilots can often (as in this case) be over a tolerance that does not seriously impede on safety. For example, if the cloudbase was 700ft that would have been contrary (as I recall) to ops limits, but potentially does not put the pilot into a major risk area. If EMS bases had compulsory weather reporting (as I think someone sensibly suggested) then the info would be clear - at least at departure point, which was relevant in this case. If reported wx was logged routinely on EMS flights monitoring of rule adherence at least in this respect would be easy.

4. "Anonymous risk-reporting" unrealistic? No idea - you may well be right!

IFR only at night - definitely safety aid and clear cut as you say. Actually tend to agree. But shouldn't really be always necessary, particularly if operating in an area of good ground illumination and sensible limits are imposed - and adhered to.

SASless - don't think we're ever going to agree on this one! Good to debate the subject though.

[SASless]

Rotorspeed,

Which professional magazine, news report, or pilot's web site you want me to quote from....we have a problem.

What does a single three crewmember fatal accident cost just in dollars and cents? What does an effective third party evaluation cost? If you prevent just one accident ....you reckon there is a money savings? What are the three lives saved worth?

Why do pilots push the rules? How many times do I repeat that question in some form to you? I have said and few argue that good people are making bad decisions....count the smoking wrecks laying around the place.


Until the facts are known about this latest accident it would be premature to announce a cause with any certainty. The weather reports were provided but are not certified as being the actual weather at the time of takeoff although they do give rise to a question. The fact the crew survived, then hopefully a better understanding of the chain of events that led up to this thing happening can be acheived and something positive come from whatever is determined.

Your example of a 700 foot cloudbase being good enough to fly but in violation of an 800 foot minimum as set by policy shows the mindset we are faced with. Minimums have to be set at some arbitrary definable value....or else they would not be "minimums". How we arrive at those values is one of the issues that must be addressed. I submit to you...the minimums are not high enough to provide a cushion for safe flight in the event of deteriorating weather.

Using your example....lets lower the standard to 700 feet for local night flight...do you apply that to an area that surrounds your home heliport and include the tallest obstacle within that area....or do you go to a corridor concept and use the same safety minimum but restrict it to the planned flight path plus a few miles either side of the centerline and apply the safety height to the tallest obstacle in that corridor. Or do you ignore the obstacle heights and just add 700 feet to elevation heights? There can be one heck of a lot of difference between all three methods...assume there is a 1000 foot tower (mast) in your area that sets on a hill that is 500 feet higher than your heliport.....how many numbers do you come up with? How far apart are the surface lights....heck of a difference between West Texas and Nebraska...South Dakota and the area around Boston, Baltimore, Philly, and New York. The two mile vis near Boston is not the same two mile vis in SD, MT, TX for example.

There is going to be third party review of a sort....the FAA is under the gun to do something. They will of course not embarrass themselves by pointing the finger at themselves....any guess who is going to bear the brunt of the blame?

As a pilot....I would beg for a third party evaluation of the situation....but one that was truely impartial...not one that was going to take care of the FAA, the Company, or the Customer. Something happens now...it is the pilot that gets handed the bucket....and it becomes a game of trying to shift the burden from there.

[Thomas coupling]

Press on itis.

Poor CRM.

[Helipolarbear]

SASLESS....I agree with your comments totally, but as most minima prescribed by FAR;s etc are statutory, then the LETTER of the Law usually applies! Is the bottle half full or half empty? In this instance it's half full in my view! The occupants survived!!!:)

[Shawn Coyle]

We have enough techology with GPS and TAWS and the like to come up with a compromise between hard IFR (airways, clearances, etc.) and VFR.
All the helicopters flying at night have attitude indicators and the appropriate navigation aids - why not adopt a semi-IFR approach - dedicated routes to get you close to the necessary scene - for scene calls, and dedicated routes from hospital to hospital. All this outside of built-up areas (which would be clearly defined).
An IFR attitude brings a whole different way of thinking - one that has proven to be extremely safe for airlines, corporate aircraft and the like. Why are we not putting something like this forward voluntarily...???

