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PHI EMS Accident - Sam Houston National Forest, Texas June 8th

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PHI EMS Accident - Sam Houston National Forest, Texas June 8th

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Old 16th Jun 2008, 16:56
  #21 (permalink)  
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I'm only slightly acquainted with this pilot. What I know of him makes him nearly the last pilot that I would ever suspect would be victim of an IIMC CFIT accident. If that's what happened, there's a reason and I hope the NTSB can discern more than pilot error. This one's enough to make me reconsider my opposition to CVRs.

I've been watching these accidents occur since 1969 in Vietnam: Single-engine or twin; IFR and VFR aircraft; Single pilot (mostly, as that's where the action is) and two-pilot crews; military and civilian. You'll notice I haven't mentioned NVGs in that list. That's because I know of only one night EMS accident in an NVG EMS aircraft in the US- the pilot and sole occupant, walked to the highway and help. To me, that's a huge indicator of worth.

Helicopters are not airplanes. Helos operate with a different, riskier flight profile, that's what we're here for. Need an illsutration? The 'sterile cockpit' module of our recurrent training- "The sterile cockpit rule will be in force during all critical phases of the flight: takeoff; landing and any flight operations below 10,000 feet..." That's pretty much all of a typical helicopter flight.
It's a waste of time comparing airplane, much less "the scheds", to helicopters. It's especially an apples and oranges comparison against EMS. I'm not saying the industry can't accomplish a safety rate comparable to Part 121 operations. I'm saying the issue can't be assessed, much less addressed blindly using an airplane operations model: EMS can't expect to operate with with exact weather knowledge (Sorry, Flungdung- METARS and TAFs don't exist for most of the world.); EMS won't always use a surface facility designed for aviation; EMS information availability can be vastly improved, but highly variable runs that require constant decisions are the rule, not the carefully defined parameters aluminum tube guys take for granted.
Pure speculation- In this particular accident, I wonder if the illusion of sound judgment wasn't presented by the consultation with EOC? Sharing the decision process can act against a conservative inclination to decline a run.

There's no substitute for being able to see and avoid obstacles and weather. Being able to see the environment is a single major external difference between day and night flights. It's rational to conclude that if you minimize that issue, you minimize risk from it. The adoption of NVGs will improve the US night EMS accident rate more than anything since the black times of the '80s. Ask anybody using NVGs if they'd rather operate at night without them...

That said, I see other issues the industry desperately need to address. Scheduling night duty shifts is done in complete disregard for human physiology, for instance. And pilot training, while perhaps not a factor in this accident, is marginal if not downright inadequate in much of the industry.
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Old 16th Jun 2008, 17:43
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TAFS/METARS/actual weather reports/forecasts of any kind are useful but as D49 correctly states.....there's too many holes in the fabric for complete reliability. Terrain and elevation variations have to be considered in addition to the usual factors.

How many of us use the temperature/dew point spread as a go/no go decision point?

How often would I merely take a peeky poo out the window to check for that wee bit of "haze" in the parking lot overhead lights.....if I saw the start of fog there....no matter the temp/dewpoint spread it was no flying for me.

Clouds are one thing....surface based weather phenomenon is something else althogether be it granite lined cloud or fog. That kind of thing kills folks like us.

I refused an EMS job offer in the mountains of North Carolina flying a BO-105. The operator could not understand my hesitation to fly around in the dark of night in the mountains without NVG's in an aircraft that could not sustain flight following an engine failure when flown at max weight.
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Old 16th Jun 2008, 23:58
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Weather observations are generally available only at airports. We don't fly out of airports, and seldom even near airports. The closest weather METAR to my base is about 30 miles away, and there will be none for any scene flight I do. It's not the third world, it's simply rural America. You can get an area forecast, but I can guess that about as well as the NWS does. There is a HEMS tool, which attempts to guess the weather everywhere, but it's very inaccurate. I've seen it showing clear and 10 when the weather was really crappy, and I've seen it showing LIFR when the weather was clear and 10. I don't trust it at all, because it's so wrong so often. You have to know your area very well, and know where the fog and low clouds generally form, and under what conditions. That takes a long time, and few pilots have that much time at a location. There simply isn't adequate weather observation and forecasting capability in existence, nor will there be any time soon. You make a decision and hope it was right. The worst enemy by far is the self-imposed (from ourselves and the rest of the crew) pressure to go out and save lives.
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Old 17th Jun 2008, 01:32
  #24 (permalink)  
 
