NTSB says EMS accident rate is too high
"Just a pilot"
Humans are not nocturnal, period. Consider your visual equipment versus a nocturnal mammal's eyes. There is a portion of the population that never accommodates itself to night duty while the rest of the surrounding world runs a normal day schedule...
Everybody shifts schedules at varying rates, and that changes with age, as does sleep efficiency. It's cliche that old people often fall asleep but it's also cliche that they don't sleep as long or as well. Those may be related.
The more or less "accepted rate" for accommodation is an hour a day.
You can't have a "sleep bonus" to carry forward against lack of sleep and even out. All one can do is be well rested when entering a short night's sleep. One also never entirely recovers from a sleep deficit, although a couple of good nights sleep makes the issue moot.
An abrupt time shift engenders circadian losses for the vast majority of the population. One can feel fairly well if well rested at the start of shift that reverses the body clock, and in the wee hours of the morning be functioning mentally at level comparable with yourself at 2-3 alcoholic beverages. You wouldn't fly after a couple of belts, but we accept flight assignments in that condition through ignorance (or maschismo?).
The first night is rough because of all this. My experience is that I feel better the second night, but the circadian issues are still there affecting mentation. Try a challenging academic challenge on your second night... There's no escaping physiology for something like 99% of the population.
The industry, and people in general, get away with ignoring all this because we have more skill reserves more than is generally required to perform tasks. Until one finds that you need ALL your capabilities to survive, say one misinterprets the import of a saturated atmosphere and/or low ceilings and launches and flys into the cloud you can't see unaided, and suddenly it's black all around and the gauges are whirly-like or you descend in a desperate effort to reacquire VFR, or you forget the tower on your route, or you're so close to base you think you can beat the weather....
I suggest that the judgement lost at critical point due to the abrupt shift change a considerable part of the issue. To my mind that explains why it's all platforms and operations- it's human factors issue.
Everybody shifts schedules at varying rates, and that changes with age, as does sleep efficiency. It's cliche that old people often fall asleep but it's also cliche that they don't sleep as long or as well. Those may be related.
The more or less "accepted rate" for accommodation is an hour a day.
You can't have a "sleep bonus" to carry forward against lack of sleep and even out. All one can do is be well rested when entering a short night's sleep. One also never entirely recovers from a sleep deficit, although a couple of good nights sleep makes the issue moot.
An abrupt time shift engenders circadian losses for the vast majority of the population. One can feel fairly well if well rested at the start of shift that reverses the body clock, and in the wee hours of the morning be functioning mentally at level comparable with yourself at 2-3 alcoholic beverages. You wouldn't fly after a couple of belts, but we accept flight assignments in that condition through ignorance (or maschismo?).
The first night is rough because of all this. My experience is that I feel better the second night, but the circadian issues are still there affecting mentation. Try a challenging academic challenge on your second night... There's no escaping physiology for something like 99% of the population.
The industry, and people in general, get away with ignoring all this because we have more skill reserves more than is generally required to perform tasks. Until one finds that you need ALL your capabilities to survive, say one misinterprets the import of a saturated atmosphere and/or low ceilings and launches and flys into the cloud you can't see unaided, and suddenly it's black all around and the gauges are whirly-like or you descend in a desperate effort to reacquire VFR, or you forget the tower on your route, or you're so close to base you think you can beat the weather....
I suggest that the judgement lost at critical point due to the abrupt shift change a considerable part of the issue. To my mind that explains why it's all platforms and operations- it's human factors issue.
The guys show up saying they are looking forward to a good nights sleep.
Doesn't really matter if my crew are struggling to keep awake out in the dark at 3am, but it does if I am. But, I don't have young kids to look after with a wife at work, so I'm lucky.
From my perspective night operations were no different than day. You had to show up for work rested and ready to go. It was easier for me to do extended night shifts. I made it a point to sleep immediately following any night shifts and attempted to completely invert my rest schedule. A more experienced pilot once wisely explained that you are resting for the next shift even if the last one had no flights.