[Helipolarbear]

You would still have to develop approach minimato a point that a safe transition to VMC/VFR exists!!,( regardles about the 1,000' obstacle clearance and lateral dimensions). This would be near impossible to achieve under any national safety conventions! The insurance liability alone would be near prohibitive! Utilization of NVG's on a common level with the correct equipment, training and currency requirements in place, would certainly reduce the minimum WX risks and up the mission accomplished stats substantially.:cool:

[Shawn Coyle]

I'm not saying that we have to fly IFR all the time - just use the IFR procedures for set routes, altitudes, etc. That way if you run into weather so that you can't still see far enough ahead at the altitudes you fly on the route, you know to either turn around or do something else (go IFR and climb, or continue IFR on the known, safe route or land or ???).
We're innovative people - given a problem we can usually solve it. But we need to think the problem through.
Did the pilot have any IFR training ? Had he had any training in flight in bad weather at night? How many times had he done something similar? A lot of stuff that should be known in the investigation.
With WAAS and RNP of 0.1nm, there is no need for 1,000' clearance for everything within 5nm of track - we can go with much tighter routes and lower altitudes. Alaska Airlines is doing it with planes full of people into some pretty tight places - why aren't we even thinking about it?

[SASless]

Shawn,

You are a bright fellow. Think about your question and in time...you will figure it out.

Let me give you a wee hint.....Dollars.

The very same people that will put you out in the middle of a very dark hole, in a Jetranger or A-star....with minimum equipment...sometimes not so much as a RadAlt beyond the bare minimum panel required by law...the same people who think a few unusual attitude recovery practices on your annual checkride and their mindset of doing it on the cheap....are the ones that have gotten us to where we are.

This is a circular argument....and as you well know...accidents are caused by a chain of events...and usually not one dramatic event.

It costs money for training...real, timely, effective, and frequent training.

It costs money to maintain IFR currency and proficiency.

It costs money to provide the equipment.

It costs money to turn down flights.

The one change that would have the most immediate effect on all this would come from the insurance companies....if they demand effective improvements or else they raise premium rates to such a level the operator could not afford the insurance....then the bottom feeders would disappear overnight. The FAA will study this to death and write all sorts of memo's to the inspectors but that will have very little affect. The EMS organizations will have their meetings and put out Press Releases and that will not affect things very much.

[arismount]

The more I think about this question, the more I think Occam's Razor applies to it. Also, never attribute to machination or conspiracy, that which can be adequately explained by stupidity.
Specifically, I'm now convinced that when a high-time, "highly-qualified and experienced" EMS pilot crashes due to weather-related cause(s), it's due to one of three situations:
1. Complacency, i.e., "The little stuff doesn't matter so much any more"; or,
2. Invulnerability, i.e., "I have been through many years of things that could kill me, yet I'm still alive and doing fine; therefore, I'm unkillable"; or,
3. Statistics, i.e., maybe the individual was just plain no good from the very start, and on the night of the accident, all the many, many links of the accident chain just finally snapped into place.

[Thomas coupling]

Press on itis.

[tottigol]

Shawn is closer than most to the answer, yet that would only be applicable over favorable orography.

WAAS is a great thing and its inherent capabilities render it almost equal to a CAT I ILS approach procedure; it is also far more portable and affordable, to the point that it would be great to see dedicated rural communities helipads associated with WAAS GPS IAPs and ASOS WX reporting systems.
HEMS Operations, by their own nature take place within a fairly small area, and this would make the local ATC familiar with the operation and location of the helipads, possibly avoiding the need for a full IFR filing procedure.
But before we get to that, whenever a "rural" operation is set up, there ought to be a WX reporting facility associated with that location, and the communities that would benefit from that helicopter presence could partecipate in the set-up expenses.
That said, IFR is often not practical in mountainous areas, and in this case the use of NVGs (still subject to WX conditions) would be a welcome addition.
Adding on to what SAS is saying, the costs associated with flight crew training (initial and recurrent) and equipping the right helicopter for IFR flight to those standards, would initiate a "Darwinian" selection process, in virtue of which those operations that (in SAS view) are responsible for the current state of things, are going to have to adapt or become extinct.

[Shawn Coyle]

It might mean a different approach (no pun deliberately intended, but taken anyway) to flying. A stabilized helicopter with an autopilot would be a great first step - both for relieving workload and providing a guarantee that the flight path would be flown accurately. That is not difficult or overly expensive - not as easy as it might be, but well within the budget of most operations even for a Jet Ranger if there is cooperation from the authorities.
Let's use our imaginations here - we have a problem and we need to define it clearly and then show the FAA that we have a solution that is safer than any other.