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Learning how to predict weather locally is something that helicopter pilots should be taught, or at least make an effort to learn.
But micro-weather is not something on the official syllabus, which is very heavily FW oriented.
Just more grist for the mill.
(I feel an article coming on....)
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Old 17th Jun 2008, 06:43
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The bottom line for HEMS is too much expectation with far too little resource. We need to look at human factors first.

Regards and respects to those involved in the tragic accident!
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Old 17th Jun 2008, 11:11
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Flung, WX reporting is widely available in the USA it just needs to be checked.
Not too far in the past, another crew from the same company crashed into the side of a house after launching from an airport WITH AN ACTIVE ASOS.
It was about 2 or 3 past midnight and the reported WX was 400/2.
The aircraft involved was a VFR Bell 206.
The spirit of most of these "community based" programs is to barge in the air at the minimum smell of money, and in my opinion the institution of operation centers is negatively affecting this particular type of operation.
A pilot with such experience ought to be able to make his own call and the operation center's only function should be to veto if necessary "go" decisions.
It shall be very interesting and very important to the outcome of the NTSB investigation to find out what kind of exchange went on between this pilot and the flight supervisor....in Arizona of all places.
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Old 17th Jun 2008, 11:29
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NTSB Preliminary Report

NTSB Identification: DEN08FA101
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Sunday, June 08, 2008 in Hunstville, TX
Aircraft: Bell 407, registration: N416PH
Injuries: 4 Fatal.
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 June 8, 2008, at 0248 central daylight time, a Bell 407 helicopter, N416PH, owned by PHI, Inc., and operated as "Med 12" was destroyed when it impacted a heavily forested area in the Sam Houston National Forest, near Huntsville, Texas. Night visual meteorological conditions prevailed at the time of the accident. The air ambulance flight was being operated under the provisions of Title 14 Code of Federal Regulations Part 135 on a company Visual Flight Rules flight plan. The pilot, flight nurse, flight paramedic, and one passenger were fatally injured. The flight departed the Huntsville Memorial Hospital at 0246, after picking up a patient, and was en route to Herman Memorial Helipad, Houston, Texas.

The accident helicopter was equipped with a Global Positioning System (GPS) flight tracking system referred to as "Outerlink". According to data from the Outerlink system, the helicopter powered up for flight at 0244:11 and departed the hospital at 0246:56. The last coordinates recorded were at 0247. The helicopter was at an altitude of 1,016 feet mean sea level and traveling at a groundspeed of 106 knots. The calculated direction of flight was 170 degrees. The flight was scheduled to report in at 0300. No transmissions were received.

The wreckage was located by aerial search and rescue teams at 0830, about 2.5 miles southwest of the last known coordinates, with the aid of the 406 emergency locator transmitter (ELT). Debris was scattered approximately 630 feet from the initial impact point to the farthest point of the main wreckage. The debris path included the aft portion of the tail boom (including the vertical fin, tail rotor, and portions of the driveshaft), the mast and transmission assembly, and three of the four main rotor blades. The fuselage separated into three sections, the aft portion (including the engine), the center portion (cabin area), and the forward section (cockpit). Following the on-scene examination, the wreckage was recovered and relocated to a hangar for further detailed examination.

The closest official weather observation station was Huntsville Municipal Airport (UTS), Huntsville, Texas, located 8 nautical miles (nm) north of the accident site. The elevation of the weather observation station was 363 feet msl. The routine aviation weather report (METAR) for UTS, issued at 0235, reported, winds variable at 6 knots, visibility 10 miles; sky condition scattered 1,200 feet; temperature 26 degrees Celsius (C); dew point 23 degrees C; altimeter 29.97 inches.