From the flight perspective I flew all flight profiles as if it were night. I always climbed to a safe obstruction altitude irrespective of weather and didn’t deviate for those profiles either day or night. If the weather wouldn’t allow this, then I wouldn’t. NO one ever questioned any nogo decisions I made over 6 years of operations. There were many instances where other pilots would comment on why I tended to cruise up in the rarefied air. My retort was that I wanted to have the altitude to accommodate at least two mistakes should an abnormal situation arise. “That is my story and I am sticking to it.”
From the flight perspective I flew all flight profiles as if it were night. I always climbed to a safe obstruction altitude irrespective of weather and didn’t deviate for those profiles either day or night. If the weather wouldn’t allow this, then I wouldn’t. NO one ever questioned any nogo decisions I made over 6 years of operations. There were many instances where other pilots would comment on why I tended to cruise up in the rarefied air. My retort was that I wanted to have the altitude to accommodate at least two mistakes should an abnormal situation arise. “That is my story and I am sticking to it.”
To follow up on the Rock Springs Accident on Page 8 See Here
The NTSB has issued its Preliminary Report
The NTSB has issued its Preliminary Report
NTSB Identification: WPR12LA065
14 CFR Part 91: General Aviation
Accident occurred Tuesday, December 13, 2011 in Rock Springs, WY
Aircraft: BELL 407, registration: N8067Z
Injuries: 5 Minor.
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 December 13, 2011, about 1620 mountain standard time, a Bell 407, N8067Z, was maneuvering at a low altitude and airspeed near the residence of some of the passengers when it descended into an open field about 12 miles west-northwest of the Rock Springs-Sweetwater County Airport, Rock Springs, Wyoming. The helicopter impacted the ground hard and was substantially damaged. The helicopter’s landing gear skids and lower cabin structure were deformed, and the tail boom was severed. Guardian Flight, South Jordan, Utah, owned and operated the helicopter. The pilot and four passengers sustained minor injuries. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. The flight began from Rock Springs about 1600.
The passengers reported that the pilot, who was an employee of Guardian Flight, immediately departed the scene. The pilot has not reported the accident to the National Transportation Safety Board. Guardian Flight management personnel reported that the pilot was not authorized to fly the helicopter, and he was employed as their Rock Springs helicopter mechanic. Law enforcement authorities reported they apprehended the pilot in another state. Federal Aviation Administration personnel reported that the pilot was issued a student pilot certificate in 1988, and they have no record of him holding any additional pilot certificate. He does hold a mechanic certificate with airframe and powerplant ratings and inspection authorization.
An acquaintance of the accident pilot reported that he observed the pilot flying N8067Z on several previous occasions for personal reasons. Passengers were carried during these “joy rides.”
14 CFR Part 91: General Aviation
Accident occurred Tuesday, December 13, 2011 in Rock Springs, WY
Aircraft: BELL 407, registration: N8067Z
Injuries: 5 Minor.
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 December 13, 2011, about 1620 mountain standard time, a Bell 407, N8067Z, was maneuvering at a low altitude and airspeed near the residence of some of the passengers when it descended into an open field about 12 miles west-northwest of the Rock Springs-Sweetwater County Airport, Rock Springs, Wyoming. The helicopter impacted the ground hard and was substantially damaged. The helicopter’s landing gear skids and lower cabin structure were deformed, and the tail boom was severed. Guardian Flight, South Jordan, Utah, owned and operated the helicopter. The pilot and four passengers sustained minor injuries. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. The flight began from Rock Springs about 1600.
The passengers reported that the pilot, who was an employee of Guardian Flight, immediately departed the scene. The pilot has not reported the accident to the National Transportation Safety Board. Guardian Flight management personnel reported that the pilot was not authorized to fly the helicopter, and he was employed as their Rock Springs helicopter mechanic. Law enforcement authorities reported they apprehended the pilot in another state. Federal Aviation Administration personnel reported that the pilot was issued a student pilot certificate in 1988, and they have no record of him holding any additional pilot certificate. He does hold a mechanic certificate with airframe and powerplant ratings and inspection authorization.
An acquaintance of the accident pilot reported that he observed the pilot flying N8067Z on several previous occasions for personal reasons. Passengers were carried during these “joy rides.”
Oh my! He took the old girl up on more than one occasion....and got away with it?
Just how does that happen?