[tottigol]

One more consideration to make with regards to the recent NTSB safety conference and the FAA's "new" EOC document, is that I cannot recall those two agencies polling pilots on what would be the best recourse.
Operators have a slightly different point of view, and if not those, then their customers may.
We need to generate a very much black and white go-no-go mechanism under which the piolots are isolated from possible external "pressures".

[SASless]

Tott,

I would begin to think "internal" pressures are even stronger than external....knowing the independent nature of most helicopter pilots. When you find a cure for both "internal and external" pressures...I bet we got it whipped!

When you consider most of these decisons are made at remote locations by a pilot that does not have access to...or is directly confronted by someone at the time the decision is being made. The guy may know that every decision to reject a flight is reviewed and unless there is a complaint, those that are accepted are never challenged. He may know there has been talk of closing the program if flight stats don't pick up...and the like. Thus that perceived pressure even if not overtly directed may be felt internally. Combine that with the fact it may be a child out there hurt....or something similar....it is hard to make a cold blooded decision sometimes.

[tottigol]

SAS wrote:
When you consider most of these decisons are made at remote locations by a pilot that does not have access to...or is directly confronted by someone at the time the decision is being made. The guy may know that every decision to reject a flight is reviewed and unless there is a complaint, those that are accepted are never challenged. He may know there has been talk of closing the program if flight stats don't pick up...and the like. Thus that perceived pressure even if not overtly directed may be felt internally.

The former I referred to as external pressures.
The internal pressures as you mention are what we call the "white knight syndrome", a condition that affects mostly newcomers to the job.
After several years, it ought to be just another flying job, except for the first paragraph above, where those pressures would possibly cause a "frequent mover syndrome" followed by "it's a very small EMS world syndrome".
Both the NTSB and the FAA are not fully aware of this or they are artfully and glaringly ignoring the issue.
I am largely with you and Mr.Coyle on these subjects.

[SASless]

You ever seen the look on the face of a Med Crew when you suggest you are in the Air Transportation business and not the Life Saving business? Shortlly after that you become a dangerous pilot whom no one can get along with and no matter what you do....besides pack yer bongo's and beat feet will make them happy. As you say...frequent mover club!

[rotorspeed]

SASless

Answer me this. In no more than 50 words please. In what approximate percentage of EMS accidents do you think the pilots have flown in accordance with existing rules, either FAA or their own operations?

[SASless]

Rotorspeed,

How the heck do I know....and I bet you the EMS industry does not know either. We do know of some that did not follow the weather minimums for some reason and found themselves answering a Roll Call Up Yonder.

Does it matter if that happens to you the very first time or the hundred and first time? Your answer please?

How many of us have gotten caught out despite our very best and honestly made decisions? That is a more telling question. Can you answer that one?

Have you an answer for the question...."Why do folks knowingly fly in adverse weather conditions that are such as to present a mortal danger to them and their crew?

Whats your view on that?

[havoc]

For those that have express their concerns, the PHI crew is doing well.

The Pilot has been discharged and the Medic and Nurse have been moved to rehab hospitals closer to their homes.

[rotorspeed]

SASless

Not entirely surprised with your post in response to my question, the answer to which is important.

If a high % of accidents occur when pilots have been in blatant breach of the rules, then a major problem is pilot compliance. If not, then there is a case for reviewing rules and imposing higher limits. Getting a clear direction and focus on what simple, inexpensive actions are required to reduce accidents is essential.

You are quite rightly very concerned that EMS accidents should reduce. Maybe you have the time to do some research and trawl through old accident reports to come up with an answer?

Answering your (somewhat strange) questions:

1. No
2. What do you mean by caught out?
3. Because they probably do not feel obliged to comply with the rules, and they believe their judgement and skill will keep them alive, which it almost always does.

Havoc: really pleased to hear that, thanks.

[SASless]

NTSB Identification: CHI06LA074
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Thursday, February 02, 2006 in Chesterfield, IN
Aircraft: Bell 206L-1, registration: N593AE
Injuries: 3 Serious.

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.

