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Old 6th Feb 2006, 07:34
  #21 (permalink)  
 
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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?
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Old 6th Feb 2006, 10:12
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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.
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Old 6th Feb 2006, 13:17
  #23 (permalink)  
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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.
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Old 6th Feb 2006, 20:16
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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
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Old 6th Feb 2006, 20:35
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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.
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Old 7th Feb 2006, 17:47
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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.
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Old 7th Feb 2006, 18:52
  #27 (permalink)  
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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.
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Old 8th Feb 2006, 11:16
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Press on itis.

Poor CRM.
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Old 8th Feb 2006, 11:44
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Devil

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!!!
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Old 8th Feb 2006, 12:54
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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...???
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Old 8th Feb 2006, 13:21
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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.
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Old 8th Feb 2006, 13:55
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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?
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Old 8th Feb 2006, 14:19
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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.
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Old 8th Feb 2006, 14:23
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Experienced pilots are doing stupid things and crashing. Why?

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.
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Old 8th Feb 2006, 18:39
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Press on itis.
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Old 9th Feb 2006, 01:01
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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.
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Old 9th Feb 2006, 01:43
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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.
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Old 9th Feb 2006, 02:06
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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".
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Old 9th Feb 2006, 02:29
  #39 (permalink)  
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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.
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Old 9th Feb 2006, 03:29
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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.
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