I dare say the Operator has more than a few problems on their hands...insurance, FAA, perhaps a few law suits from whoever "owns" the helicopter (Bank...Lease Holder....).
I guess they could go against the ex-Mechanic/Pilot!
Just how does that happen?
I dare say the Operator has more than a few problems on their hands...insurance, FAA, perhaps a few law suits from whoever "owns" the helicopter (Bank...Lease Holder....).
I guess they could go against the ex-Mechanic/Pilot!
"Just a pilot"
Links
Wikipedia on shift work sleep disorder:
Shift work sleep disorder - Wikipedia, the free encyclopedia
Pilot fatigue:
Pilot Fatigue
Shift work sleep disorder - Wikipedia, the free encyclopedia
Pilot fatigue:
Pilot Fatigue
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New HEMS Probable Cause, no comment beyond the highlighting:
NTSB Identification: ERA09FA537
14 CFR Part 91: General Aviation
Accident occurred Friday, September 25, 2009 in Georgetown, SC
Probable Cause Approval Date: 01/19/2012
Aircraft: EUROCOPTER AS-350, registration: N417AE
Injuries: 3 Fatal.
After conducting an interfacility patient transfer, the pilot refueled and then requested flight-following services from air traffic control, departing in visual meteorological conditions (VMC) for the return flight to his base. During the return flight, the pilot encountered instrument meteorological conditions (IMC). A review of Sky Connect data for the accident flight revealed that the helicopter was cruising at varying altitudes and never reached a steady state cruise altitude for any significant period of time. The majority of the flight was flown at altitudes below 1,000 feet with the greater part of the last 8-minute segment of the flight being operated below 800 feet. (The lowest altitude recorded during the last cruise segment of flight was 627 feet.) Witnesses who observed the helicopter before the accident described it as flying about 1,000 feet above ground level (agl), with its searchlight turning on and off, in moderate to heavy rain. A subsequent loss of control occurred, and the helicopter impacted terrain about 1.92 nautical miles (nm) southwest of Georgetown County Airport (GGE).
Postaccident examination of the main wreckage revealed no evidence of any preimpact failures or malfunctions of the engine, drive train, main rotor, tail rotor, or structure of the helicopter. Additionally, there was no indication of an in-flight fire.
During the first legs of his flight, the pilot experienced and observed VMC conditions along his route. However, postaccident witness reports and in-flight statements from the accident pilot indicated that the weather in the area had deteriorated since his southbound flight 2 hours prior. According to Omniflight’s Savannah, Georgia, base manager, who was also a pilot operating in the area on the night of the accident, the weather that night was deteriorating but was forecast to remain well above minimums for his flight from Savannah to Greenville, South Carolina, and then to the Medical University of South Carolina (MUSC) in Charleston. However, while he was refueling at the Greenville airport, the pilot of the accident helicopter contacted him by radio and advised him to double check the weather before returning to MUSC. The accident pilot stated that “bad thunderstorms” were in the GGE area and that he did not know if he would be able to return to his base that night. The Savannah base manager then advised the accident pilot that he could stay at the Charleston base that night. However, the accident pilot decided to return to his base at Conway-Horry County Airport (HYW), Conway, South Carolina.
Review of radar data and weather observations provided by the National Oceanic and Atmospheric Administration revealed that, after departing, the helicopter entered an area of convective activity and precipitation. The University Corporation for Atmospheric Research regional radar mosaic chart for 2333 also depicted a large area of echoes north of the frontal boundary, with several defined thunderstorms and rain showers extended over South Carolina and over the accident helicopter’s flight route. Additionally, correlation of the radar data to the location of the accident site revealed that several defined cells surrounded the site at the time of the accident.
The terminal aerodrome forecast (TAF) for Myrtle Beach International Airport, Myrtle Beach, South Carolina, which was located 29 nm northeast of the accident site, was issued about 1928 and indicated expected marginal visual flight rules conditions through 0100 on September 26. From 2000 through 2130, variable winds to 15 knots with visibility of 4 miles in thunderstorms, moderate rain, and a broken ceiling of 3,500 feet agl in cumulonimbus clouds were expected. From 2130 to 0100, the wind was expected to be from 040 degrees at 12 knots with a visibility of 6 miles in light rain showers and mist and a broken ceiling at 2,000 feet agl. About 2207, the National Weather Service issued an amended TAF that expected instrument flight rules (IFR) conditions to prevail during the period with a broken ceiling at 700 feet agl and light drizzle and mist after midnight.
