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NTSB says EMS accident rate is too high

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Old 30th Dec 2011, 21:16
  #121 (permalink)  
 
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Shell Management, I have to take exception to your comment. I retired into the US HEMS system and found the flying very rewarding and safe. The key to that safety was my ability to make go/nogo decisions unhampered by upper management (Omniflight, CJ Systems, AMC). Any pressure to go would have been self imposed. Having flown out of a remote South Western mountain base in single engine Bell 206s and A-Stars it was nice knowing that the only weather reporting available was my mark one eyeball. No one could or would ever dispute my call.

Each one of the mishaps you listed have there own story. As an example, the La Crosse mishap was a single pilot IFR certified aircraft with a SPIFR certified pilot that was not permitted to fly IFR due to a recent change in the operational vender. The FAA requires the new vender to train and certify the previous venders already certified pilot. As such the crew and aircraft capabilities were not available.

In the end it all boils down decisions made by the PIC. I believe that the term the NTSB frequently uses with respect to the cause of many mishaps is; “An unprofessional decision by the PIC”. Once again many can argue the number of pilots and engines but it all come down to the PIC.
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Old 30th Dec 2011, 21:44
  #122 (permalink)  
 
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Sadly US HEMS tends not to have the gear or expertise for the job,

(gear)
I think that a generalization blind to the demographics of demand and supply capability. Especially if it were based on a comparison to old blighty where we others could generalize that all is laid on by ER, and the scope of operational area is postage stamp size.

(expertise)
The slur against our rotary brethren stateside is not necessary.


and seem to favour their testicles for decision making.
This is a most confusing statement, do you mean for or from?

Are you implying that they have used their unmentionables instead of their head to made the wrong decision to go, or used them for decision making instead of using their head?
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Old 30th Dec 2011, 21:51
  #123 (permalink)  
 
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SM,
I have to take exception to your last comment too.For every accident that makes the news in a big way (and each one is one too many---admittedly) there are hundreds of flights being routinely completed by people ,like me, with a minimum of fuss.
Given the unique geography and regulatory framework of the US ,I think that is pretty darn good. For you to imply otherwise is flat out despicable.
As to the guy who parked in the carport, well, they completed the transport, took a decision to avoid weather,landed,went home to their families and returned to collect a perfectly serviceable aircraft later. In my book that was an A+ performance and I work for that particular company's competition!
Maybe ,as SASLess has said, we do not appreciate Govt .spoon feeding us and maybe,just maybe my testicles have more sense than your management brain.
Have a happy 2012. And,SM, just try and be happy every now and then.Please!
Alt3.
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Old 31st Dec 2011, 01:57
  #124 (permalink)  
 
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As an Ex HEMS Pilot (UK AS355 Unstabilsed Day/Night Capability) I have been fascinated by this thread.

Jack Carson. You do us all a disservice. If it is indeed "All down to the decisions taken by the PIC" please consider which outfit below you would like to make your particular decisions in:

1. Balloon, equipped with sextant and plum-bomb line for altitude. A Packet of sticking plasters, pair of washing up gloves and 2 x aspirin.

OR

2. State of the art ME-MPH IFR with modern lifesaving and first aid treatment equipment. Moving map/GPS/FMS/EFIS etc.


This thread just goes to prove we are all our own worst enemy because we are by nature optimists. We try to make the very best of what we are given.

But we need to be saved from ourown folly and eagerness. Thats what good regulation provides. An opportunity to set up an operation with the best possible chance of success. Embrace regulation and go one step further, mke it work for the better. Force the regulators to get tough.

I completed 1500 HEMS missions in my trusty old AS355 with no autopilot, often at night. At the time bright, shiny new machines in the same category were getting invented almost every day. Bells, whistles and computers. All designed to make life easier and therefore safer. I looked on in awe and wonder and not one day went by where I did not miss the autopilot. 30 seconds to look at a map without wobbling around. 1 minute to be able to program the awkward Trimble Transpac GPS at 300 feet AGL trying to reach the casualty without the harrowing fear of CFIT.

"Ahh! but a man's reach should exceed his grasp, or what's a heaven for"

Flying EMS at Night in a B206 is not even a remotley sensible thing to try and do. If you are actively doing this kind of thing I feel very, very sorry for you, your medical team and your patients and concerned for all your safety.