According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the moon rose at 1023 on the preceding day and set at 0015 the day of the accident. The moon was waxing crescent with 30 percent of the moon's visible disk illuminated.
Index for Jun2008 | Index of months
___________________________________
Zalt:

This particular aircraft did not have NVG's because, even though PHI had already pre-paid for NVG sets for every EMS helicopter that it operates, the NVG manufacturer(s) have made the US Gov't a priority customer, and have pushed back civilian orders to serve the Gov't needs in Iraq. PHI simply cannot get the NVG's as quickly as it needs them.

___________________________________

Others:

Yes, in certain regions, due to the micro-climates that exist, the forecasts are nearly worthless, and the weather reporting stations are not located anywhere near places where they might provide relevant information for HEMS flights.

There are many weather reporting black holes in the South Texas Region. Temp/Dew Point is a major player in most HEMS pilots' go/no go decision, because we often have nothing else to go on. Fog sometimes forms when winds are well over 15 kts... basic weather knowledge is not enough to operate safely here.

__________________________________

Links:

Memorial service- Long, but gives you an idea who the pilot was- (1:59) http://www.kbtx.com/home/misc/19798899.html

News segment (0:09)
http://www.kbtx.com/home/misc/19796104.html
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Old 17th Jun 2008, 13:46
  #28 (permalink)  
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Flungdung:
There's a lot of weather reporting in the US, but the official stuff is very regional. It's not unusual for me to go a whole 7 day duty period and only fly to one area covered by a TAF- but, there's 4 TAF stations there. I use a lot of different WX sources to cover the emptyness, from online WX cameras and amateur WX stations, to calling somebody I know and asking stuff like "Can you see the top of Black Mountain?"
The way to get old in this business is to always have a back door, an escape plan from what might happen, and use it- often. I never, ever go where I can't see. Sometimes that means I have to land in a parking lot or field, usually I chicken out early enough to get to an airport, and sometimes that means I have to decline runs for 'maybe" and endure a whole night's sleep.

Tottigol:
You highlight valid issues regarding stupid or careless pilots and I'll readily admit that they exist in EMS. The Huntsville accident pilot was neither, in my estimation.
But, Sir, you ignorantly insult the memory of the individual and all his fellow pilots in community based EMS, me included, when you say "The spirit of most of these "community based" programs is to barge in the air at the minimum smell of money, and in my opinion the institution of operation centers is negatively affecting this particular type of operation." That may be true in some cases, but that is patently NOT the spirit I've encountered at my program of 7 years, or with my employer- the largest helicopter EMS operator in the U.S. The quickest way to become a former employee here is to push weather or imply that a run should be taken, period- medics, mechanics, management (any level, but no vice presidents yet)- you are GONE if you meddle with the PIC's conservative call. I also worked for the accident company in this case, and that rule held there, as well.
The poor, and the stupid will always be with us, to paraphrase. What's worse, even the best of us will be stupid on occasion. Perhaps that happened in Huntsville, once is enough for any of us.
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Old 17th Jun 2008, 16:17
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Dev, if you taaaake the time to read my post you'll see that I never implied that the pilot of the 407 was guilty of anything, au contrair, I believe that a pilot of his experienced should not allow external "judgment" be a factor in his decision if not in the direction of being conservative.
Neither I implied that WX was a factor in the accident.
My reply was directed to Flungdung, and yes I stand by my call in regard to "standalone" programs, you may be the exception but certainly not the rule; I do not insult anyone's memory rather those who continue flying and operating without regard to their safety and that of their charges do.
After working for the same company you do for more than you have, I am yet to see any outstanding public punishment for individuals at all levels who take upon themselves to push the business just that much further.

Can we push for CVRs and FDRs in all EMS helicopters?
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Old 17th Jun 2008, 19:37
  #30 (permalink)  
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As far as I'm concerned, the media has forever fouled that nest- NO CVRs!