The pilot had previously flown helicopters in IMC but was not current in instrument ratings at the time of the accident. The accident helicopter was not certificated for flight in IMC but had sufficient instrumentation to operate in the event of an inadvertent encounter with IMC. On the pilot’s last Part 135 airman competency/proficiency check, which occurred on December 12, 2008, he satisfactorily demonstrated inadvertent IMC loss of control recovery.
Although the pilot encountered an area of deteriorating weather and IMC, this did not have to occur as the pilot did not have to enter the weather and could have returned to Charleston Air Force Base/International Airport or landed at an alternate location. The pilot, however, chose to enter the area of weather, despite the availability of safer options. Based on the pilot’s statement to the Savannah-based pilot regarding bad thunderstorms in the area, he was aware of the weather and still chose to fly into it. In addition, the pilot’s inability to maintain a steady state cruise altitude during the flight and the declining altitude throughout the flight likely reflected his attempt to stay below the cloud level. These cues should have indicated to the pilot that it was not safe to continue flight into IMC. This decision-making error played an important causal role in this accident.
In the absence of evidence indicating a mechanical malfunction, severe turbulence, or some other factor that would explain the accident pilot’s apparent loss of control of the helicopter, spatial disorientation is a likely explanation, as it has contributed to many accidents involving loss of control. In many cases, loss of control follows a pilot’s inappropriate control inputs resulting from confusion about the aircraft’s attitude. Two major situational risk factors for spatial disorientation were present in this accident, including high workload and transitions between VMC and IMC that require shifting visual attention between external visual references and cockpit flight instruments. Attempts to continue visual flight into IMC are even more problematic for helicopter pilots than for pilots of fixed-wing aircraft because helicopters are inherently less stable and require near-continuous control inputs from the pilot. Helicopters, like the accident helicopter, that are not equipped for IFR flight and do not have control stabilization or an autopilot impose high perceptual and motor demands on the pilot. This can make it very challenging for pilots to maintain stable flight by referring to flight instruments alone. When the accident pilot attempted to continue visual flight into IMC, he would have been subjected to a high workload to maintain control of the helicopter. The extent of the weather and the duration of the flight also suggest that the pilot’s encounter with IMC was prolonged. This would have further complicated the pilot’s workload and increased the potential for spatial disorientation resulting from hazardous illusions, thereby increasing the potential for inappropriate control input responses.
According to Omniflight’s 135 Operations Manual, the pilot-in-command was responsible for obtaining weather information before beginning a series of flights. During interviews with National Transportation Safety Board (NTSB) investigators, Omniflight pilots indicated that, at the beginning of each shift, they would obtain weather information from a base computer and would advise the Omniflight Operational Control Center (OCC) of weather conditions in the operating area throughout the period of their flight. Before any launch, the OCC must approve the flight. If the OCC knew of adverse weather, it would contact the pilot to evaluate the weather. Based on launch approval and actual weather conditions encountered and reported by the pilot, the weather at takeoff and along the flight route was VMC. About 2242, an MUSC communications center specialist spoke with an Omniflight OCC operations coordinator and indicated that the helicopter would be returning to HYW as soon as the patient transfer was complete. The operations coordinator then advised the MUSC specialist that if the pilot called before takeoff, they would review the weather with him for his return flight. However, the pilot never called the OCC, and the OCC did not contact the pilot. While the OCC was not required to contact the pilot and review the weather, if the OCC had contacted the pilot before takeoff, the OCC could have advised the pilot about the adverse weather, given him the updated TAF information issued about 2207 with IMC, and noted the potential risks involved with the flight. On February 7, 2006, the NTSB issued Safety Recommendation A-06-14, which asked the Federal Aviation Administration (FAA) to “require emergency medical services operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.” On February 18, 2010, based on the FAA’s pending notice of proposed rulemaking concerning helicopter operations and pending timely issuance of a final rule mandating formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions, the NTSB classified this recommendation “Open—Acceptable Response.”