I urge you to truly understand how these accidents come about and take all steps in your power to not become one of them. Fight for better equipment. Fight for better training. And for God's sake, use accidents like these as justification for your struggle rather than your prowess. Do not stumble on in denial believing what you are doing is safe. The facts prove that it is not.

On the other hand, technology, unsupported by training and checking and most important of all, recency, is worst than no technology at all. Many SPIFR/MPIFR accidents have written this argument in blood.

For all of you in HEMS/EMS. Keeping making those tough calls. Fly within your own limits and not necessarily the lower limits afforded by the regs.

If you are under contract to a health service, try to remember you Company was probably the lowest bidder. Treat their pressure accordingly!!

Above all, every EMS/HEMS Helicopter starts every mission loaded with live, healthy humans on board. The worse the accident you are attending, the less likely the victims will survive. Therefore consider just how appropriate the risks are that you take to try and save one person who might not survive against the risks of losing the healthy humans you already have on board. For HEMs crews these are the tough calls that have to be made. I wish you all luck and skill in your continued judgements.

For Shell Management. You message is sound but the messenger sucks! Sort that sh*t out man!!

My Best Regards to you all.
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Old 31st Dec 2011, 02:28
  #125 (permalink)  
 
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The only 'hand-wringing' that I see comes from your side of the pond, just as in this thread.

There are literally hundreds of flights that take place every night in the US, in mostly single-pilot, single-engine helicopters, and very few result in accidents. Probably more take place in a 24-hour period than in an entire year in England. I don't know the exact numbers, but I doubt it would be very far from that. So there will naturally be more accidents in the US, because there are orders of magnitude more flights. Properly planned and flown, night flight is safe enough. But there will always be those whose ego, need to be a hero, or whatever, outweighs good judgment, and no amount of regulation will stop idiocy. Regulation has slowed it down, though, and there are fewer accidents caused by weather than before. Most programs use NVGs now, and that helps. There is an effort to get autopilots that work in small helicopters, and that will help even more, if decent ones can be certified. Things are getting better, slowly, but accidents won't cease to happen, not overnight nor in the long run. We will continue to find new ways to kill ourselves and our passengers.
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Old 31st Dec 2011, 07:19
  #126 (permalink)  
 
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We will continue to find new ways to kill ourselves and our passengers.
No, you will keep using the same old ways of doing that - NVG single pilot at night just invites worse decision making and increased cockpit workload - the result will be the same, sadly.

The ' it's bigger and better in the US' argument doesn't hold water, neither does the ' no amount of regulation will stop idiocy' concept.

You said yourself
Regulation has slowed it down, though,
Now I'm not saying that if some regulation does some good then more regulation will do more good but your own argument points to the fact that ONLY regulation will make HEMS safer.

Self regulation hasn't reduced gun crime, self regulation didn't stop bankers wrecking the world economy and self regulation won't stop needless deaths in an industry that is supposed to save life not waste it.

As for hand-wringing, every EMS crash reported on PPrune comes from posters in the US - if there is not concern for why it is happening, why post it on a discussion forum?
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Old 31st Dec 2011, 09:21
  #127 (permalink)  
 
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The facts are fairly simple. The US EMS industry does retain the old tried and true methods of killing themselves. The Stats show Night alone is the biggest factor in fatal accidents....especially when combined with Marginal Weather....simply because the Human Eye cannot see much in the dark.

The Industry tries to compensate for that by going to NVG's....which as anyone with experience with new generation NVG's...is the only way to fly in the Dark. Thus...there is an improvement underway.

Marginal weather compounded by two factors...one fixable by techology....that being the lack of adequate weather reporting for the routes/areas most EMS helicopters must fly...and pre-flight decision making which cannot be fixed by techology have yet to be adequately dealt with.

There is improvement in the weather reporting arena...but there is a long way to go yet.

Pilot decision making is always going to be the Achilles Heel of EMS flying as not one of us are clairvoyant. Add in the fact that even the very best made decision is limited by the accruacy of the information that it was based upon. Which takes us back to the weather reporting and trying to guess what the weather actually is and shall be when we go flying especially at night.