Nobody has a right to release the final screams of terror of a flight crew, as has been done. I don't care if the law's been re-written- the law is whatever is most convincingly argued in court that day. There's too many smart lawyers and amoral, ambitious journalists for me to ever favor the risk of that happening again. Besides which, how many "secure" files have been publicly acknowledged as missing? A CVR file is more secure, how? If I have to sacrifice benefit of the knowledge gained from a CVR, so be it.
Those who have to live with existing installations have my sympathy.
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Old 17th Jun 2008, 20:30
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Devil,

Perhaps you may have to surrender if this Senate Bill passes into law. Although it may never happen in your lifetime with the way the law is worded.


Section 508 of S. 1300 would mandate compliance with Part 135 regulations whenever medical crew are on board, without regard to whether there are patients on board the helicopter. Within 60 days of the date of enactment of S. 1300, the FAA would be required to initiate rulemakings to create standardized checklists of risk evaluation factors and require helicopter EMS operators to use the checklist to determine whether a mission should be accepted. Additionally, the FAA would be required to complete a rulemaking to create standardized flight dispatch procedures for helicopter EMS operators and require operators to use those procedures for flights.

Any helicopter used for EMS operations that is ordered, purchased, or otherwise obtained after the date S. 1300 was enacted would also be required to have on board an operational terrain awareness and warning system (TAWS) that meets the technical specifications of section 135.154 of the Federal Aviation Regulations (14 C.F.R. 135.154).

To improve the data available to National Transportation Safety Board (NTSB) investigators at crash sites, the FAA would also be required to complete a feasibility study of requiring flight data and cockpit voice recorders on new and existing helicopters used to EMS operations. Subsequent to the feasibility study, the FAA would be required within two years of S. 1300’s enactment to complete a rulemaking requiring flight data and cockpit voice recorders on board such helicopters.
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Old 18th Jun 2008, 13:36
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It's possible to get METARs for airports, of course, but they aren't necessarily that close to where you need to go. Calling for weather is a joke since the government privatized the FSS system. The last time I called for weather from a live briefer, I had to give him the airport identifiers for all the airports I wanted, because he had no idea where I was, or the airports near me. He was in a room in Minnesota, and I was in Texas, and all he did was read the same information from the computer that I already had, but he had less. The FSS is completely useless now. The next project seems to be privatization of ATC, and I'm not looking forward to that.

Having experienced CVRs for many years, I'm actually in favor of them. On at least one occasion they saved my job, because they provided proof that we had done the checklist properly. They can be misused, like any other tool, but they can give lots of information about the cause of accidents. Releasing them to the media is unconscionable, of course, and they must be tightly controlled. The rest of the Senate bill is already being complied with, for the most part, by the larger operators. There aren't many full TAWS installations, but you can get a workable version from a GPS. Our Garmins pop up terrain warnings from towers and terrain, and they're not that expensive.
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Old 19th Jun 2008, 19:25
  #33 (permalink)  
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FAA Fact Sheet from May 2008

This is an extract from a May 08 FAA Fact sheet on HEMS operations. It is nothing new, and has probably been posted already; but supports what many are saying in this thread. Night, single pilot VFR in many parts of the USA is an open invitation to any of these causes listed below. To think that piloting skill alone is enough to overcome the issue, is a mindset that needs changing.

"There are approx. 750 emergency medical service helicopters operating today, most of which operate under Part 135 rules. HEMS operators may ferry or reposition helicopters (without passengers/patients) under Part 91.
The number of accidents nearly doubled between the mid-1990s and the HEMS industry’s rapid growth period from 2000 to 2004. There were nine accidents in 1998, compared with 15 in 2004. There were a total of 83 accidents from 1998 through mid-2004. The main causes were controlled flight into terrain (CFIT), inadvertent operation into instrument meteorological conditions and pilot spatial disorientation/lack of situational awareness in night operations. Safety improvements are needed."
 