On February 2, 2006, at 0143 eastern standard time, a Bell 206L-1 helicopter, operated by Petroleum Helicopters, Inc., based in Lafayette, Louisiana, was destroyed during impact with trees, wires, and residential structures while maneuvering near Chesterfield, Indiana. The emergency medical service (EMS) flight was dispatched to pickup a patient at the St. Joseph Hospital, Kokomo, Indiana, and was operating under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed during the flight. The pilot, flight nurse, and paramedic were seriously injured. The flight departed Anderson Municipal Airport (AID), Anderson, Indiana, at 0139.

According to company dispatch records, shortly after departure the pilot reported that he was aborting the flight due to poor weather conditions. At 0145, the weather station at the departure airport reported calm winds, overcast ceilings of 400 feet above ground level (agl) and 2-1/2 statute mile visibility.

[Shawn Coyle]

Let me see if I remember the weather info given earlier:
Temperature and dewpoint both 2C.
Unless someone has changed the lapse rate and not told us, 2C/1,000 feet means that somewhere not far above the weather station, the temperature would definitely be below the dewpoint, and it would be pretty thick fog (amazing - it says here 400' higher).
So how high did the pilot think he was going to get, and what about local variations in temperature that might (shock, horror) be lower than where the temperature was taken?
And did they get any weather report from the scene?

It might be something to add to your list of things to check or get a second opinion on when things are this close.
What statistics do we have on what percentage of calls (day or night) get turned down because of weather, lack of weather reporting / information critical to the flight, etc.?
Sorry for the unconnected nature of the rant, but the industry needs to do something about the continued bad safety record.

[Thomas coupling]

Has anyone checked the stats to identify whether it was:
pilot error
weather
mechanical
CRM
etc

that causes the majority of these EMS crashes?

From that it should be relatively easy to backtrack to the source of the problem and fix it.

My money is on pilot error it being a mixture of:

Press on itis
experience
press on itis
experience

oh...yes..and...press on itis.

[tottigol]

Shawn, here's the key to the accident:
The emergency medical service (EMS) flight was dispatched to pickup a patient at the St. Joseph Hospital, Kokomo, Indiana, and was operating under the provisions of 14 Code of Federal Regulations Part 91.

Pt.91 operations do not envision any particular WX restrictions for helicopters.

Today, we have a live example (fortunately with no fatalities) of the reasons why Pt.91 ought to go away for EMS operations, unless the FAA decides to change the wording regarding helicopters in CFR14 FAR 91.155.

[Revolutionary]

Tottigol, PHI's EMS WX limitations are more restrictive than Part 91 and are followed on all legs, wether Part 91 or Part 135. So in this instance, that would not have made a difference. I agree with you though that from a regulatory point of view it would be much better to declare all EMS flights Part 135, regardless of wether there is a patient on board or not.

I know this will never happen but I sometimes wonder how much safer it would be if every EMS helicopter had a designated, protected service area and if dispatch was a government operated, nationwide entity. No more trying to muscle in to each other's service areas; no more helicopter shopping by 911 operators. EMS operators could simply bid on service areas and be assured of a certain amount of business, handed out by an independent dispatching agency.

[SASless]

Rev,

Make it simpler yet....and Nick Lappos woud love you for it...just make all EMS in the country government run operations and do away with private operators. The down side to that immediately would be the operations would be "Public Use" aircraft and standards except for the State of Oregon that has a state law that forbids "Public Use Operations" by state owned aircraft. Thus it would have to be a Federal operation there I would think.

[tottigol]

SAS, that would be a huge culture clash, and it would go against the grain of a typically privately run hospital system as it is in this country, however some level of filtering ought to be applied.
Training EMS dispatchers to Part 121 standards is not going to cure the problem as long as we have pilots (and med crews) accepting flights they have no reason to.
Where we need to work is in educating the medical community to understand and accept the fact that sometimes the risks involved are just not acceptable, and no means just that.
As long as someone out there is willing to jump the gun and expose his/her personal safety and that of the transported medical team (be they passengers or crew) there shall be someone "weather shopping" for aircraft.
One possible solution (as I believe someone already proposed in this forum) would be to remove direct call privileges from requesting hospitals, and have them go through 911 regional call centres (boy, would that tickle someone) even for inter-hospital transfers.

In the end the only thing that shall stop this "scramble for customers" phenomenon is accountability and one way to rpovide for that is to have WX reporting located anywhere there is a EMS helicopter; to make that an IFR operation would require other and more expensive propositions but the "traffic light" would be there for all to see.