Then...we have the raw fatal fact that way too many of us are not making the right decisions for any number of reasons. Some of these NTSB described "Unprofessional Decisions" border on suicide as when reviewed by others on clear blue and twenty two days....defy logical explanation.

Did I mention the FAA in any of the above or how a new Regulation alone will improve the situation? We have plenty of rules and regulations, industry standards, certification requirements, and all that....but all it takes is bad judgement or a bad decision and the result is the same.

I flew EMS in an un-Sas'd VFR Only BO-105 (the next thing to a Jet Ranger) right up to a fully decked out Bell 412 SPIFR machine. My experience and that of others....remained the same....bad weather compounded by bad decisions and believing legal IFR currency confused as being IFR Proficiency is a dead certain killer of EMS crews.

Until that situation is cured....there may be new ways found to kill ourselves...but they will be few and far between and the old fashioned ways will still continue to thin the herd.

The best of all worlds is to stay out bad weather while flying twin engined...two piloted...fully kitted out SPIFR helicopters while using NVG's.

The problem is paying for it.....as someone must either in Dollars or if you do not....in blood.
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Old 31st Dec 2011, 10:03
  #128 (permalink)  
 
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Sas, I agree with all you have said there but
bad weather compounded by bad decisions and believing legal IFR currency confused as being IFR Proficiency is a dead certain killer of EMS crews.
giving the same poor decision makers NVG just invites them to push on further or go lower because they can see the ground. Then when it all goes wrong and they are back to IIMC it is still that lack of proficiency that will kill them.

Surely the need for proper IF currency and proficiency is the regulation that is needed here - yes it will require the operators to foot the bill but an hour a month per pilot is still much cheaper than a new helicopter and crew.
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Old 31st Dec 2011, 13:12
  #129 (permalink)  

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NVGs are good but aren't the full answer. As Crab says, there needs to be an IFR option too, because if the goggles do finally become unworkable due to worsening weather, the pilot will then find himself far more deeply into IMC than if he had been using unaided eyesight. Been there, done it , seen it, then not seen it, if you get my drift.

If the pilot has no IFR fall back / abort / climb on instruments to a safe altitude plan, then it's possibly game over.

Because the pilot is now flying at night, in IMC, in a non-IFR equipped, unstabilised aircraft, having done no regular IF training, below safety altitude, in the hills, over sparsely lit terrain. With a pair of toilet roll tubes to look down. At least until he can find a spare hand to sort them out and start even thinking about an instrument scan, possibly whilst in an unintentional UP at low level above rising terrain.
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Old 31st Dec 2011, 13:55
  #130 (permalink)  
 
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.....believing legal IFR currency confused as being IFR Proficiency is a dead certain killer of EMS crews.
Crab and Shy.....I fully and completely agree with your thoughts on the matter.

The situation is the Training Captain shows up at the remote base...does some ground school maybe...an hour of flight...or so....then in the most common scenario...does a check ride and you are now Legal, Current, and in most folk's mind...."Proficient" to conduct IFR flight following IIMC.

If that happens to be your trusty steed with no SAS, no Auto-Pilot, and you happen to be single pilot.....it all too often means a tragedy is about to happen.

You want to have some fun....attend a Safety Meeting of Active EMS Pilots and ask simple questions and watch them start squirming.

My favorite is along the lines of this.....

Do you carry a Sectional Map (standard issue 1:500,000 VFR Nav Map) on each flight?

How often do you use the Map while in flight?

How often do you use the Map at Night in flight?

If one starts by asking them to respond by holding their hands up....by the time they answer the last question there are darn few hands up if they are honest.

Reading a Map at night in an single piloted unstablized helicopter...with the basic issued factory lighting...when you are in your 50's (think "glasses" here)....is not a simple task. If you added NVG's to that....do you look under them....or flip them up to read the map?

Do we then rely upon the GPS to find our way around? What if it is just a standard unit and does not show a map with obstacles identified?

Most EMS units will advertise a 150NM radius of operation....there is a lot of ground in a cirlce that big...to be flown on "local knowledge" standards!
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Old 31st Dec 2011, 15:59
  #131 (permalink)  

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SASless, The market here is much smaller than that of the USA for obvious reasons. However, the UK's Air Ambulance network (funded by charity in the main) is much greater than it was before the regulations were tightened up.