The accident helicopter was not equipped with an autopilot. On September 24, 2009, the NTSB issued Safety Recommendation A-09-96, which asked the FAA to “require helicopters that are used in emergency medical services transportation to be equipped with autopilots and that the pilots be trained to use the autopilot if a second pilot is not available.” On December 23, 2009, the FAA stated that it would conduct a study of the feasibility and safety consequences of requiring a second pilot or operable autopilot. On October 7, 2010, pending the NTSB’s review of the results of this study, Safety Recommendation A-09-96 was classified “Open—Acceptable Response.”
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s decision to continue the visual flight rules flight into an area of instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and a loss of control of the helicopter. Contributing to the accident was the inadequate oversight of the flight by Omniflight’s Operational Control Center.
NTSB Identification: ERA09FA537
14 CFR Part 91: General Aviation
Accident occurred Friday, September 25, 2009 in Georgetown, SC
Probable Cause Approval Date: 01/19/2012
Aircraft: EUROCOPTER AS-350, registration: N417AE
Injuries: 3 Fatal.
After conducting an interfacility patient transfer, the pilot refueled and then requested flight-following services from air traffic control, departing in visual meteorological conditions (VMC) for the return flight to his base. During the return flight, the pilot encountered instrument meteorological conditions (IMC). A review of Sky Connect data for the accident flight revealed that the helicopter was cruising at varying altitudes and never reached a steady state cruise altitude for any significant period of time. The majority of the flight was flown at altitudes below 1,000 feet with the greater part of the last 8-minute segment of the flight being operated below 800 feet. (The lowest altitude recorded during the last cruise segment of flight was 627 feet.) Witnesses who observed the helicopter before the accident described it as flying about 1,000 feet above ground level (agl), with its searchlight turning on and off, in moderate to heavy rain. A subsequent loss of control occurred, and the helicopter impacted terrain about 1.92 nautical miles (nm) southwest of Georgetown County Airport (GGE).
Postaccident examination of the main wreckage revealed no evidence of any preimpact failures or malfunctions of the engine, drive train, main rotor, tail rotor, or structure of the helicopter. Additionally, there was no indication of an in-flight fire.
During the first legs of his flight, the pilot experienced and observed VMC conditions along his route. However, postaccident witness reports and in-flight statements from the accident pilot indicated that the weather in the area had deteriorated since his southbound flight 2 hours prior. According to Omniflight’s Savannah, Georgia, base manager, who was also a pilot operating in the area on the night of the accident, the weather that night was deteriorating but was forecast to remain well above minimums for his flight from Savannah to Greenville, South Carolina, and then to the Medical University of South Carolina (MUSC) in Charleston. However, while he was refueling at the Greenville airport, the pilot of the accident helicopter contacted him by radio and advised him to double check the weather before returning to MUSC. The accident pilot stated that “bad thunderstorms” were in the GGE area and that he did not know if he would be able to return to his base that night. The Savannah base manager then advised the accident pilot that he could stay at the Charleston base that night. However, the accident pilot decided to return to his base at Conway-Horry County Airport (HYW), Conway, South Carolina.
Review of radar data and weather observations provided by the National Oceanic and Atmospheric Administration revealed that, after departing, the helicopter entered an area of convective activity and precipitation. The University Corporation for Atmospheric Research regional radar mosaic chart for 2333 also depicted a large area of echoes north of the frontal boundary, with several defined thunderstorms and rain showers extended over South Carolina and over the accident helicopter’s flight route. Additionally, correlation of the radar data to the location of the accident site revealed that several defined cells surrounded the site at the time of the accident.
The terminal aerodrome forecast (TAF) for Myrtle Beach International Airport, Myrtle Beach, South Carolina, which was located 29 nm northeast of the accident site, was issued about 1928 and indicated expected marginal visual flight rules conditions through 0100 on September 26. From 2000 through 2130, variable winds to 15 knots with visibility of 4 miles in thunderstorms, moderate rain, and a broken ceiling of 3,500 feet agl in cumulonimbus clouds were expected. From 2130 to 0100, the wind was expected to be from 040 degrees at 12 knots with a visibility of 6 miles in light rain showers and mist and a broken ceiling at 2,000 feet agl. About 2207, the National Weather Service issued an amended TAF that expected instrument flight rules (IFR) conditions to prevail during the period with a broken ceiling at 700 feet agl and light drizzle and mist after midnight.