Rev, at no time in my posts have I implied or pointed out that any one particular operator is more or less guilty of keeping WX in disregard and I wouldn't expect any operator's official position to be any different than the utmost respect of regulations.

As we stand, we are once again spending rivers of words while there's someone out there doing a regulatory work that is out of balance and is failing to consider the opinions of those whom ought to actually be at the forefront of this battle.

[Hippolite]

The decision to launch with a +2 +2 temp and dewpoint and any common sense is questionable as I have said previously. The 400' cloudbase is well below PHI minima.

What puzzles me even more is that this was a patient transfer, the helicopter was en route TO the hospital. It wasn't even a scene call. In my mind, the crew decision has to be even MORE questionable. PHI has a combined CRM course for EMS crews, the decision must have been supported by all crew.

This one baffles me somewhat.

[Shawn Coyle]

At the risk of adding fuel to the fire - some (loosely connected) thoughts....
The US Air Force has a system where the Supervisor of Flying has to approve all flights - bit cumbersome and not the way most others operate, but they did it for a good reason (I suppose). The RAF has an 'authorization' system where someone has to authorize you to go flying. Again, implemented for a good reason.
Why not implement a watered down version of these systems with the dispatchers having to have something (verbal or faxed or emailed) from the pilot (and only the pilot) that he has checked the weather and confirming it is within limits. To those who say it's going to increase the time it takes to respond to a call, this is not a war, and I doubt the extra minute would make the difference in most cases.
In return, dispatchers would have to state to the person accepting the call (may not initially be a pilot who answers the phone) that another operator or base has turned down the call and the reason why it was turned down. Keeps everybody on the responbility curve.
And since there are more hospitals than airports, why not make it a requirement for the hospital to have a mini-weather station with temperature and dewpoint as a minimum (you can determine a lot about cloud base and potential vis from those two numbers).
And how much would some of those mini-weather stations cost to be put at police and fire stations or even on fire trucks (which seem to be on most scenes before the helicopter)?

[tottigol]

Shawn, believe it or not a document defined as EOC (Enhanced Operational Control) Policy has been sent forth by the FAA some time back, prior to the 25 jan NTSB conference and prior to this latest accident.
IIRC that document has its origins in the USAA community, and may or may not be a version of the USAF one.
The process is cumbersome and does nothing to improve response accountability on the part of the pilot.
I agree with you on the WX reporting facilities, the only problem is cost for those that shall need to be certificated by the FAA and unless they would be directly accessible by the pilots what operators are going to be trained to be authorized WX observers as for part 135 operations?

WX reporting stations at those locations from where EMS helicopters operate shall have two effects:

Pilots shall be accountable for launching in WX they ain't supposed to, but at the same they'll be able to use the same WX to support their no-go decisions.

[SHortshaft]

We operate such a system of authorisation for all flights in our AOC (Part 135? equivalent) operation.

Depending on the risk level determined by our risk matrix assessment the flight may even require authorisation by the company Vice President (the accountable manager). Of course such a system does not preclude the pilot from deciding it is a no-go early in the process.

Is it cumbersome? On paper maybe, but the system is part of our procedure and there is no doubt that it concentrates the mind of someone who is considering an action that may be extreme.

[tottigol]

Yeah, I can imagine calling our CEO at 02:00 for a flight authorization.
Maybe we should do that a couple of times.;) :E

[havoc]

PHI has implemented a program that a pilot is now in the EMS dispatch center. Basically another set of eyes on the decision process. He can say no based on information but cannot tell you to go.
Got to use him last night on a dispatch, quick discussion on the weather forecast for the return flight (TEMPO conditions). Planned to get the patient to where they needed to go and then we had another discussion prior to returning to base. Painless, basically he listened to what my plan was based on the weather I had and pressed on.
PHI has been using the risk matrix for a couple of months, still a work in progress, but again painless if you keep an eye on the weather.
There is nothing offical about the Anderson accident, and really just piece meal of speculation. The crewmembers are doing fine.



Note to Shawn: The Air Force SOF did not have the authority to launch aircraft. They did last chance looks at the hammer head, braking action checks, occassional drop off of left behind equipment for the aircrew, and at times a set of eyes on low passes to checking parts and pieces on aircraft (gear down/hung gear) etc.
to be the SOF, you had to be an Aircraft commander and then eventually it was opened up to other rated crew positions (Share in the fun of SOF duties).