BTW, you skipped answering my questions asked of you on the previous page at post #72. You changed the subject to mines rescue!
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Old 31st Dec 2011, 16:43
  #132 (permalink)  
 
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Is this the question Shy?

So what is your "text book" solution to the issue in question, ie. how would you make "VFR" Night Ops safer?
The most effective way would be to adopt the UK method....ban it! If one does not do it...one cannot have an accident.

My recipe....

Work like heck encouraging Pilots and Crews to take more time considering the weather, route, and reason for the flight before launching. I would require a pre-takeoff briefing of the Med Crew by the Pilot or (P-I-C) on the reasons "Why" the flight is going to be undertaken and not just the reasons why a flight was declined.

If one cannot articulate the reasons and factors that contribute to the decision to go....as well as why not to go....then that should be a warning sign.

Over a period of time....an inconsistent explanation would stand out during the brief and hopefully someone would question that.

That process would also slow down the pace just a bit....which in the middle of the night...with a pilot wakiing from a nap or sound sleep....would not be a bad thing but still allow for a timely departure.

Educating pilots and Med Crews about dangerous weather and reviewing in detail as many fatal accidents as possible citing the chain of events that led to the crash would also be a good thing. Judgement cannot be taught but it can be improved by education.

I also believe in written debriefs or after action reports. Documenting the existing weather prior to takeoff....and later comparing the forecasts and anticipated weather against that encountered would also work as a tool to improve awareness of weaknesses in the weather reporting and evaluation of weather by crews.

Most fatal accidents are a result of bad weather at night...thus that is where the focus needs to be. Prevention is far more effective than any other measure....that comes down to using the best information possible and making a logical, business-like, professional decision.

Some of the changes that have taken effect over the past few years has improved the situation....the accident rate is showing that. NVG's are an improvement, raising the miniumums for Night VFR helped, and requiring Operators to operate centralized dispatch/operations centers has helped.

As long as helicopters fly in the dark, in remote areas, far from weather reporting stations, and humans are involved....the potential for tragedy shall stay with us.

Knowing when to Chicken Out is the key to any pilot's continued longevity! There is not a rule book anywhere that can beat that for effectiveness!

Getting the folks to know when to Chicken Out and encouraging them to do so is the key.
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Old 31st Dec 2011, 17:29
  #133 (permalink)  

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The most effective way would be to adopt the UK method....ban it! If one does not do it...one cannot have an accident.
Again, the UK haven't banned it; only you seem to think they have.

But they have mandated that better equipped aircraft are used for public transport by night.
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Old 31st Dec 2011, 17:43
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Many thanks to the hard work people at the JAA.
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Old 31st Dec 2011, 19:37
  #135 (permalink)  
 
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This thread makes for depressing reading...

Also I wish people who either haven't read it fully, or are totally ignorant of the difference in the general level of equipment between a VFR single engine helicopter, and an IFR certified multi engine helicopter would stop banging on about engines...

Chances are this was not an engine failure, but more likely LOC/CFIT. Therfore the point we are trying to get across is:

Single engine:-

Generally unstabilised, WITH NO SAS, autopilot, no duplicated systems, or IFR certified instruments and equipment

Multi engine:-

Generally stabilised WITH SAS & autopilot, duplicated systems & IFR certified intruments and equipment

It may be possible to have some such equipment fitted to a single engine helicopter, but MOST DO NOT. That is the difference. If you want to fit such equipment to a VFR single and fly it around at night in bad weather there will be less chance of crashing into a hillside, but as many here have said repeatedly it comes down to:-

a. cost
b. they don't want change

Therefore similiar accidents will continue to happen and lives will be lost. An totally unbelievable and entirely avoidable situation.
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Old 31st Dec 2011, 20:34
  #136 (permalink)  
 
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Bladcrack

It may be possible to have some such equipment fitted to a single engine helicopter, but MOST DO NOT. That is the difference. If you want to fit such equipment to a VFR single and fly it around at night in bad weather there will be less chance of crashing into a hillside, but as many here have said repeatedly it comes down to:-

a. cost
b. they don't want change

Therefore similiar accidents will continue to happen and lives will be lost. An totally unbelievable and entirely avoidable situation.
I don't think it's anything to do with not wanting change. If we are talking about here in the UK it will never happen because although this could save many more lives, the CAA would never allow it.
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Old 31st Dec 2011, 20:44
  #137 (permalink)  
 
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From the Griffin Accident Database......