Old 19th Jun 2008, 23:49
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Health care in the US is already enormously expensive, and a large percentage of the middle class cannot afford health insurance. Where I work, the closest Level 1 trauma center is about 90 NM. Given this, and the fact that people get hurt at night as well as in the day, there has to be a philosophic decision, whether to allow single-engine helicopters to transport those people, or not. There are risks to life on both sides, and I think the greater risk to more people is in prohibiting these flights. Some people will undoubtedly die in either case, but I think more will die if the flights are banned. In any case, those in authority, presumably the voters, have to make a decision. I'm willing to live with whatever decision is made, but I'm not willing to accept the criticism of those who have no stake in the decision, especially those from the other side of the world. Europeans can do whatever they want, as long as they accord us the same courtesy. I predict that things will continue here pretty much as they have, because there is too much money involved for all concerned. Money drives all decisions in the US, in true capitalistic style. People are going to die, either way. We just have to decide which ones, and how many.
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Old 20th Jun 2008, 01:44
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Well said
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Old 20th Jun 2008, 16:43
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Gomer Pilot says: "Money drives all decisions in the US, in true capitalistic style"

And, this system feeds insurance companies, which anyway got a big part of the money. Hopefully insurance companies start understand that we need EMS helicopters, but how climb up the safety. Move part of the money straight to the safety. They already have money for that. Don't they?

Hostile
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Old 20th Jun 2008, 17:16
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Where we operate budget constraints are a reality. Approximately 60 000 people benefit a year directly by our service with AS350, Ec130 and PC12. My question remains on the amount of engines issue.

1. We all live in the perfect world and get twin IFR machines. Where are we going to cut to remain within the budget: Pilot training? Crewman/paramedic training? Maintenance? Less staff? Have to do this flight for revenue mentality? IFR twin but no ground support for the instrumentation ie ILS let downs, plates etc and have to do it because my machine and I are IFR?

or

2. I stick to what I can afford(single eng) BUT: 1. lower operating cost allow me to train my pilots and do recurrency checks for night, mountain and IF training every 3 months! Lower maintenance cost means I can actually afford preventative maintenance! I restrict myself to what I am a VFR operation with singles trained to handle a inadvertant IMC situation!

I am all for the ultimate safety picture, but does 2 engines automatically make you a safer operation?
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Old 20th Jun 2008, 17:36
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That it is victor papa. Who needs or wants to operate with helos, must also get more involved with operating costs and safety issues. Operators can by all what they needed to buy. Twin engines are just first step.

Hostile
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Old 20th Jun 2008, 17:39
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I wonder if there is a study out there in the ether that reports the statistics for helicopter engine failures by phase of flight. That might begin to show the benefit/burden of having that second engine.

It goes without saying that a single engine failure on a twin is less critical than the same event in a single.

I define "critical engine" as being the last running engine on the aircraft as that has the most adverse effect upon the flight characteristics of the helicopter.

If we then weighed the outcome of the "landing" by engine failure and type of aircraft (single or twin) then perhaps we could determine the "value" of the second engine in re injuries/deaths per engine failure and thus arrive at some sort of a decision regards single versus twin.

I come from the school of thought that twin engines are the way to go.

I had several engine failures in twins and always made an uneventful landing whereas the only single engine aircraft engine failure resulted in a safe landing for machine and occupants but it was anything but "non-eventful".
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Old 20th Jun 2008, 19:44
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Agree sasless, BUT which twin? I can operate a 105 and advocate I am safe because I operate a twin. Question is at 5500ft 30-40 degrees C am I safe or am I just over confident? We have never hit close to limits or over exert our machines at up to 5800 ft 42 degrees C. Which twins are really a twin at these altitudes and temps? 139, 332, maybe N3 on a good day and good engines. C++? Should I not rather on limited resources spend it on crew training and terrain avoiding devices preventing human factors and CFIT and keep my singly flying sweet on preventative maintenance and lots of training rather on a twin that might fly away or maybe not and if fly away bancrupt me so I can not reach 60 000 people a year?

The last few accidents have all been CFIT or some form of it. Surely I sould have the choice of equipping my crews with EGPWS, NVG, and training them in the machine as much as possible.

My question remains: "Does 2 engines prevent HEMS accidents?" I do not think the last years statistics proofes that.
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