The pilot had previously flown helicopters in IMC but was not current in instrument ratings at the time of the accident. The accident helicopter was not certificated for flight in IMC but had sufficient instrumentation to operate in the event of an inadvertent encounter with IMC. On the pilot’s last Part 135 airman competency/proficiency check, which occurred on December 12, 2008, he satisfactorily demonstrated inadvertent IMC loss of control recovery.
Although the pilot encountered an area of deteriorating weather and IMC, this did not have to occur as the pilot did not have to enter the weather and could have returned to Charleston Air Force Base/International Airport or landed at an alternate location. The pilot, however, chose to enter the area of weather, despite the availability of safer options. Based on the pilot’s statement to the Savannah-based pilot regarding bad thunderstorms in the area, he was aware of the weather and still chose to fly into it. In addition, the pilot’s inability to maintain a steady state cruise altitude during the flight and the declining altitude throughout the flight likely reflected his attempt to stay below the cloud level. These cues should have indicated to the pilot that it was not safe to continue flight into IMC. This decision-making error played an important causal role in this accident.
In the absence of evidence indicating a mechanical malfunction, severe turbulence, or some other factor that would explain the accident pilot’s apparent loss of control of the helicopter, spatial disorientation is a likely explanation, as it has contributed to many accidents involving loss of control. In many cases, loss of control follows a pilot’s inappropriate control inputs resulting from confusion about the aircraft’s attitude. Two major situational risk factors for spatial disorientation were present in this accident, including high workload and transitions between VMC and IMC that require shifting visual attention between external visual references and cockpit flight instruments. Attempts to continue visual flight into IMC are even more problematic for helicopter pilots than for pilots of fixed-wing aircraft because helicopters are inherently less stable and require near-continuous control inputs from the pilot. Helicopters, like the accident helicopter, that are not equipped for IFR flight and do not have control stabilization or an autopilot impose high perceptual and motor demands on the pilot. This can make it very challenging for pilots to maintain stable flight by referring to flight instruments alone. When the accident pilot attempted to continue visual flight into IMC, he would have been subjected to a high workload to maintain control of the helicopter. The extent of the weather and the duration of the flight also suggest that the pilot’s encounter with IMC was prolonged. This would have further complicated the pilot’s workload and increased the potential for spatial disorientation resulting from hazardous illusions, thereby increasing the potential for inappropriate control input responses.
According to Omniflight’s 135 Operations Manual, the pilot-in-command was responsible for obtaining weather information before beginning a series of flights. During interviews with National Transportation Safety Board (NTSB) investigators, Omniflight pilots indicated that, at the beginning of each shift, they would obtain weather information from a base computer and would advise the Omniflight Operational Control Center (OCC) of weather conditions in the operating area throughout the period of their flight. Before any launch, the OCC must approve the flight. If the OCC knew of adverse weather, it would contact the pilot to evaluate the weather. Based on launch approval and actual weather conditions encountered and reported by the pilot, the weather at takeoff and along the flight route was VMC. About 2242, an MUSC communications center specialist spoke with an Omniflight OCC operations coordinator and indicated that the helicopter would be returning to HYW as soon as the patient transfer was complete. The operations coordinator then advised the MUSC specialist that if the pilot called before takeoff, they would review the weather with him for his return flight. However, the pilot never called the OCC, and the OCC did not contact the pilot. While the OCC was not required to contact the pilot and review the weather, if the OCC had contacted the pilot before takeoff, the OCC could have advised the pilot about the adverse weather, given him the updated TAF information issued about 2207 with IMC, and noted the potential risks involved with the flight. On February 7, 2006, the NTSB issued Safety Recommendation A-06-14, which asked the Federal Aviation Administration (FAA) to “require emergency medical services operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions.” On February 18, 2010, based on the FAA’s pending notice of proposed rulemaking concerning helicopter operations and pending timely issuance of a final rule mandating formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions, the NTSB classified this recommendation “Open—Acceptable Response.”