UK Helicopter Fatal Accident Causes+/-



Fatal Accidents [By First Event]


Loss Of Control IMC (25.00%) 10

Spatial Disorientation (10.00%) 4

Other Weather (7.50%) 3

42.50 % of UK Helicopter Fatal Crashes are due to the the three causes listed above.

Any need for improvement in those numbers?


From the IHST 2009 report....a long quote but worth reading. bold print is my doing.

There were 174 U.S.-registered helicopter accidents in 2001, which worked out to 8.0 per 100,000 flight hours. The good news: “This is a decrease of 12.1 percent over the CY2000 accident rate of 9.1 per 100,000 flight hours,” the report states. The bad news: In those accidents, 137 helicopters were “substantially damaged.” That’s 79 percent of the total 174. “Of the remaining, 32 (18 percent) were destroyed, one (0.6 percent) had minor damage and four (2.3 percent) had no damage reported,” it continues.

Only 14 (4 percent) of the helicopters in U.S. 2001 accidents were twin turbines. In contrast, 84 (48 percent) were single-engine turbines and 76 (44 percent) were single-piston helicopters. The majority of CY2001 accidents occurred during personal/private flying, 38 missions (22 percent) and instructional/training, 29 missions (17 percent). The landing phase accounted for 45 (26 percent) of the accidents, hover 30 (17 percent) and maneuvering 29. There was a direct correlation between a higher percentage of accidents and lesser amounts of flying experience in the specific make/model involved in a crash. “For example, the group with the most accidents, personal/private, also has very low median time in rotorcraft,” the report states.

As for casualties: 91 (52 percent) of the CY2001 accidents didn’t result in injuries. “There were 38 accidents (22 percent) with minor injuries, 17 (10 percent) with serious injuries, and 28 accidents (16 percent) that resulted in fatal injuries,” the report continues. The bottom line: of the 174 accident helicopters, there were a total of 373 people on board at the time of the accident with a total of 48 fatalities, or 12.9 percent. Reviewing the statistics, HAI’s Zuccaro noted that “66–75 percent” of the accidents that occurred in 2001 were caused by “human factors.” But he was quick to point out that human factors are not a synonym for ‘pilot error’. Although that is a part of the mix, other elements such as pilot workload, aircraft design, inadequate training for the missions required and technological shortfalls were also to blame.

“We’re not pointing our fingers at pilots,” he said. “They’re just one factor.” In particular, Zuccaro said that many aircraft feature designs that require pilots to do too much. He also chastised managers who send their pilots on night missions without proper tools such as night vision goggles. Still, of the various Standard Problem Statements (SPS) the U.S. JHSAT used to classify accident causes in its CY2001 report, “The SPS, pilot judgment and actions, dominated the problems, appearing in over 80 percent of the accidents analyzed.”

Last edited by SASless; 31st Dec 2011 at 21:09.
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Old 31st Dec 2011, 21:05
  #138 (permalink)  
 
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chopjock - i was referring to the US.

SASless - if the accident rate isnt zero there is always a need for improvement, wouldn't you agree? Not sure what your point is? Out of those statistics I think you will find there are very few, if any ME/IFR helicopters?

BC
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Old 31st Dec 2011, 21:17
  #139 (permalink)  
 
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Finding stats conveniently broken down for use is hard.

The CAA rightly breaks out Offshore Operations from On-shore as they are two very different environments and types of operation. The US NTSB data base has proven to be less than useful in a lot of ways and as always....one cannot just hang a hat on numbers alone.

I am sure there are comparisons somewhere about the accident rates of the UK and USA that if found would be interesting to consider.

Even the IHST quote combines Private Sector flying and Public Transport data which doesn't work well either.
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Old 31st Dec 2011, 21:30
  #140 (permalink)  
 
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SASless - I agree with what you say re stats being hard to interperet... However as we in Europe had JAA/JAR implemeted quite some time ago, maybe a fairer comparison would be US Vs JAA member states (grouped together) when it comes to accident stats rather than US Vs UK? Just a thought...

BC
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