The accident helicopter was not equipped with an autopilot. On September 24, 2009, the NTSB issued Safety Recommendation A-09-96, which asked the FAA to “require helicopters that are used in emergency medical services transportation to be equipped with autopilots and that the pilots be trained to use the autopilot if a second pilot is not available.” On December 23, 2009, the FAA stated that it would conduct a study of the feasibility and safety consequences of requiring a second pilot or operable autopilot. On October 7, 2010, pending the NTSB’s review of the results of this study, Safety Recommendation A-09-96 was classified “Open—Acceptable Response.”
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s decision to continue the visual flight rules flight into an area of instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and a loss of control of the helicopter. Contributing to the accident was the inadequate oversight of the flight by Omniflight’s Operational Control Center.
Why...why....why?
SASless: we know the answer, its yankie mentality - simples. Where have you been with this thread?
As a previous poster said, the FAA will NEVER regulate against the industry in this regard..land of the free etc etc.
It boils down to CRM...an eductional process practiced by some and totally ignored by others.
The WHOLE EMS problem in the US can be contained in one sentence:
PRESS ON ITIS.
It has nothing whatsoever to do with number of engines / number of pilots / autostabilisation, etc.
Until this is addressed, the US will continue to kill their own.
[I read another post recently where the boss of an EMS outfit had an SOP where the duty dispatcher was not allowed to tell the pilot what the circumstances of the trip were, nor what the condition of the patient was. This enabled the pilot to some degree to concentrate on the task in hand which was to fly his helo from A to B: SAFELY and without undue pressures.
So there are some responsible operators out there practicing what they preach. I like that
As a previous poster said, the FAA will NEVER regulate against the industry in this regard..land of the free etc etc.
It boils down to CRM...an eductional process practiced by some and totally ignored by others.
The WHOLE EMS problem in the US can be contained in one sentence:
PRESS ON ITIS.
It has nothing whatsoever to do with number of engines / number of pilots / autostabilisation, etc.
Until this is addressed, the US will continue to kill their own.
[I read another post recently where the boss of an EMS outfit had an SOP where the duty dispatcher was not allowed to tell the pilot what the circumstances of the trip were, nor what the condition of the patient was. This enabled the pilot to some degree to concentrate on the task in hand which was to fly his helo from A to B: SAFELY and without undue pressures.
So there are some responsible operators out there practicing what they preach. I like that
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Based on the pilot’s statement to the Savannah-based pilot regarding bad thunderstorms in the area, he was aware of the weather and still chose to fly into it.
Maybe the pilot had “got away with” incursions of lesser extent in the past and figured he could tough it out this time. WX forecast mechanisms or visibility minima didn’t get a look in and might not have made an iota of difference had they been tougher or less demanding.
Anyone that has been in the tropics for more than five minutes will possibly have been caught in a severe thunderstorm cell deluge and understand the terror of it, in daylight. To pull the same on at night without at least a storm scope and full IFR ability is sheer lunacy.
Just yesterday I was out at last light, well technically, but with heaps of cloud it’s easy to imagine the visual range and I was seeing heavy storms cells all round with strong lightning and was reminded once again of how fickle we really are in the scheme of things. I was reminded of such an uncomfortable event from about ’86.
I was inbound to Darwin in close company with the late Tevi Borthwick who was in another ’47 with not even a slip indicator back then. He couldn’t hear his VHF, I couldn’t transmit on mine, yeah we’d been out bush a while, but we could talk to each other on HF. We had been cleared from about twenty miles out and then bamm down it came. As we neared the tower to fly by it by about sixty metres its big bright flashing light disappeared at about 100 metres.
Certainly no risk of running into other traffic, but the runway and the entire tarmac area disappeared in a grey sheen and merged with the rain; the green grass straight down was our only reference. That just demonstrates the power of it all and that was at four pm, still three hours of daylight left.
Big cells are often of 15 to 20 nautical miles diameter, visibility down to fifty or sixty metres on the ground, that’s less than 200 feet if there are HT power pylons around.
There must be an answer to your question i thought as I tossed and turned last night. I have no idea how many EMS pilots there are in the US but worldwide in comparison to the number of off shore pilots there may be some similarity in numbers?
So I thought, well all of the off shore guys and their pax have to do HUET courses, which does involve a big bit of capital expenditure at centralised areas, why not have it mandatory for all NVMC, even all EMS pilots to do a mandatory sim ride involving total loss of visibility and then final disorientation.
I figured it’s all too easy on a check ride under the hood, (like this dude) recovering from unusual attitudes day or night or inadvertent IMC penetration, with a safety pilot beside you. That’s no big deal is it 'cos you know he ain't gonna let it crash so how stupid is it as preparation against this type of crash?
In that situation they don’t get the real logic which is aimed at teaching one to recover a sticky situation and thus they get a false sense of confidence, of winning.
That logic is absolutely counterproductive to learning the NOGO line in the sand.
They must be really frightened by an unwinnable situation and thus learn the deep lesson of avoidance. Therefore they must be pushed beyond their ability to a crash conclusion with a tough ride in a simulator.
That will show them that with limited panel and deluge conditions – as forecast on this trip- that it is NOGO, no ifs or bloody butts.
It would also be a good venue to show the flight controllers of followers, as spectators in the sim while the check ride is going on, just how tough it is so they get a real appreciation of the terrors and risks of the – marginal – forecast - in – the – blackness.
It would represent a fair cap-ex for sure in a cash strapped economy, but perhaps cheap compared to the cost of broken machinery already accumulated and the precious lost souls.
My 2 cents worth.
Sasless, all that a certain 'Spartan General' had in his Favour in the Western Desert was, “A line in the sand” which he drew with his baton in front of his assembled staff. He of course won that little tiff to become ‘Montgomery of Alamein.’ It can be done.
Now i hope this big satellite blocking rain storm blows over so we can see if Rafael wins his little match as that will make Mrs. TET very happy.
Cheers.
tet
So I thought, well all of the off shore guys and their pax have to do HUET courses, which does involve a big bit of capital expenditure at centralised areas, why not have it mandatory for all NVMC, even all EMS pilots to do a mandatory sim ride involving total loss of visibility and then final disorientation.
I figured it’s all too easy on a check ride under the hood, (like this dude) recovering from unusual attitudes day or night or inadvertent IMC penetration, with a safety pilot beside you. That’s no big deal is it 'cos you know he ain't gonna let it crash so how stupid is it as preparation against this type of crash?
In that situation they don’t get the real logic which is aimed at teaching one to recover a sticky situation and thus they get a false sense of confidence, of winning.
I figured it’s all too easy on a check ride under the hood, (like this dude) recovering from unusual attitudes day or night or inadvertent IMC penetration, with a safety pilot beside you. That’s no big deal is it 'cos you know he ain't gonna let it crash so how stupid is it as preparation against this type of crash?
In that situation they don’t get the real logic which is aimed at teaching one to recover a sticky situation and thus they get a false sense of confidence, of winning.
You sum it up in a very good way....and I fully agree with you on this one!
When it happens for real...when you feel that JOLT of Adrenalin...your hand tenses...your butt clinches....your breathing pauses...and you realize....that you are in a very life threatening situation....the Checkride IIMC exercise just doesn't even come close to the the real thing.
There's been studies done on how quickly one can lose control of the aircraft....perhaps we need to see a study done on what percentage of pilots do lose control following IIMC.
SIM rides would be a good step forward but still would lack the psychological stress that the real event produces.
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That would be great. I'm lucky with my company in that we train twice as often as our nearest competitor, and all the recurrent sessions except one are at night. Our checkrides are all under NVG's.
But even so, when the man switches your eyes off and you're over the big black, without so much as a farm light to tell you which way is down and then he does all that stuff to mess your SA about - sure, you're uncomfortable but you still know that he's not going to let you get unrecoverable. The sim has no such self-interest.
But even so, when the man switches your eyes off and you're over the big black, without so much as a farm light to tell you which way is down and then he does all that stuff to mess your SA about - sure, you're uncomfortable but you still know that he's not going to let you get unrecoverable. The sim has no such self-interest.
